Algorithm for the prevention of early-onset GBS infection in the newborn. (Adapted with permission from Centers for Disease Control and Prevention. Prevention of perinatal group B streptococcal disease: prevention of perinatal group B streptococcal disease from CDC, 2010. MMWR Recomm Rep. 2010;59[RR-10]:1–32.) a Full diagnostic evaluation includes a blood culture; CBC count, including white blood cell differential and platelet counts; chest radiograph (if respiratory abnormalities are present); and lumbar puncture (if the patient is stable enough to tolerate procedure and sepsis is suspected). b Antibiotic therapy should be directed toward the most common causes of neonatal sepsis, including intravenous ampicillin for GBS and coverage for other organisms (including Escherichia coli and other Gram-negative pathogens) and should take into account local antibiotic-resistance patterns. c Consultation with obstetric providers is important in determining the level of clinical suspicion for chorioamnionitis. Chorioamnionitis is diagnosed clinically, and some of the signs are nonspecific. d Limited evaluation includes blood culture (at birth) and CBC count with differential and platelets (at birth and/or at 6–12 hours of life). e GBS prophylaxis is indicated if 1 or more of the following is true: (1) mother is GBS-positive within the preceding 5 weeks; (2) GBS status is unknown and there are 1 or more intrapartum risk factors, including <37 weeks' gestation, rupture of membranes for ≥18 hours, or temperature of ≥100.4°F (38.0°C); (3) GBS bacteriuria during current pregnancy; or (4) history of a previous infant with GBS disease. f If signs of sepsis develop, a full diagnostic evaluation should be performed, and antibiotic therapy should be initiated. g If at ≥37 weeks' gestation, observation may occur at home after 24 hours if other discharge criteria have been met, there is ready access to medical care, and a person who is able to comply fully with instructions for home observation will be present. If any of these conditions is not met, the infant should be observed in the hospital for at least 48 hours and until discharge criteria have been achieved. h Some experts recommend a CBC count with differential and platelets at 6 to 12 hours of age.24 IV indicates intravenously.
Evidence-Based Rating System Used to Determine Strength of Recommendations
Strength of recommendation
Strong evidence for efficacy and substantial clinical benefit
Strong or moderate evidence for efficacy, but only limited clinical benefit
Insufficient evidence for efficacy, or efficacy does not outweigh possible adverse consequences
Moderate evidence against efficacy or for adverse outcome
Generally not recommended
Strong evidence against efficacy or for adverse outcome
Quality of evidence supporting recommendation
Evidence from at least 1 well-executed randomized, controlled trial or 1 rigorously designed laboratory-based experimental study that has been replicated by an independent investigator
Evidence from at least 1 well-designed clinical trial without randomization; cohort or case-controlled analytic studies (preferably from more than 1 center); multiple time-series studies; dramatic results from uncontrolled studies; or some evidence from laboratory experiments
Evidence from opinions of respected authorities based on clinical or laboratory experience, descriptive studies, or reports of expert committees
Adapted with permission from Centers for Disease Control and Prevention. Guidelines for the prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep. 2009;58(RR-11):1–166.