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Management of the infants at increased risk for early onset sepsis from group B streptococcal infection

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

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Management of the infants at increased risk for early onset sepsis from group B streptococcal infection

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  1. Management of the infants at increased risk for early onset sepsis from group B streptococcal infection Martin Skidmore University of Toronto

  2. 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

  3. GBS bacteriuria at anytime during the pregnancy • Previous child with invasive GBS disease

  4. 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

  5. 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

  6. Recommendations • Screen ALL mothers with rectovaginal cultures at 35-37 weeks for GBS • Treat those with positive cultures with penicillin in labour

  7. “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

  8. 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”

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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)

  14. Chorioamnionitis • ‘pyrexia’ may occur with epidural and/or dehydration • ‘possible’ chorioamnionitis • fever only • ‘definite’ chorioamnionitis • fever • ‘left shift’ in mat CBC • lower uterine tenderness

  15. 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)

  16. How should an infant be monitored, investigated and treated given the: • Presence of clinical signs of sepsis • GBS culture status of the mother • Treatment status of the mother • Presence / absence of maternal risk factors for neonatal sepsis?

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