Pumping Up Prevention of Late Onset GBS Sepsis in the NICU

Introduction: Group B Streptococcus (GBS) is a known cause of early and late onset neonatal sepsis. Case reports have shown an association between GBS late onset sepsis (LOS) and GBS colonization of breast milk, but there is disagreement on the causality of the relationship. We present a case of GBS LOS in premature twins with GBS isolated from breast milk and the breast pump. From this case, methods were changed to reinforce breast pump sanitation. Case Report: Dichorionic diamniotic infants were delivered via C-section at 30+1 weeks due to preterm labor. Maternal serologies were notable for a negative GBS swab. Initial hospitalization was relatively unremarkable until day of life 33 when twin A began having multiple desaturation events. A complete sepsis evaluation reveled GBS bacteremia. Four days later, twin B had similar events and treatment. Her blood culture also grew GBS. Maternal expressed breast milk was cultured and grew GBS. A short time thereafter, the mother was diagnosed with mastitis. Investigation revealed improper sterilization of the breastmilk pump and supplies, with a culture of the pump resulting in GBS growth. All GBS isolates were identified as the same organism via pulsed-field gel electrophoresis. Discussion: GBS is a frequent cause of LOS and is associated with colonization of breast milk. Use of intrapartum antibiotic prophylaxis has reduced the incidence of early onset disease (< 7 days of life), however GBS LOS is unchanged. Debate exists whether the milk or infant is colonized first. One area not discussed in previous literature is the role of the breast pump in transmission or prevention. Guidance issued by the Center for Disease Control (CDC) in 2017 highlights the importance of breast pump sanitation. Twin B highlighted in our case was not direct breastfeeding and her only exposure was maternal expressed breast milk coming from an improperly sterilized breastmilk pump and given via nasogastric feeding. As a result of this case, unit practices were modified on how breast pump sanitation is counseled. Upon admission to the NICU all new parents get a CDC handout on cleaning breast pump supplies and there are reminders for providers to discuss breast pump hygiene at regular intervals. Conclusion: Much is still unknown about GBS LOS, but there is clearly a relationship between breast milk colonization with GBS and GBS LOS. All patients should be appropriately counseled on breast pump hygiene and this should be a standardized pr