Newborns At Risk for Sepsis Algorithm Signs of Neonatal Sepsis Yes Full diagnostic evaluation with antibiotic therapy and NICU transfer No Maternal Chorioamnionitis? Yes See Chorio Algorithm No GBS Prophylaxis indicated for mother? No Routine Newborn Clinical Care Yes Yes See GBS Algorithm Mother received ≥ 4 h of penicillin, ampicillin or cefazolin IV? No Yes See GBS Algorithm ≥ 35 wk AND duration of ROM < 18 h? No Yes See GBS Algorithm < 35 wk OR duration of ROM ≥18 h? Adapted from Reference: Algorithm for the Prevention of early-onset GBS infection in the newborn. Pediatrics, Vol 128, Number 3, Pg. 3, September 2011

Maternal GBS Colonization or GBS unknown status: Care of the Well-Appearing Newborn at Risk for Sepsis GBS colonization: GBS in urine this pregnancy, GBS disease in infant in prior pregnancy, GBS swab positive in last 5 weeks GBS colonization, GBS unknown < 37 weeks 0 days, and GBS unknown ≥ 37 weeks 0 days with ROM ≥ 18 hours require IAP Intrapartum Antibiotic Prophylaxis (IAP): Adequate IAP = Mother received 1st dose Ampicillin or Cefazolin > 4 hrs prior to delivery Inadequate IAP = Mother received 1st Ampicillin or Cefazolin < 4hrs prior to delivery (or not at all) or received Clindamycin or Vancomycin Adequate IAP Inadequate IAP Without Risk Factors: Infant > 35 weeks AND ROM < 18 hrs Inadequate IAP With Risk Factors: Infant < 35 weeks OR ROM > 18 hrs · CBC with manual diff at 6 hrs of age · Routine clinical care If lab values are WNL, observe NB for 48 hrs If lab values are abnormal, contact Newborn LIP and strongly consider Blood Culture, antibiotics and continuous monitoring · Routine Newborn Care · Observation for > 48 hrs* *24 hrs may be adequate if other discharge criteria are met and there is ready access to medical follow up care CPM: Newborns at Risk for Sepsis ; 2-2016

CPM: Newborns at Risk for Sepsis ; 2/2016 Maternal Chorioamnionitis: Care of the Well-Appearing Newborn at Risk for Sepsis Maternal fever ≥ 100.4°F without clear alternative explanation is adequate for a presumptive diagnosis of chorioamnionitis, even in the absence of other features: tachycardia > 100, leukocytosis, uterine tenderness, foul-smelling amniotic fluid or fetal tachycardia > 160. Dedicated NRP team attends delivery if chorioamnionitis is diagnosed Maternal Temp > 101 °F Up to 1 hour post delivery Maternal Temp 100.4-100.9 °F Up to 1 hour post delivery NB High Risk for Sepsis NB Moderate Risk: PROM > 18 hrs OR < 37 weeks NB Low Risk: > 37 weeks AND ROM < 18 hrs. Initial NB transition care (up to 2 hrs of age) Followed by blood culture and initiation of antibiotic therapy CBC with manual diff at 6-12 hrs of age Close observation / monitoring for 12 – 24 hours · CBC with manual diff & blood culture completed at 4-6 hrs of age · Results called to Newborn provider · Labs & History reviewed by Newborn provider Evaluate potential for infant to be cared for within routine couplet care assignment after 12-24 hrs of age. NB hospital stay ≥ 48 hrs Abnormal Lab Results Newborn provider to consider antibiotics If antibiotics initiated, close observation / monitoring for 12 – 24 hours NB hospital stay ≥ 48 hrs Results WNL’s Infant cared for within routine couplet care assignment. Antibiotics not started. Newborn provider may consider serial CBCs. NB hospital stay ≥ 48 hrs CPM: Newborns at Risk for Sepsis ; 2/2016