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December 5 2021

Late Group B Strep Disease

PME-Admin article, medical children, group b strep, infections, pediatrics, strep

Late Group Strep B Disease — Santa J. Bartholomew M.D.

Group B Strep (GBS) is a huge burden of disease in developed countries. It is divided into three categories: early GBS, Late GBS (7-89 days post birth) and very late GBS (> 90 days post birth). Early onset rates have fallen in the last 20 years due in great part to screening and treatment of mothers prior to delivery and as written about in another blog early onset GBS is caused by passage through the birth canal. This is an organism that lives in the vagina without causing disease in the mother.

Late onset GBS rate have remained steady for the last 25 years: 0.4/1000 live births despite changes in care of mother making it clear that acquisition of disease is not via delivery through the birth canal but acquired after birth of infant. Late onset GBS disease is as severe as that suffered by younger infants causing 27% of all meningitis in this age group as well as severe sepsis without meningitis. The mortality rate of meningitis in late onset GBS ca be as high as 10% with 35% of survivors having severe neurologic sequelae. In addition to sepsis and meningitis, however, GBS has been the cause of bone infections in infants (osteomyelitis) as well as joint infections, cellulitis, urine infections, brain infarction (stroke), and subdural collections in infants.

Late onset GBS is acquired by the infant from the mother or other colonized household members through routine care and touching but this is not typically a disease acquired passing through the birth canal. The infant can also become colonized going through the birth canal by swallowing vaginal secretions that result in bacterial adherence in the respiratory and GI tract mucous membranes that can later cause bacterial invasion causing pneumonias and sepsis much later in infancy. As many as 50% of infants of mothers colonized with GBS can become colonized with the same organism as the mother.

Late onset GBS is acquired by the infant from the mother or other colonized household members through routine care and touching.

Although it is not acquired through the birth canal it is most seen in in pre-term infants born <28 weeks of gestation. Other risk facts for late onset group B strep include young maternal age, HIV exposure, ethnicity (being more common in black children). There is also emerging data that breast milk may also expose infant to GBS in colonized mothers however it is believed that the benefits of breast feeding overall outweigh the risk of acquiring late GBS infection.

CLINICAL PRESENTATION

Temperature: fever, low or unstable temperature
Eating habits: feeds poorly, refuses to eat, not waking to feed, vomiting
Sleeping habits: sleeping too much, difficulty being aroused
Breathing: fast, slow, or difficult breathing
Sounds: high pitch cry, shrill moaning, whimpering, inconsolable, constant grunting
Behavior: marked irritability, reacting as if skin is tender, listless, floppy, not moving an arm or leg, blank stare, body stiffening, uncontrollable jerking
Skin Appearance: blue, gray or pale skin, blotchy or red skin, tense or bulging fontanelle, infection at the base of umbilical cord or head punctures from internal fetal monitor. Sometimes jaundice.

HOW TO DIAGNOSE

It is imperative that late onset GBS be considered in any infant that presents with signs of infection in the first three moths of life. High index of suspicion and empiric treatment are invaluable in prognosis.

Blood culture
Urine culture
CBC with differential
Lumbar puncture
Chest x-ray
If there is concern about joint swelling than radiographs of joints or MRI may be indicated.
If there is a twin, that infant should be evaluated.

TREATMENT

ANTIBIOTICS

Recognition and management of shock
Careful management of body salts
Management of breathing if child has oxygenation issues or is not awake and alert including placement of breathing tube and ventilator management.
Treatment of seizures
Treatment of anemia

All of these secondary treatments are aimed at preventing secondary brain injury while the antibiotics kill the organism.

DURATION OF THERAPY DIFFERS

Bacteremia without a focus – 10 days
Meningitis – 14 days is sufficient for uncomplicated meningitis; complicated central nervous system (CNS) infections require longer treatment
Cellulitis-adenitis – 10 to 14 days
Septic arthritis – 14 to 21 days
Osteomyelitis – 21 to 28 days
Urinary tract infection – 10 days

PROGNOSIS

Fatality is 1-3% for late onset disease, considerably higher in preterm infants up to 8%.

Meningitis in particular has substantial morbidity including:

Seizures
Permanent neurologic disability
Cerebral palsy
Greatly impaired cognitive development.

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November 15 2021

Early Group B Strep Infections in Children

PME-Admin article, medical children, group b strep, infections, pediatrics, strep

Early Strep B Infections in Children — Santa J. Bartholomew M.D.

Group B Strep (GBS) is an organism that lives in the bowels and genitals of adults. In women group B strep lives in the vagina and does not cause illness in these women but as the infant comes through the birth canal, they can become infected causing great harm to the infant. Because of the catastrophic consequences to the infant, pregnant women are routinely checked for GBS and treated before the infant is born. Group B strep infections in infants come in two categories: early onset and late onset. It is only early onset that is transmitted via birth. There are many serotypes of this bacteria but only 6 cause significant disease.

Neonatal or early onset GBS is acquired in utero via “silent” intraamniotic infection or via early rupture of membranes as well as passage through the vagina. When mothers are tested the higher quantities of bacteria in the vagina the greater risk of transmission to the infant. GBS infections are 0.5 per 1000 births with higher rates in black infants.

Despite many prevention policies enacted early onset GBS has not been eradicated in the USA. Late onset GBS disease has seen no decrease since the 1990’s and this is NOT prevented by treating the mother before birth.

Because of the catastrophic consequences to the infant, pregnant women are routinely checked for GBS and treated before the infant is born.

Incidence of early- and late-onset neonatal invasive group B streptococcal disease: Active Bacterial Core surveillance areas (1990 to 2018).

Early and Late Onset Neonatal Group B Strep

RISK FACTORS FOR BABIES GETTING GBS

Colonized mother: transmission to the baby is 1 in 2 (50%)
Prior delivery of a baby with GBS disease
Delivery of a baby < 37 weeks gestation
Rupture of membranes more than 18 hours
Preterm labor with rupture of membranes
Chorioamnionitis
Fever in mom during labor

These risk factors have been incorporated into a prevention guideline to minimize risk to the newborn. This can be found at CDC website: ”Prevention of perinatal group B streptococcal disease.” These are imperative to follow as they dramatically decrease the risk of infection in the neonate.

Diagnosis of early-onset GBS disease in infants presents in fist week of life. It is crucial to review pregnancy and labor and delivery history as this can avoid catastrophic disease in the newborn.

GBS can manifest as Generalized Sepsis: temperature instability, poor perfusion, lethargy, respiratory symptoms like grunting and fast breathing, shock.
These babies can also have Persistent Pulmonary Hypertension in which blood does not flow easily to the lungs and can be quickly fatal disease.
Pneumonia accounts for 10% of GBS disease in newborns and usually include CXR findings of alveolar disease, as well as low oxygen levels and signs of distress like fast breathing, gruntiong noises, periods of apnea.
Meningitis Occurs in 5-10% of infants and presents as irritability, lethargy, poor feeding, vomiting, may or may not have respiratory symptoms.

When a baby is identified at high risk, there are two acceptable approaches to care listed below.

Approach to evaluating neonates born ≥35 weeks gestation who are at risk for group B strep infection:

“Enhanced observation” approach to evaluating neonates born ≥35 weeks gestation who are at risk for group B streptococcal infection:

TREATMENT

In any infant who shows symptoms, an evaluation should be initiated immediately and should include:

Blood cultures
CBC with differential
Lumbar puncture if there is clinical suspicion for sepsis
CXR
Urine culture

Treatment should be started with intravenous Ampicillin and Gentamicin.

PROGNOSIS

Approximately 3% die of infants infected with GBS. Among the infants that survive the risk of dying remains elevated in the first decade of life as much as 3 times higher than uninfected infants. There is even higher mortality in infants that are preterm, weigh less than 2500 grams, present in shock, have apnea, seizures or low white count or platelets at presentation.

Even in the survivors they are at serious risk for cerebral palsy, seizures, neurologic disabilities, and blindness. Infants who have meningitis have the highest risk of disability, as high as 22-25%.

The key to good outcome is prenatal testing of mothers and treatment of mothers before birth. If this is not possible then high index of suspicion and observation +/- treatment in the neonate is paramount for good neonatal outcome.