- AAP —
- American Academy of Pediatrics
- CBC —
- complete blood cell
- COFN —
- Committee on Fetus and Newborn
- COID —
- Committee on Infectious Diseases
- GBS —
- group B streptococcal
- MMWR —
- Morbidity and Mortality Weekly Report
In 2010, the Centers for Disease Control and Prevention in collaboration with the American Academy of Family Physicians, American Academy of Pediatrics (AAP), American College of Nurse-Midwives, American College of Obstetricians and Gynecologists, and American Society for Microbiology published revised group B streptococcal (GBS) guidelines entitled “Prevention of perinatal group B streptococcal disease: revised guidelines from CDC 2010” in the Morbidity and Mortality Weekly Report (MMWR).1 The recommendations were endorsed by all the collaborating organizations including AAP after review by the Committee on Infectious Diseases (COID) and the Committee on Fetus and Newborn (COFN) and after AAP Board approval. In the report, a revised algorithm for “Secondary prevention of early-onset group B streptococcal disease” was included. This algorithm represented the expert opinions of the technical working group (based on current literature available at that time). In 2011, the COID and the COFN published a policy statement in Pediatrics that was in agreement with the 2010 GBS guidelines and included the same algorithm.2
In the spring of 2012, the COFN published a clinical report containing management guidelines entitled “Management of neonates with suspected or proven early-onset neonatal sepsis.”3 The 2012 COFN document includes guidance on laboratory evaluations and treatment duration, which were not addressed in the 2010 GBS prevention guidelines. The algorithms at the end of the COFN report differed from those in the 2010 guidelines published in the MMWR.1 The discordance in the algorithms prompted questions by the pediatric community as to which recommendations to follow.
The purpose of this commentary is to clarify AAP policy. Discordant algorithms for secondary prevention of GBS were published in 2 separate policy statements.2,3 This commentary includes the algorithm that has been approved as current AAP policy. Providing a single algorithm will avoid confusion and ensure that the guidelines achieve their desired effects.
The COFN and the COID strongly support the recommendations made in the 2010 prevention guidelines approved by the AAP and the other collaborating organizations (secondary prevention of GBS algorithm representing current AAP policy is attached in Fig 1). However, the COFN notes that in some situations, other approaches might be considered that differ from guidance provided in the 2010 prevention guidelines. The following recommendations include the recommendations from the 2010 MMWR publication and those made by the COFN:
Neonates who have signs of sepsis should receive broad-spectrum antimicrobial agents.
Healthy-appearing preterm and term infants born to women with suspected chorioamnionitis should receive a blood culture at birth, a complete blood count with differential +/− C-reactive protein at age 6 to 12 hours. These infants should be treated with broad-spectrum antimicrobial agents.
For well-appearing infants ≥37 weeks’ gestation whose mother did not have suspected chorioamnionitis, but who did have an indication for intrapartum antibiotic prophylaxis and did not receive at least 4 hours of intrapartum penicillin, ampicillin or cefazolin:
The 2010 GBS prevention guidelines and the 2012 COFN statement agree that infants who are well appearing can be observed without additional testing if duration of rupture of membranes is <18 hours. The COFN believes that infants at 35 to 36 weeks’ gestation can be treated similarly if the physical examination is normal.
If duration of membrane rupture is ≥18 hours and IAP is inadequate, the 2010 GBS prevention guidelines recommend a limited evaluation (blood culture and complete blood cell [CBC] count with differential at birth or 6 to 12 hours of age) and hospital observation for 48 hours. The COFN recommends hospital observation for 48 hours in this circumstance (without further testing or cultures). However, when close observation is not possible, the COFN recommends a laboratory evaluation.
For well-appearing infants <37 weeks’ gestation whose mother did not have suspected chorioamnionitis, but who did have an indication for IAP and did not receive adequate prophylaxis, the 2010 GBS prevention guidelines recommend a limited evaluation (blood culture and CBC count) and hospital observation for 48 hours. The COFN also recommends a limited evaluation, but no blood culture unless antibiotics are started because of abnormal laboratory data.
The 2010 GBS prevention guidelines do not address the duration of antibiotic therapy. The COFN makes recommendations for the duration of antimicrobial therapy based on the results of laboratory testing. Healthy-appearing infants without evidence of bacterial infection should receive broad-spectrum antimicrobial agents for no more than 48 hours. In small preterm infants, some may continue antibiotics for up to 72 hours while awaiting bacterial culture results.
Published data to support recommendations for prevention and management of newborn sepsis are limited. However, success of the GBS prevention guidelines provides evidence that reductions in early-onset GBS disease have been possible by the development of consensus guidelines with consistent implementation.1 The COFN’s 2012 recommendations complement the 2010 GBS prevention guidelines by providing additional treatment information that is not addressed in the 2010 prevention guidelines. These should provide clinicians with guidance for optimal duration of antimicrobial therapy and reduce excess exposure to broad-spectrum antimicrobial therapy in healthy-appearing uninfected infants who had empirical antimicrobial therapy initiated.
- Accepted April 24, 2013.
- Address correspondence to Michael T. Brady, MD, 700 Children’s Dr, AB 7048, Columbus, OH 43205. E-mail:
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
- Committee on Infectious Diseases; Committee on Fetus and Newborn,
- Baker CJ,
- Byington CL,
- Polin RA
- Polin RA
- Copyright © 2013 by the American Academy of Pediatrics