COMMENTARY

Late-Onset GBS Infection in Infants: Do We Really Need to Treat for 10 Days?

William T. Basco, Jr., MD, MS

Disclosures

February 08, 2019

Do We Really Need to Treat Infants With GBS for 10 Days?

Uncomplicated late-onset (acquired between 7 and 90 days of life) group B streptococcus (GBS) disease is serious, as are the recommendations for treatment, which call for a prolonged course of intravenous (IV) therapy. Some small—usually single-center—studies have suggested that the recommended 10-day course is necessary and that shorter courses are insufficient.

The authors of this current study set out to determine how often shorter IV antibiotic courses are used and to compare rates of recurrence in infants treated with longer versus shorter courses. The study utilized data collected between 2000 and 2015 from the Pediatric Health Information System database, which includes information from 49 large US children's hospitals. Full-term infants ≤ 4 months old who were treated for uncomplicated GBS were identified. Any treatment duration ≤ 8 days was categorized as "short-course" therapy.

The primary outcome was recurrence of GBS disease. Any recurrence within 14 days was classified as a "treatment failure." The analyses examined a number of covariates, including sex, age, race or ethnicity, insurance type, calendar year, and hospital. Propensity scores were used to account for the non-random assignment to short-course therapy.

The final sample included 775 infants with uncomplicated, late-onset GBS bacteremia. The majority, 79%, received prolonged IV therapy. The median age at the onset of the index infection was 48 days. There was considerable variation in the initial antibiotics chosen for treatment:

  • 37% of infants received ampicillin plus a third-generation cephalosporin;

  • 28% received only a third-generation cephalosporin;

  • 7% received vancomycin plus a third-generation cephalosporin.

Approximately 2% of all infants experienced a recurrence of GBS (1.8% in the short-course group vs 2.3% of the group that received the recommended 10 days of therapy), a difference that was not statistically significant. Of note, there were no recurrent infections in the small group of 27 infants who received short-course IV treatment along with oral antibiotics at discharge.

The authors concluded that notable percentages of infants with uncomplicated GBS bacteremia are already treated with short-course therapy, and there does not appear to be a difference in recurrence rate or treatment failure between those treated for ≤ 8 days (short course) compared with longer courses of treatment. One important point to emphasize is that recurrent episodes may be multifactorial in origin and not just related to duration of IV treatment.

Viewpoint

These are very thought-provoking data. As noted in an accompanying editorial[2] by Charles Woods in the same issue, the best way to answer the question of appropriate duration of IV therapy to treat uncomplicated GBS, given that a large, multicenter, randomized trial is unlikely, is a comparative-effectiveness study such as this one.

The study found that, on average, any hospital treated one to three of these patients each year, meaning that most of us would have only anecdotal hunches to drive our decision-making. It's interesting to think that oral therapy following IV may prevent recurrence in babies who, probably for different reasons, do not receive 10 full days of therapy. However, even the question of how long the oral therapy should be following IV treatment was not answered by this trial. Therefore, this study will probably stimulate more discussion than it will answer questions. For now, that can only be a good thing.

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