1. Newborn Management
Chorioamnionitis

2. Labor & Delivery Spontaneous labor Epidural
ROM of clear fluid for 3 hours prior to delivery
2 maternal temps of 100.4, no antibiotics
Category 2 FHTs with variable decelerations
SVD of female infant
Apgars 6/8; required brief CPAP/30% oxygen for transition
After delivery, maternal temp of with shaking chills

3. Newborn management
Infant admitted to Intermediate NICU for antibiotics (Ampicillin and Gentamicin) and monitoring
VS: T 99.4, HR 188, RR 84, 61/39, 98% in RA
HR and RR normal by 2 hours of age, no oxygen required
PE: caput, mild tachypnea – no distress, well perfused.
Cord blood culture drawn
CBC at birth with WBC of 21,000 and I:T ratio of 0.27

4. Newborn management
Infant became hypoglycemic to 22mg/dL despite nursing so was transferred to the NICU for IV fluids at ~8 hours.
Cord blood culture grew E. coli at 10.5 hours.
E coli resistant to Ampicillin, but sensitive to 3rd generation cephalosporins and aminoglycosides
LP obtained on day 3 (after several unsuccessful attempts).
RBC 1130, WBC 35, glucose 37 and protein 167
Culture & meningitis panel negative (after >72 hours antibiotics)
Second blood culture remained negative.
Infant treated with Cefotaxime for 21 days for presumed E coli meningitis due to pleocytosis.

5. Impact on the Neonate FIRS: Fetal inflammatory response syndrome
Perinatal death
Asphyxia
Early-onset sepsis
Pneumonia
IVH
Cerebral white matter damage
Long term disability including CP
4 fold increase in near term/term
Clinics in Perinatology.
Tita, Alan T.N., MD, PhD; Andrews, William W., PhD, MD. Published May 31, Volume 37, Issue 2. Pages

6. Current recommendations
CDC
AAP
2010 Guidelines for Prevention of Perinatal GBS disease
If maternal chorioamnionitis (clinically diagnosed):
Limited evaluation: blood culture at birth and CBC with diff at birth or 6-12 hours
Antibiotic therapy – no guidance on duration
2012 Management of Neonates with Suspected or Proven EOS
Clarified in 2014
If maternal chorioamnionitis:
Blood culture at birth with CBC/diff +/- CRP at 6-12 hours
Antibiotic therapy
Blood culture negative: D/C antibiotics by hours
Blood culture positive: LP, continue antibiotics

7. Alternatives…
Eunice Kennedy Shriver NICHD Chorioamnionitis Workshop Executive Summary
Higgins. Chorioamnionitis Workshop Executive Summary. Obstet Gynecol 2016.

8. Neonatal sepsis calculator
kp.org\eoscalc

10. What is “not well-appearing”?
Clinical illness:
Persistent need for NCPAP / HFNC / mechanical ventilation (outside of the delivery room)
Hemodynamic instability requiring vasoactive drugs
Neonatal encephalopathy /Perinatal depression
Seizure
Apgar 5 minutes < 5
Need for supplemental O2 > 2 hours to maintain oxygen saturations > 90% (outside of the delivery room)
Equivocal: abnormality can be intermittent
Persistent physiologic abnormality > 4 hrs
Tachycardia (HR > 160)
Tachypnea (RR > 60)
Temperature instability (> 100.4˚F or < 97.5˚F)
Respiratory distress (grunting, flaring, or retracting) not requiring supplemental O2
Two or more physiologic abnormalities lasting for > 2 hrs
Well appearing: no persistent physiologic abnormalities .

11. Diagnostic tests Single blood culture of at least 1 ml Lumbar puncture
Blood culture can be negative in up to 38% of infants with meningitis
Indicated if positive blood culture, strongly suspect bacterial sepsis, clinical course worsens
Tracheal aspirate immediately after intubation
Not recommended:
Urine culture
Gastric aspirate
Body surface cultures

12. Biomarkers Acute phase proteins Cell surface antigens
CRP, procalcitonin
Cell surface antigens
CD64 expression increases with bacterial infection
Cytokines & chemokines
IL-6, TNFα, IL-1
Soluble adhesion molecules
E-selectin, ICAM
C- Reactive Protein

13. Treatment Most common pathogens are GBS and Escherichia coli
Ampicillin 100mg/kg/dose Q 12h
Gentamicin 4mg/kg/dose Q 24h
This combination has synergistic activity against GBS and Listeria
Together they cover most strains of E coli
3rd generation cephalosporins (Cefotaxime) can replace Gentamicin
Increased risk resistance and invasive candidiasis
Use for gram negative meningitis given excellent CSF penetration

14. Duration of antimicrobial therapy
Evidence is limited!
NICHD Executive Summary: “in most well-appearing neonates, there is no compelling evidence that antimicrobial agents need to be continued beyond 48 hours, especially when blood cultures are negative and irrespective of how “abnormal” lab data are…”
AAP guidelines recommend against treatment of infants with sterile cultures for longer than hours on basis of lab alone.
What is the validity of blood cultures in neonates born to women who received broad spectrum antibiotics before delivery?

15. Consequences of current practice
Increased number of neonates exposed to antimicrobial agents with potential toxicities
Exposure to a NICU environment with increased risk of acquiring infections with multidrug resistant bacteria.
Mother-baby separation interferes with bonding and successful breastfeeding
Altered gut microbiome
Fosters development of antibiotic resistant flora
Painful procedures (IV(s), LP)