WELCOME APPLICANTS! Morning Report: Friday, November 4 th, 2011 Geaux Tigers!!!! Roll Tide Roll…around the bowl and down the hole!

Group B Streptococcal Infections

Background  Encapsulated gram-positive diplococcus  Currently 10 known serotypes  Major cause of bacterial infections in pregnant women in the perinatal period  Bacteremia  Amnionitis  Endometritis  UTIs  Also causes focal and systemic infections in newborns

Background  RARE cause of infection in older children and non- pregnant adults  Three types of neonatal infection:  Early-onset disease (EOD): occurs within the first week of life (usually within 72h)  Late-onset disease (LOD): occurs between 1 and 4 weeks of life  Late,late-onset disease: occurs between 1 and 6 months of age Can be associated with immunodeficiency Most often seen in premature infants

Epidemiology  Common inhabitant of the maternal GI and genital tract  Colonizes ~20% of pregnant women  Increased risk of colonization Low SES Black race Age <20 yo  Cultures obtained after wga have a negative predictive value of 97% and a positive predicitve value of 89%

Epidemiology  Women identified as GBS+ through culture-based screening are 25 times more likely to deliver an infant with EOD.  Identification of colonized women along with intrapartum antibiotic prophylaxis has  80% decrease in EOD (since 2002)

Pathogenesis  Maternal colonization with GBS in the GI/GU tract and transmission to the infant either in utero or during passage through the birth canal  Horizontal transmission either in the nursery or at home Early-onset DiseaseLate-onset Disease

*Clinical Aspects Spectrum of EOD: bacteremia  septic shock; can also see persistent fetal circulation or RDS

Diagnosis  Non-specific testing  Leukocytosis/ left shift  CSF pliocytosis  Elevated acute phase reactants  Lab signs of complications of sepsis (DIC, acidosis, hepatic injury, BM failure)  Isolation of organism from normally sterile site  BCx  CSF Cx  Joint space Cx

Diagnosis  Latex agglutination  Can identify GBS polysaccharide Ag in isolates from culture as well as biologic fluids  Culture more sensitive  Should be used when either mother or infant has been treated with ABx prior to culture

Treatment  Empiric treatment for EOD  Ampicillin ( mg/kg/d) AND  Aminoglycoside  Empiric Treatment for LOD  Ampicillin PLUS  Cefotaxime OR Ceftriaxone  Continued for several days until GBS has been isolated (with sensitivities) and there is a good clinical response or the CSF becomes sterile

Treatment  Meningitis  Antibiotic changes: Penicillin G 300,00U/kg/d Ampicillin mg/kg/d  Some experts believe a second LP 24-48h after initiation of therapy aids in management and prognosis

Treatment  Duration  Bacteremia/ PNA/ soft tissue infection 10 days  Meningitis/ arthritis days  Osteomyelitis/ endocarditis days  *Repeated LPs and diagnostic imaging if response to therapy is unclear

An Ounce of Prevention…

Step 1…Testing!  Universal screening at 35-37wga  Options for GBS identification  Culture of maternal vaginal/ rectal swabs  Positive identification from chromogenic agar media  Nucleic acid amplification tests (NAATs)

Step 2…Who Needs Prophylaxis?  Prophylaxis indicated with:  Previous infant with invasive GBS  GBS bacteruria during the current pregnancy  Positive GBS screen during the current pregnancy  Unknown GBS status AND: Gestation <37 wks ROM> 18h Intrapartum fever >38.0

Step 3…What to Give?  Penicillin is the agent of choice, ampicillin is an acceptable alternative  PCN-allergic women without a history of severe reaction to PCN (anaphylaxis) or cephalosporins should receive cefazolin  PCN-allergic women with high risk of anaphylaxis should receive clindamycin if their isolate is susceptible or Vancomycin if it’s resistant  Adequate IAP= at least 4 hours of penicillin, ampicillin or cefazolin  All others inadequate (including Vanc and Clinda)

The Old Nomogram

The New Nomogram

Prognosis  Mortality=5%  Major determinates of outcome  Severe prematurity  Septic shock  Periventricular leukomalacia may develop as a sequela of septic shock without meningitis  significant DD

Prognosis  After meningitis:  Cortical blindness  Spasticity  Global intellectual disability Minor or severe  Deafness  Motor defecits

How would you proceed?  Ex 38 wga well-appearing F whose mother had a previous infant with GBS meningitis. Mom received 3 doses of Clindamycin before delivery. ROM 15 hours PTD  Inadequate IAP  Observation x48h  Ex 36 wga M born via C-section. ROM at delivery. Mother was GBS+ by screening at 35wga. No IAP was given. The infant has a normal newborn exam.  Routine newborn care  IAP not indicated when C/S happens before the onset of labor (membrane are intact)

How would you proceed?  Ex 40 wga healthy M whose mother broke out in a rash when she received PCN as a child. She was GBS+ by screening and received 1 dose of cefazolin 4h PTD.  Adequate IAP  Observe for 48 hours, but may be discharged after 24h if all other criteria met and close f/u with PCP possible

How would you proceed?  Ex 37 wga M whose mother was GBS+ treated with 4 doses of ampicillin prior to delivery. Mom had a temp of during delivery, and you overheard the OB resident saying they were very suspicious of chorioamnionitis.  Limited evaluation (CBC, BCx) and empiric antibiotics until clinical course and lab evaluation can exclude sepsis (48h)

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