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This guideline supersedes previous guidance for the prevention and treatment of Group B Streptococcal infection in the neonate. It is relevant to all medical, nursing and midwifery staff working with neonates in the hospital or community settings. Staff using this document should also be familiar with additional guidance on the use of antibiotics in the neonate and the monographs of the drugs referred to in this guidance. Staff should also refer to the NICE guideline "Antibiotics for early-onset neonatal infection" and the RCOG Green-top guideline “Group B Streptococcal Disease, Early-onset” which have been used as the basis for this document.
Early Onset Sepsis (EoS) in the Neonate is defined as infection in the first 72 hours after birth, although, in practice, most of these infections present within the first 24h of life. The organisms responsible for EoS in the neonate are predominantly those which may colonise the vagina or lower gastrointestinal tract in the mother. Such colonisation is frequently asymptomatic however it may be associated with rupture of the membranes and preterm labour. Less frequently these organisms may lead to chorioamnionitis which may in turn lead to sepsis in the mother or the neonate.
Causative organisms
The commonest organism is GBS. The incidence of early onset sepsis in the neonate due to GBS may be reduced by offering intrapartum antibiotic prophylaxis (IAP) to mothers who are at risk of transmitting this organism to their baby during the birth. Those women who may benefit from IAP have been identified in two ways: firstly by screening for GBS carriage during the pregnancy and secondly by identifying clinical risk factors. The most cost-effective method depends on local epidemiology including maternal GBS carriage rates and the incidence of neonatal sepsis in the population. In the UK a risk-factor based approach is employed which is outlined in detail in the RCOG guideline “Group B Streptococcal Disease, Early-onset” (Green-top Guideline No. 36 2017)
The following groups of women should be offered IAP with an intravenous antibiotic which is effective against group B Streptococcus. This will be Benzylpenicillin or, for penicillin sensitive women, another antibiotic with activity against GBS should be used. (This will usually be either Vancomycin, Teicoplanin, or Clindamycin dependent on local antibiotic policy)
IAP should be given, where possible, at least 2 hours prior to delivery for optimum efficacy
Note: - Women with GBS in a previous pregnancy
Women with GBS detected in a previous pregnancy have a 50% risk of recurrent GBS carriage and should be offered routine IAP or the option of bacteriological testing in late pregnancy, followed by IAP if still positive.
If performed, bacteriological testing should be carried out at 35-37 weeks gestation or 3-5 weeks prior to the anticipated delivery date, i.e. 32-34 weeks gestation in multiple pregnancies. A single (Amies charcoal) swab should be taken from the lower vagina and anorectum. Healthcare professionals should indicate that the swab is being taken for GBS.
Potentially infected women who require antibiotics that also cover GBS
For the following women, antibiotic therapy should be determined by Obstetric guidelines for sepsis, but in addition must include specific GBS prophylaxis (as above).
The NICE guideline shifts the emphasis away from offering treatment to babies whose mothers did not receive adequate intrapartum prophylaxis for GBS.
Babies with ‘red flags’, multiple risk factors or abnormal clinical signs
In a number of high-risk situations referred to as "red flags", or where there are a number of lesser risk factors or clinical signs (see table 1 below), NICE recommends the prompt introduction of intravenous antibiotics.
NB. Antibiotics are recommended in this group even if adequate intrapartum prophylaxis has been given.
Babies with a single risk factor and no abnormal clinical signs
For infants without any "red flags", who have only a single risk factor for sepsis, NICE recommends withholding antibiotics but closely monitoring the clinical condition of the infant over the first 24-36 hours.
NICE further recommends that parents are involved in planning the care of their baby. We will provide a parental information leaflet to explain the recommendations outlined above. If parents remain concerned about the possibility of infection after having received this advice, they may opt to have the antibiotic therapy and/or the investigations offered to babies with multiple risk factors.
Use the following framework based on risk factors and clinical indicators, including red flags, to direct antibiotic management advice:
Table 1 - Risk Factors and Clinical indicators
Red Flags |
Risk Factors |
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Invasive group B streptococcal infection in a previous baby |
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Maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy |
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Prelabour rupture of membranes - (spontaneous ROM more than 24 hours before the onset of established labour at term) |
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Preterm birth following spontaneous labour (before 37 weeks' gestation) |
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Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth |
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Intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis |
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Parenteral antibiotic treatment given to the woman for confirmed or suspected invasive bacterial infection (such as septicaemia) at any time during labour, or in the 24-hour periods before and after the birth [This does not refer to intrapartum antibiotic prophylaxis] |
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Suspected or confirmed infection in another baby in the case of a multiple pregnancy |
Red Flags |
Clinical Indicators |
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Altered behaviour or responsiveness* |
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Altered muscle tone (for example, floppiness) |
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Feeding difficulties (for example, feed refusal)* |
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Feed intolerance*, including vomiting, excessive gastric aspirates and abdominal distension |
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Abnormal heart rate (bradycardia or tachycardia) |
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Signs of respiratory distress |
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Respiratory distress starting more than 4 hours after birth |
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Hypoxia (for example, central cyanosis or reduced oxygen saturation level) |
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Jaundice within 24 hours of birth |
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Apnoea |
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Signs of neonatal encephalopathy |
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Seizures |
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Need for cardio–pulmonary resuscitation |
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Need for mechanical ventilation in a preterm baby |
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Need for mechanical ventilation in a term baby |
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Persistent fetal circulation (persistent pulmonary hypertension) |
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Temperature abnormality ( 36°C or 38°C) unexplained by environmental factors |
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Signs of shock |
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Unexplained excessive bleeding, thrombocytopenia, or abnormal coagulation |
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Oliguria persisting beyond 24 hours after birth |
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Altered glucose homeostasis (hypoglycaemia or hyperglycaemia) |
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Metabolic acidosis (base deficit of 10 mmol/litre or greater) |
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Local signs of infection (for example, affecting the skin or eye) |
* note that sleepiness, minor vomiting and early reluctance to feed are common symptoms in the normal neonate in the first day of life. Clinical judgement must be used to determine whether these are more pronounced than usual for a baby of that gestation and age.
For babies with ' red flags' OR a strong clinical suspicion of sepsis.
NB – follow this guidance whether or not Intrapartum Prophylaxis has been given
These babies will be managed initially on the neonatal unit and treated according to the antibiotic guideline.
NB – If there is strong evidence, or proof, of Early Onset Sepsis (EOS) the paediatric team should inform their Obstetric colleagues. This may help guide maternal therapy if the mother is also unwell.
For babies with two or more risk factors or clinical indicators but without a strong clinical suspicion of sepsis
NB – follow this guidance whether or not Intrapartum Prophylaxis has been given
These babies may be managed on the postnatal wards after their initial investigations.
For babies with a single 'non-red flag' risk factor or clinical indicator and no clinical evidence of sepsis.
For these infants we would recommend the following:
Parents should be informed about the risk factor which has prompted this recommendation. The parents should be told that the clinical examination has not identified any current signs or symptoms of active infection and that we will continue to monitor these clinical signs throughout the first day of life. (Most babies who develop EOS will become unwell in the first 12-24h).
We recommend that all such infants are observed for this period irrespective of whether intrapartum prophylaxis was given or not.
A parental leaflet will be provided which will explain this recommendation and to provide information about the signs and symptoms of infection in a baby.
If the parents are uncomfortable with the decision not to perform any additional investigations, or treat with antibiotics, then this should be taken into account when planning the baby's care. At the discretion of the medical staff the baby could be managed in the same way as babies with multiple risk factors or clinical concerns as outlined above.
For those babies identified as requiring investigation the following tests should be requested.
Baseline
Babies receiving antibiotic therapy
Selected babies
If performing the lumbar puncture would unduly delay starting antibiotics, perform it as soon as possible after starting antibiotics.
18-24 hours
Babies receiving antibiotic therapy
If antibiotic therapy continuing
Subsequent investigations
Only babies requiring ongoing antibiotic therapy require additional investigations
*It is important to ensure that the local microbiology department regularly monitors blood cultures for growth during the incubation period. This will ensure that the lack of a positive culture report in the period between 24-36h truly indicates a lack of microbial growth.
Decisions regarding investigation and treatment
Babies with a strong clinical suspicion of sepsis must receive appropriate treatment promptly to reduce the mortality and morbidity associated with early onset sepsis. Parents should be fully informed regarding their baby's condition and the treatment required. However, this counselling should not delay appropriate therapy.
Where a baby has only 'non-red flag' risk factors, or clinical indicators, we will recommend withholding antibiotics and keeping the baby under close observation for 24 hours. If the parents are uncomfortable with this recommendation the clinician may, at discretion, manage the baby in the same fashion as an infant with multiple risk factors or clinical signs.
Advice regarding babies who become unwell after discharge
If there have been any concerns about early-onset neonatal infection before a baby is discharged, whether or not the baby received treatment, advise the parents and carers verbally and in writing that they should seek medical advice (for example, from NHS 24, their general practice, or an accident and emergency department) if they are concerned that the baby:
Last reviewed: 19 April 2018
Next review: 01 April 2021
Author(s): Dr Andrew Powls - Consultant Neonatologist. Princess Royal Maternity, Glasgow
Approved By: WoS Neonatal MCN