Group B Strep, though a common component of vaginal flora, can cause serious and even life-threatening disease in newborns. For this reason, efforts to identify infants at risk and initiate treatment before symptoms develop have been intense. Though controversy still exists about the best way to manage at-risk infants, the information presented here is a suggested approach.
Updates to the Clinical Guidelines
Management of Infants Born to GBS+ Mothers
In 1996, the CDC published guidelines for the use of prophylactic antibiotics to prevent perinatally acquired Group B Strep infection. This was the first major effort to review the scientific evidence of this topic and present a set a guidelines aimed at developing a more consistent and effective approach to GBS disease prevention. Click on the link below for the original article.
Based on information available since the 1996 guidelines were published, the CDC published a ”modified” approach to newborns born to women who receive IAP (Intrapartum Antibiotic Prophylaxis) to prevent early-onset GBS disease or to treat suspected chorioamnionitis. Variations in the algorithm that incorporate individual circumstances or institutional preferences may be appropriate.
Chorioamnionitis:
If a woman receives intrapartum antibiotics for treatment of suspected chorioamnionitis, her newborn should have a full diagnostic evaluation and empiric therapy pending culture results, regardless of clinical condition at birth, duration of maternal antibiotic therapy before delivery, or gestational age at delivery.
Symptomatic Infants and LPs:
When clinical signs in the infant suggest sepsis, a full diagnostic evaluation should include a lumbar puncture. Blood cultures can be sterile in as many as 15% of newborns with meningitis and the clinical management of an infant with abnormal CSF findings differs from that of an infant with normal CSF. If a lumbar puncture has been deferred for a neonate receiving empiric antibiotic therapy, and the therapy is continued beyond 48 hours because of clinical instability, CSF should be obtained for cell count, glucose, protein, and culture.
Intrapartum Antibiotics:
Intrapartum intrapartum antibiotic prophylaxis with penicillin, ampicillin, clindamycin, or cefazolin at least 4 hours before delivery can be considered adequate, based on achievable amniotic fluid concentrations.
Discharge after 24 hours:
Intrapartum antibiotic prophylaxis has been demonstarted to be effective at preventing early-onset GBS, and clinical onset occurs within the first 24 hours of life in over 90% of infants who are affected. Therefore, a healthy-appearing infant who is >38 weeks' gestation at delivery and whose mother received >4 hours of intrapartum antibiotic prophylaxis before delivery may be discharged home as early as 24 hours.
If all discharge criteria are NOT met, the infant should remain in the hospital for at least 48 hours of observation and until criteria for discharge are achieved. Criteria for discharge include (but are not limited to) infants with "no concerns" and follow-up location and access confirmed.
Management of Infants Born to Group B Strep Positive Mothers
In the event that intrapartum antibiotics are NOT given to a GBS positive mother, sufficient data are not available on which to recommend a management strategy for the newborn. That said…
Identify Group to which Infant Belongs:
- GBS positive and received IAP >4 hrs prior to delivery, no other risk factors
- GBS positive, inadequate or no IAP, no other risk factors
- GBS positive (regardless of IAP) and presence of 1 other risk factors*
- GBS positive (regardless of IAP) with presence of 2 other risk factors*
*Risk factors: <37 wks gestation, PROM, maternal fever
Group 1: GBS positive, received IAP >4 hrs prior to delivery, no other risk factors
Management: Observe 24 to 48 hours. Must meet discharge criteria.
Group 2: GBS positive, inadequate or no IAP, no other risk factors
Management option 1: Observe for 48 hours. Must meet discharge criteria.
Management option 2: Sepsis Screen, including CBC/diff, 2 CRPs: first >8hrs of life and second >24hrs after the first.
Management option 3: IM ampicillin, 50 mg/kg q 12 hours x 4 doses, NO blood tests!
Management option 4: IM penicillin G 50,000 units single dose if >2 kg within 1 hour of birth, NO blood tests!
Group 3: GBS positive (regardless of IAP) and presence of 1 other risk factor
Management option 1 : Sepsis Screen, including CBC/diff, 2 CRPs: first >8hrs of life and second >24hrs after the first.
Management option 2 : IM ampicillin, 50 mg/kg q 12 hours x 4 doses, NO blood tests!
Management option 3 : IM penicillin G 50,000 units single dose if >2 kg within 1 hour of birth, NO blood tests!
Group 4: GBS positive (regardless of IAP) with 2 other risk factors OR clinical signs of sepsis OR infant’s mother has chorioamnionitis
Management: Admit to NICU or PSCN for full sepsis evaluation and empiric antibiotic therapy
ABurgos, reviewed 5-06
