Early-Onset Neonatal Sepsis: A Continuing Problem in Need of Novel Prevention Strategies Barbara J. Stoll, MD Early-onset neonatal sepsis (EOS) colonized women or targeted IAP for remains a feared cause of severe women with obstetrical risk factors illness and death among infants of all in labor known to increase GBS birthweights and gestational ages, transmission. 5 Revised guidelines with particular impact among preterm in 2002 recommended universal infants. Centers for Disease Control and antenatal screening for GBS at 35 to Prevention investigators have studied 37 weeks’ gestational age to identify the changing epidemiology of invasive colonized women who should receive EOS for several decades. The Active IAP. 6 Guidelines were additionally Bacterial Core surveillance (ABCs) refined in 2010 to provide neonatal network, a collaboration between management recommendations based the Centers for Disease Control and on maternal risk factors and clinical H. Wayne Hightower Distinguished Professor in the Medical Prevention, state health departments, condition of the infant at birth, with Sciences and Dean, McGovern Medical School, University of and universities, was established in an attempt to reduce unnecessary Texas Health Science Center at Houston, Houston, Texas 1995 to address emerging infectious evaluations of well-appearing infants Opinions expressed in these commentaries are diseases of public health importance, without risk factors. 7 Widespread those of the author and not necessarily those of the including infections due to major adherence to national guidelines American Academy of Pediatrics or its Committees. neonatal pathogens. 1, 2 ABCs data resulted in a remarkable decline DOI: 10.1542/peds.2016-3038 are remarkable because of the in early onset GBS disease, but a Accepted for publication Sep 12, 2016 geographic distribution and size of the concomitant increase in exposure Address correspondence to Barbara J. Stoll, 8 population-based network, laboratory- to intrapartum antibiotics. Several MD, McGovern Medical School, University of based identification of cases, linked studies have reported missed Texas Health Science Center at Houston, 6431 epidemiologic and laboratory data, opportunities for GBS prevention. 9 Fannin St, MSB G.150, Houston, TX 77030. E-mail: and surveillance over many years. In At the same time, clinicians and [email protected] this issue of Pediatrics, Schrag and investigators voiced concerns about PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, colleagues 3 present ABCs data on the increased exposure to IAP with 1098-4275). epidemiology of early-onset neonatal potential for an increase in non-GBS Copyright © 2016 by the American Academy of sepsis collected over a recent 10-year invasive pathogens and emergence of Pediatrics period, with special attention to group antibiotic resistance in GBS and other FINANCIAL DISCLOSURE: The author has indicated B streptococcal (GBS) and Escherichia pathogens. she has no fi nancial relationships relative to this coli infections. article to disclose. Schrag et al 3 describe trends in EOS FUNDING: No external funding. Invasive GBS infection among sepsis due to GBS and E coli and POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential confl icts of interest neonates, identified in the 1960s, 4 compare clinical and epidemiologic to disclose. emerged as the most common cause characteristics of these infections. of EOS, with high risk of morbidity Their findings once again document COMPANION PAPER: A companion to this article can be found online at www. pediatrics. org/ cgi/ doi/ and mortality. National guidelines missed opportunities for GBS 10. 1542/ peds. 2016- 2013. for the prevention of perinatal GBS, prevention; 37% of women with an first issued in 1996, recommended indication did not receive IAP. The vast either antenatal screening for majority of neonates have bacteremia, To cite: Stoll BJ. Early-Onset Neonatal Sepsis: A GBS colonization and intrapartum with only a minority diagnosed with Continuing Problem in Need of Novel Prevention Strategies. Pediatrics. 2016;138(6):e20163038 antimicrobial prophylaxis (IAP) for meningitis. Rates of EOS overall and of Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 6 , December 2016 :e 20163038 COMMENTARY E coli are stable, with some continued microbiome, 13 support efforts to 3. Schrag SJ, Farley MM, Petit S, et decline in GBS, easing concerns about prevent unnecessary therapy. The al. Epidemiology of invasice early- potential increase of E coli infection global epidemic of antimicrobial onset neonatal sepsis, 2005 to 2014. in the face of increased IAP. Although resistance demands continued Pediatrics. 2016;138(6):e20162013 GBS remains the most common surveillance of susceptibility patterns 4. Eickhoff TC, Klein JO, Daly AK, Ingall EOS pathogen overall, the relative as well as evidence-based guidelines D, Finland M. Neonatal sepsis and incidence of GBS and E coli varied by for antibiotic stewardship in high- other infections due to group B beta- state, with some states having more E risk newborns. hemolytic streptococci. N Engl J Med. coli than GBS cases for at least one of 1964;271(24):1221–1228 Unlike GBS, there are no evidence- the years studied. Rates of infection, 5. Centers for Disease Control and based strategies to reduce the risk of morbidity, and mortality continue to Prevention. Prevention of perinatal early-onset Gram-negative infections, be highest among preterm, especially group B streptococcal disease: a particularly E coli. Additional studies very low birth weight, infants and public health perspective. MMWR to delineate specific risk factors for Recomm Rep. 1996;45(RR-7):1–24 among black infants. Eleven percent non-GBS EOS might lead to novel of infected infants died. Although 6. Schrag S, Gorwitz R, Fultz-Butts K, preventive interventions. Maternal mortality was higher among very Schuchat A. Prevention of perinatal immunization against invasive low birth weight infants infected group B streptococcal disease. Revised pathogens could prevent disease guidelines from CDC. MMWR Recomm with E coli, birth weight, pathogen, in the triad of mother, fetus, and Rep. 2002;51(RR-11):1–22 and mortality are interconnected. newborn, a worthy goal. 14 GBS Although ABCs collects limited 7. Verani JR, McGee L, Schrag SJ; Division immunization would prevent both neonatal clinical information, 6% of Bacterial Diseases, National Center early- and late-onset neonatal disease of survivors were reported to have for Immunization and Respiratory and might have an impact on other Diseases, Centers for Disease Control sequelae at hospital discharge. adverse outcomes of pregnancy, and Prevention (CDC). Prevention including stillbirth, prematurity, of perinatal group B streptococcal This study underscores the need and culture-negative clinical sepsis. disease--revised guidelines from for continued adherence to national More than 50 years after neonatal CDC, 2010. MMWR Recomm Rep. GBS guidelines: universal antenatal GBS was first described, it is time to 2010;59(RR-10):1–36 screening and attention to the special see GBS vaccines in the clinical arena 8. Schrag SJ, Verani JR. Intrapartum cases of women in preterm labor preventing disease in mothers and antibiotic prophylaxis for the who should be screened at delivery infants. prevention of perinatal group B and women with presumed penicillin streptococcal disease: experience in allergy. The identification of infants the United States and implications with possible EOS is based on ABBREVIATIONS for a potential group B streptococcal obstetrical and neonatal risk factors vaccine. Vaccine. 2013;31(4 Suppl and the condition of the infant at ABC: Active Bacterial Core 4):D20–D26 surveillance birth. In particular, evaluating the 9. Stoll BJ, Hansen NI, Sánchez PJ, infant’s condition is challenging and EOS: early-onset neonatal sepsis et al; Eunice Kennedy Shriver National depends on clinical experience. The GBS: group B streptococcus Institute of Child Health and Human relative severity of clinical symptoms IAP: intrapartum antimicrobial Development Neonatal Research with different pathogens deserves prophylaxis Network. Early onset neonatal sepsis: the burden of group B Streptococcal additional study, especially because and E. coli disease continues. pathogen and neonatal complications Pediatrics. 2011;127(5):817–826 may impact neurodevelopmental outcomes among survivors. 10 REFERENCES 10. Stoll BJ, Hansen NI, Adams- Chapman I, et al; National Institute Although not specifically addressed 1. 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