Chorioretinitis of the newborn with herpes simplex virus type 1. Report of a case

A disseminated herpes simplex virus (HSV) infection involving the central nervous system and accompanied by chrioretinitis in a a 3-week-old girl is described. The aetiologic diagnosis was established on the basis of vrius isolated from skin vesicles, and a significant rise in complement fixing antibodies to HSV type 1. The mode of transmission of the virus to the infant apparently was direct contact with an oral lesion in the mother, that was present at the time of delivery. The patient survived but became blind and microcephalic, with severe neurological sequelae. The virus isolated was identified as HSV type 1, which is an infrequent finding in herpetic chorioretinitis of the newborn.

Natural history of perinatal cytomegaloviral infection

Epidemiological data presented here indicate that cytomegaloviral (CMV) infection is one of the most common perinatal infections found in human beings. Transmission to the offspring occurs in utero at birth and postnatally. Intrauterine infection results from primary or recurrent maternal involvement, the latter being more common in populations where infection is initially acquired during childhood or adolescence, such as in low socioeconomic settings. Congenital infection is usually subclinical with either type of maternal involvement but primary infection has a greater tendency to produce disease in the fetus. About 20% of the offspring infected in utero are damaged, infrequently with generalized disease, but more often with auditory involvement. The latter can develop in utero or postnatally and can be progressive. The major cause of recurrent maternal infection according to restriction enzyme analysis is reactivation of latent virus, which occurs in the face of substantial maternal humoral immunity, even with intrauterine transmission of virus. Reinfection by exogenous virus remains a lesser possibility for maternal recurrences. Even more commonly, CMV can be transmitted at birth from the infected maternal genital tract and postnatally through infected breast milk, especially in highly immune populations. With the possible exception of early pneumonia, these infections appear to be innocuous.

CNS diseases associated with varicella zoster virus and herpes simplex virus infection. Pathogenesis and current therapy

In recent years, herpes simplex virus has been recognized as an important CNS pathogen in neonates and adults. The recent development of effective antiviral therapy has substantially reduced the excessive morbidity and mortality associated with these infections. For neonatal herpes simplex infections, the current drug of choice is vidarabine. The results of ongoing clinical trials comparing vidarabine with acyclovir in neonatal herpes may lead to a change in the recommended therapy. In the adult, the therapy of choice for herpes simplex encephalitis is acyclovir. Although effective, the present therapies for herpes simplex infections of the CNS leave much room for improvement. In addition to the development of more effective antiviral drugs and less invasive diagnostic techniques, prevention of these often devastating infections will be important in reducing morbidity and mortality. The CNS diseases associated with varicella and herpes zoster may have a different pathogenesis. The implication for therapy in these diseases favors nonspecific supportive therapy in the varicella-associated syndromes. The few anecdotal reports of the use of vidarabine and acyclovir in herpes zoster encephalitis and the histopathologic evidence suggesting viral invasion of the CNS in many cases of zoster-associated neurologic syndromes makes the use of specific antiviral therapy in zoster encephalomyelitis more rational. However, appropriate therapeutic recommendations will have to be based on controlled clinical trials that have not yet been performed.

Neonatal cytomegalovirus infections due to blood

Infants with very low birthweights (less than 1250g) are immunocompromised and have immature hematopoietic systems. They require frequent blood transfusions and have an increased susceptibility to infection. These very low birthweight infants who lack passively acquired antibody against CMV, acquire transfusion-associated CMV infections with a frequency of approximately 30%. These infections are associated with significant morbidity and mortality. The source of these postnatally acquired CMV infections are seropositive blood donors. These infections can be prevented by appropriate donor selection and/or blood processing. Recent but limited data suggests that all infants (regardless of birthweight or the presence of antibody against CMV) should receive CMV seronegative blood products if they are likely to receive multiple transfusions from multiple donors.

Detection of group B streptococci by agglutination testing from selective broth cultures

A rapid technique for the immunological identification of group B streptococci in vaginal swabs is reported. Vaginal swabs obtained from 567 pregnant women at term or during labor were incubated for eight hrs in Todd Hewitt broth containing 15 micrograms per ml nalidixic acid, one microgram per ml polymixin, and 0.1 microgram per ml crystal violet (NPC broth). After streaking the swabs on blood agar plates, both plain broth cultures and their nitrous acid extracted pellets were tested with a commercial latex agglutination reagent. Beta-hemolytic colonies grown on the blood agar plates after overnight incubation were grouped with commercial latex agglutination and coagglutination reagents for reference identification. Sensitivities for the broth culture and nitrous acid techniques were 86.8 percent and 94.7 percent, respectively; specificities were 97.4 percent and 98.7 percent respectively. Nitrous acid extraction of vaginal broth cultures followed by latex agglutination testing can significantly shorten the time needed to detect group B streptococci, resulting in the intrapartum detection of these organisms.

Sexually transmitted diseases and pregnancy

The association of adverse pregnancy outcome with Treponema pallidum, Neisseria gonorrhoeae and herpes simplex infections is well known and specific recommendations for management have been formulated. However, other agents that are not so well known can be transmitted sexually and threaten an otherwise healthy pregnancy. These agents are discussed in order to make the nurse more aware of related maternal and fetal diseases.

Congenital cytomegalovirus infection: on the relation between type and time of maternal infection and infant's symptoms

Maternal sera from 45 live-born infants with congenital cytomegalovirus (CMV) infection and 4 cases of legal abortion were analysed for CMV IgG and IgM. The investigation included cases from routine work and prospective studies of unselected infants. The purpose was to elucidate the relation between the maternal type and time of infection and the signs and symptoms of the offspring at birth and follow-up. Serological patterns compatible with primary maternal infection during trimesters I and II, but also with secondary infection (in at least 1 case), were associated with infant sequelae or death. Asymptomatic infant infection was found after primary infection in trimesters II and III and after secondary infection. Virus could not be isolated from some of the fetuses legally aborted due to primary maternal infection in trimester I. Attempts to demonstrate CMV IgM activity as a marker of active infection in sera from early pregnancy (period of legal abortion) were successful in only half of the 10 cases with infant sequelae or death. Symptoms at birth were prognostically serious, but the further course was sometimes uneventful even in infants with neonatal signs of cerebral infection. A few children without initial symptoms developed sequelae (impairment of hearing).

Epidemiology of group B streptococci: one year's experience in an obstetric and special care baby unit

The epidemiology of group B streptococci (GBS) was studied in an obstetric unit and the related special care baby unit (SCBU). In 1 year 53 (77%) of 69 babies who acquired GBS from their mothers were colonized within 24 h of birth, compared with only 9 (35%) of 38 who acquired GBS from non-maternal sources. While 38 (36%) of 107 GBS colonized babies in the obstetric unit derived the organism from a non-maternal source, the value for the SCBU was only 2 (9%) of 23. In babies rectal and umbilical swabs gave the highest GBS isolation rates. Phage-typing and serotyping suggested that colonized mother baby pairs, rather than staff, were the primary source of hospital acquired GBS. This mode of GBS acquisition did not result in long-term carriage once babies had left hospital. Nosocomial transmission can play an important part in GBS epidemiology, but can be minimized by attention to infection control procedures.

Shedding and survival of herpes simplex virus from 'fever blisters'

Shedding of herpesvirus by adults with herpes labialis and survival of the virus in the environment were examined. In nine adults with virus-positive herpes labialis, herpesvirus was detected in the anterior oral pool of seven (78%) and on the hands of six (67%). Herpesviruses isolated from patients with oral lesions were found to survive for as long as two hours on skin, three hours on cloth, and four hours on plastic. These findings support earlier recommendations for the protection of neonates from adults with "fever blisters." In addition, environmental surfaces may be a source of transmission of herpesvirus to the neonate.

The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit

Understaffing and overcrowding in the neonatal nursery are thought to contribute to the spread of infectious diseases among neonates, although little scientific documentation exists to support the view. In the present investigation of recurring epidemics in one nursery, the incidence rate of clustered staphylococcal infection was 16 times higher after periods when the infant:nurse ratio exceeded 7, seven times higher after periods when the infant census exceeded 33, three times higher in the summer months, and 1.5 times higher in the absence of bathing with hexachlorophene. All four factors were significantly associated with infection in a multivariate statistical model which predicted the occurrence of infection well (goodness-of-fit chi 2 = 6.08; df = 9; P = 0.73). These results support the contention that staphylococcal outbreaks periodically resulted when, in the presence of overcrowding, serious understaffing made frequent handwashing between infant contacts difficult. Elimination of these problems appears to be important in reducing cross infection in the nursery.

Successful chemotherapy of transfusion babesiosis

We describe babesiosis transmitted by transfusion. The infected blood donor was identified and a minimum period of infectivity of the donor's blood was established. We report a new modality for chemotherapy consisting of quinine plus clindamycin, and a new endemic focus for this zoonosis on Fire Island, New York. There are insufficient data to establish a reasonably safe period after which visitors and residents of Babesia-endemic foci can become blood donors. Screening of such persons by a rapid serologic test, such as the ELISA or immunofluorescent antibody tests, is suggested.

Concurrent outbreaks of rhinovirus and respiratory syncytial virus in an intensive care nursery: epidemiology and associated risk factors

An outbreak of viral respiratory disease occurred in eight infants in a neonatal intensive care unit during the 1980 winter respiratory season. Four infections with respiratory syncytial virus and four infections with rhinovirus were identified. Epidemiologic investigation revealed that viral respiratory infection was significantly associated with intubation with orotracheal tubes (P = 0.001), with the presence of both a nasal feeding tube plus an orotracheal tube together (P = 0.007), and with assisted ventilation (P = 0.009) when compared to uninfected controls. Twenty-seven of 85 (30.6%) personnel working in the unit at the time of the outbreak reported a history of upper respiratory illness during the week prior to the outbreak, and 46 (54.1%) of them had had contact with patients in areas of the hospital where patients infected with RSV and rhinovirus were housed. The data suggest that both viruses were transmitted to the babies by hospital personnel. Rhinoviruses can be nosocomial pathogen in neonates with compromised pulmonary function, and the clinical presentation of rhinovirus infection in neonates may be difficult to distinguish from that produced by RSV.

Epidemic Serratia marcescens in a neonatal intensive care unit: importance of the gastrointestinal tract as a reservoir

Between a March and December of 1979, and outbreak of infections due to multiply antibiotic resistant Serratia marcescens took place in a 50-bed neonatal intensive care unit. Fifteen neonates suffered major infections (sepsis, meningitis and pneumonia) with one death, and 20 suffered minor infections (conjunctivitis, cystitis, wound infections). Epidemiologic investigation failed to reveal a common source; S. marcescens, however, ws isolated from an employee's hand, emollient skin cleanser, suction tubing, and three in-use manual infant resuscitation bags. The skin cleanser and equipment-cleaning agents were ineffective against S. marcescens. Asymptomatic, colonized infants were the major reservoir of S marcescens. These infants were identified by daily cultures of the nose, umbilicus and rectum. The rectal swab most commonly (76%) yielded first-positive cultures in previously uncolonized infants, and was ultimately positive in 92% of colonized infants. A control program was begun by: 1) removing all inanimate sources of S. marcescens; and 2) cohorting patients and staff into a S. marcescens-exposed group and a new patient group. The new patient group of infants was surveyed by daily triple-site cultures for colonization and subsequent transfer to the S. marcescens-exposed group. After four months, the epidemic was controlled and the organism eradicated from the neonatal intensive care unit.

Nursery epidemic due to multiply-resistant Klebsiella pneumoniae: epidemiologic setting and impact on perinatal health care delivery

Gram-negative bacilli frequently cause epidemics in high-risk newborn intensive care units. Recently, an epidemic caused by a multiply-resistant K. pneumoniae, serotype 21, occurred in the Vanderbilt University intensive care nursery. The background of this outbreak included an increasing endemic nosocomial sepsis rate, operation of the facility in excess of rated capacity, and increasingly inadequate nurse-to-patient staffing ratios. The epidemic lasted 11 weeks; 26 (12%) of the 232 infants at risk in the unit became colonized. Five infants developed systemic illness and one died. Cohorting, reinforcement of strict handwashing and isolation procedures, and closure of the unit to outborn admissions resulted in rapid termination of the outbreak. Followup studies performed on infants colonized with the epidemic bacterium demonstrated persistent fecal shedding up to 13 months following discharge from the hospital. This epidemic had a detrimental influence on high-risk newborn and obstetric health care delivery in an area encompassing portions of three states. Under a system of progressively more sophisticated referral units, nosocomial infections occurring at a tertiary center can have an impact on other hospitals within the network.

Epidemiology, pathology and clinical features of genital mycoses--1981 status

The clinical picture of candidal vaginitis was described for the first time in 1792. The connection with yeasts was already discovered in the 19th century. Not until the last 35 years, however, have the epidemiologic aspects of genital mycoses and the diagnostic and therapeutic principles been systematically developed. The rise in the incidence of the disease is due to several factors: the administration of corticosteroids, cystostatic agents, and oral contraceptives as well as socioeconomic circumstances. Two serious complications of vaginal yeast infection in pregnant women should be noted: the amniotic infection syndrome and neonatal contamination at the time of delivery. Vulvovaginitis is one of the most common genital diseases in childhood and adolescence. Mycoses can be diagnosed in daily gynecological practice by simple, reliable methods, but only culture on prepared media or by incubation of standardized plates can be depended upon to establish or rule out a mycosis. Effective antimycotics with a broad spectrum of activity have been developed in the last 15 years. We have been primarily concerned with clotrimazole because of our own investigations and impartial comparisons with other fungicidal drugs. Studies of patient compliance have shown that the diseased women accept short-term therapy most readily. However, appropriate control examinations are needed to document the results of treatment.

Epidemiology and the prevention of peripartal mycoses

About 30% of all pregnant women are affected by antepartal vaginal yeast contamination. During the past 40 years this incidence has remained unchanged throughout the world. Due to the close contact of the baby with the contaminated area during parturition, yeasts are transmitted to the skin surface of the newborn. Yeasts are still demonstrable in more than 10% of all newborn on the 5th day of life. All newborn presenting yeast contamination on the 7th day of life are likely to develop a clinically manifest thrush by the end of the 2nd week of life. If the yeast contamination is acquired at a later stage, the risk of infection is much lower. Extensive mycological examinations of the newborn nursing staff and of the environment of newborn have not indicated any causal relationship to contamination. The yeast reservoir of the maternal vagina may therefore, in the majority of cases, be regarded as the cause of perinatal thrush which affects about 13% of all newborn by the 4th week of life. A prophylaxis of neonatal thrush should thus be carried out before parturition. Both the incidence of vaginal and neonatal yeast contamination can be reduced by more than 60% by a general mycological examination of all pregnant women between the 34th and 36th week of pregnancy and treatment of a possible yeast contamination with a local antifungal.

Epidemiology of an outbreak in a maternity unit of infections with an antigenic variant of Echovirus 11

After an 8-day-old child had died with clinical signs of septicemia, 6 other newborns fell ill. Virus was isolated from various sites from all the 6 children (28 isolations). The agent was identified by cross neutralization tests as an antigenic variant of Echovirus 11. The agent could not be isolated from mothers or nursery staff (49 people). We therefore tried to trace the path of infection by isolating specific IgM and IgG antibodies. A laboratory infection by the agent isolated enabled the time pattern of the serologic immune response to be roughly determined. The data collected indicate that the infection spread through close contact between the affected newborns and nurses working in the newborn room. Rigorous hygienic and isolation measures, initiated immediately, appeared to interrupt the spread of infection.

Mammary mycoses

Since 1969 we have had at our hospital a special consulting room for mammary gland diseases in which we have so far seen more than 17,000 patients. Mycoses are a rare disease of the mammary glands. We are reporting below on the incidence of this disease, the mode of infection and the diagnostic possibilities within the framework of our special clinic.

The influence of group B streptococcal-carriership on pregnancy outcome

762 women were screened for GBS-carriership in the first trimester of pregnancy. The mean age of carriers was 27.2 years. Follow-up was performed in 64 initially positive and 97 negative cases. Persistent carriership was the most important determinant for neonatal GBS-acquisition. Race, birth-weight, gestational-age, interval between rupture of the membranes and birth could not be associated with GBS-carriership or neonatal acquisition. The number of neonates with fetal distress was significantly higher amongst those born to all GBS-carriers; the number of S.G.A.-infants was significantly elevated amongst those born to permanently positive women. Vertical transmission was found in 86% of the mother-infant pairs. GBS serotype III and Ib were predominant. Serotype III was significantly more isolated from non-caucasian women. The transmission frequency of all types was equal (46%), except for type IIc (22%). None of the serotypes was especially associated with fetal distress or smallness for gestational age.