Screening for toxoplasmosis in pregnancy

The prevalence of antibody against Toxoplasma gondi in a population of 715 pregnant women has been evaluated by two methods: indirect haemagglutination antibody (IHA) and indirect fluorescent antibody (IFA) test and all positive sera were checked by the dye test. Five hundred of the study population were questioned on diet and on animal contact to elucidate a possible relation to the prevalence of antibody. Results are expressed in international units (IU) of antibody against T gondi. Of the 715 sera, 171 were positive by IHA and 173 by IFA. One hundred and sixty-seven sera were positive by both tests, ninety-eight (58%) correlating exactly, as to the concentration of antibody. The ten sera which were not positive by both tests all had detectable antibody at the minimum concentration only (12 IU). The dye test confirmed all sera positive by both tests with the exception of three. It also confirmed one of four sera positive by IHA antibody alone and two of six positive by IFA alone. All sera that proved dye test-negative had low antibody concentrations (12 IU) by IHA or IFA. The IHA test, which is commercially available in kit form, would be suitable for use as a screening test during pregnancy. The estimated annual rate of antibody acquisition over the age range 16-40 years is 1.2% per annum with the highest rate in the 36-40 age group (2.5% per annum) and the lowest in the 26-30 age group (0.4% per annum). The clinical history was not significantly different between those with and those without antibody against T gondi but significantly more women in the 36-40 age group had a history of animal contact than those in the 26-30 age group. No conclusive evidence of recent or current infection was found.

Bloodstream infections and perinatal mortality

Bloodstream infection is demonstrable at necropsy in 21.1% of perinatal death but is almost invariably a secondary event, often terminal, contributing to death as a secondary cause. In only 3.8% is infection recorded as the primary cause of death. Escherichia coli predominates, and postmortem and antemortem studies alike confirm the tendency of this and other microbes to involve the meninges in the course of bloodstream infection. Fatal viral and fungal infections are rare, and life-threatening disease is overwhelmingly of bacterial origin. A separate, prospective study of septicaemia in the newborn is reported, and the data are tabulated. The overall incidence in inborn and outborn populations, together with the incidence of specific infections, is stated, and the relationship to birthweight is analysed. The overall mortality for treated cases is 40.7% the mortality being inversely proportional to birthweight, and highest at 62.5% in those born weighting less than 1000 g. The advent of meningitis (1 in 5 cases of septicaemia) aggravates the mortality (83%). The potential hazard of nursing seriously infected babies is emphasised.

Intrapartum and postpartum pyrexia and infection after induction with extra-amniotic prostaglandin E2 in tylose

One hundred and twenty-four women, bearing 127 children, in whom labour was induced with extra-amniotic prostaglandin E2 in tylose were studied. High vaginal swabs taken from 111 patients immediately before insertion of prostaglandin E2 were examined, specific identification of microbes being restricted to those present in the amniotic fluid, to haemolytic streptococci, and to other specific microbes. Lancefield group B streptococci were isolated from nine patients, and in eight of these the microbes were isolated from the amniotic fluid. Amniotic fluid was examined from 86 patients and was shown to be contaminated with microbes potentially pathogenic for mother or baby in 11 out of 86 (13 per cent) of the patients examined; in eight patients, the contaminating pathogen was the group B streptococcus. All 127 blood cultures taken during or just after delivery were negative. Six out of nine patients with a group B streptococcus in the vagina developed fever and proven streptococcal endometritis; one child developed fever and another streptococcal septicaemia.

Comparison of methods available for assay of chloramphenicol in clinical specimens

Eight methods for the assay of chloramphenicol in clinical samples were compared with our own modification of a plate diffusion technique using Sarcina lutea and yeast extract agar. Six of the eight methods were less sensitive than originally reported, and five of them were considered unsuitable for use in clinical microbiology practice. The remaining three methods together with the S. lutea/yeast extract modification were used to assay chloramphenicol in 20 samples of serum. Twenty samples of cerebrospinal fluid were also assayed by the S. lutea/yeast extract method. Our results indicate that only the Bacillus subtilis (sensitivity 6x0 mg/l) and the S. lutea (sensitivity 2x5 mg/l) diffusion methods are suitable for use with clinical samples in routine practice. The problems of chloramphenicol toxicity, appropriate dosage regimens, and the need for assay of the drugs are considered.

Susceptibility to rubella in a pregnant population after the introduction of vaccination

The results of testing for the presence of rubella antibody by haemagglutination inhibition in pregnant women are presented for a number of years, together with an analysis of results for the year 1977. Levels of immunity are correlated with age and British nationality. The influence of vaccine availability on numbers with antibody cannot be demonstrated nor can any evidence for the boosting of antibody levels by natural infection can be discerned.

Candida vaginitis

The pathogenesis incidence and epidemiology of Candida vaginitis is considered.

Vertical transmission of hepatitis B surface antigen in carrier mothers in two west London hospitals

126 children of 102 hepatitis B surface antigen (HBsAg) carrier mothers were delivered at Hammersmith Hospital and Queen Charlotte's Maternity Hospital, between 1971 and mid-1978. Blood tests on 110 of these children showed that 8 out of the 18 with Chinese mothers, but only 6 out of the 92 other children, have become HBsAg positive. The presence of maternal hepatitis B e antigen (HBeAg) is also significantly correlated with transmission of HBsAg to the children. The management of children whose mothers are carriers is discussed.

Biochemical identification of clinically important yeasts

Four commercially available kits for the speciation of yeasts were tested against 50 clinical isolates that had been identified by conventional methods. On biochemical grounds alone, the four systems varied from 71% to 100% in their efficiency in identifying Candida albicans. Yeasts other than C. albicans were identified with an efficiency varying from 24% to 83%. Conclusions are drawn on the value of these systems to the routine laboratory.

Genital mycoplasmas and birth weight in offspring of primigravid women

The relationship between colonization of pregnant women by Ureaplasma and Mycoplasma and the outcome of pregnancy in a study of 104 women is reported. There were eight abortions but no multiple births or stillbirths. Excluding abortions, the mean gestational length was 39.6 weeks and the corrected mean birth weight was 3.28 kilograms. There was no relationship between maternal colonization by genital mycoplasmas and reduction in birth weight of the offspring, but five of the eight women who aborted harbored Ureaplasma, suggesting an increased trend toward abortion in women harboring Ureaplasma.

Bacteriology of abscesses of the central nervous system: a multicentre prospective study

Pus from 46 patients with abscesses of the central nervous system (CNS) was examined for bacteria; bacteria were found in all patients. Streptococci were isolated from 36 patients and most isolates were Streptococcus milleri, Lancefield Group F, Ottens and Winkler type O III. Staphylococci were isolated from nine patients, organisms of the bacteroides group from 11, Proteus spp from seven, Klebsiella aerogenes from one, and Haemophilus aphrophilus from one. Pure cultures predominated over mixed cultures. Streptococci were isolated from abscesses of all types, and at all sites, but members of the Enterobacteriaceae and of the bacteroides group were isolated, in mixed cultures, principally from abscesses of the temporal lobe secondary to infection of the middle ear. Staphylococci predominated in abscesses that followed accidental or surgical trauma. Compared with fully sensitive control organisms, microbes infecting half the patients were resistant to penicillin. The prognosis of abscess of the CNS is grave, and the microbiological findings have important consequences for treatment. Prompt inoculation of specimens to culture plates and prompt incubation are mandatory if bacteria are to be cultured. Inhibitors of antimicrobial agents should be added to culture media if antibiotics have been administered. Provided that the site of the abscess and the antecedent history are ascertainable, the neurosurgeon should be able to start appropriate treatment while awaiting the results of culture.

Antibiotic treatment of abscesses of the central nervous system

Samples of intracranial pus and serum from 32 patients were assayed to determine the concentrations reached in them of penicillin, ampicillin, cloxacillin, cephaloridine, gentamicin, chloramphenicol, fusidic acid, and lincomycin. Metronidazole had not been given. Penicillin penetrated abscesses reasonably well, but other beta-lactam antibiotics did not. The penetration of chloramphenicol was erratic. Aminoglycosides penetrated poorly, but lincomycin and fusidic acid penetrated well. Assay of sulphonamides and co-trimoxazole in pus was unreliable. These studies indicate that treatment of abscesses of the central nervous system should be considered according to the site and the likely antecedent cause. Abscesses of sinusitic origin, usually in the frontal lobe, yield penicillin-sensitive streptococci. Penicillin is the drug of choice. Abscesses of otitic origin, usually in the temporal lobe, yield a mixed flora, often including anaerobic bacteria. Multiple antibiotic therapy is indicated. Abscesses of metastatic or cryptogenic origin yield streptococci or mixed cultures, and multiple therapy is appropriate while awaiting the bacteriological results. Spinal and post-traumatic abscesses yield Staphylococcus aureus, and fusidic acid is the drug of choice.

Inactivation of penicillin by purulent exudates

Four of 22 specimens of human pus inactivated up to 90% of added penicillin within one hour in vitro. Ampicillin and cephaloridine were also inactivated, but streptomycin and fusidic acid were not. The effect was not related to the protein content of the pus, nor to its pH value. Microbes that may produce beta-lactamase in small quantities were isolated from three of the four specimens, but the enzyme was not detected in the pus by physical methods nor by microbiological inhibition assay. The inactivating effect was shown to be a property of the solid portion of the pus, and was absent from the filtrate. We suggest that the effect may be an intrinsic property of the host, which should be investigated further as it has important implications for clinical practice.

Candidal vaginitis

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Morbidity of the lower genital tract during pregnancy

The lower genital tract of 280 pregnant women was studied in detail, and symptoms relevant to its morbidity were elicited and recorded. The study was contemporaneous with a study of microbial flora in the genital tract of these women (de Louvois et al, 1975). Complaint was made frequently of discharge (42%), irritation (15%), or both (11%). Apart from these symptoms, 14% admitted a past history of vulvovaginitis, emphasizing the importance of this condition in obstetric and gynaecological practice. The notorious discrepancy between the complaint, and the objective demonstration of discharge, was confirmed, but a significant difference in observations, varying with the clinical observer (P less than 0-001), was also demonstrated. This illustrates the necessity of even more accurate grading of signs when clinicopathological correlations are to be attempted. Only 30% of women had no evidence of vulvovaginitis or cervicitis. Morbidity did not relate to age, gestation or parity, but there was a significant correlation between clinical acumen, as evidenced by a request for a microbiological report with a view to treatment, and morbidity (P less than 0-001), between past vulvovaginitis and present morbidity (P less than 0-01), and between cervicitis and the presence of pus cells in the smear (P less than 0-001). The results indicate that microbiological investigations should be requested when there is past history of vulvovaginitis, and that lesions of the cervix, if not already noted, should be suspected if pus cells are demonstrable in stained smears.

Microbial flora of the lower genital tract during pregnancy: relationship to morbidity

Nineteen genera and groups of micro-organisms were isolated from the lower genital tract of 280 women at their first antenatal visit. Chlamydia, viruses, and T-strain mycoplasmas were not sought, and only routine methods of anaerobic culture were used. Growth was recorded as scanty, moderate or heavy. The population studied was grouped according to age, parity, gestational stage at booking, presence and degree of severity of lower genital tract morbidity, past history of vulvovaginitis, and suspicion of lower genital tract morbidity as evidenced by a request for a report on the microbiological findings. The frequency of isolation of the various microbes in health and in disease is given. The grading of Gram-stained smears bore no relation to the isolation rates of lactobacilli, but there was a significant increase (p less than 0-001) in the isolation rates of each of the following: Mycoplasma hominis, Bacteroides spp., Trichomonas vaginalis, Gram-variable cocco-bacilli, and anaerobic streptococci in those patients with smears in which lactobacilli were adjudged to be absent. The isolation of faecal streptococci was increased (p less than 0-001) in women aged more than 34 years. Escherichia coli (p less than 0-05) and anaerobic and microaerophilic streptococci (p less than 0-02) were isolated more frequently from those booking after the 25th week of pregnancy. The incidence of M. hominis (p less than 0-02) and of anaerobic streptococci (p less than 0-05) increased between the first and third trimesters. No significance positive correlations were established between the isolation rates of the various microbes and objective assessment of lower genital tract morbidity or the demonstration of pus cells, but lactobacilli were isolated less frequently (p less than 0-01) from those with morbidity. The isolation of Candida albicans (p less than 0-02), T. vaginalis (p less than 0-05), and M. hominis (p less than 0.05) was increased in patients in whom vulvovaginitis was suspected, and that of T. vaginalis (p less than 0-05) was increased in those with a past history of vulvovaginitis. The study indicates that, other than the pathogens T. vaginalis and C. albicans, only M. Hominis could be suspected, on statistical grounds, of being associated with disease of the lower genital tract during early pregnancy.

Doxycycline treatment and human infertility

The role of mycoplasmas in infertility was studied in 120 couples. During the twelve months of the study 27 couples (22-5%) conceived. T mycoplasmas were isolated from 63% of these couples, and Mycoplasma hominis from 18%, compared with 56% and 13%, respectively, in those who did not conceive. 88, with primary infertility of unascertained cause, took part in a controlled trial with doxycycline. The couples in the trial were allocated randomly to three groups: 30 received doxycycline, 28 received a placebo, and 30 couples were untreated. Although a twenty-eight-day course of doxycycline eradicated M. hominis and T-strain mycoplasmas from 27 (96%) of the 28 couples harbouring them, the rate of conception was no higher in those treated with the drug than in control groups. It is concluded that mycoplasmas are not associated with primary infertility and that, although doxycycline eradicates them, this drug is of no benefit in the treatment of primary infertility of unascertained cause.

Candida precipitins in pregnant women: validity of the test systems used

Sera from 200 pregnant women, with symptoms suggestive of vaginitis and harbouring yeast in the vagina, were examined for precipitating antibodies to three antigens of C. albicans, using a gel double diffusion test. A high overall incidence of precipitin-positive sera (47.5%) was found compared with an incidence of 18% in the unselected pregnant population previously studied (Stanley, Hurley, and Carroll 1972). Using the clinicopathological criteria of Carroll, Hurley, and Stanley (1973), a final aetiological diagnosis of C. albicans mycosis was reached in 75 cases and precipitins were demonstrated in 64%. Forty-eight women harbouring C. albicans responded favourably to a single course of antifungal treatment, and probably had mycotic vaginitis. The incidence of precipitins in this group was 42%. C. albicans was isolated from a further 55 of 62 patients, in whom the incidence of precipitins was 32%.;Booking' sera were investigated from 50 of the 200 women studied. Sixty-four per cent of women had symptoms of vaginitis at booking and 32% were precipitin positive. Twenty-eight per cent had precipitins on both occasions, and a further 24% acquired candida precipitins during pregnancy. None of the seven newborn with oral or skin thrush had precipitins to C. albicans.The results indicate that the detection of precipitating antibodies to C. albicans, particularly to all three of the antigens described in this paper, would be a useful additional criterion in the diagnosis of candida vaginitis, particularly if the vaginitis were persistent, recurrent, or unresponsive to therapy. The sensitivity of the test system used was 64%, and its specificity 87%; as such, the test is valid and may be reasonably useful as a screening procedure.

Rubella epidemic in a maternity unit

Four cases of rubella, the last confirmed by laboratory tests, occurred among the nurses of a large obstetric unit. Immediate measures were taken to prevent the spread of the infection to pregnant patients and staff, and none was in fact infected.Persons susceptible to rubella and who become infected may pose a real danger to women in early stages of gestation during the incubation period. We recommend that the immune status of medical and nursing personnel working in obstetric departments should be ascertained serologically, and that rubella vaccine should be offered to those who are susceptible.

Massive pulmonary haemorrhage in the newborn associated with Coxsackie B virus infection

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