Management of the infants at

increased risk for early onset

sepsis from group B
streptococcal infection

Martin Skidmore
University of Toronto
 Group B Streptococcus (GBS)
• Most GBS early onset sepsis (EOS) caused by
types Ia, Ib, II, III & V
– Type III more commonly associated with late onset
sepsis/meningitis
• 20-30% of American women are colonised (may
be as high as 60%)
• 50% of infants born to colonised mothers
become, themselves, colonised
• 1-2% of colonised infants will develop invasive
GBS
• GBS bacteriuria at anytime during the pregnancy
• Previous child with invasive GBS disease
 BACKGROUND
• 1996: consensus guidelines from The Centers
for Disease Control and Prevention
recommended intrapartum antibiotic prophylaxis
(IAP) to women at risk for delivering an infant
with EOS, GBS infection

• 2002: CDC conducted a large, retrospective

cohort study which demonstrated positive impact
and issued universal screening guidelines
 Impact
Incidence of EOS from GBS

• 1993: 1.7 cases/1000 live births

• 2003-5: 0.34 cases/1000 live births
» a reduction of 80%

• Incidence of EOS from non GBS

unchanged
 Recommendations

• Screen ALL mothers with rectovaginal

cultures at 35-37 weeks for GBS

• Treat those with positive cultures with

penicillin in labour
 “Cost”

• As many as 22% of all mothers will

receive IAP to prevent disease in 0.2 % of
infants and prevent mortality in 0.01% of
infants
 Strategies (A)
• Well-appearing infant of GBS positive
mother, who received IAP more than 4
hours prior to delivery
– N/B requires no therapy
– ± stay in hospital ≥ 24 hours

• Insufficient evidence regarding efficacy of

alternative antibiotics – treat as “incomplete IAP”
 Strategies (B)
Well-appearing infant of GBS positive mother, who
received IAP less than 4 hours prior to delivery (or
not at all)
– Risk approximately 1%
– ¼ are asymptomatic
– Is empiric treatment therefore justified?
– 95% who develop EOS will present with clinical signs
< 24 hours
– 4% between 24 and 48 hours
– 1% > 48 hours

– Therefore: to detect each case of EOS 2000 infants

would require 48 hours hospitalization
– Therefore: case for careful assessment and discharge
at 24 hours
 Use of the CBC
• Positive predictive value is low in the newborn
• One study: “abnormal CBC”:
– WBC 5.0 x109/L or lower
– WBC 30 x109/L or greater
– Immature/mature ratio > 0.2

– 1665 well appearing term infants at risk for EOS

– PPV of 1.5% of abnormal CBC in identifying the
development of “clinical sepsis”
– None developed positive blood culture
» Ottolini et al; 2003
 Use of the CBC cont.

• Various scoring systems for analyzing CBCs

• best individual finding with highest PPV is a low
total WBC (5.0 x109/L)
– LR between 10 and 20
• ? justifies treatment even if “well appearing”
infants
– (only 22%-44% of infants with sepsis will have such a
low WBC)
» Fowlie, Schmidt; 1998
 Strategies (C)
Well appearing infant of a GBS-negative mother
with risk factors at delivery
eg.
– ROM ≥ 18 hours
– Pyrexia ≥38°C\premature labour at < 36 weeks
– GBS bacteriuria
– Previous child with invasive GBS disease
• Present in 22% and only identified 50% who
eventually developed invasive GBS disease
» Schrag et al, 2002
» Towers et al, 1999
• “Limited evaluation”: CBC & 24 hours of
observation
 Strategies (D)
Well appearing infant of mother with unknown
GBS status
•Managed as per ‘risk factors’:
– Absence of risk factors – no intervention required
– Risk factors present
• IAP > 4 hours: routine care
• IAP < 4 hours: limited evaluation

(applies to late preterm infant as GBS screening results

may not be available)
 Chorioamnionitis
• ‘pyrexia’ may occur with epidural and/or
dehydration
• ‘possible’ chorioamnionitis
– fever only
• ‘definite’ chorioamnionitis
– fever
– ‘left shift’ in mat CBC
– lower uterine tenderness
 Chorioamnionitis
• Chorioamnionitis but infant well at birth
– OR for sepsis 0.26 (95% C1 0.11to 0.63)
– Invasive infection < 2%
» Jackson et al, 2004

– Therefore limited evaluation only?

• requirement for resuscitation at birth
• otherwise, treat only if CBC is suggestive of
infection (ie low WBC)
 Recommendations
• Any newborn with clinical signs suggestive
of sepsis should have an immediate full
diagnosis evaluation followed by the
institution of empirical antibiotic therapy

• If a mother who is GBS positive receives

IAP with a penicillin more than 4 h before
delivery, no further evaluation or
observation for invasive GBS disease in a
well-appearing infant
 Recommendations
• If a GBS-positive woman receives IAP less than
4 h before delivery (or receives no antibiotics or
a nonpenicillin regimen), then a limited
diagnostic evaluation is required, and the infant
should not be discharged before 24 h of age. At
the time of discharge, the infant should be
evaluated and the parents should be educated
regarding signs of sepsis in the newborn.
Discharge at 24h to 48h is conditional on the
parents’ ability to immediately transport the baby
to a health care facility if clinical signs of sepsis
develop
 Recommendations
• If the CBC reveals a total WBC count less
than 5.0x109/L, full diagnostic evaluation
and empirical antibiotic therapy should be
considered
• If a GBS-negative woman with risk factors
delivers a baby who remains well, the
infant does not require evaluation for GBS
• If a woman with unknown GBS status and
with risk factors at the time of delivery
receives IAP more than 4h before delivery,
the infant requires no specific intervention
 Recommendations
• If a woman with unknown GBS status and with
risk factors at the time of delivery receives IAP
less than 4h before delivery, limited diagnostic
evaluation is required and the infant is not
discharged for 24 h of life
• The well-appearing infant born at less than 36
weeks gestation with an unknown maternal GBS
status should have a limited diagnostic
evaluation and is not a candidate for early
discharge
• The well appearing infant of a mother with
possible chorioamnionitis requires a limited
diagnostic evaluation for sepsis