Primary prevention
Group B streptococci (GBS) are a leading cause of neonatal sepsis, and are acquired before birth from bacteria colonizing the maternal vagina. Studies have shown that active screening for colonization, together with intrapartum antibiotics given to carriers and at-risk groups, has reduced the incidence of early-onset GBS infection and is the recommended means of prevention in the US.[6][55][56] However, the effectiveness of screening has been disputed in a systematic review. The review concluded that although intrapartum antibiotics in GBS-colonized mothers appear to reduce early-onset GBS disease, this may be the result of bias in study design and execution. In addition, the review noted that intrapartum antibiotic prophylaxis did not significantly reduce the incidence of all-cause mortality, mortality from GBS infection, or from infections caused by bacteria other than GBS.[57] The American College of Obstetricians and Gynecologists recommends a screening strategy for prevention of early-onset GBS infection.[6] Local guidelines should also be referred to.
In clinical practice, patients with indications for intrapartum antibiotic prophylaxis should receive either penicillin G or ampicillin until delivery. The recommended antibiotics for patients with penicillin allergy depend on the risk of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin or a cephalosporin. Patients with penicillin allergies and a low risk for anaphylaxis (based on clinical history) should receive cefazolin until delivery. Prophylaxis for those at high risk of anaphylaxis depends on antimicrobial susceptibility tests. If the isolate shows no inducible resistance and is sensitive to it, clindamycin should be administered until delivery, while if resistance or inducible resistance is present or sensitivities are unknown, vancomycin should be administered until delivery. For the purposes of determining neonatal management, maternal antibiotic prophylaxis is only deemed adequate if penicillin, ampicillin, or cefazolin has been continued for at least 4 hours prior to delivery. Maternal prophylaxis with clindamycin or vancomycin is not considered adequate with respect to the neonate, regardless of the duration of administration.[6]
Rectal and vaginal swabs should be obtained immediately for GBS culture, and GBS prophylaxis commenced, if signs or symptoms of premature labor (gestation <37 weeks, 0 days) develop. If true labor is entered, prophylaxis should be continued until delivery, unless negative culture results from samples taken within the previous 5 weeks are available. If delivery does not occur at this time, these culture results can be used to inform GBS status at the onset of true labor. Cultures must be repeated at 36 to 37 weeks' gestation if delivery has not yet taken place.[6]
In the event of premature rupture of membranes (PROM), GBS cultures should be obtained and prophylaxis commenced. If labor is not entered, prophylactic antibiotics should be continued for 48 hours and further antibiotics given at the onset of true labor if culture results are positive.[6]
In nonpregnant adults, infection can be prevented by attention to predisposing factors (e.g., skin care, care of urinary or central venous catheters, handwashing) and appropriate management and modulation of risk factors (e.g., diabetes, immunosuppression).[13][58]
There are currently no primary prevention measures for late-onset neonatal infection, or infection in infants, children, or pregnant women. In 2015, however, the World Health Organization identified the development of GBS vaccines as a global priority, and has since published a report describing the public health rationale for a maternal immunization programme. Maternal vaccine candidates remain in phase 2 clinical trials.[59]
Although vaginal chlorhexidine results in a statistically significant reduction in colonization of neonates, studies did not show a reduction in other outcomes. There is therefore no evidence to support use of vaginal chlorhexidine as a means of preventing early-onset GBS disease.[60][61][62]
[ 
]
Indications for intrapartum antibiotics:[6][55][63]
Previous infant with GBS disease
GBS colonization, bacteriuria, or infection during current pregnancy
GBS colonization, bacteriuria, or infection in a previous pregnancy (not necessary if screening culture or polymerase chain reaction test performed between 36 and 37 weeks' gestation or 3 to 5 weeks before the anticipated delivery date if current pregnancy is negative)
Delivery at <37 weeks' gestation (not necessary if screening culture result taken within previous 5 weeks is known to be negative)
Unknown GBS status and intrapartum temperature ≥100.4°F (38°C) OR premature rupture of membranes ≥18 hours
Antibiotics clinically indicated (e.g., urinary tract infection or chorioamnionitis).
Intrapartum antibiotics are not recommended for women having a preterm planned cesarean section with intact membranes.[6][55]
The following table summarizes recommendations for the prevention of Group B streptococcal early-onset disease in newborns, from the American College of Obstetricians and Gynecologists (ACOG).[6]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Pregnant; previous neonate with invasive GBS disease
All
Intervention
Include intrapartum GBS prophylaxis in the obstetric management plan
This is an overriding indication for antibiotic prophylaxis against GBS during labor, regardless of screening results or other risk factors. Make a note in the medical record and inform the patient that antibiotic prophylaxis is recommended during labor.
Refer to appropriate local guidance regarding antibiotic choice.
Intravenous penicillin G is typically the recommended treatment of choice for intrapartum prophylaxis, with intravenous ampicillin as an acceptable alternative.
For women reporting a penicillin allergy, the recommended antibiotic depends on the risk of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin or a cephalosporin.
For patients with penicillin allergies and a low risk for anaphylaxis (based on clinical history) cefazolin is recommended until delivery.
Prophylaxis for those at high risk of anaphylaxis depends on antimicrobial susceptibility tests:
If the isolate shows no inducible resistance and is sensitive to it, clindamycin is recommended until delivery.
If resistance or inducible resistance is present or sensitivities are unknown, vancomycin is recommended until delivery.
Prompt initiation of intrapartum antibiotic prophylaxis is recommended in order to maximize the ability to achieve the optimal antibiotic treatment window of at least 4 hours before birth.
However, avoid delaying obstetric interventions, when necessary, solely to provide 4 hours of antibiotic administration before birth.
Some variation in practice may be warranted based on the needs of individual patients to enhance intrapartum antibiotic exposure.
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn
Pregnant; with GBS bacteriuria detected at any trimester of current pregnancy
All
Intervention
Include intrapartum GBS prophylaxis in the obstetric management plan
GBS bacteriuria at any concentration identified at any time in pregnancy represents heavy maternal vaginal–rectal colonization. This is an overriding indication for antibiotic prophylaxis against GBS during labor, regardless of screening results or other risk factors. Make a note in the medical record and inform the patient that antibiotic prophylaxis is recommended during labor.
Additionally, GBS bacteriuria during pregnancy at levels of ≥105 CFU/mL regardless of symptoms, or at a level <105 CFU/mL but in the presence of symptoms suggestive of a urinary tract infection (UTI), warrants acute treatment for a UTI as well as subsequent intrapartum antibiotic prophylaxis against GBS during labor.
See Urinary tract infections in women.
Refer to appropriate local guidance regarding antibiotic choice for intrapartum GBS prophylaxis.
Intravenous penicillin G is typically the recommended treatment of choice for intrapartum prophylaxis, with intravenous ampicillin as an acceptable alternative.
For women reporting a penicillin allergy, the recommended antibiotic depends on the risk of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin or a cephalosporin.
For patients with penicillin allergies and a low risk for anaphylaxis (based on clinical history) cefazolin is recommended until delivery.
Prophylaxis for those at high risk of anaphylaxis depends on antimicrobial susceptibility tests:
If the isolate shows no inducible resistance and is sensitive to it, clindamycin is recommended until delivery.
If resistance or inducible resistance is present or sensitivities are unknown, vancomycin is recommended until delivery.
Prompt initiation of intrapartum antibiotic prophylaxis is recommended in order to maximize the ability to achieve the optimal antibiotic treatment window of at least 4 hours before birth.
However, avoid delaying obstetric interventions, when necessary, solely to provide 4 hours of antibiotic administration before birth.
Some variation in practice may be warranted based on the needs of individual patients to enhance intrapartum antibiotic exposure.
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn
Pregnant; with positive GBS culture obtained at 36 weeks of gestation or more during current pregnancy
It is recommended that, regardless of planned mode of birth, all pregnant women undergo antepartum screening for GBS at 36 weeks, 0 days to 37 weeks, 6 days of gestation, unless intrapartum antibiotic prophylaxis for GBS is indicated because of GBS bacteriuria during the pregnancy or because of a history of a previous GBS-infected newborn.
Cesarean birth not planned
Intervention
Include intrapartum GBS prophylaxis in the obstetric management plan
Intrapartum antibiotic prophylaxis against GBS is recommended for all women whose vaginal–rectal culture at 36 weeks, 0 days to 37 weeks, 6 days of gestation is positive for GBS, unless a prelabor cesarean birth is performed in the setting of intact membranes.
Refer to appropriate local guidance regarding antibiotic choice for intrapartum GBS prophylaxis.
Intravenous penicillin G is typically the recommended treatment of choice for intrapartum prophylaxis, with intravenous ampicillin as an acceptable alternative.
For women reporting a penicillin allergy, the recommended antibiotic depends on the risk of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin or a cephalosporin.
For patients with penicillin allergies and a low risk for anaphylaxis (based on clinical history) cefazolin is recommended until delivery.
Prophylaxis for those at high risk of anaphylaxis depends on antimicrobial susceptibility tests:
If the isolate shows no inducible resistance and is sensitive to it, clindamycin is recommended until delivery.
If resistance or inducible resistance is present or sensitivities are unknown, vancomycin is recommended until delivery.
Prompt initiation of intrapartum antibiotic prophylaxis is recommended in order to maximize the ability to achieve the optimal antibiotic treatment window of at least 4 hours before birth.
However, avoid delaying obstetric interventions, when necessary, solely to provide 4 hours of antibiotic administration before birth.
Some variation in practice may be warranted based on the needs of individual patients to enhance intrapartum antibiotic exposure.
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn
Cesarean birth planned
Intervention
Individualized management
When a cesarean birth is planned, intrapartum antibiotic prophylaxis against GBS is recommended only for those with a positive GBS culture result in whom onset of labor or rupture of membranes occurs before the planned cesarean birth.
Refer to appropriate local guidance regarding antibiotic choice for intrapartum GBS prophylaxis as well as for guidance on antibiotic prophylaxis against postoperative infection in general.
A single dose of an antibiotic (or combination of antibiotics) that provides GBS prophylaxis and presurgical prophylaxis is typically recommended. In most clinical situations, cefazolin will meet both of these criteria.
Delaying the cesarean birth to administer additional doses of antibiotics for GBS prophylaxis alone is not indicated.
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn.
With suspected or confirmed early labor; unknown GBS status at labor onset (culture not done or results not known)
With suspected preterm labor (onset at less than 37 weeks, 0 days of gestation)
Intervention
Intrapartum GBS prophylaxis followed by individualized management guided by subsequent culture results
In this scenario, it is recommended that intrapartum antibiotic prophylaxis for GBS is started immediately while initial management of possible preterm labor is being undertaken. If preterm labor progresses, continue intrapartum antibiotic prophylaxis for GBS throughout the duration of labor.
If it is determined that preterm birth is not imminent, intrapartum antibiotic prophylaxis for GBS can be stopped, and subsequent management can then be guided by the most recent culture result:
If the subsequent preterm GBS culture is positive, the culture does not need to be repeated, and intrapartum antibiotic prophylaxis for GBS is indicated whenever labor occurs.
If the GBS culture result is unavailable and preterm labor reoccurs, reinstitution of intrapartum antibiotic prophylaxis is recommended.
If the GBS culture is negative and preterm labor reoccurs within 5 weeks, intrapartum antibiotic prophylaxis against GBS is not necessary.
If the patient remains pregnant ≥5 weeks after a negative baseline GBS test, repeat GBS screening is recommended.
Refer to appropriate local guidance regarding antibiotic choice for intrapartum GBS prophylaxis.
Intravenous penicillin G is typically the recommended treatment of choice for intrapartum prophylaxis, with intravenous ampicillin as an acceptable alternative.
In women who report an allergy to penicillin, the choice of the initial intravenous antibiotic given for GBS prophylaxis will be guided by two factors:
the woman’s history of the penicillin allergy to determine if she is at a low risk or high risk of anaphylaxis, and
antibiotic susceptibility results of the GBS culture, if available.
If a woman with preterm labor has or is suspected of having intra-amniotic infection, administration of broad-spectrum intrapartum antibiotics, including an agent that provides antimicrobial coverage against GBS, is indicated.
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn
With premature prelabor rupture of membranes (PPROM)
Intervention
Latency antibiotic regimen (including coverage for GBS prophylaxis) followed by individualized management
Current guidelines recommend induction of labor if PPROM occurs at or beyond 34 weeks of gestation, although a period of expectant management may be considered for women who request additional time for the onset of spontaneous labor.
A vaginal–rectal swab for GBS culture is recommended for all women with PPROM in order to guide ongoing treatment decisions.
For those entering labor, a latency antibiotic regimen incorporating agents active against GBS is recommended, to be continued until birth takes place.
For those in whom expectant management is being considered, a latency antibiotic regimen incorporating agents active against GBS is recommended, to be continued for 48 hours. Those with a positive result for GBS, and those for whom the result is not available at onset of labor, require intrapartum GBS antibiotic prophylaxis.
Those with a negative result do not require GBS antibiotic prophylaxis during labor, but if the patient remains pregnant ≥5 weeks after a negative baseline GBS test, repeat GBS screening is recommended.
Discuss with women with PPROM who also are colonized with GBS the potential additional neonatal risks associated with prolonged expectant management, and review with her the reasons for discouraging such management.
Refer to appropriate local guidance regarding the latency antibiotic regimen. The optimal latency regimen is unclear; regimens that include ampicillin given in the setting of preterm prelabor rupture of membranes are adequate for GBS prophylaxis.
If a woman with PPROM has or is suspected of having intra-amniotic infection, administration of broad-spectrum intrapartum antibiotics, including an agent that provides antimicrobial coverage against GBS, is indicated.
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn
Term labor; with unknown GBS status at labor onset (culture not done or results not known)
With GBS colonization in a previous pregnancy
Intervention
Offer intrapartum GBS prophylaxis; consider using shared decision making
If a woman presents in labor at term with unknown GBS colonization status and does not have risk factors that are an indication for intrapartum antibiotic prophylaxis but reports a known history of GBS colonization in a previous pregnancy, the risk of GBS early-onset disease in the neonate is likely to be increased.
Given this increased risk, it is reasonable to offer intrapartum antibiotic prophylaxis based on the woman’s history of colonization. Healthcare providers also may consider discussing the option of intrapartum antibiotic prophylaxis against GBS as a shared decision-making process in this clinical scenario.
Refer to appropriate local guidance regarding antibiotic choice for intrapartum GBS prophylaxis.
Intravenous penicillin G is typically the recommended treatment of choice for intrapartum prophylaxis, with intravenous ampicillin as an acceptable alternative.
For women reporting a penicillin allergy, the recommended antibiotic depends on the risk of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin or a cephalosporin.
For patients with penicillin allergies and a low risk for anaphylaxis (based on clinical history) cefazolin is recommended until delivery.
Prophylaxis for those at high risk of anaphylaxis depends on antimicrobial susceptibility tests:
If the isolate shows no inducible resistance and is sensitive to it, clindamycin is recommended until delivery.
If resistance or inducible resistance is present or sensitivities are unknown, vancomycin is recommended until delivery.
Prompt initiation of intrapartum antibiotic prophylaxis is recommended in order to maximize the ability to achieve the optimal antibiotic treatment window of at least 4 hours before birth.
However, avoid delaying obstetric interventions, when necessary, solely to provide 4 hours of antibiotic administration before birth.
Some variation in practice may be warranted based on the needs of individual patients to enhance intrapartum antibiotic exposure.
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn
With premature rupture of membranes (PROM) for 18 hours or more
Intervention
Intrapartum GBS prophylaxis
When a woman is in labor at term and her GBS colonization status is unknown, rupture of membranes for ≥18 hours is independently associated with an increased risk of neonatal GBS early-onset disease.
Refer to appropriate local guidance regarding antibiotic choice for intrapartum GBS prophylaxis.
Intravenous penicillin G is typically the recommended treatment of choice for intrapartum prophylaxis, with intravenous ampicillin as an acceptable alternative.
For women reporting a penicillin allergy, the recommended antibiotic depends on the risk of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin or a cephalosporin.
For patients with penicillin allergies and a low risk for anaphylaxis (based on clinical history) cefazolin is recommended until delivery.
Prophylaxis for those at high risk of anaphylaxis depends on antimicrobial susceptibility tests:
If the isolate shows no inducible resistance and is sensitive to it, clindamycin is recommended until delivery.
If resistance or inducible resistance is present or sensitivities are unknown, vancomycin is recommended until delivery.
Prompt initiation of intrapartum antibiotic prophylaxis is recommended in order to maximize the ability to achieve the optimal antibiotic treatment window of at least 4 hours before birth.
However, avoid delaying obstetric interventions, when necessary, solely to provide 4 hours of antibiotic administration before birth.
Some variation in practice may be warranted based on the needs of individual patients to enhance intrapartum antibiotic exposure.
Although reduction of neonatal GBS early-onset disease can be achieved with intrapartum antibiotic prophylaxis, if suspected or confirmed intra-amniotic infection develops, it is recommended that intrapartum antibiotic prophylaxis targeted against GBS is converted to a more broad-spectrum antibiotic regimen for treatment of intra-amniotic infection that includes activity against GBS (generally ampicillin plus an aminoglycoside).
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn
With intrapartum temperature ≥100.4°F (≥38°C)
Intervention
Intrapartum GBS prophylaxis
When a woman is in labor and her GBS colonization status is unknown, a temperature of ≥100.4°F (≥38°C) is independently associated with an increased risk of neonatal GBS early-onset disease.
Refer to appropriate local guidance regarding antibiotic choice for intrapartum GBS prophylaxis.
Intravenous penicillin G is typically the recommended treatment of choice for intrapartum prophylaxis, with intravenous ampicillin as an acceptable alternative.
For women reporting a penicillin allergy, the recommended antibiotic depends on the risk of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin or a cephalosporin.
For patients with penicillin allergies and a low risk for anaphylaxis (based on clinical history) cefazolin is recommended until delivery.
Prophylaxis for those at high risk of anaphylaxis depends on antimicrobial susceptibility tests:
If the isolate shows no inducible resistance and is sensitive to it, clindamycin is recommended until delivery.
If resistance or inducible resistance is present or sensitivities are unknown, vancomycin is recommended until delivery.
Prompt initiation of intrapartum antibiotic prophylaxis is recommended in order to maximize the ability to achieve the optimal antibiotic treatment window of at least 4 hours before birth.
However, avoid delaying obstetric interventions, when necessary, solely to provide 4 hours of antibiotic administration before birth.
Some variation in practice may be warranted based on the needs of individual patients to enhance intrapartum antibiotic exposure.
Although reduction of neonatal GBS early-onset disease can be achieved with intrapartum antibiotic prophylaxis, if suspected or confirmed intra-amniotic infection develops, it is recommended that intrapartum antibiotic prophylaxis targeted against GBS is converted to a more broad-spectrum antibiotic regimen for treatment of intra-amniotic infection that includes activity against GBS (generally ampicillin plus an aminoglycoside).
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn
With positive intrapartum nucleic acid amplification test (NAAT) result
Intervention
Intrapartum GBS prophylaxis
At some centers, intrapartum GBS testing of a vaginal–rectal specimen using NAAT is used to inform treatment decisions for women presenting in labor at term with an unknown GBS culture status.
Intrapartum antibiotic prophylaxis is indicated for women with a positive intrapartum NAAT result for GBS.
Women with a negative NAAT result who do not develop clinical risk factors during labor (e.g., temperature of ≥100.4°F [≥38°C], or rupture of membranes for ≥18 hours) do not need intrapartum antibiotic prophylaxis.
However, if maternal risk factors develop, GBS prophylaxis is recommended.
This recommendation to administer antibiotics based on intrapartum risk factors supersedes a negative NAAT result, because intrapartum NAAT results are not 100% sensitive for the detection of GBS.
Refer to appropriate local guidance regarding antibiotic choice for intrapartum GBS prophylaxis.
Intravenous penicillin G is typically the recommended treatment of choice for intrapartum prophylaxis, with intravenous ampicillin as an acceptable alternative.
For women reporting a penicillin allergy, the recommended antibiotic depends on the risk of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin or a cephalosporin.
For patients with penicillin allergies and a low risk for anaphylaxis (based on clinical history) cefazolin is recommended until delivery.
Prophylaxis for those at high risk of anaphylaxis depends on antimicrobial susceptibility tests:
If the isolate shows no inducible resistance and is sensitive to it, clindamycin is recommended until delivery.
If resistance or inducible resistance is present or sensitivities are unknown, vancomycin is recommended until delivery.
Prompt initiation of intrapartum antibiotic prophylaxis is recommended in order to maximize the ability to achieve the optimal antibiotic treatment window of at least 4 hours before birth.
However, avoid delaying obstetric interventions, when necessary, solely to provide 4 hours of antibiotic administration before birth.
Some variation in practice may be warranted based on the needs of individual patients to enhance intrapartum antibiotic exposure.
Although reduction of neonatal GBS early-onset disease can be achieved with intrapartum antibiotic prophylaxis, if suspected or confirmed intra-amniotic infection develops, it is recommended that intrapartum antibiotic prophylaxis targeted against GBS is converted to a more broad-spectrum antibiotic regimen for treatment of intra-amniotic infection that includes activity against GBS (generally ampicillin plus an aminoglycoside).
Goal
Reduced incidence of neonatal GBS colonization and sepsis
This requires both:
Adequate maternal antibiotic levels
Adequate antibiotic levels in the fetus and newborn
Secondary prevention
Women who have babies with GBS infection should be advised to have antibiotic prophylaxis during future pregnancies.
In order to diagnose early-onset GBS infection, neonates should be managed according to ACOG guidelines.[6] Any neonate with signs of sepsis should receive empirical antibiotics pending investigation results (blood culture, complete blood count (CBC) with white cell differential and platelet count, chest x-ray if focal respiratory signs are present, and lumbar puncture if the baby is stable enough). The antibiotic regimen should cover GBS and any other potential infecting organisms.
Neonates born to mothers with chorioamnionitis, but who appear well, should undergo limited clinical evaluation (blood culture, and CBC with white cell differential and platelet count) and receive prophylactic antibiotics pending culture results. Confirmation of the diagnosis of chorioamnionitis is required to inform appropriate further management of the neonate. Those without signs of sepsis born to mothers requiring GBS prophylaxis should be observed for at least 48 hours. If the mother has received adequate GBS prophylaxis (penicillin, ampicillin, or cefazolin continued for at least 4 hours prior to delivery), the neonate can be discharged after 24 hours if medical attention is easily accessible and information for home observation is given. If adequate GBS prophylaxis has not been received by the mother and the neonate was born before 37 weeks' gestation or PROM lasting >18 hours occurred, the neonate should undergo limited clinical evaluation and be observed for at least 36-48 hours.[64]
Use of this content is subject to our disclaimer