Treatment risk may outweigh benefit for asymptomatic chorioamnionitis-exposed infants

1. The majority of infected infants born to mothers with chorioamnionitis were found to exhibit signs or symptoms of sepsis within 6 hours of birth.

2. It was estimated that for each asymptomatic infant with culture-confirmed early-onset infection, between 60 and 1400 asymptomatic infants unnecessarily received diagnostic evaluation and antibiotic therapy.

Evidence Rating Level: 2 (Good)

Study Rundown: Maternal chorioamnionitis complicates between 0.5% and 10% of deliveries and, regardless of initial signs or symptoms of sepsis,,may lead to infant group B streptococcal infection. The Centers for Disease Control and Prevention (CDC) currently recommends that chorioamnionitis-exposed babies receive a complete blood count (CBC) with differential platelets and blood culture and empirical antibiotic treatment; however, this recommendation is from the 2010 Guidelines for Prevention of Perinatal Group B Streptococcal Disease, implemented before maternal intrapartum antibiotic prophylaxis (IAP) was common practice. Thus, especially with regard to exposed, asymptomatic infants, it was unclear whether treatment was necessary. This study reviewed data from infants exposed to chorioamnionitis with culture-confirmed early-onset infections to investigate the onset of clinical signs and symptoms of sepsis. Of the 229 infected infants whose medical records were analyzed, 13% were asymptomatic within 6 hours of birth and 9% remained asymptomatic at 72 hours. Based on this finding and current CDC guidelines, as many as 60 to 1400 asymptomatic, exposed (but healthy) infants were estimated to have received unnecessary diagnostic evaluation and treatment. The lack of precision in this estimate is the result of limited knowledge regarding the prevalence of chorioamnionitis. Until this is better understood, it will remain difficult for clinicians to assess whether all initially asymptomatic chorioamnionitis-exposed infants should receive treatment.

Click to read the study, published today in Pediatrics

Relevant Reading: Early onset neonatal sepsis: the burden of group b streptococcal and e. coli disease continues

In-Depth [retrospective cohort]: The medical records of 229 culture-confirmed early-onset infected infants whose mothers were diagnosed with chorioamnionitis were analyzed. Of the 229 infants, 159 (69%) had mothers who received IAP. Despite 29 (13%) newborns showing no clinical signs or symptoms of sepsis within 6 hours of birth, 18 of the 29 (62%) were found to be infected with Group B Streptococcus. Elevated maternal temperature (≥100.4°F/38°C) after starting labor (P = 0.01) or in the 72 hours leading up to delivery (P < 0.001) was associated with asymptomatic presentation at birth. A significant difference in the proportion of initially asymptomatic and symptomatic infants whose mothers received IAP was observed for term infants (18/23, 78% vs 30/58, 52%; P = 0.04), although no difference was seen when preterm (22-26 weeks, n = 148) and term (≥37 weeks, n = 81) newborns were considered in aggregate. Another difference between infected term and preterm infants was the type of microbe detected: of the 222 single-pathogen infections, Escherichia coli was the most prevalent bacterium isolated from preterm neonates (75/144; 52%), whereas Group B Streptococcus was most common in term infants (47/78; 60%).

Image: PD

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