Staphylococcus aureus bloodstream infection in neonates is associated with a high risk of mortality. The aim of this study was to describe the incidence and epidemiology of Staphylococcus aureus bacteraemia in our unit. We retrospectively reviewed Staphylococcus aureus bloodstream infections in our neonatal unit at the Rotunda Hospital, Dublin, Ireland over a 7-year period using both laboratory and clinical data. We noted a high incidence of methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia of 7.3 per 1,000 admissions. The majority of these (89%) were hospital-acquired and the source was deemed to be venous catheter-related in 47% neonates. Several measures were instituted to address the issue of MSSA bacteraemia on the unit including the introduction of line care bundles and screening for MSSA with decolonisation of carriers. Conclusions: We observed a high incidence of MSSA bacteraemia in our unit correlating with an increasingly busy unit and sub-optimal staffing levels. Root cause analysis revealed inadequate documentation of venous catheter insertion and line maintenance. There was a reduction in the number of MSSA bacteremias in 2010 following multiple interventions. Continued surveillance will reveal in time whether the observed reduction in the number of MSSA bacteremias is sustained.

Background: Early detection of Congenital Toxoplasmosis (CT) may improve neurological outcome and reduce chorioretinitis. Aim: To assess feasibility of newborn CT screening & determine CT incidence. Methods: Beginning 7/05, a 2 year pilot screening programme of consented testing was added to the national newborn screening programme using dried heel blood spots obtained 72 -120 hours after birth. A quantitative toxoplasma IgM assay was 1st performed, if > predetermined value, an ISAGA IgM was performed. Screen positive cases were confirmed with paired mother/infant serology. Confirmed CT infants underwent detailed evaluation and received 1 year anti-protozoals. Screening failure rate will be determined by cases referred to the paediatric infectious diseases service. Results: From 7/05-7/07, 144 564 infants were screened, 363 (0.25%) opted out. 34 required confirmatory serology. CT was confirmed in 15/34 infants; 13 asymptomatic, 2 symptomatic (1unilateral absence of central vision and fixation, & 1 congenital hydrocephalus). 4/13 asymptomatic cases had CT related abnormalities: 2 unilateral retinitis (1 with subsequent ocular reactivation), 2 bilateral retinitis & intracranial calcification. 14/15 confirmed cases commenced treatment. 1 infant with equivocal early serology, negative by Western Blot at 3 months, had CT confirmed at 1 year with persistent IgA and increasing dye test. 15/19 false positive results were attributed to prior maternal infection and confounding maternal antibody. 4/19 had no serologic evidence of maternal infection. Conclusion: 15 infants had CT; 1 in 10 000, 2 (13%) were symptomatic. CT screening can be successfully added to existing newborn screening programmes. No screen failure case was identified.

Background: Early detection of Congenital Toxoplasmosis (CT) may improve neurological outcome and reduce chorioretinitis.

BACKGROUND:Streptococcus pneumoniae is an important cause of childhood illness. Recently a safe and effective 7-valent conjugate pneumococcal vaccine for children has been licensed in the EU.AIMS:To calculate the incidence of invasive pneumococcal disease (IPD) in children in Ireland, to estimate the burden of disease and to anticipate the protective effect of the conjugate vaccine.METHODS:Retrospective review of data from children with IPD.RESULTS:Ninety-six cases of IPD in 95 children including two related deaths were identified. All childhood IPD incidence was estimated at 10.6/100,000. We anticipate that the 7-valent conjugate vaccine could prevent up to 90% of sepsis and up to 82.5% of meningitis cases.CONCLUSIONS:IPD is an important cause of mortality and morbidity in children in Ireland. Routine use of conjugate pneumococcal vaccine would have a significant impact on pneumococcal disease, especially in vaccinated children but also in unvaccinated children and older adults.

Background:Chlamydia trachomatis can cause a sexually transmitted infection, which, untreated, may result in considerable morbidity. Methods: A prevalence study was conducted for C trachomatis using nucleic acid amplification technology in asymptomatic women, and certain risk factors that may be used to direct future screening strategies were assessed. Results: The study population comprised 945 asymptomatic women, of whom 783 were attending antenatal clinics, 91 were attending infertility clinics and 71 were attending family planning clinics. An overall C trachomatis prevalence of 3.7% (35/945) was found, with the highest prevalence of 11.2% (22/196) in Irish single women aged <25 years. Logistic regression analysis showed that single status and age <25 years were independent, statistically significant predictors of C trachomatis infection. Conclusion: These results support routine screening of asymptomatic women who are sexually active and aged <25 years. An opportunist active screening of all sexually active women independent of age should be additionally considered if resources permit.

The aim of this study was to determine the sero-prevalence of cytomegalovirus (CMV) IgG antibody in pregnant women in Ireland and assess individual risk factors for prior acquisition of CMV. In 2002, sera from 1047 pregnant women were tested by enzyme immunoassay for CMV IgG. Age and nationality were recorded for each patient. Among Irish-born women the following additional factors were also recorded: socio-economic status, number of children and occupational exposure to children. Only 30.4% (204/670) of Irish women were CMV antibody positive compared to 89.7% (322/359) of non-Irish women (p < 0.001). Non-Irish women were mostly from Sub-Saharan Africa, Eastern Europe and Asia. Lower socio-economic group and increasing number of children were significant independent predictors of CMV sero-positivity among Irish pregnant women (p < 0.05). Irish pregnant women have one of the lowest reported CMV sero-prevalence rates worldwide, indicating low circulation of CMV within the community. However, up to 70% of Irish women are susceptible to a primary infection during pregnancy.

Varicella-zoster (VZV), rubella (RV) and parvovirus B19 (B19V) infections are important causes of rash illness in pregnancy, due to their potential adverse impact on both mother and fetus. We determined susceptibility to these infections in pregnant women attending our hospital in 2002. Age and nationality were recorded. Sera were tested for VZV, RV, and B19V antibody by enzyme immunoassay. Of 7,980 women screened for VZV IgG, 11.3% were seronegative and therefore susceptible to infection. Across different worldwide regions, 6.9% of Irish and other Western European women were susceptible to VZV, compared to 19.7% of other women tested (p < 0.001), most of whom were from Central and Eastern Europe, sub-Saharan Africa and Asia. Of 7,872 women screened for RV IgG, 2.3% were seronegative. Few Irish (0.6%) or other Western European women (0.7%) were rubella non-immune, but 5.5% of women from other regions tested were susceptible to rubella (p < 0.001). A random subset of 1,048 women were tested for B19V IgG. About 38% were susceptible, varying from 22% to 63% across the different regions studied. There are important differences in immunity to these infections and so of potential risk of an adverse outcome in indigenous and immigrant pregnant women in Ireland.

To test the hypothesis that the infecting meningococcal serogroup modulates the presentation, course, and outcome of invasive meningococcal disease (IMD), we performed a retrospective review of cases of IMD in 407 children from 2 tertiary referral centers and 2 regional centers in Ireland. Patients infected with serogroup C meningococci (n = 104) were older than those infected with serogroup B (n = 303; median, 2.5 vs. 1.5 years; P = .04); all other demographic and clinical parameters were similar for the 2 groups. Among serogroup B patients, mortality was 3.6% and morbidity was 10%; for serogroup C patients, mortality was 4.8% and morbidity was 12.5% (P = .81 and P = .76, respectively). Serogroup C-associated sequelae more often were multiple (P = .003). Despite the introduction of serogroup C conjugate vaccine into the routine immunization schedule of some countries, ongoing morbidity from IMD is anticipated, because group B disease was very similar to group C disease in this pediatric population.

BackgroundHepatitis C virus (HCV) can be transmitted vertically from mother to infant, either late in pregnancy or at delivery.AimsTo determine the outcome of infants bom to HCV infected women, to characterise epidemiology and to design an appropriate infant monitoring schedule.MethodsThree hundred and fourteen infants, born to 296 HCV positive women between 1994 and 1999 were monitored for a median of 18 months (range 1–52).ResultsForty per cent of infants were small for age and 46% had neonatal abstinence syndrome (NAS). Of 173 infants of delned status, 11 were infected (vertical transmission rate [VTR] 6.4%, 95% CI 2.8–10). Infected infants were diagnosed at a median of three months (range 0.5–10). Liver transaminases elevation was documented in 8% of uninfected infants. A negative HCV PCR test before one month of age did not exclude infection but all infected patients had detectable HCV RNA when next tested (range 2–10 months).Conclusions94% of infants bom to HCV antibody positive women are not HIV infected. Liver transaminase elevation in exposed infants is not always indicative of infection. A minimum monitoring schedule of testing (PCR and antibody) at six to eight weeks, six and 18 months allows early diagnosis while detecting late seroconversions.

Routine antenatal testing for hepatitis B carriage with maternal consent was introduced at the Rotunda in January 1998. The uptake of testing has been excellent; 99.98% of women presenting for antenatal care accepted hepatitis B (HBV) screening in the 30-months from January 1998 through June 2000. The prevalence of HBV carriage was 0.35% (58 pregnancies of 16,222 tested) increasing from 0.25% in 1998 (16 of 6227) to 0.45% in the first six months of 2000 (16 of 3484). Fifty-five women had 58 pregnancies (three women had two pregnancies). Two of these were e-antigen positive. HBV carrier status was previously unknown in 48 (87%). Two additional women had acute HBV infection in pregnancy. Forty-five infants have been born to mothers included in this screening programme. Audit of infant outcome reveals excellent compliance with immunisation and follow-up: 29 (64%) have completed the 3 dose HBV vaccination schedule to date. Thirteen infants (31%) are still attending; three are lost to follow-up including one whose family has emigrated. Routine antenatal screening for hepatitis B carriage is cost-effective and should be considered a standard of care in maternity practice.

Background Hepatitis C infection (HCV) has an estimated seroprevalence of 1-2% in women of child-bearing age and vertical transmission rate of 5-15%.Aims To characterise the current trends of HCV in an Irish antenatal population.Methods Infants of HCV seropositive women. born 1994 to 1999, were referred to the Paediatric infectious Diseases service. Maternal details were collected retrospectively.Results 296 HCV seropositive women were studied. 244 (82%) were infected through intravenous drug use (IVDU), 25 (8%) through heterosexual contact and 13 (7%) via blood products. Nine women had no identifiable risk factors. Coinfection with other blood borne viruses was uncommon (4.7% HIV, 3.4% hepatitis B). Of 84 women tested for HCV-RNA, 46 (55%) were positive. Eighty three (26%) delivered prematurely; the caesarean section rate was 11%.Conclusions HCV is increasingly detected in antenatal clinics. Heterosexual contact is a mode of spread. Maternal HCV viraemia can be variable in pregnancy. Further study of HCV in pregnancy is needed to define the impact of pregnancy on HCV, accurately predict infant outcome and selectively target interventions to women at greatest risk of transmission.

The pathogenesis of recurrent tonsillitis is largely unknown. Selection of appropriate antibiotic therapy for patients with recurrent tonsillitis is difficult because of the limitations of traditional methods of sampling tonsillar microflora and the increasing incidence of beta-lactamase producing bacteria in the tonsil. In addition, little attention has been paid to the bacteriology of normal tonsils. The tonsil core bacteria was assessed in 124 patients with recurrent acute tonsillitis. Fifty-five of these patients were randomly selected for fine-needle aspiration which revealed a similar profile of bacteria in 85%. Fine-needle aspiration of 10 normal tonsils found few pathogens; the predominant organisms being normal flora. No Haemophilus influenzae were detected in this control group. This study demonstrates the accuracy of fine-needle aspiration in identifying tonsil core bacteriology and its suitability in the clinical setting. It reports on the flora of normal healthy tonsils and it highlights the association between H. influenzae and recurrent acute tonsillitis.

Two hundred and nine culture confirmed cases of meningococcal disease were reported in the Republic of Ireland in 1995, using a new laboratory based surveillance system. The reported rate of 5.9/100000 population is one of the highest in western Europe, but the rate differed widely between regions. Fifty-three per cent of cases were female. Half of the cases occurred in four months (January, February, March, and December). Nineteen cases (9%) died. The highest age specific incidence was in infancy (under 1 year). Infections with serogroup B accounted for 105 cases (54%) and serogroup C 87 cases (45%). We estimate that up to 30% of cases of meningococcal disease may be preventable when conjugate meningococcal group C vaccines become available, but cost benefit analyses will be required to determine how they should be employed.

The minimum inhibitory concentrations (MICs) of cefaclor, co-amoxiclav, clarithromycin and ciprofloxacin for 59 strains of vaginal lactobacilli were determined by both the reference agar dilution and E test methods. With the exception of clarithromycin, there was poor correlation between the results obtained by the two techniques. This was most apparent for the beta-lactams studied, the MICs of cefaclor as determined by the E test being particularly difficult to define. The stability of antimicrobial gradients in the E test may cause problems when testing slow-growing bacteria and/or organisms which grow only under anaerobic conditions. Accordingly, only those MICs determined by the agar dilution method are reported. The percentages of susceptible isolates were as follows: clarithromycin, 100; co-amoxiclav, 100; cefaclor, 20; and ciprofloxacin, 4. The administration of antimicrobials, such as ciprofloxacin and cefaclor, which have poor activities in vitro against lactobacilli, may therefore be advantageous to the host because it allows the protective effects of the normal vaginal flora to be preserved.

Invasive aspergillosis in now the second most common mycosis encountered in patients with cancer, particularly those with haematological malignancies. The present review discusses strategies for the chemoprophylaxis of invasive pulmonary aspergillosis. Recommendations for chemoprophylaxis are currently based on the particular fungal pathogens seen in individual centres and the resources available. In many units, only BMT recipients are nursed in protected environments and the majority of patients at risk of invasive mycosis, i.e. patients undergoing remission induction or consolidation therapy, are nursed on open wards. The studies so far reported have included relatively small numbers of patients and provide insufficient data for definitive recommendations. The measures used at present should be considered as ad hoc approaches for use in units in which spore-free air for profoundly neutropenic patients is lacking. Nebulized amphotericin B allows deposition of a chemical barrier throughout the airways. Intravenous low dose amphotericin B would be protective when invasion occurs and is clearly the chemoprophylaxis of choice in patients with an established diagnosis of previous invasive aspergillosis at any site. The role of surgery in removing a focus of infection before further chemotherapy, should not be overlooked. The potential role of cytokines in accelerating host defence recovery may in future also prove to be important in controlling invasive fungal infection.

The impact of 7 days pre-tonsillectomy antibiotics on the aerobic bacterial content of the tonsil was studied in 70 consecutive patients. One group received no antibiotic, one group received pre-operative amoxycillin and the final group, pre-operative cefaclor. The qualitative bacteriology was similar in the three groups Haemophilus influenzae was the predominant isolate present in the centre ('core') of the resected tonsil. Similar numbers of beta-lactamase producers including H. influenzae and Straphylococcus aureus were found in all three groups. Quantitative bacteriology of the tonsil core demonstrated that there was a significant reduction in core tonsil pathogens associated with antibiotic therapy. The most statistically significant difference was between the untreated control group and the cefaclor treated group. We conclude that in patients with established recurrent acute tonsillitis, oral antibiotics penetrate the diseased tonsil and influence the predominant core aerobic microflora.

The value of pernasal swabs and direct adenoid swabs in chronic adenoid and adenotonsillar disease was assessed in 175 patients. Prior to adenoidectomy (53 patients) or adenotonsillectomy (122 patients), pernasal and direct adenoid swabs were taken. Adenoid currettings and tonsil tissue were cultured. Haemophilus influenzae was the bacterium most frequently isolated from adenoid currettings and from the centre (core) of the resected tonsil. There was a close relationship between the bacteriology of the pernasal swab and the adenoid tissue and tonsil core in 72 and 71% of patients, respectively. There was an identical profile of pathogens in 52 and 49%, respectively. We suggest that in children with adenoiditis or adenotonsillitis and hypertrophy of the adenoid, a pernasal swab should be used in preference to a throat swab in selecting appropriate antimicrobial therapy. Penicillin and ampicillin are not appropriate blind therapy in chronic adenoid and adenotonsillar infections because of the prevalance of β-lactamase-producing aerobes (40%) in adenoid and tonsil core in these conditions.

The precise molecular mechanism of Staphylococcus aureus beta-toxin inactivation by the serotype F triple-converting phage phi 42, phi A1 and phi A3 was investigated. Sequence analysis of the phi 42 (attP) and Staphylococcus aureus (attB) attachment sites and the left (attL) and right (attR) chromosomal/bacteriophage DNA junctions of individual lysogens, each harbouring a triple-converting phage, revealed the presence of a common 14-bp core sequence in all four sites. These findings indicate that the genomes of the triple-converting phage integrate into the 5'-end of the beta-toxin gene (hlb) by a site- and orientation-specific mechanism identical to that previously described for the serotype F double-converting phage phi 13.

A diagnosis of gastrointestinal infection with Yersinia frederiksenii was made in a 24-year-old female hospital doctor, resident in hospital. An additional three of nine medical residents screened were found to be faecal carriers of Y. frederiksenii. The latter three residents denied any gastrointestinal symptoms. Screening of 25 resident nurses and 25 in-patients for carriage of Y. frederiksenii was negative. Initial investigation revealed that the medical residents frequently drank unpasteurized milk, which was supplied on the understanding that it would be used for cooking only. Counts of > 108 cfu 1−1 were obtained from unpasteurized milk samples, including 24 species of Gram-negative bacilli. Yersinia spp. were not isolated. Residents also drank water from the cold taps in the bedrooms; this water was supplied by a holding tank on the hospital roof. Subsequent investigations revealed that three of the 21 holding tanks supplying stored water to the hospital were not covered. Y. enterocolitica was isolated from the uncovered water tank supplying the medical residence.