Impact of Intrapartum Antibiotics on the Care and Evaluation of the Neonate

Sharon Balter, MD, Elizabeth R. Zell, MSTAT, Katherine L. O'Brien, MD, MPH, Aaron Roome, Phd, MPH, Heather Noga, Meena Thayu, MD, Anne Schuchat, MD

Disclosures

Pediatr Infect Dis J. 2003;22(10) 

In This Article

Abstract and Introduction

Background: Management of infants whose mothers receive intrapartum antibiotic prophylaxis (IAP) is controversial. In 1996 consensus guidelines for prevention of neonatal Group B streptococcal disease included an algorithm for management of infants whose mothers received IAP. To assess practices for testing and treatment of infants, we evaluated a population-based sample of deliveries to see whether excessive evaluation and treatment occurs after IAP.
Methods: Medical records for 869 deliveries in Connecticut during 1996 were sampled. IAP was administered in 96 full term deliveries. We excluded infants <37 weeks and those with intrapartum fever. We reviewed hospital records for infants born after IAP (n = 81) and a random sample of those not exposed (n = 180). Analyses were conducted with sample weights to account for unequal probability of selection.
Results: Infants whose mothers received IAP were more likely to have complete blood counts, (26% vs. 9% P = 0.05) but were no more likely to receive antibiotics in the first week of life (P = 0.48), have an intravenous catheter placed (P = 0.83), or to have other invasive procedures. Mean length of hospital stay was 6 h longer for infants born by vaginal delivery to mothers who had IAP (47.0 h) than for those without IAP (41.3 h) (P = 0.06).
Conclusion: Despite concerns that IAP guidelines would result in excessive neonatal evaluations, infants sampled whose mothers received IAP were not more likely to undergo invasive procedures or to receive antibiotics. Consistent with the guidelines, collection of complete blood counts was more common among such infants.

Group B Streptococcus (GBS) is the leading cause of serious neonatal infection. In May 1996 the CDC, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics (AAP) issued consensus guidelines for prophylactic use of intrapartum antibiotics for women at risk of transmitting GBS disease to their newborns.[1,2,3] The report included recommendations and a sample algorithm for the management of neonates whose mothers had received intrapartum antimicrobial prophylaxis for prevention of early-onset GBS. This algorithm was developed on the basis of expert opinion, since limited data were available for the development of evidence-based guidelines for evaluation and treatment of neonates in this setting. With an increasing number of women receiving intrapartum antibiotics, there was concern that pediatricians, unsure how to evaluate such infants, would give more antibiotics to those infants, do more invasive procedures on them and keep them in the hospital longer. To avoid such unintended consequences, the prevention guidelines offered the management algorithm.[1,2] The algorithm recommended that neonates with symptoms of sepsis be given a full diagnostic workup and receive empiric antibiotics. For infants with gestational age < 35 weeks or whose mothers received their first dose of antibiotics <4 h before delivery[2] (or only 1 dose instead of 2 or more),[1] the neonatal algorithm recommend a limited diagnostic evaluation. For all other infants whose mothers received intrapartum antibiotics, only observation for 48 h was recommended unless symptoms developed. However, results of several surveys conducted from 1990-1996 of pediatricians and neonatologists who self-reported clinical practices, suggest that clinicians were more likely to do diagnostic testing and to begin empiric antibiotic treatment of the newborn if the mother had received prophylactic intrapartum antibiotics, regardless of the infant's signs and symptoms.[4,5,6,7]

The goal of this study was to evaluate the actual practice of care-givers managing newborns in Connecticut in 1996. In the 30 hospitals in Connecticut where infants are delivered, we compared evaluation and treatment of a population-based sample of full-term infants whose mothers received intrapartum antibiotics with term infants whose mothers were not treated.

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