Approach
Targeted antibiotic therapy is the mainstay of therapy in patients with demonstrated group B streptococcal (GBS) infection. Adjunctive surgery (e.g., drainage of abscess) may be required in some instances.
The treatments detailed in this topic are for confirmed GBS infection only. For empirical treatment of these infections, please refer to our topics on the specific infections. Local guidelines on antibiotic therapy may vary and should be consulted.
Early- or late-onset neonatal infection (age 0-89 days)
In US guidelines, benzylpenicillin or ampicillin are recommended when GBS is definitively identified in neonates.[2][65] Benzylpenicillin is preferred because it has a narrower antimicrobial spectrum.
In the UK, guidelines recommend benzylpenicillin in combination with gentamicin for confirmed GBS meningitis.[64]
A glycopeptide (e.g., vancomycin) is a suitable alternative in patients with severe penicillin allergy; however, in this setting, advice from a paediatric infectious disease specialist should be sought.
Duration of treatment depends on the clinical syndrome. Patients with uncomplicated meningitis should be treated intravenously for 14 days.[2] Those with a more complicated course may require a longer duration of therapy. Duration for patients with urinary tract infection (UTI), bacteraemia without focus, or pneumonia is generally 10 days.[2] If either the dose or duration is inadequate, relapse can occur.
Infants and children
The most common presentations are sepsis with unknown focus, meningitis, pneumonia, septic arthritis, and peritonitis.[7] Therapy depends on the infection focus.
Sepsis with unknown focus
Start treatment immediately if a senior clinical decision-maker makes a diagnosis of suspected sepsis. Follow your local protocol (e.g., Sepsis Six or Surviving Sepsis Campaign 1-hour care bundle) for investigation and treatment of all patients with suspected sepsis, or those at risk, within 1 hour.[89] SCCM and ESICM: Surviving Sepsis Campaign - pediatric patients Opens in new window
First-line treatment: rapid administration of benzylpenicillin or ampicillin, plus gentamicin.
Patients with penicillin allergy: a second- or third-generation cephalosporin (e.g., cefuroxime, cefotaxime, or ceftriaxone) may be appropriate depending on the type of allergy, or a glycopeptide (e.g., vancomycin) with or without gentamicin.[90]
Treatment course: minimum of 10 days. Duration will vary according to clinical presentation, risk of complications, and initial response to therapy.
See Sepsis in children.
Meningitis
First-line treatment: benzylpenicillin or ampicillin, plus gentamicin.
Patients with penicillin allergy: consult infectious disease specialist, as the presentation is rare and management complicated.
Treatment course: 14-21 days.
Pneumonia
First-line treatment: benzylpenicillin or ampicillin.
Patients with penicillin allergy: a second- or third-generation cephalosporin may be appropriate depending on the type of allergy, a macrolide (e.g., clarithromycin), or a glycopeptide (e.g., vancomycin).[90]
Treatment course: minimum of 10 days.
Septic arthritis
First-line treatment: benzylpenicillin or ampicillin.
Patients with penicillin allergy: a second- or third-generation cephalosporin may be appropriate depending on the type of allergy, or a glycopeptide (e.g., vancomycin) with or without gentamicin in selected cases.[90]
Joint must be aspirated and a formal washout in operating room strongly considered.
Treatment course: 3-4 weeks.
See Septic arthritis.
Peritonitis
First-line treatment: cefuroxime plus metronidazole, or ampicillin/sulbactam with or without gentamicin.
Patients with penicillin allergy: a cephalosporin may be appropriate depending on the type of allergy plus metronidazole. Other regimens may be used, but an infectious-disease specialist should be consulted.
Infection is often polymicrobial. If polymicrobial infection is suspected (i.e., as in peritonitis), broad-spectrum antibiotic therapy selected according to the site of infection may be required.
Adults
The most common infections are cellulitis, sepsis, meningitis, and UTI. Less common manifestations include septic arthritis, pneumonia, conjunctivitis, sinusitis, otitis media, and intra-abdominal infection. Therapy depends on the infection focus.
Sepsis
Start treatment immediately if a senior clinical decision-maker makes a diagnosis of suspected sepsis. Follow your local protocol (e.g., Sepsis Six or Surviving Sepsis Campaign 1-hour care bundle) for investigation and treatment of all patients with suspected sepsis, or those at risk, within 1 hour.[89] SCCM and ESICM: Surviving Sepsis Campaign - adult patients Opens in new window
First-line treatment: rapid administration of benzylpenicillin or ampicillin.
Patients with penicillin allergy: a second- or third-generation cephalosporin may be appropriate depending on the type of allergy, or a glycopeptide (e.g., vancomycin).[90]
Gentamicin may be considered as adjunctive therapy in selected cases, but seek advice from an infectious-disease specialist.
Treatment course: minimum of 10 days. Duration will vary according to clinical presentation, risk of complications, and initial response to therapy.
See Sepsis in adults.
Meningitis
First-line treatment: benzylpenicillin or ampicillin.
Patients with penicillin allergy: consult infectious-disease specialist, as the presentation is rare and management complicated.
Treatment course: 14-21 days.
See Bacterial meningitis.
Cellulitis
First-line treatment: benzylpenicillin or ampicillin.
Patients with penicillin allergy: a second- or third-generation cephalosporin may be appropriate depending on the type of allergy, a glycopeptide (e.g., vancomycin), or a macrolide, clindamycin, or a quinolone (e.g., levofloxacin).[90]
Treatment course: 10 days.
See Cellulitis and erysipelas.
UTI
First-line treatment: amoxicillin or ampicillin (uncomplicated infections); benzylpenicillin or ampicillin, with or without gentamicin (complicated infections such as pyelonephritis).
Patients with penicillin allergy: trimethoprim, or nitrofurantoin (uncomplicated infections), or vancomycin with or without gentamicin (complicated infections). A cephalosporin may be appropriate depending on the type of allergy, or a quinolone (e.g., levofloxacin).[90]
Treatment course: 3-7 days (uncomplicated infections); 14 days (complicated infections).
See Urinary tract infections in men and Urinary tract infections in women.
Pneumonia
First-line treatment: benzylpenicillin or ampicillin.
Patients with penicillin allergy: a second- or third-generation cephalosporin may be appropriate depending on the type of allergy, a glycopeptide (e.g., vancomycin), linezolid, a macrolide (e.g., clarithromycin), or a quinolone (e.g., levofloxacin).[90]
Rifampicin or gentamicin may be considered as adjunctive therapy in selected cases, but seek advice from an infectious-disease specialist.
Treatment course: 10 days.
Septic arthritis
First-line treatment: benzylpenicillin or ampicillin.
Patients with penicillin allergy: a second- or third-generation cephalosporin may be appropriate depending on the type of allergy, clindamycin, or a glycopeptide (e.g., vancomycin).[90]
Gentamicin may be added as an adjunctive therapy in selected cases, but seek advice from an infectious-disease specialist.
Joint must be aspirated and a formal washout in operating room strongly considered.
Treatment course: 3-4 weeks.
See Septic arthritis.
Conjunctivitis, sinusitis, otitis media, and intra-abdominal infections are often polymicrobial. Refer to separate topics for detailed recommendations on these infections.
As GBS infection occurs more commonly in older patients, hepatic and renal impairment must be taken into account when selecting the dose of some drugs.
Clinicians should be aware that fluoroquinolones have been associated with disabling and potentially irreversible musculoskeletal or nervous system adverse events.[91][92] In addition, the US Food and Drug Administration has issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[93][94]
Pregnant and postnatal women
Infections caused by GBS in pregnant and postnatal women may include asymptomatic bacteriuria (pregnant women with >10⁵ colony-forming units per mL), UTI, chorioamnionitis, postnatal endometritis, and postnatal wound infection. The choice of antibacterial therapy is influenced by allergy history, antimicrobial susceptibility testing, and the potential effects on the fetus or penetration into the breast milk. If a severe beta-lactam allergy is suspected, allergy testing is recommended.[6] Antenatal treatment is not effective in eliminating carriage or preventing neonatal disease; therefore, pregnant women should also receive intranatal prophylactic therapy.[95]
Chorioamnionitis and endometritis (GBS colonisation)
Infection is often polymicrobial; therefore, initial empirical regimens should be guided by allergy history and in vitro susceptibilities of frequent pathogens, including Enterobacteriaceae and Bacteroides sp.
Supportive therapy
All patients, regardless of age, should receive supportive therapy (except patients with uncomplicated UTIs). The major goal is to restore and maintain normal respiratory, cardiac, and neurological function. GBS infections may progress rapidly, and clinical deterioration may continue despite prompt institution of antibiotic therapy.
Initial assessment should follow the principles of paediatric and adult advanced life support, with evaluation of the patient's airway, breathing, and circulatory status, with secure large-calibre intravenous catheters established for the administration of fluids.
Patients with symptoms of compensated shock or respiratory distress should receive supplemental oxygen. Those with decompensated shock, hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation. See Shock.
Vasopressors should be given to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation.
Fluids should be given cautiously to patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome.
Cardiopulmonary support may be needed in an intensive-care setting.
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