What is the management for a newborn with eye discharge born to a Group B streptococcal (Strep B) positive mother?

Management of Eye Discharge in Newborns Born to Group B Streptococcus Positive Mothers

A newborn with eye discharge born to a Group B Streptococcal (GBS) positive mother requires a targeted approach based on clinical presentation, with treatment including eye swab cultures and appropriate topical antibiotics, while also following the established GBS management algorithm to evaluate for systemic infection.

Initial Assessment

When evaluating a newborn with eye discharge born to a GBS-positive mother, two separate but related clinical issues must be addressed:

1. The eye discharge (conjunctivitis)
2. Potential risk for early-onset GBS disease

Eye Discharge Management

• Obtain cultures: Take conjunctival swabs from both eyes before initiating treatment 1
• Initiate empiric topical therapy:
  • Chloramphenicol eye drops are effective for most cases of neonatal conjunctivitis 1
  • Alternative: erythromycin 0.5% ophthalmic ointment or tetracycline 1% ointment 2
• Monitor response: If no improvement within 48-72 hours, consider:
  • Changing antibiotics based on culture sensitivity results
  • Adding oral erythromycin if chlamydial infection is suspected or for cases of dacryocystitis 1

Risk Factors That Increase Concern

• Premature rupture of membranes (significantly associated with higher incidence of conjunctivitis, p<0.01) 1
• Vaginal delivery (higher risk compared to cesarean section) 3
• Midwife interference during delivery 3

Systemic GBS Risk Assessment

Simultaneously, the newborn must be evaluated according to established GBS management protocols:

Algorithm for GBS Risk Management

1. Assess for signs of sepsis:

   • If present: Full diagnostic evaluation (blood culture, CBC with differential, chest X-ray if respiratory symptoms, lumbar puncture if stable) and immediate empiric antibiotic therapy 4

2. If no signs of sepsis, assess maternal factors:

   • Maternal chorioamnionitis?

     • If yes: Limited evaluation (blood culture, CBC with differential) and empiric antibiotic therapy 4

   • If no chorioamnionitis, did mother receive adequate intrapartum antibiotic prophylaxis (IAP)?

     • Adequate IAP = penicillin, ampicillin, or cefazolin for ≥4 hours before delivery 4
     • If yes: Routine observation for ≥48 hours (may be discharged at 24 hours if term infant, other discharge criteria met, and reliable follow-up within 48-72 hours) 4
     • If no: Continue to next step

   • If inadequate or no IAP:

     • Term infant (≥37 weeks) with membrane rupture <18 hours: Observation for 48 hours 4
     • Term infant with membrane rupture ≥18 hours: Limited evaluation (blood culture, CBC with differential) and observation for 48 hours 4
     • Preterm infant (<37 weeks): Limited evaluation and observation for 48 hours 4

Treatment Specifics

For Conjunctivitis

• First-line topical therapy: Chloramphenicol eye drops 1
• Second-line options:
  • Gentamicin eye drops (if no response to chloramphenicol) 1
  • Oral erythromycin for resistant cases or suspected chlamydial infection 1

For Systemic GBS Risk

If empiric antibiotic therapy is indicated:

• First-line: Ampicillin plus gentamicin IV 4
• Duration: Depends on culture results and clinical course
  • Negative cultures and asymptomatic: May discontinue after 48 hours 4
  • Positive cultures or symptomatic: Complete full course (typically 10-14 days) 5

Important Considerations

• Common pathogens in neonatal conjunctivitis: Staphylococcus aureus (most common), Enterococcus, Klebsiella, and E. coli 1, 3
• GBS can cause conjunctivitis: Although less common than other pathogens, GBS should be considered in the differential diagnosis, especially with a GBS-positive mother 6
• Dual approach is critical: Treat the local eye infection while simultaneously evaluating for potential systemic GBS disease 4

Follow-up

• For conjunctivitis: Continue treatment until discharge resolves, typically 7-10 days
• For GBS risk: Follow the observation period as indicated by the algorithm (minimum 48 hours)
• Arrange follow-up: Within 24-48 hours after discharge if discharged before 48 hours of age

Remember that while conjunctivitis is typically a localized infection, in a newborn with a GBS-positive mother, it could potentially represent an early manifestation of systemic disease, requiring vigilant monitoring and appropriate management.