Risk factors of multidrug-resistant organisms neonatal sepsis in Surabaya tertiary referral hospital: a single-center study

BACKGROUND

Bacterial organisms causing neonatal sepsis have developed increased resistance to commonly used antibiotics. Antimicrobial resistance is a major global health problem. The spread of Multidrug-Resistant Organisms (MDROs) is associated with higher morbidity and mortality rates. This study aimed to determine the risk factors for developing MDRO neonatal sepsis in the Neonatal Intensive Care Unit (NICU), dr. Ramelan Navy Central Hospital, in 2020-2022.

METHODS

A cross-sectional study was performed on 113 eligible neonates. Patients whose blood cultures were positive for bacterial growth and diagnosed with sepsis were selected as the study sample. Univariate and multivariate analysis with multiple logistic regression were performed to find the associated risk factors for developing multidrug-resistant organism neonatal sepsis. A p-value of < 0.05 was considered significant.

RESULTS

Multidrug-resistant organisms were the predominant aetiology of neonatal sepsis (91/113, 80.5%). The significant risk factors for developing MDRO neonatal sepsis were lower birth weight (OR: 1.607, 95% CI: 1.003 - 2.576, p-value: 0.049), history of premature rupture of the membrane (ProM) ≥ 18 (OR: 3.333, 95% CI: 2.047 - 5.428, p-value < 0.001), meconium-stained amniotic fluid (OR: 2.37, 95% CI: 1.512 - 3.717, p-value < 0.001), longer hospital stays (OR: 5.067, 95% CI: 2.912 - 8.815, p-value < 0.001), lower Apgar scores (OR: 2.25, 95% CI: 1.442 - 3.512, p-value < 0.001), and the use of respiratory support devices, such as invasive ventilation (OR: 2.687, 95% CI: 1.514 - 4.771, p-value < 0.001), and non-invasive ventilation (OR: 2, 95% CI: 1.097 - 3.645, p-value: 0.024).

CONCLUSIONS

Our study determined various risk factors for multidrug-resistance organism neonatal sepsis and underscored the need to improve infection control practices to reduce the existing burden of drug-resistant sepsis. Low-birth-weight, a maternal history of premature rupture of the membrane lasting more than 18 hours, meconium-stained amniotic fluid, longer hospital stays, a low Apgar score, and the use of ventilators were the risk factors for developing drug-resistant neonatal sepsis.

Listeriosis in infants: Prospective surveillance studies in Canada and Switzerland

Objectives

International data on listeriosis during infancy from large populations are essential to guide evidence-based empiric antibiotic guidelines for sepsis in infancy. We aimed to determine the incidence, clinical manifestations, and outcome of listeriosis in infants <6 months of age in Canada and Switzerland.

Methods

Prospective, active surveillance of listeriosis in infants <6 months of age was conducted through the Canadian Paediatric Surveillance Program (May 2015 to April 2017) and the Swiss Paediatric Surveillance Unit (April 2017 to March 2018). Confirmed and probable cases were included.

Results

In Canada, eight sporadic listeriosis cases were reported (incidence, 1.1/100,000 live births/year). In Switzerland, four cases were reported (incidence, 4.5/100,000 live births/year) of which three were part of a confirmed outbreak with an unclear source. In the two countries, eight of the 12 cases (66.6%) presented as early-onset disease (within the first 7 days of life) and none presented after 28 days life.

Conclusions

Neonatal listeriosis is rare. Infants presenting with sepsis, especially after 4 weeks of life, may not routinely require empiric antibiotic coverage for listeriosis. Outbreak-related cases still occur. Continued surveillance is important.

Early-onset neonatal sepsis: Organism patterns between 2009 and 2014

OBJECTIVE

To evaluate trends in organisms causing early-onset neonatal sepsis (EONS). Congruent with recent reports, we hypothesized there would be an increase in EONS caused by Escherichia coli.

STUDY DESIGN

National data on infants admitted to neonatal intensive care units from 2009 to 2014 were compared to previously reported data from 2003 to 2008. We report 430 cases of EONS from 2009 to 2014. Bivariate analyses were used to analyze the distribution of causative organisms over time and differences by gestational age. Linear regression was used to estimate trends in causative organisms.

RESULTS

Since 2003, there has been a trend of increasing numbers of cases caused by E coli (P<0.01). The predominant organism was E coli in preterm infants and Group B Streptococcus in term infants.

CONCLUSIONS

With the majority of EONS cases now caused by E coli, our findings emphasize the importance of continued surveillance of causative organism patterns and developing approaches to reduce cases caused by E coli.

C-reactive protein as a predictor of meningitis in early onset neonatal sepsis: a single unit experience

Objectives To determine whether there is a cut off value of serum C-reactive protein (CRP) associated with a higher risk of meningitis in suspected early onset sepsis (EOS) (onset birth to 7 days of life). Methods A retrospective cohort study on neonates admitted in neonatal intensive care unit at McMaster Children's Hospital from January 2010 to 2017 and had lumbar puncture (LP) and CRP for workup of EOS. Included subjects had either (a) non-traumatic LP or (b) traumatic LP with cerebral spinal fluid (CSF) polymerase chain reaction or gram stain or culture-positive or had received antimicrobials for 21 days. Excluded were CSF done for metabolic errors, before cytomegalovirus (CMV) treatment; from ventriculo-peritoneal (VP) shunts; missing data and contamination. Neonates were classified into definite and probable meningitis and on the range of CRP. We calculated sensitivity, specificity, and likelihood ratios for CRP values; and area under the receiver operating characteristic (AUROC) curve. Results Out of 609 CSF samples, 184 were eligible (28 cases of definite or probable meningitis and 156 controls). Sensitivity, specificity, predictive values, likelihood ratios, and AUROC were too low to be of clinical significance to predict meningitis in EOS. Conclusions Serum CRP values have poor discriminatory power to distinguish between subjects with and without meningitis, in symptomatic EOS.

Evaluation of compliance with the 2017 Canadian Paediatric Society Position Statement for the management of newborns at risk for early-onset sepsis: A retrospective cohort study

Introduction

Due to the nonspecific clinical presentation, clinicians often empirically treat newborns at risk of early-onset sepsis (EOS). Recently, the Canadian Paediatric Society (CPS) published updated recommendations that promote a more judicious approach to EOS management.

Objective

To examine the compliance with the CPS statement at a tertiary perinatal site and characterize the types of deviations.

Methods

A retrospective chart review was conducted for all term and late pre-term newborns at risk for sepsis, between January 1 and June 30, 2018. The prevalence of newborns with EOS risk factors was measured during the first month. Management strategies for eligible newborns during the 6-month period were compared to the CPS recommendations to establish the rate of noncompliance. The type of noncompliance, readmission rate, and rate of culture-positive EOS were examined.

Results

In the first month, 29% (66 of 228) of newborns had EOS risk factors. Among the 100 newborns born in the 6-month period for whom the CPS recommendations apply, 47 (47%) received noncompliant management. Of those, 51% (N=24) had inappropriately initiated investigations, 17% (N=8) had inappropriate antibiotics, and 32% (N=15) had both. The rate of readmission for a septic workup was 1.6% (N= 2). None had culture-positive sepsis while admitted.

Conclusion

A large proportion of term and late preterm newborns (29%) had EOS risk factors, but none had culture-confirmed EOS. The rate of noncompliance with the CPS recommendations was high (47%), mainly due to overzealous management. Future initiatives should aim at increasing compliance, particularly in newborns at lower EOS risk.

Management of newborns at increased risk for early-onset sepsis in perinatology department

Introduction: Assessing newborn infants at risk for early-onset sepsis (EOS) is a common clinical task conducted by pediatricians. A change in the internal protocol for managing neonates at risk was implemented in 2016. Unlike the previous protocol, which determined laboratory testing in asymptomatic newborns in the presence of one risk factor (RF) for sepsis; the new protocol advocates the screening in the presence of at least two RF. The purpose of this study was to characterize newborns at increased risk for EOS before and after the implementation of a diagnostic/treatment protocol.Methods: Retrospective analysis of asymptomatic newborns with RF to EOS who had laboratory testing performed at perinatology department in a central hospital in north of Portugal before and after the protocol was reviewed (2016), in the years 2015 and 2017, respectively. Patients were divided in two groups: preprotocol (2015) and postprotocol (2017), according to the date of admission.Results: A total of 361 newborns were enrolled, 296 (82%) pre-protocol and 65 (18%) post-protocol. There was a significant raise in the number of preterm newborns (9.5 versus 30.8%, pre- and post-protocol, respectively; p < .001), with similar other sociodemographic characteristics. There were 36 positive laboratory screenings at 12 h of life and 8.6% were transferred to the neonatology department, without differences between the groups (p = .250 and p = .488). All presented a favorable outcome, without differences in the number of readmissions in the first month of life (p = .204).Discussion: The modification of the approach protocol has led to a significant decline in the laboratory testing performed, minimizing newborn pain, unnecessary antibiotic exposure and costs, without increased risk of readmission for sepsis.

No. 298-The Prevention of Early-Onset Neonatal Group B Streptococcal Disease

OBJECTIVE

To review the evidence in the literature and to provide recommendations on the management of pregnant women in labour for the prevention of early-onset neonatal group B streptococcal disease. The key revisions in this updated guideline include changed recommendations for regimens for antibiotic prophylaxis, susceptibility testing, and management of women with pre-labour rupture of membranes.

OUTCOMES

Maternal outcomes evaluated included exposure to antibiotics in pregnancy and labour and complications related to antibiotic use. Neonatal outcomes of rates of early-onset group B streptococcal infections are evaluated.

EVIDENCE

Published literature was retrieved through searches of MEDLINE, CINAHL, and The Cochrane Library from January 1980 to July 2012 using appropriate controlled vocabulary and key words (group B streptococcus, antibiotic therapy, infection, prevention). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

The recommendations in this guideline are designed to help clinicians identify and manage pregnancies at risk for neonatal group B streptococcal disease to optimize maternal and perinatal outcomes. No cost-benefit analysis is provided.

SUMMARY STATEMENT

There is good evidence based on randomized control trial data that in women with pre-labour rupture of membranes at term who are colonized with group B streptococcus, rates of neonatal infection are reduced with induction of labour (I). There is no evidence to support safe neonatal outcomes with expectant management in this clinical situation.

RECOMMENDATIONS

Antibiotic exposure and development of necrotizing enterocolitis in very preterm neonates

OBJECTIVE

To examine the association between the duration of antibiotic exposure and development of stage 2 or 3 necrotizing enterocolitis (NEC) in very preterm neonates.

STUDY DESIGN

A retrospective case-control study was conducted from Canadian Neonatal Network data for preterm neonates born before 29 weeks' gestation and admitted 2010 through 2013. Efforts were made to match each NEC case to two controls for gestational age, birth weight (±100 g) and sex.

RESULTS

A total of 224 cases and 447 controls were identified. The incidence of antenatal steroid administration, the number of days nil-per-os and the number of antibiotic days prior to onset of NEC were significantly different in neonates with NEC. A multiple regression analysis revealed that the duration of antibiotic use was higher among NEC cases compared to controls (P<0.01). Empiric antibiotic treatment of 5 or more days was associated with significantly increased odds of NEC as compared with antibiotic exposure of 0 to 4 days (adjusted odds ratio: 2.02; 95% CI 1.55, 3.13).

CONCLUSION

Empiric antibiotic exposure for 5 or more days in preterm neonates born before 29 weeks' gestation was associated with an increased risk of NEC.

Cord blood neutropenia is an independent predictor of early sepsis

OBJECTIVE

The significance of cord blood neutropenia as a screening tool for early-onset sepsis (EOS) is unclear. The objectives were to define reference values for cord blood neutrophil count and to determine the sensitivity and positive likelihood ratio of cord neutropenia for the detection of EOS.

STUDY DESIGN

This retrospective observational cohort study included all mother-infant pairs with deliveries between 2009 and 2014 for whom cord neutrophil counts were routinely done. EOS cases were identified by interrogation of electronic charts. Maternal and perinatal factors were assessed to determine reference values of cord neutrophil. The diagnostic value of neutropenia for detecting EOS was assessed. A nested case-control design was used to measure the value of neutropenia in the detection of EOS in comparison with other risk factors.

RESULTS

A total of 8,590 mother-infant pairs were included. We identified 84 sepsis cases. The neutrophil count was strongly associated with gestational age. Neutropenia adjusted for gestational age was strongly associated with EOS and had good specificity but poor sensitivity. The addition of neutropenia to other EOS risk factors increased sensitivity without decreasing specificity.

CONCLUSION

Cord blood neutropenia was significantly associated with EOS and the addition of cord neutropenia to current EOS risk factors increased the detection rate of EOS.

Management of term infants at increased risk for early-onset bacterial sepsis

Early-onset neonatal bacterial sepsis (EOS) is sepsis occurring within the first 7 days of life. This statement provides updated recommendations for the care of term (≥37 weeks' gestational age) newborns at risk of EOS, during the first 24 hours of life. Maternal Group B streptococcus (GBS) colonization in the current pregnancy, GBS bacteriuria, a previous infant with invasive GBS disease, prolonged rupture of membranes (≥18 hours) and maternal fever (temperature ≥38°C) are the factors most commonly associated with EOS. These risk factors are additive; the presence of more than one factor increases the likelihood of EOS. At present, there is no laboratory test, including white blood cell indices, that has sufficient sensitivity to allow clinicians to safely rule out EOS. All unwell infants with clinical signs suggesting sepsis must be treated empirically with antibiotics, once cultures have been taken. The management of well-appearing, at-risk term infants depends on the number of risk factors (including maternal GBS colonization) and whether maternal intrapartum antibiotic prophylaxis for GBS was used. In some cases, management should be individualized. Careful assessment and observation of these at-risk infants are a fundamental component of appropriate care.

Prévention de l'infection néonatale à streptocoques du groupe B d'apparition précoce

OBJECTIF

Analyser les données issues de la littérature et formuler des recommandations sur la prise en charge des parturientes en vue de prévenir l'infection néonatale à streptocoques du groupe B d'apparition précoce. Parmi les révisions clés que renferme la présente directive clinique mise à jour, on trouve des modifications quant aux recommandations en ce qui concerne les schémas posologiques d'antibioprophylaxie, les épreuves de sensibilité et la prise en charge des femmes présentant une rupture prématurée des membranes.

ISSUES

Parmi les issues maternelles évaluées, on trouvait l'exposition aux antibiotiques au cours de la grossesse et du travail, ainsi que les complications associées à l'administration d'antibiotiques. Les issues néonatales associées aux taux d'infection néonatale à streptocoques du groupe B d'apparition précoce ont été évaluées. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed, CINAHL et The Cochrane Library entre janvier 1980 et juillet 2012, au moyen d'un vocabulaire contrôlé et de mots clés appropriés (« group B streptococcus », « antibiotic therapy », « infection », « prevention »). Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune restriction n'a été appliquée en matière de date ou de langue. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en mai 2013. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales.

VALEURS

La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). AVANTAGES, DéSAVANTAGES ET COûTS: Les recommandations que renferme la présente directive clinique sont conçues de façon à aider les cliniciens à identifier et à assurer la prise en charge des grossesses exposées à un risque d'infection néonatale à streptocoques du groupe B, en vue d'optimiser les issues maternelles et périnatales. Aucune analyse de rentabilité n'est fournie. DéCLARATION SOMMAIRE: Nous disposons de bonnes données (issues d'essais comparatifs randomisés) indiquant que, chez les femmes présentant une rupture prématurée des membranes à terme qui sont colonisées par des streptocoques du groupe B, le déclenchement du travail entraîne une baisse des taux d'infection néonatale. (I) Aucune donnée ne permet de soutenir que, dans une telle situation clinique, la prise en charge non interventionniste permet l'obtention de bonnes issues néonatales. RECOMMANDATIONS.

The Prevention of Early-Onset Neonatal Group B Streptococcal Disease

OBJECTIVE

To review the evidence in the literature and to provide recommendations on the management of pregnant women in labour for the prevention of early-onset neonatal group B streptococcal disease. The key revisions in this updated guideline include changed recommendations for regimens for antibiotic prophylaxis, susceptibility testing, and management of women with pre-labour rupture of membranes.

OUTCOMES

Maternal outcomes evaluated included exposure to antibiotics in pregnancy and labour and complications related to antibiotic use. Neonatal outcomes of rates of early-onset group B streptococcal infections are evaluated.

EVIDENCE

Published literature was retrieved through searches of MEDLINE, CINAHL, and The Cochrane Library from January 1980 to July 2012 using appropriate controlled vocabulary and key words (group B streptococcus, antibiotic therapy, infection, prevention). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

The recommendations in this guideline are designed to help clinicians identify and manage pregnancies at risk for neonatal group B streptococcal disease to optimize maternal and perinatal outcomes. No cost-benefit analysis is provided.

SUMMARY STATEMENT

There is good evidence based on randomized control trial data that in women with pre-labour rupture of membranes at term who are colonized with group B streptococcus, rates of neonatal infection are reduced with induction of labour (I). There is no evidence to support safe neonatal outcomes with expectant management in this clinical situation.

RECOMMENDATIONS

Recognising early onset neonatal sepsis: an essential step in appropriate antimicrobial use

Early diagnosis and timely treatment of early onset neonatal sepsis (EOS) are essential to prevent life threatening complications. Subtle, nonspecific clinical presentation and low predictive values of biomarkers complicate early diagnosis. This uncertainty commonly results in unnecessary and prolonged empiric antibiotic treatment. Annually, approximately 395,000 neonates (7.9% of live term births) are treated for suspected EOS in the European Union, while the incidence of proven EOS varies between 0.01 and 0.53 per 1000 live births. Adherence to guidelines for the management of suspicion of EOS is poor. Pragmatic approaches to minimise overtreatment in neonates with suspected EOS, using combined stratified risk algorithms, based on maternal and perinatal risk factors, clinical characteristics of the neonate and sequential biomarkers are promising.

Variation in Current Management of Term and Late-preterm Neonates at Risk for Early-onset Sepsis: An International Survey and Review of Guidelines

BACKGROUND

Uncertainty about the presence of infection results in unnecessary and prolonged empiric antibiotic treatment of newborns at risk for early-onset sepsis (EOS). This study evaluates the impact of this uncertainty on the diversity in management.

METHODS

A web-based survey with questions addressing management of infection risk-adjusted scenarios was performed in Europe, North America, and Australia. Published national guidelines (n = 5) were reviewed and compared with the results of the survey.

RESULTS

439 Clinicians (68% were neonatologists) from 16 countries completed the survey. In the low-risk scenario, 29% would start antibiotic therapy and 26% would not, both groups without laboratory investigations; 45% would start if laboratory markers were abnormal. In the high-risk scenario, 99% would start antibiotic therapy. In the low-risk scenario, 89% would discontinue antibiotic therapy before 72 hours. In the high-risk scenario, 35% would discontinue therapy before 72 hours, 56% would continue therapy for 5-7 days, and 9% for more than 7 days. Laboratory investigations were used in 31% of scenarios for the decision to start, and in 72% for the decision to discontinue antibiotic treatment. National guidelines differ considerably regarding the decision to start in low-risk and regarding the decision to continue therapy in higher risk situations.

CONCLUSIONS

There is a broad diversity of clinical practice in management of EOS and a lack of agreement between current guidelines. The results of the survey reflect the diversity of national guidelines. Prospective studies regarding management of neonates at risk of EOS with safety endpoints are needed.

Gentamicin trough levels using a simplified extended-interval dosing regimen in preterm and term newborns

To evaluate a simplified gentamicin extended-interval dosing regimen in a large cohort of preterm and term newborns, we conducted a retrospective cohort study over a 4-year period. All inborn newborns who received gentamicin for the first episode of suspected or proven sepsis were eligible. Newborns received 4 mg/kg gentamicin intravenously 24-hourly, except for those at <28 weeks of gestation who received gentamicin 36-hourly. Trough levels were taken before the third dose and considered non-toxic if ≤2 μg/mL. Infants were analysed in gestational age subgroups: <28 weeks, 28-31 weeks, 32-35 weeks, 36-39 weeks and ≥40 weeks. Newborns who received indomethacin co-medication were analysed separately. Nine hundred ninety-three newborns, gestational age range 23(+2)-42(+1) weeks, birth weight range 397-5936 g, were included. The median (interquartile range (IQR)) gentamicin trough level for all newborns was 1.3 μg/mL (0.8-1.7). Ninety per cent of newborns had non-toxic trough levels. The incidence of trough levels >2 μg/mL was between 2.2 and 9.7 % in all subgroups except for infants born at 28-31 weeks of gestation, where 21.7 % of trough levels were >2 μg/mL. Indomethacin co-medication significantly increased the median gentamicin trough level in preterm infants at <32 weeks of gestation.

CONCLUSION

This study demonstrates that simplified gentamicin dosage regimens are feasible. Prospective evaluations are required to establish safety profiles.

The prevention of early-onset neonatal group B streptococcal disease

OBJECTIVE

To review the evidence in the literature and to provide recommendations on the management of pregnant women in labour for the prevention of early-onset neonatal group B streptococcal disease. The key revisions in this updated guideline include changed recommendations for regimens for antibiotic prophylaxis, susceptibility testing, and management of women with pre-labour rupture of membranes.

OUTCOMES

Maternal outcomes evaluated included exposure to antibiotics in pregnancy and labour and complications related to antibiotic use. Neonatal outcomes of rates of early-onset group B streptococcal infections are evaluated.

EVIDENCE

Published literature was retrieved through searches of MEDLINE, CINAHL, and The Cochrane Library from January 1980 to July 2012 using appropriate controlled vocabulary and key words (group B streptococcus, antibiotic therapy, infection, prevention). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

The recommendations in this guideline are designed to help clinicians identify and manage pregnancies at risk for neonatal group B streptococcal disease to optimize maternal and perinatal outcomes. No cost-benefit analysis is provided.

SUMMARY STATEMENT

There is good evidence based on randomized control trial data that in women with pre-labour rupture of membranes at term who are colonized with group B streptococcus, rates of neonatal infection are reduced with induction of labour. (I) There is no evidence to support safe neonatal outcomes with expectant management in this clinical situation.

RECOMMENDATIONS

1. Offer all women screening for colonization with group B streptococcus at 35 to 37 weeks' gestation with culture taken from one swab first to the vagina and then to the rectum (through the anal sphincter). (II-1A) This includes women with planned Caesarean delivery because of their risk of labour or ruptured membranes earlier than the scheduled Caesarean delivery. (II-2B) 2. Because of the association of heavy colonization with early onset neonatal disease, provide intravenous antibiotic prophylaxis for group B streptococcus at the onset of labour or rupture of the membranes to: • any woman positive for group B streptococcus by vaginal/rectal swab culture screening done at 35 to 37 weeks' gestation (II-2B); • any woman with an infant previously infected with group B streptococcus (II-3B); • any woman with documented group B streptococcus bacteriuria (regardless of level of colony-forming units) in the current pregnancy. (II-2A) 3. Manage all women who are < 37 weeks' gestation and in labour or with rupture of membranes with intravenous group B streptococcus antibiotic prophylaxis for a minimum of 48 hours, unless there has been a negative vaginal/rectal swab culture or rapid nucleic acid-based test within the previous 5 weeks. (II-3A) 4. Treat all women with intrapartum fever and signs of chorioamnionitis with broad spectrum intravenous antibiotics targeting chorioamnionitis and including coverage for group B streptococcus, regardless of group B streptococcus status and gestational age. (II-2A) 5. Request antibiotic susceptibility testing on group B streptococcus-positive urine and vaginal/rectal swab cultures in women who are thought to have a significant risk of anaphylaxis from penicillin. (II-1A) 6. If a woman with pre-labour rupture of membranes at ≥ 37 weeks' gestation is positive for group B streptococcus by vaginal/rectal swab culture screening, has had group B streptococcus bacteriuria in the current pregnancy, or has had an infant previously affected by group B streptococcus disease, administer intravenous group B streptococcus antibiotic prophylaxis. Immediate obstetrical delivery (such as induction of labour) is indicated, as described in the Induction of Labour guideline published by the Society of Obstetricians and Gynaecologist in September 2013. (II-2B) 7. At ≥ 37 weeks' gestation, if group B streptococcus colonization status is unknown and the 35- to 37-week culture was not performed or the result is unavailable and the membranes have been ruptured for greater than 18 hours, administer intravenous group B streptococcus antibiotic prophylaxis. (II-2B) 8. If a woman with pre-labour rupture of membranes at < 37 weeks' gestation has an unknown or positive group B streptococcus culture status, administer intravenous group B streptococcus prophylaxis for 48 hours, as well as other antibiotics if indicated, while awaiting spontaneous or obstetrically indicated labour. (II-3B).

Safe discharge of the late preterm infant

Late preterm infants are infants who are premature, but often mature enough to be managed in settings and with treatment plans appropriate for term newborns. They are arbitrarily defined as infants born at gestational ages of 34, 35 and 36 weeks. Late preterm infants have more problems with adaptation than term infants, and may require neonatal intensive care and prolonged admission. However, those who do not may, appropriately, be triaged to mother-baby care in a low-risk nursery setting. Special attention must be offered to the late preterm infant in ensuring adequate thermal homeostasis and the establishment of successful feeding before discharge. In particular, care must be taken to ensure that these babies do not experience severe late hyperbilirubinemia, which characteristically occurs in the breastfeeding late preterm infant at four to five days of age and is not always predictable by routine bilirubin screening before 48 h of age. Discharge of a late preterm infant places particular demands on the community; accessible facilities for retesting, re-evaluation and readmission must be made available by the discharging institution.