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I. PROBLEM

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Two infants are born within the last hour. One infant's mother had premature rupture of membranes (PROM) but no antibiotics. The other infant's mother was pretreated with antibiotics for a positive group B Streptococcus (GBS) culture taken at 36 weeks. Should a sepsis workup be done, and should antibiotics be started in either of these newborns?

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Early-onset sepsis (EOS) occurs within the first 3 days of life and is vertically transmitted (ascending organisms from the birth canal) and can occur from ruptured membranes, inhaling or swallowing infected amniotic fluid, or an amniotic fluid leak before or during labor. Sepsis in the first 3 days of life is a leading cause of morbidity and mortality among preterm infants. The incidence of sepsis is 1–10 in 1000 live births and 1 in 250 live premature births, with GBS being the most common pathogen followed by Escherichia coli. Black preterm infants have the highest incidence and case fatality. Since the institution of Centers for Disease Control and Prevention (CDC) guidelines, the incidence of early-onset GBS has decreased by 80%. Late-onset sepsis is discussed in Chapter 130, and infections of premature infants with prolonged hospital stays may require a different workup and antibiotic choice. This on-call problem focuses on postdelivery antibiotics for early-onset or suspected sepsis. The American Academy of Pediatrics (AAP) has a practical evidence-based approach to managing infants with suspected and culture-proven early-onset sepsis.

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II. IMMEDIATE QUESTIONS

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  1. Are there any major risk factors for early-onset sepsis? Major risk factors are preterm birth, low birthweight (risk factor most associated with early-onset sepsis), rupture of membranes (ROM) >18 hours, maternal colonization with GBS (if inadequate intrapartum therapy), or maternal chorioamnionitis (defined as maternal fever ≥38.0°C [≥100.4°F] and a minimum of 2 of the following: maternal white blood cell [WBC] count >15,000 mm3, maternal tachycardia [>100 beats/min], fetal tachycardia [>160 beats/min], uterine tenderness, foul odor of the amniotic fluid).

  2. Are there any other maternal risk factors for sepsis in the infant? Other risk factors include African race, maternal malnutrition, recently acquired sexually transmitted disease/sexually transmitted infection (STD/STI), maternal age <20 years, low socioeconomic status, and asymptomatic maternal bacteriuria. Maternal history of a previous infant with GBS infection also increases the risk of sepsis.

  3. Are there other intrapartum risk factors for sepsis in the infant? These include maternal infection, any untreated or incompletely treated infection of the mother, and maternal fever without identifiable cause. The use of fetal scalp electrodes in the intrapartum period increases the risk of infection in the infant. Meconium-stained amniotic fluid and traumatic delivery are also risk factors.

  4. Are there any other neonatal risk factors involved? Other risk factors include male sex, low Apgar scores, severe depression at birth with intubation and resuscitation, perinatal asphyxia, twin birth, and presence of the metabolic disorder galactosemia (increased risk of gram-negative sepsis).

  5. How long before delivery did the membranes rupture? ROM that occurs >18 hours before birth is associated with an increased incidence of infection in the neonate.

  6. Was the infant monitored during labor? Fetal tachycardia ...

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