What is the management plan for a 3-week-old infant born to a GBS positive mom, with reported fever at home, now afebrile on arrival?

Management of a 3-Week-Old Infant with Reported Fever and GBS-Positive Mother

This infant should be admitted for observation for at least 48 hours with close monitoring for signs of sepsis, without the need for empiric antibiotics or laboratory testing if the infant remains well-appearing. 1

Assessment of Risk Factors

The case involves several important considerations:

• 3-week-old full-term female infant
• Mother was GBS positive during pregnancy
• Mother received 2 doses of penicillin prior to delivery
• Rupture of membranes (ROM) for 2 hours
• Reported fever at home (45°C, measured with broken thermometer)
• Currently afebrile on arrival to ED

Risk Factor Analysis:

1. Maternal GBS status: Positive, but mother received intrapartum antibiotic prophylaxis (IAP)
2. Duration of IAP: Two doses of penicillin (likely adequate if ≥4 hours before delivery) 1
3. ROM duration: 2 hours (< 18 hours threshold for increased risk) 1
4. Current clinical status: Well-appearing and afebrile

Management Algorithm

Step 1: Evaluate for Signs of Sepsis

The infant is currently well-appearing and afebrile. The reported fever at home was measured with a broken thermometer, making this reading unreliable.

Step 2: Determine Need for Diagnostic Evaluation

Based on CDC guidelines, well-appearing infants without signs of sepsis should be managed according to maternal risk factors 1:

• If the infant develops any signs of sepsis (respiratory distress, temperature instability, lethargy, poor feeding), a full diagnostic evaluation should be performed immediately, including:

  • Blood culture
  • Complete blood count with differential
  • Chest X-ray (if respiratory symptoms)
  • Lumbar puncture (if stable enough)
  • Empiric antibiotics (ampicillin plus gentamicin) 2, 3

• Since the infant is currently well-appearing and afebrile, observation is appropriate

Step 3: Determine Duration of Observation

The infant should be observed for at least 48 hours 1:

• Monitor vital signs including temperature every 4-6 hours
• Perform serial physical examinations to detect early signs of sepsis
• Observe feeding patterns and activity level

Special Considerations

Reported Fever at Home

The reported temperature of 45°C is physiologically implausible and was measured with a broken thermometer, making it unreliable. However, any reported fever in a 3-week-old warrants careful evaluation. The fact that the infant is afebrile on arrival is reassuring but does not eliminate the need for observation.

Age of the Infant

At 3 weeks of age, this infant is beyond the typical window for early-onset GBS disease (first 7 days of life) 4. However, late-onset GBS disease can occur up to 3 months of age, so vigilance is still required.

Discharge Planning

If the infant remains well-appearing throughout the observation period:

• Discharge can be considered after 48 hours of observation 1
• Ensure caregivers understand warning signs that should prompt immediate medical attention:
  • Fever > 38°C (100.4°F)
  • Poor feeding
  • Lethargy or irritability
  • Respiratory distress
  • Color changes

Common Pitfalls to Avoid

1. Overreliance on laboratory tests: No laboratory test, including white blood cell indices, has sufficient sensitivity to safely rule out sepsis in neonates 4

2. Premature discharge: Even well-appearing infants with risk factors should be observed for at least 48 hours 1

3. Unnecessary antibiotic exposure: For well-appearing infants without clear signs of infection, observation without antibiotics is appropriate to avoid unnecessary antibiotic exposure and antimicrobial resistance 5, 6

4. Dismissing parental concerns: Despite the broken thermometer, parental concern about fever should be taken seriously and warrants the current observation admission

5. Failure to reassess: Regular reassessment during the observation period is crucial to detect subtle changes in clinical status 1