Review Question - QID 216559

This neonate with no prenatal care presenting with poor feeding, lethargy, poor tone, and fever with Gram-positive cocci on CSF analysis has meningitis secondary to Group B Streptococcus (GBS) infection. GBS meningitis is prevented by intrapartum administration of penicillin to the mother.

Neonatal meningitis is commonly caused by 3 pathogens: GBS, Escherichia coli, and Listeria monocytogenes. Neonatal meningitis is clinically indistinguishable from neonatal sepsis without meningitis, so a high index of suspicion must be maintained. Clinical features commonly include temperature instability (fever or hypothermia), poor feeding, lethargy, and poor tone. GBS is a beta-hemolytic, Gram-positive cocci that can colonize the rectum or vagina, causing neonatal infection. Pregnant women who have a positive GBS culture from the vagina or rectum, a history of a prior child born with early-onset GBS disease, or GBS bacteriuria during the current pregnancy should receive intrapartum penicillin prophylaxis.

Hasperhoven et al. conducted a systematic review and meta-analysis of universal GBS screening versus risk-based protocols during pregnancy. They found that universal GBS screening in the third trimester of pregnancy was associated with a lower incidence of early-onset GBS disease. They recommend adopting these screening practices during pregnancy.

Incorrect Answers:
Answer 1: Abstaining from eating soft cheeses during pregnancy helps prevent maternal infection with Listeria monocytogenes, which is found in unpasteurized dairy products. While maternal listeriosis increases the risk for neonatal meningitis secondary to Listeria, CSF analysis would reveal Gram-positive rods, not cocci. Treatment is with ampicillin to the newborn.

Answer 3: Avoiding cat feces during pregnancy may prevent congenital toxoplasmosis. Congenital toxoplasmosis presents with the triad of chorioretinitis, intracranial calcifications, and hydrocephalus. CSF analysis would not reveal Gram-positive cocci. Treatment is with pyrimethamine and sulfadiazine to the newborn.

Answer 4: Cessation of maternal immunosuppressive therapy during pregnancy, depending on the medication, may be appropriate due to the toxicity of some immunosuppressant drugs to the fetus. Sulfasalazine and hydroxychloroquine are compatible with pregnancy whereas methotrexate is not. Active immunosuppression increases the risk for congenital cytomegalovirus infection, which would present with microcephaly, petechiae, and hepatosplenomegaly. Treatment is with ganciclovir to the newborn.

Answer 5: Maternal vaccination with a polysaccharide vaccine is not typically indicated during pregnancy. The pneumococcal vaccine is a polysaccharide vaccine typically administered to older adults and those who have certain medical conditions such as asplenia to prevent pneumococcal meningitis. Pneumococcal meningitis is not a common cause of meningitis in neonates.

Bullet Summary:
Group B Streptococcal meningitis in neonates can be prevented with intrapartum penicillin administration to eligible pregnant women.