Chapter 66

1. Problem. Two infants are born within the last hour. One infant's mother had premature rupture of membranes (ROM) 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? The incidence of sepsis is 1 in 10 in 1000 live births and 1 in 250 live premature births. This section focuses on postdelivery antibiotics for early-onset sepsis because late infections of premature infants with prolonged hospital stays may require a different workup and antibiotic choice.

2. Immediate questions

1. Are there any maternal risk factors for sepsis in the infant? Risk factors include African race, malnutrition in the mother, maternal colonization with GBS organism, recently acquired sexually transmitted diseases, and maternal age <20 years. Low socioeconomic status and asymptomatic bacteriuria in the mother are associated with increased prematurity and sepsis. Maternal history of a previous infant with GBS infection also increases the risk of sepsis for the unborn infant.

1. Are there intrapartum risk factors for sepsis in the infant? These include ROM >18 h, chorioamnionitis (defined as sustained fetal tachycardia, uterine tenderness, purulent amniotic fluid, unexplained maternal temperature ≥38.0°C (>100.4°F), 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. Perinatal asphyxia (defined as a 5-min Apgar score <6) with prolonged ROM also increases the risk of infection in the neonate.

1. Are there any neonatal risk factors involved? Neonatal risk factors include male sex, twin birth, prematurity (<37 weeks), low birthweight (<2500 g), and presence of the metabolic disorder galactosemia that increases risk of Gram-negative sepsis.

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

1. Was the infant monitored during labor? Fetal tachycardia (>160 beats/min), especially sustained, and decelerations (usually late) can be associated with neonatal infection. Prolonged duration of intrauterine monitoring is a risk factor for early-onset group B streptococcal disease.

1. Did the mother have a cerclage for cervical incompetence? Cerclage increases the risk of infection in the infant.

1. Are signs of sepsis present in the infant? Signs of sepsis include apnea and bradycardia, temperature instability (hypothermia or hyperthermia), feeding intolerance, tachypnea, jaundice, cyanosis, poor peripheral perfusion, hypoglycemia, lethargy, poor sucking reflex, increased gastric aspirates, and irritability. Other signs include tachycardia, shock, vomiting, seizures, abnormal rash, abdominal distention, and hepatomegaly.

1. Did the mother have epidural analgesia? Studies have shown an increase in maternal intrapartum fever with the use of epidural analgesia. Because of this fever, an increase in sepsis evaluations and antibiotic treatment was found. However, the study did not find that epidurals caused infections or even increased the risk of infections.

1. Was the mother tested for GBS, and did she receive antibiotics if she tested positive? There are now specific guidelines to follow after delivery if the mother was treated for GBS.

3. Differential diagnosis

1. Infant at increased risk for sepsis. The factors noted previously can increase the risk of sepsis.

1. Infant at low risk for sepsis. Newborns without risk factors noted previously are at low risk of sepsis.

4. Database

1. Complete maternal, perinatal, and birth history should be obtained and reviewed in an attempt to identify risk factors. ...

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