EXTENSION OF REVIEW DATE - Queensland Health

1 Translating evidence into best clinical practice Queensland Health EXTENSION OF REVIEW DATE RELEVANT TO Early onset group B streptococcal disease clinical guideline DATE OF EXTENSION 15 November 2021 NEW REVIEW DATE December 2022 CONTENT AFFECTED Date of REVIEW only. No other amendments RATIONALE Original REVIEW date (November 2021) exceeded Content remains current REVIEW in progressAUTHORISED BY Queensland Clinical Guidelines Steering Committee Queensland Clinical Guidelines Maternity and NeonatalClinical GuidelineQueensland Health Clinical Excellence Queensland Early onset group B Streptococcal disease Queensland Clinical Guideline: Early onset group B Streptococcal disease Refer to online version, destroy printed copies after use Page 2 of 26 Document title: Early onset group B Streptococcal disease Publication date: November 2016 Document number: Document supplement: The document supplement is integral to and should be read in conjunction with this guideline.

2 Amendments: Full version history is supplied in the document supplement. Amendment date: April 2020 Replaces document: Author: Queensland Clinical Guidelines Audience: Health professionals in Queensland public and private maternity and neonatal services REVIEW date: November 2021 Endorsed by: Queensland Clinical Guidelines Steering Committee Statewide Maternity and Neonatal Clinical Network ( Queensland ) Contact: Email: URL: Disclaimer This guideline is intended as a guide and provided for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect. The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances, may be appropriate.

3 This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: Providing care within the context of locally available resources, expertise, and scope of practice Supporting consumer rights and informed decision making, including the right to decline intervention or ongoing management Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary Ensuring informed consent is obtained prior to delivering care Meeting all legislative requirements and professional standards Applying standard precautions, and additional precautions as necessary, when delivering care Documenting all care in accordance with mandatory and local requirements Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.

4 Recommended citation: Queensland Clinical Guidelines. Early onset group B Streptococcal disease. Guideline No. Queensland Health . 2020. Available from: State of Queensland ( Queensland Health ) 2020 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit For further information, contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email phone (07) 3131 6777. For permissions beyond the scope of this licence, contact: Intellectual Property Officer, Queensland Health , GPO Box 48, Brisbane Qld 4001, email phone (07) 3234 1479. Cultural acknowledgement We acknowledge the Traditional Custodians of the land on which we work and pay our respect to the Aboriginal and Torres Strait Islander elders past, present and emerging.

5 Queensland Clinical Guideline: Early onset group B Streptococcal disease Refer to online version, destroy printed copies after use Page 3 of 26 Flow Chart: Maternal management of early onset group B Streptococcal disease (EOGBSD) Queensland Clinical Guidelines: EOGBSD Flowchart version Culture for GBS If imminent risk of birth, give IAPIf no labour and no local protocol give: Erythromycin 250 mg 6 hourly for 10 daysOR Amoxicillin/ampicillin 2 g IV 6 hourly for 48 hours, followed by amoxycillin 250 mg oral 6 hourly for 7 days total (IV + oral), PLUS erythromycin oral 250 mg 6 hourly for 7 daysYesIntrapartum antibiotics Commence after onset of labour (aim for at least 4 hours prior to birth)Loading dose Benzylpenicillin 3 g IV onceMaintenance dose Benzylpenicillin g IV 4 hourly until birth Commence 4 hours after loading dose If penicillin allergy: determine risk of anaphylaxis: o High risk:#lincomycin 600 mg IV 8 hourlyo Low risk: cephazolin 2 g IV followed by cephazolin 1 g IV 8 hourly Consult with expert as requiredPreterm PROM?

6 YesLabour established orMembranes ruptured Labour at < 37+0 weeks?Gestation < 37+0 weeks?NoNoNoYes Antibiotics to prolong latency not recommendedIf GBS status: Positive: Recommend IOL with IV oxytocin Negative: Offer IOL with IV oxytocin or expectant careo Discuss risks/benefits of approaches Unknown: Offer culture for GBSYesTermPROM?Maternal risk factors?YesNoFollow neonatal management If maternal temperature 38 oC within 24 hours of birth, notify paediatric/neonatal staff immediatelyAdministration of IAP to women with risk factors, reduces the risk of neonatal EOGBSDNoMaternal risk factors for EOGBSD GBS colonisation in current pregnancy GBS bacteriuria in current pregnancy Preterm labour (< 37+0 weeks) Previous baby with EOGBSD ROM > 18 hourso If labour established: at 14 hours after ROM and birth is unlikely by 18 hours, then commence IAP Temperature 38 oC If CS with no labour and no ROM, IAP is not required (even if risk factors).

7 Give routine surgical antibioticsIf maternal temperature 38 oC, give broad spectrum antibiotics that includes an agent active against GBSEOGBSD: early onset group B Streptococcal disease, GBS: group B streptococcus , IAP: intrapartum antibiotic prophylaxis, IV: intravenous, IOL: induction of labour, PROM: prelabour rupture of membranes ROM: rupture of membranes, >: greater than, <: less than #clindamycin may be substituted for lincomycin Queensland Clinical Guideline: Early onset group B Streptococcal disease Refer to online version, destroy printed copies after use Page 4 of 26 Flow Chart: Neonatal management of early onset group B Streptococcal disease Queensland Clinical Guidelines: EOGBSD Flowchart Recommended antibiotics Benzylpenicillin OR ampicillin/amoxicillin AND gentamicin Any of the following? Signs of neonatal infection Suspected chorioamnionitis Maternal temperature 38 oC intrapartum or within 24 hours of birth Previous baby with EOGBSDI nvestigate and treat FBC (with differential) Blood cultures Commence antibiotics within 30 minutesLumbar puncture if: Blood cultures positive or Clinical signs of infectionOther investigations As indicatedObserve for 24 48 hours2 1 Adequate intrapartum antibiotics = Intrapartum antibiotics given more than 2 hours before birth2 Discharge after 24 hours if usual readiness for discharge criteria met and parents can understand and follow instructions (recognise signs of infection, contact help via telephone, transport baby for care if required)ALL newborn babies are at risk of infection irrespective of gestation, maternal risk factors or adequacy of IAPS igns of infection.

8 Respiratory distress, temperature instability, unexpected need for resuscitation, apnoeic episodes, lethargy, seizures, poor feeding, abdominal distension, hypotension, metabolic acidosisGestation < 37+0 weeks?1 Adequate IAP?Elective CS? (no labour, no ROM)Any of the following? GBS colonisation this pregnancy GBS bacteriuria this pregnancy Preterm labour < 37+0 weeks ROM > 18 hoursGestation< 37+0 weeks? Signs of infection? Investigate and treatNoNoNoYesNoNoYesYesNoYesYesYesRoutine newborn careFBC and observe for 48 hoursAll newborn babiesCS: caesarean section, EOGBSD: early onset group B Streptococcal disease, FBC: full blood count, GBS: group B streptococcus , IAP: intrapartum antibiotic prophylaxis, IV: intravenous, ROM: rupture of membranes, T: temperature, >: greater than, <: less than, : greater than or equal to Refer to NeoMedQ at Queensland Clinical Guideline: Early onset group B Streptococcal disease Refer to online version, destroy printed copies after use Page 5 of 26 Table of Contents Abbreviations.

9 6 Definition of terms .. 6 1 Introduction .. 7 Universal screening versus risk factor approach .. 7 Burden of disease .. 7 Clinical standards .. 8 2 Risk factors .. 9 Risk reduction .. 9 Specimen collection .. 9 3 Intrapartum antibiotic prophylaxis .. 10 Penicillin hypersensitivity .. 11 IAP not required .. 11 4 Specific condition management .. 12 Prelabour rupture of membranes .. 13 Term prelabour rupture of membranes .. 13 Preterm prelabour rupture of membranes .. 14 5 newborn care .. 15 Signs of sepsis .. 15 Investigation of sepsis .. 16 Antibiotic therapy .. 17 Gentamicin monitoring .. 17 6 Postnatal care for asymptomatic well baby .. 18 7 Discharge .. 19 Late onset GBS disease .. 19 References .. 20 Appendix A: Rationale for risk factor approach in Queensland .. 23 Appendix B: Normal laboratory reference ranges for a term baby .. 25 Acknowledgements .. 26 List of Tables Table 1. Burden of illness.

10 7 Table 2. Clinical standards .. 8 Table 3. Risk reduction .. 9 Table 4. Specimen collection .. 9 Table 5. Intrapartum antibiotic prophylaxis .. 10 Table 6. Penicillin hypersensitivity .. 11 Table 7. Specific conditions .. 12 Table 8. Prelabour rupture of 13 Table 9. Term prelabour rupture of membranes .. 13 Table 10. Preterm prelabour rupture of membranes .. 14 Table 11. Signs of 15 Table 12. Investigation of sepsis .. 16 Table 13. Antibiotic therapy .. 17 Table 14. Asymptomatic well baby .. 18 Table 15. Discharge .. 19 Table 16. Late onset group B Streptococcal disease .. 19 Queensland Clinical Guideline: Early onset group B Streptococcal disease Refer to online version, destroy printed copies after use Page 6 of 26 Abbreviations CI Confidence interval CS Caesarean section CRP C-reactive protein EOGBSD Early onset group B streptococcus disease FBC Full blood count gbs group b streptococcus IAP Intrapartum antibiotic prophylaxis IOL Induction of labour IV Intravenous LOD Late onset disease PMC Primary maternity carer PPROM Preterm prelabour rupture of membranes PROM Prelabour rupture of membranes PTL Preterm labour RANZCOG Royal Australian and New Zealand College of Obstetricians and Gynaecologists RCT Randomised controlled trial RDS Respiratory distress syndrome ROM Rupture of membranes RR Relative risk Definition of terms Colonised The presence of microorganisms at levels that provoke neither symptoms nor immune response.