Clinical Context

Initially, the Centers for Disease Control and Prevention (CDC) guidelines for the prevention of perinatal group B streptococcal (GBS) disease were published in 1996 and revised again in 2002. Since then, the incidence of early-onset GBS disease in neonates has decreased by an estimated 80%. However, in 2010, GBS disease remained the leading cause of early-onset neonatal sepsis.

The CDC issued revised guidelines in 2010. These revised and comprehensive guidelines, which the American Academy of Pediatrics (AAP) has endorsed, reaffirm the major prevention strategy — universal antenatal GBS screening and intrapartum antibiotic prophylaxis (IAP) for culture-positive and high-risk women — and include new recommendations for laboratory methods for identification of GBS colonization during pregnancy, algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes, updated prophylaxis recommendations for women with a penicillin allergy, and a revised algorithm for the care of newborn infants.

The purpose of this policy statement is to review and discuss the differences between the 2002 and 2010 CDC guidelines that are most relevant for the practice of pediatrics.

Study Synopsis and Perspective

The AAP has issued a policy statement, reported online August 1 in Pediatrics, on preventing perinatal GBS disease. The policy statement was intended to review and discuss the differences between the 2002 and 2010 CDC guidelines that are most relevant to pediatric practice.

"In 2002, the CDC published revised guidelines that recommended universal antenatal GBS screening; the AAP endorsed these guidelines and published recommendations based on them in the 2003 Red Book," write Carol J. Baker, MD, and colleagues from the AAP. "The CDC issued revised guidelines in 2010 based on evaluation of data generated after 2002. These revised and comprehensive guidelines, which have been endorsed by the AAP, reaffirm the major prevention strategy—universal antenatal GBS screening and intrapartum antibiotic prophylaxis for culture-positive and high-risk women—and include new recommendations for laboratory methods for identification of GBS colonization during pregnancy, algorithms for screening and intrapartum prophylaxis for women with preterm labor and premature rupture of membranes, updated prophylaxis recommendations for women with a penicillin allergy, and a revised algorithm for the care of newborn infants."

Specific recommendations in the AAP policy statement for the care of newborn infants include the following:

• Full diagnostic evaluation, including lumbar puncture, and empiric antimicrobial treatment are indicated for all newborn infants with signs of sepsis (AII recommendation).
• Limited diagnostic evaluation without lumbar puncture and empiric antimicrobial treatment are indicated for all well-appearing newborn infants of mothers diagnosed with chorioamnionitis by their obstetrician (AII).
• Newborn infants of all women who received adequate IAP require only routine care and observation in the hospital for 48 hours (B III). They may be discharged as early as 24 hours after birth, with follow-up care by a clinician within 48 to 72 hours, if they meet other discharge criteria, including term birth and ready access to medical care (CII). Adequate IAP includes penicillin (preferred), ampicillin, or cefazolin (in penicillin-allergic women at low risk for anaphylaxis) for at least 4 hours before delivery.
• Observation only for 48 hours is required for well-appearing term newborn infants whose mothers received no or inadequate IAP and had rupture of membranes for less than 18 hours (BIII).
• "Limited evaluation" (blood culture and complete blood cell count with differential and platelets at birth) and observation for at least 48 hours are indicated for well-appearing term infants born to women with no or inadequate IAP and rupture of membranes for 18 or more hours before delivery (BIII).
• All preterm infants of mothers with no or inadequate IAP should undergo limited evaluation and observation for at least 48 hours (BIII).

Pediatrics. Published online August 1, 2011.

Related Link

The California Perinatal Quality Care Collaborative provides a downloadable delivery room management toolkit, revised in July 2011, for the Prevention of Perinatal Group B Streptococcus Disease.

Clinical Implications

• Penicillin remains the agent of choice for IAP, and the definition of adequate IAP is administration of at least 4 hours of penicillin, ampicillin, or cefazolin.
• All newborn infants with signs of sepsis should undergo a full diagnostic evaluation. However, limited evaluation is warranted for well-appearing newborn infants born to women with a diagnosis of chorioamnionitis and to women with no or inadequate IAP and rupture of membranes for 18 or more hours before delivery, and all preterm infants born to women with no or inadequate IAP.

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