Management of the Infant At Increased Risk Of Sepsis

Question 1

What is the incident of early onset GBS disease

Answer 1

2 per 1000 in the absence of intra-partum prophylaxis

Question 2

What is the fatality of early onset GBS disease

Answer 2

2-13%

Question 3

What are the recommendations for investigating and managing GBS in pregnant women

Answer 3

Screen every women at 35-37 weeks

Treat GBS positive women with penicillin antibiotics in labour, 4 hours before delivery

Question 4

What is the risk of invasive early-onset GBS disease a baby whose GBS positive mom did not receive antibiotics

Answer 4

1%

Question 5

What proportion of babies with invasive early onset GBS disease are symptomatic at birth?

Answer 5

75%

Question 6

What percentage of neonates with invasive early onset GBS disease present within 24 hours?

The rest?

Answer 6

95%

4% present at 24-48 hours
1% present > 48 hours

Question 7

What do you do with a well-appearing baby with a GBS positive mom appropriately treated?

Why?

Answer 7

Observe til 24 hours and discharge with advise to return if unwell and ability to transport back.

Because there are infants who get GBS sepsis despite IPA. They are likely to present within 24 hours of life

Question 8

What do you do with a well appearing neonate with a GBS positive mom, who did not receive appropriate IAP

Answer 8

CBC
Vitals Q4H x 24 hours

Advise to return if unwell and transport. Can only be discharged then if parents can comply.

Question 9

Other than GBS, who else should get IPA?

Answer 9

ROM over 18 hours
Pyrexia (38)
Premature labour (37wks)
Bacteriuria with GBS at any point in pregnancy
Previous infant with invasive GBS disease

Question 10

What do you do with a well appearing neonate from a GBS negative mom with other risk factors

Answer 10

A limited evaluation: exam at 24 hours, vitals Q4H and CBC

Question 11

Does the approach of a well appearing neonate born less than 37 weeks differ?

Why?

Answer 11

Yes.
Do not discharge before 48 hours.
Well appearing - limited evaluation

Almost all children will present before 48 hours

Question 12

How do you clinically diagnose chorioamnionitis?

Answer 12

Fever
Uterine tenderness
Left shift
Foul discharge

Question 13

What is the risk of sepsis from a mom with chorioamnionitis?

Answer 13

8%

Question 14

Who gets a full diagnostic evaluation?

Answer 14

1. Unwell infant: temperature instability, tachycardia, tachypnea, poor perfusion, respiratory distress
   2 Positive limited screen with WBC

Question 15

What is a full diagnostic evaluation?

Answer 15

BCX
LP
CBC
or CXR

Question 16

What is a limited diagnostic evaluation:

Answer 16

Vitals Q4H x24 hours

CBC

Question 17

What are the most common organisms causing early-onset neonatal sepsis?

Other organisms?

Answer 17

Most common: GBS

Other:
Other streptococci
E. coli
Other gram negative organisms (klebsiella, citobacter, enterobacter seratia, pseudomonas)
Listeria

Question 18

What are you looking for on the LP?

Answer 18

Pleocytosis

Low glucose in serum

Question 19

What are you looking for on the LP?

Answer 19

Pleocytosis

Low glucose in serum

Question 20

What antibiotics would you choose for the different pathogens?

Answer 20

GBS - ampicillin (or penicillin) and gentamicin
Listeria - ampicillin and gentamicin
Gram negative - ampicillin and cefotaxime

Question 21

What antibiotics would you choose for the different pathogens?

Answer 21

GBS - ampicillin (or penicillin) and gentamicin
Listeria - ampicillin and gentamicin
Gram negative - ampicillin and cefotaxime

Question 22

If the kid was too stable for an LP, which antibiotic should you choose?

Answer 22

Ampicillin and gentamicin

Question 23

If mom is penicillin allergic and receives a different antibiotic, is that ok?

Answer 23

There is insufficient evidence to support the use of alternative antibiotics and these kids should be considered not covered

Question 24

What’s the difference between possible and definite chorioamnionitis?

Answer 24

Possible: fever
Definite: fever, uterine tenderness and left shift

Question 25

What are risk factors for GBS?

4

Answer 25

Maternal pyrexia or signs of chorio
Preterm
ROM > 18 hours
Previous child with GBS sepsis

Question 26

What do you do:
GBS Unknown 
No risk factors
Well appearing
Received IAP

Answer 26

Discharge at 24 hours with no investigations

Question 27

What do you do:
GBS Unknown
Risk factors
No IAP

Answer 27

Limited diagnostic evaluation