CHAPTER 9

CONTENTS

Bacteria 283
Fungi 293
Protozoa 294
Viruses 296

B a c te ria

1. B acteria
• A re prokaryotic (i.e. have no m em brane-bound organelles)
• Can be classified into 3 main groups (Box 9.1)

B ox 9.1 Bacterial groups

G ra m sta ina b le A cid -fa st b acilli U nusual

Gram positive • Cell w all has high lipid • Have no peptidoglycans

Gram negative content w hence d ifficult to (e.g. Chlamydia, Mycoplasma)
Gram variable (Gardenella stain (e.g. Mycobacteria,
vaginalis, Mobiluncus) :. Norcardia)

• A re visible by light m icroscopy (average diam eter = 1 pm)

• Have a cell wall which is m ade up o f
i. N-acetyl glucosamine/muramic acid
ii. Peptidoglycans (M u r e in )
■ Have penicillin-binding sites
■ A re th e targ et fo r [i-lactams
iii. Polypeptides
iv. Polysaccharides

2 . T axon om y
• By shape
i. Bacilli (rods)
ii. C o cci (grains)
• By 0 2 requirem ent
i. A erobes
ii. A naerobes
 284 C h a p te r 9 Microbiology ' 1

• By sp o re forming
• By staining

3. Anaerobe organisms can be classified into 2 types

• Facultative anaerobes, which are capable o f aerobic respiration if 0 2 is present
• O bligate anaerobes, which die in th e presence o f 0 2

4. G ram stain
• Process involves
i. Staining with crystal violet
ii. Then staining with G ram ’s Iodine
iii. Decolourizing with aceton e
iv. Counter-stain with methyl red
• Gram -positive bacteria
i. Stain blue — retain crystal violet stain
ii. Stain due to peptidoglycan - a thick polysaccharide co at that loses stain very slowly once
taken up
iii. Include (Box 9.2)

Box 9.2 Examples o f gram positive bacteria

Staphylococcus (form chains) Clostridium

Streptococcus (form grape-like clusters) Corynebacterium
Listeria
Bacillus
Actinomycetes

Gram -negative bacteria (Fig. 9.1)

i. Stain pink because th e cell wall is thinner and does no t retain th e crystal violet dye, so it
takes up th e methyl red stain
ii. Cell wall consists o f
■ O u te r layer o f LPS
■ Periplasmic layer containing p-lactam ase

Figure 9.1 G ram -negative bacteria nom enclature

 ■ Inner peptidoglycan layer
iii. Gram -negative bacilli include
* Haemophilus influenzae
■ Klebsiella pneumonia
* Legionella
* Pseudomonas aenjginosa
* Escherichia coli
■ Proteus mirabilis
■ Helicobacter pylori
■ Salmonella typhi
■ Campylobacter
iv. Can also be divided based on lactose ferm entation (B o x 9.3)

B ox 9.3 Gram negative bacteria classification according to lactose ferm entation

Lactose fe rm e n te rs (o range on M c C o n ke y agar) L acto se n o n -fe rm e n te rs (p in k o n M cC o n k e y agar)

• Klebsiella • Pseudomonas
• ' Ebc ‘ : ' 1 • Salmonella
• Enterobacter • Shigella
• C itrobacter • Yersinia
• Salmonella
• Helicobacter pylori
• Proteus

5. Bacterial toxins consist o f 2 types

• Exotoxins
i. Se creted by organisms
ii. A featu re o f Gram -positive and Gram -negative bacteria
iii. Form toxoids o
• Endotoxin
i. Released on cell death and lysis
ii. A feature o f Gram -negative bacteria
iii. T h e main form s is lipid A from LPS

6. Bacterial antimicrobial resistance occurs via

• Bacterial m echanisms o f antimicrobial resistance
i. Drug inactivation (e.g. production o f p-lactam ases)
ii. A lteration o f drug targ et site (e.g. alteration o f penicillin-binding sites)
iii. Bacterium m etabolic pathway alteration
iv. Fibronectin co at
v. IgA cleaving p rotease
• Mechanisms o f transfer o f antimicrobial resistance
i- Horizontal gene transfer
ii. Vertical gene transfer
• Mechanisms o f horizontal gene transfer
i- Plasmid DN A transfer
ii. C hrom osom al mediated resistance
iii. Bacterial conjugation

' Vaginal flo ra is influenced by o e stro g e n levels co n tribu tin g to

• Increased vaginal glycogen concentration
• pH 3 .S -4 .5 due to conversion o f glycogen to lactic acid by lactobacilli
 286 C h a p te r 9 Microbiology________ _________ ___________________ _

8. Clinical isolation o f bacteria

• U se o f specific m icrobiological swabs
• Storage at 4 °C
• Preliminary laboratory rep ort takes 18 h
• Identification is via d etection o f
i. Antigens
ii. Antibodies
iii. Nucleic acids

E xam ples o f G ram -positive organisms

1. Streptococcus - general facts
• Many are facultative anaerobes
• T hey can be Staff = Cat
i. Catalase negative
ii. O xidase negative
• Form chains
• Divided into 3 groups based on levels o f haemolysis when cultured on horse blood agar
(Box 9.4)

B o x 9.4 Strep to cocci classification according t o haemolysis when cultured on horse blood agar

N o n -h a e m o ly tic B P a rtia l h a e m o ly tic ( a ) I C o m p le te h ae m o lytic ({'})

'• E faecalis • S. viridans • G roup A, C, and G

• Enterococcus • G roup B
• Pneumococcus • G roup F

2. P-haemolytic streptococci are subdivided by Lancefield grouping ( A -O )

• G roups A, C, and G are associated with
i. T oxic shock syndrome
ii. Necrotizing fasciitis
iii. Vaginitis
• Group B is associated with
i. Chorioamnionitis
ii. N eonatal sepsis
iii. Endometritis
• Group F - can cause abscesses

3. G roup A streptococcus
• Also known as Streptococcus pyogenes
• Virulence factor is determ ined by th e presence o f
i. M protein
ii. Hyaluronidase
iii. Streptokinase
iv. D N A se
v. Superantigens
• M-protein is
i. A fimbrial protein
ii. Involved in capsule form ation
iii. Is anti-phagocytic
iv. Involved in destroying C 3 convertase and preventing opsonization by C 3b
v. Responsible fo r organism adhesion and invasion
 • Causes
i Scarlet fever
jj T oxic shock
jjj_ Rheumatic fever
iv. Glom erulonephritis
v. Necrotizing fasciitis

4 Group B s tre p to c o c c u s (G B S )
• Also known as Streptococcus agalactia
• Maternal carriage
■ IT i- 2 0 -3 5 % carry GBS
ii. Interm ittent carriage
• Fetal
j. Maternal to fetal colonization rate = 80%
ii. Invasive neonatal disease occurs in 0.5 : 1000 births
iii. N eonatal m ortality from early-onset GBS disease in UK is 6%
• Indications fo r antibiotic prophylaxis during labour (following a risk-based
approach)
i. Early-onset G BS disease in a previous baby
ii. GBS found in vagina/urine during index pregnancy
iii. Prolonged rupture o f m em branes at term (> 1 8 h )
iv. Preterm labour < 3 7 com pleted w eeks o f gestation
v. Preterm rupture o f m em branes with known GBS
vi. Intrapartum pyrexia
• Antibiotic regimens
i. Benzylpenicillin
■ 3 g i.v. loading d ose follow ed by
■ Benzylpenicillin 1.5 g i.v. 4 hourly until delivery
ii. Clindamycin 9 0 0 mg i.v. 8 hourly until delivery
iii. Erythromycin 5 00 mg 6 hourly until delivery
iv. Vancomycin as a very last resort

5. Streptococcus pneumoniae
• Is a diplococcus (form s pairs)
• Forms draughtsman-shaped colonies
• Is optochin sensitive
• Is bile soluble
• Causes
i. Meningitis
ii. Pneumonia
iii. Primary bacterial peritonitis (in prepubertal girls)

Enterococcus genus
• Consists o f 2 species
i. Enterococcus faecalis
ii. Enterococcus faecium
• A re gastrointestinal com m ensal organisms
• A re resistant to many antimicrobials
• Causes
i. Endocarditis
ii. Proctitis
• Can be haemotytic o r non-haemolytic - used to be classified as group D
 288 C h a p te r 9 Microbiology .
7. Listeria monocytogenes
• A ffects 1 : 1 0 0 0 0 pregnant wom en
• Som e strains are (3-haemolytic
• Produces flagella at room tem peratu re but not at 37 °C
• Causes - listeriosis
i. Meningitis
ii. Hepatosplenom egaly
iii. Bradycardia
• T ransmitted
i. In contam inated food
ii. T o the fetus via
■ Transplacental spread
■ Ascending infection
• In th e placenta causes
i. Miliary granuloma
ii. Focal necrosis
• Fetal m ortality rate from listeriosis is 50%
• T reatm ent
i. Amoxicillin o r gentamicin
ii. Duration 3 w eeks

8. Staphylococcus
• Is a genus o f facultative anaerobes
• Forms grape-like bunches
• Classified on ability to form coagulase
• Cause
i. Scalded skin syndrom e
ii. T o xic shock
iii. Slime in i.v. cannutae
• M eticillin-resistant Staphylococcus aureus (MRSA) is
i. Coagulase positive
ii. D N A se positive
iii. Catalase positive

9. Actinomycetes israelii
• Is
i. An anaerobe
ii. A bacillus
• Show s branching
• Is slow growing
• O ccu rs in
i. Mouth
ii. Intrauterine contraceptive devices (lU C D s)
• Causes chronic granulom atous disease
• Produces sulphur granules in tissues
• T reatm en t
i. Penicillin
ii. Requires 6—12 m onths antibiotic therapy

E xa m p le s o f G ra m -n e g a tiv e /v a ria b le organisms

1. Neisseria family
• A re diplococci
 • Cause
i. Meningitis (N. meningitidis)
ii. G on orrh o ea (N. gonorrhoeae )
• Are capnophitic (i.e. thrive in th e presence o f high C 0 2)
• T reatm en t = cephalexin
• Multidrug resistance is growing

2. Gonorrhoea
• Infects m ucous m em branes o f
U rethra
ii. Endocervix
iii. Rectum
iv. Pharynx
V. Conjunctiva
• Can infect Bartholin’s gland
• T reatm ent
i. IM ceftriaxone 250 mg stat
ii. O ral cefixim e 400 mg
iii. IM spectinom ycin 2 g
• A te st o f cu re should be done 3 days after treatm en t
• 40% will also have concu rren t Chlamydia
• Com plications
i. G on oco ccal ophthalmia neonatorum
ii. N eonatal vaginitis, proctitis, and urethritis
iii. Disseminated g on ococcal infection

3. Gardnerelta vaginalis
• Is a facultative anaerobe
• Is Gram variable
• Is a bacillus
• Is a normal com m ensal organism o f th e vagina
• Is P-haemolytic

4. B acterial vaginosis (BV )

• Polymicrobial condition o f th e vagina characterized by
i. Variable degrees o f depletion o f protective Lactobacillus species
ii. Marked increase in th e population o f o th e r organisms especially anaerobes including
G. vaginalis, Mobincullus, and Atopobium vaginale
• O v er 60% o f affected w om en are asymptomatic
• Aetiology is unknown
• A ssociated with m id-trim ester miscarriage, preterm birth, rupture o f m em branes,
endom etritis
• More com m on in black w om en
• Amsel criteria fo r diagnosis (require 3 ou t o f 4)
i. Vaginal discharge
ii. Clue cells
iii. pH >4.5
iv. Fishy od ou r with alkali (10% KOH ) on a w et m ount (whiff test)
• Hay/Ison criteria (is based on Gram stain o f vaginal discharge)
i- G rade 1 = normal flora (predominantly lactobacilli)
ii- G rade 2 = mixed flora
iii. G rade 3 = BV and absent lactobacilli
 290 C h a p te r 9 Microbiology_____________________ _________ ________ ■
.

• Clinical features
i. Fishy smelling vaginal discharge (w orse a fte r intercourse)
ii. W h ite o r grey vaginal discharge
• T re a tm e n t = m etronidazole 400 mg b.d. fo r 7 days

5. Syphilis
• Is caused by th e spirochaete Treponema pallidum
• Classification
i. Early - includes prim ary, secondary and early la te n t stages (i.e. < 2 years o f infection)
ii. Late - includes late la te n t and te rtia ry stages (i.e. > 2 years o f infection)
• Stages
i. Prim ary - chancre r ^ p r s 10—90 days after initial exposure (persist 4 -6 weeks before
disappearing)
ii. Secondary - occurs 1 -6 m onths post prim ary infection
■ Sym m etrical non-itchy rash on tru n k and
■ C ondylom ata latum
■ Mucous patches around genitals o r m outh
iii. T e rtia ry - occurs 1-10 years a fte r initial infection
■ Characterized by th e fo rm a tio n o f gummas
* Neurosyphilis - tabes dorsalis; generalized paresis o f th e insane; A rg yll Robertson
pupil
* de Musset’s sign Q
o
M icrobiological identification
i. C annot be cu ltu re d in lab
ii. Serology is indistinguishable fro m
■ Yaw
■ Pinta
iii. D iffic u lt to differentiate betw een active and trea te d past infection o f syphilis
iv. N on-specific te st
■ Venereal Disease Research Laboratory (VDRL)
■ Rapid plasma reagin (RPR)
■ W asserm an’s reaction
■ H in to n ’s te st
v. Specific tests
■ Fluorescent trep o n e m a l antibody-absorption te st (FTA-ABS)
* Treponema pallidum particle agglutination assay (TPPA)
vi. Serology progress: IgM/FTA-ABS —» IgG —» TPPA —» VDR L
vii. Fatse positives in non-specific tests o ccu r in
■ Viral infections
■ Lymphoma
■ Tuberculosis
* Malaria
* Chagas’ disease
■ Pregnancy
Causes endarteritis obliterans
T reatm ent
i. Penicillin G
ii. D oxycycline
• The Jarisch-H erxheim er reaction is com m on post tre a tm e n t i—-

6 . Mycoplasma hominis i-_ _

Present in 20 % o f sexually active w om en
Can be e ith e r a p rim ary o r a co-pathogen in pelvic inflam m atory disease (PID)
 Bacteria 291

• Can cause postpartum pyrexia No cell wall

• Can be a co-pathogen in chorioam nionitis
• T re a tm e n t
i. D oxycycline
ii. Clindam ycin
iii. Resistant to macrolides
o
7 . Chlamydia trachom atis
a Is an obligate intracellular grarr\ negative organism
• Has 3 subgroups
i. A - C (follicu la r conjunctivitis)
ii. D - K (genital)
iii. L1-L3 (lym phogranulom a venereum )
• Contains b o th D N A and R N A
o G row s on M cC oy’s culture
9 Lifecycle
i. Is 72 h
ii. Elementary body —s> Reticular body —» Inclusion body
• T re a tm e n t
i. A zith ro m ycin Macro
ii. D oxycycline
iii. Erythrom ycin M a c ro
iv. O flo xa cin Cipro (Quinolones)
v. Rifampicin
• Test o f cure is only recom m ended in pregnant o r breastfeeding w om en

8. Vaginal discharge in c h ild re n can be caused by

• Foreign body (which is th e com m onest cause)
• Streptococcus pyogenes
• Haemophilus influenza
® Shigella sonnei
• Pinworm s
• Chlamydia
® Neisseria gonorrhoeae

W ound in fe ctio n
1. Typically require 105 organisms to establish

2- In the presence o f a foreign body 103 organisms are required

N e cro tizin g fasciitis

1- Consists o f 2 types

2. T ype 1
® Is associated w ith surgery/diabetes
• Is due to polym icrobial infection
i. Anaerobes
ii. Facultative anaerobes
iii. O bligate anaerobes

T ype 2 - due t o G ro u p A stre p to co ccu s

T re a tm e n t
® Surgical d e b ridem ent
• A n tib io tic com bination
 292 Chapter 9 Microbiology

i. BenzylpeniciUin 1.2g i.v. q.d.s.

ii. Clindam ycin
iii. C ip ro floxa cin
Surgical re-e xp lo ra tio n o f th e wound

PID
1. C lin ic a l m an ife sta tio n s include
• Pelvic a n d /o r abdom inal pain
• Dyspareunia
® Post-coital bleeding
• Discharge
e Cervical tenderness
« Fever

2. C o m p lic a tio n s
® Ectopic pregnancy
• Tubal in fe rtility
i. 12 % a fte r 1 st episode
ii. 20 % a fte r 2 nd episode
iii. 50% a fte r 3rd episode
• C h ron ic pelvic pain
• F itz -H u g h -C u rtis syndrom e (i.e. rig ht upper quadrant pain and perihepatitis - occurs in 15%
o f w om en w ith PID)
o
3. Causative organisms include
• Chlamydia
• Neisseria
• Mycoplasma
i. hominis
ii. ureaplasma
• Gardnerella
• Trichomonas vaginalis
• GBS

4. Treatm ents regimens (Fig. 9.2)

IV cefoxitin 2g t.d.s. + IV IV clindamycin 900 mg t.d.s.

doxycycline 100 mg b.d.
O floxacin 400 mg b.d +
fo llo w e d by o ra l doxycycline
m etronidazole 400 mg b.d.
100 mg b.d. + oral
(14 days)
m etronidazole 400 m g b.d.
(14 days)
+ IV gentam icin (2 mg/kg
loading dose fo llo w e d by
1.5 mg/kg t.d.s.) follo w e d by
o ra l clindamycin 450 mg
q.d.s. (14 days)

IM ceftriaxone 250 mg stat

IV ofloxacin 400m g b.d. + IV
follo w e d by o ra l doxycycline
m etronidazole 500 mg t.d.s.
100 m g b.d. + m e tronidazole (14 days)
400 m g b.d. (14 days)
tk d . v ' , v . . *' . - __ _

Figure 9.2 PID tre a tm e n t regimens

R e i t e r ’s syndrom e
j Is a reactive arthritis caused by bacterial infection

2 C au sative o rga n ism s include

• Salmonella
• Yersinia
0 Shigella
• Campylobacter
• Chlamydia
• N . gonorrhoeae

3 Clinically m anifests as a triad o f

• U re th ritis
• A rth ritis aseptic
• Uveitis

Fungi

1 . A re m u ltic e llu la r e u k a ry o tic organism s

1. C e ll w alls
• Have no peptidoglycans
• Contains ergosterol

3. A re e u k a ry o tic (i.e. have m em b ran e -b o un d organelles)

4. C o ntain
e Fibrils
® Chitins
® Mannan
• Glucan

5. A re a e ro b ic

6. R eproduce via b o th asexual and sexual m e th o d s

7. Secrete keratinase

8. 4 m ain g ro u p s (Box 9,5)

Box 9.5 Fungal groups

T ru e yeast

• Multicellular ® Unicellular ® Example: Candida ® Grow s as yeast at

• Grows as branching
filam ent (hyphae/
mycelia)
* Reproduces by spores
® Example: Aspergillus
• Reproduces by 37 °C
budding ® Grow s as mycelia at
® Example: Cryptococcus 20 °C
® Example: Histoplasma
 294 Chapter 9 Microbiology ' :5

P ro to z o a

1. Protozoa are unicellular, eukaryotic, free-living organisms

2. Consist o f 2 types
• Protozoa
• H elm inths

3. Include
• Trichomonas vaginalis
• Toxoplasma gondii
• Giardia
• Cryptosporidium
• Plasmodium

4. Reproduction can eith er be asexual o r sexual

5. Methods o f asexual replication include

• M erogony (also know n as schizogony)
• Sporogony
• Endodyogeny
• Endopolygeny

6. Form
• T ro p h o zoite s (the p ro to z o o n p roliferative stage w ith in th e host cell)
• Schizonts
• Sporozoites (the cell fo rm th a t infects new hosts)
• M erozoites (re su lt o f m erogony th a t occurs w ith in th e h o st cell)
• Bradyzoites
• Tachyzoites
• O ocysts
• O okinetes (the fe rtilized zygotes capable o f m ovem ent)

7. Helminths are divided into 3 groups

• Fluke (tre m ato d e )
• Tape (cessatode)
• Ring (nem atode)

8 . T. vaginalis
• Is a flagellate p ro to z o o n
• Transmission is venereal
• Diagnosed via
i. W e t prep
ii. Polymerase chain reaction (PCR)
iii. C u ltu re
• Symptoms include
i. Discharge
ii. Intense vulvo-vaginat itching and irrita tio n
iii. S traw berry cervix
iv. Preterm delivery
• T re a tm e n t is w ith m etronidazole o r tinidazole

9. T. gondii
• Is a z o o n o tic infection (predom inantly via felines)
• Diagnosis
 . ■ ... r k l£ .. ‘ . fii - ■ ■' r - ' V . r ' , ' v"- ■ - ■
____________________ ■■ -________________________________ Protozoa 295

i. IgM /A avidity
ji. Serial samples taken 3 weeks apart
• Affects
i. Muscle
ii. N e u ra l tissue
iii. Placenta
• Transm ission in pregnancy
j. Is via transplacental in p rim ary infection
ii. G reatest risk = 26-AO weeks
iii. Low est risk = 10-24 weeks
iv. T he e arlier the infection occurs in pregnancy the m ore severe th e disease in the
new born
• M aternal risk
i. C h o rio re tin itis
ii. Encephalitis
® C ongenital infection causes
i. Stillbirth
ii. Cerebral calcifications
iii. M icrocephaly/hydrocephalus
iv. C h o ro id o re tin itis
V. Cerebral palsy
vi. Epilepsy
vii. Hepatosplenom egaly
viii. T hrom bocytopenia
« T reatm ent
i. Spiramycin
ii. Sulfadiazine/pyrim etham ine/folinic acid
• T oxoplasm a IgM persist fo r 3 years a fte r eradication

10. Malaria
• Is a m osquito-borne (female Anopheles m osquito) infectious disease
® infects red blood cells
• Caused by Plasmodium
i. falciparum
ii. vivax
iii. ovale
iv. malariae
v. knowlesi
• Severe malaria is defined as parasitaemia o f m ore than 2%
• M aternal clinical features include
i. Fever
ii. Respiratory distress and pulm onary oedem a
iii. A rthralgia
iv. Retinal damage
V. Splenomegaly
vi. Hepatom egaly
vii. Haem oglobinuria and renal failure
viii. Biochemical abnorm alities
■ Hypoglycaemia
■ Anaemia
■ T hrom bocytopaenia
[ 296 Chapter 9 Microbiology

B o x 9.6 Management o f malaria

V e c to r c o n tro l

Insecticides (D D T , perm ethrin) Mefloquine

Mosquito nets Doxycycline
Skin repellents (50% DEET) Malarone
Quinine

■ Acidosis
* Hyperlactataem ia
ix. Com a
x. Convulsions
xi. M o rta lity (20% in non-pregnant w om en and 50% in pregnant w om en)
Fetal effects o f malarial infection include
i. Miscarriage
ii. Stillbirth
iii. Premature labour
iv. Low b irth w eight
v. Placental parasitaemia
Diagnosis is made via thin and th ic k blo o d film s
Management (Box 9.6)

' " j?
V iru se s

1. G e n era l facts
• Viruses have no organelles
• They depend on th e ir host fo r
i. Energy m etabolism
ii. Protein synthesis
• T h e ir genetic m aterial is in th e fo rm o f e ith e r (Box 9.7)
i. R N A
ii. D N A
• Have a viral coat = capsid
• Fetal transm ission rate generally increases w ith gestational age
• Incubation p e riod fo r m ost viruses is approxim ately 21 days

Box 9.7 Examples o f viruses according to genetic m aterial type

Rubella Herpes
HIV Parvovirus
Hepatitis A, C, D, E, G HPV
H epatitis B
EBV
CMV
VZV

2. Herpes is a virus family consisting of

• C ytom egalovirus (CM V)
• Herpes simplex
• Varicella
 CM V
50 - 80% w om en are seropositive dormant i.e. 90% are Asx
Feto-m aternal transmission rate = 40% (increases w ith gestational age)
Causes sym ptom s in 10% o f infected infants
Causes congenital defects
Hearing loss - sensorineural responsible for 10% of MR
Retinitis
C erebral palsy
reactivation and reinfection are common
Hepatosplenom egaly
Transmission : sexual, BT, lactation
Hyperbilirubinaem ia
Intracranial calcification
Advanced GA and 1ry inf a risk of NN dis
vii. T hro m b o cyto p e n ia
viii. In trauterine FGR
Dx : 1ry inf by significant rise in IgM
ix. M icrocephaly
• C M V IgM persists fo r m onths/years
which persists for 4-8m, recurrence
• Diagnosis o f m aternal infection by rise in IgG titers over 4-6 wks
i. M aternal IgG avidity
ii. High avidity means o ld infection
• Excreted in neonatal urine = 30%
can be cultured from the urine
4. Herpes sim plex
• 2 types
i. Type 1 - accounts fo r 30% o f genital infections in th e UK (50% in th e USA)
ii. T ype 2 - accounts fo r 70% o f genital infections in th e U K (50% in th e USA)
• Fetal transmission
i. Is high if p rim ary infection o ccurred in th e last trim e ste r w ith a rate >30%
ii. If th e re is a secondary episode during labour, th e transmission rate is 1—3%
• Incubation = 21 days
Dx by culture from the Recurrence : stress, sex,
Affects
i. Skin serum of the vesicles or menstruation but milder
ii. Eyes swabbing base of the and shorter than 1ry inf.
iii. M outh ulcer, serology, fluorescent
iv. CNS
Ab test
High fetal m o rta lity 1
Retative indication fo r caesarean section — presence o f m aternal lesions wi
b irth in th e absence o f Rx : analgesia, in preg oral
x i. R uptured membranes or IV Aciclovir 200mg 5x/d
x ii. Spontaneous ru p tu re o f mem branes (SROM) >6 h
for 5d
5- Varicella zoster
Fetal transm ission (congenital fetal varicella syndrom e) Active 1ry gential herpes a
i. Lim ited t o th e 1st 20 weeks o f gestation
Q 40-50% vertical trans.
ii. O ve ra ll rate = 1%
iii. Rate a t 1—12 weeks = 0.4%
Transplacental trans. □
iv. Rate a t 13—20 weeks = 2%
Fetal varicella syndrom e is characterized by
with GA (50% in last 4
i. C NS anomaly p HA Hydrops wks)
“ M icrocephaly
B C o rtic a l a trophy Dx : VZ Ig in booking visit, if
ii. Lim b hypoplasia immune Ok, nonimmune <20 wk
iii. C icatricial scarring VZ Ig can be given
iv. Eye defects
IgM acute inf (2% risk of CVS)
 298 Chapter 9 Microbiology

■ M icrophthalm ia
■ Cataracts 50% risk of trans (1/3 bbys are affected by clinical
■ c h o rio re tin itis Varicella)
T here is a risk o f neonatal varicella if m aternal infection occurs w ith in 10 days o f delive
M aternal com plications include
i. Pneum onitis (10%)
ii. Encephalitis
iii. Hepatitis
T re a tm e n t
i. If m aternal infection occurs — aciclovir ____ J
ii. If exposed to varicella - prevention o f disease w ith VZIgG administration
iii. VZIgG is n o t beneficial in a patient w ith chicken p o x
Q
6. Rubella
• Is also know n as G erm an measles
• Is a togavirus
• Has a single-stranded R N A genom e enclosed in a capsid
• Spreads via droplets
• C ongenital defects (congenital rubella syndrom e) if acquired during pregnancy include
i. Eye manifestations
■ C ataract
■ Glaucoma
ii. H e a rt defects
■ PDA o
■ VSD
■ Pulm onary stenosis
iii. Sensorineural hearing toss
iv. Haem atological manifestations
■ T hro m b o cyto p e n ic purpura
* H aem olytic anaemia
■ Lym phadenopathy
• Feto-m atem al transm ission rate
i. 1st trim e s te r = 90%
ii. 2nd trim e s te r = 30%
iii. Risk o f transm ission is decreased a fte r 16 weeks
• Causes defects in
i. 1st trim e s te r = 90% o f infected fetuses
ii. 2 nd trim e s te r = 20% o f infected fetuses
iii. >16 weeks = m inim al risk o f deafness only
o
iv. >20 weeks = no increased risk

7. Parvovirus B19 Erythrovirus

• A lso know n as
i. Fifth disease
resp droplet
ii. Slapped cheek syndrom e
iii. Erythema infectiosum
• 60% o f w om en are im m une to parvovirus B19
• Causes
i. Miscarriage (overall risk o f fetal loss = 6-12%)
ii. H ydrops fetalis (3%) —due to fetal anaemia o
• Does n o t cause congenital defects
• The virus attacks P b lo o d group antigen (globiside) on RBCs and fetal heart
Fetal tr a n s m is s io n
j M a in ly in 1 s t t r im e s t e r
jj. R ate = 30%
T re a tm e n t = in tra u te rin e fetal blo o d tra n s fu s io n
|s|ot an indication f o r te rm in a tio n o f pregnancy

V
Is a lentivirus (a member of the retrovirus family)
Primarily infects
j. Th cells (particularly C D 4)
ii. Macrophage
iii. Dendritic cells
Transmission
i. Sexual — risk o f transm ission p e r act (in high risk countries) is
a Female to male = 0.04%
■ Male to male = 0.08%
■ Receptive anal intercourse = 1.7%
ii. (Latex condom s reduce this risk by 85%)
iii. Blood products, i.e.
» Intravenous drug users
® Blood transfusion
iv. Perinatal transmission
v. (H IV have been found in lo w concentration in saliva, tears, and urine — p otential fo r
transmission fro m these is negligible)
Structure
i. Spherical (120 nm diam eter)
ii. C om posed o f 2 copies o f single-stranded R N A enclosed by a capsid
iii. Capsid is
18 Com posed o f viral p ro te in p24
H Surrounded by a m atrix com posed o f viral p ro te in p17
iv. Viral envelope
H Surrounds th e m atrix
B Com posed o f phospholipids and g lyco p ro te in (i.e. gp120 and gp41)
v. G lyco p ro te in enables th e virus to attach to and fuse w ith ta rg e t cells
Prevalence in th e UK antenatal population
i. Average is 0.17% (highest in London - 0.32%, and lo w e st in th e N o rth East and South
W e s t - 0.08%)
ii. A p p ro xim a te ly 1/3 o f infections are due to HIV1 and 2/3 due to HIV2
Fetal transm ission rate
i. W ith o u t tre a tm e n t = 1 5 % (in European o r N o rth Am erican countries)
ii. W ith tre a tm e n t < 1 %
Factors th a t increase vertical transm ission rates
i- High m aternal viral load
ii. Low C D 4 co u n t
iii. Prolonged ru p tu re o f membranes
iv. C horioam nionitis
v. C o -m o rb id ity e.g. malaria, hepatitis C virus (H C V )
vi. Breastfeeding
vii. Preterm birth
Neonatal serology is o f lim ited value as passively acquired m aternal antibodies persist until
18 m onths o f age
AIDS occurs w hen C D 4 co u n t is b e lo w 200/m m 3 blood
| 300 Chapter 9 Microbiology______________________ - ■. ____________- t

• Increases risk o f
i. Miscarriage
ii. Pre-term delivery
iii. Intrauterine FGR
• Com plications include
i. Kaposi’s sarcoma
ii. Pneumocystis carinii pneum onia
iii. N o n -H od g kin ’s lymphoma
iv. AIDS -related dem entia

9. H um an p a p illo m a viru s (H P V )
• Consists o f 5 groups
i. a-papiUomavirus
ii. P-papillomavirus
iii. y-papillom avim s
iv. Nu-papillom avirus
v. M u-papillomavirus
• a-papillom aviruses consist o f 2 subtypes
i. Lo w risk - 6 and 11 (induce non-m alignant changes)
ii. High risk - 16, 18, 31, 33 and 45 (induce m alignant changes)
• O n ly infects epithelial cells
• Structure
i. Is made up o f 75 capsomeres
ii. Each capsomere consist o f 5 m olecules o f L1 co -p ro te in
iii. Contains circular D N A
• G enom e is composed o f
i. Early proteins (E1, E2, E3, E4, E6, E7)
ii. Late proteins (L1 and L2)
• E6 and E7 are HPV proteins associated w ith cancer
• Causes inactivation o f
i. p53
ii. pRB
• Incubation period is 2 -8 m onths
• Regresses spontaneously via cell-m ediated im m u n ity (70% regress w ith in 1 year; 90% regress
w ith in 2 years)
• T reatm ent
i. P odophyllotoxin
ii. Im iquim od
iii. C ryotherapy

( 10. Hepatitis virus

• Types A - G
• H epatitis A - m aternal-fetal transm ission is rare
• Hepatitis B (Table 9.1)
i. Incubation = 6 weeks to 6 m onths
ii. Progress o f antigen detection w ith tim e
■ Surface —> C ore —> e Antigen
iii. A n tib o d y pro d u ctio n chronology (IgM)
■ C o re —> e Antigen —» Surface
iv. Im m unity is confirm ed by anti-surface IgM
v. Prevalence among pregnant w om en in U K = 0.5%
vi. M o th e r to child transmission
 ■ O ccurs via vertical transm ission (includes pregnancy, labour and lactation)
■ T he transplacental ro u te accounts fo r 5% o f transmissions
vii. Feto-m aternal transmission rate
■ Transmission rates depend mainly on th e viral load and on th e antigen p ro file
■ If m o th e r is Hep B surface-antigen positive (HBsAg) = 20%
■ If m o th e r is Hep B e-antigen positive (HBeAg) = 90%
■ Transmissions occurring during the 1st trim e s te r = 10%
a Transmissions occurring during th e 3rd trim e s te r = 90%
viii. T re a tm e n t in pregnancy is possible w ith
■ Interferon a
m Lamivudine
ix. Prophylaxis to a neonate o f a Hep B e-antigen positive m o th e r should be given at birth
H Hep B vaccine
■ IgG
• Hepatitis C
i. Prevalence in U K = 0.3—0.7%
ii. Increases risk o f ob stetric cholestasis
iii. Vertical transmission = 3—5%
• Hepatitis E
i. Risk o f m aternal m o rta lity = 5%
ii. Risk o f fulm inant hepatic failure in pregnancy = 20%

Table 9.1 Hepatitis B serology

Stage o f in fe c tio n HBsAg HBeAg IgM anti­ IgG anti­ Hep B Anti- Anti-
(surface (e Ag) core Ab core Ab virus HBe Ab HBs Ab
Ag) DNA

Acute (early) + + + + + - -

Acute (resolving) + - + + - + /- -

Chronic (high + + /- - + + + /- —
infectivity)

Chronic (low + - - + - + /- —
infectivity)

Immune (90%) - - - + - + /- + /-

Post vaccination - - - - - - +

11. H T LV
• Prevalence in U K = 0.25%
• Feto-maternal transm ission is via breast m ilk
• Manifestations o f congenital infection o ccu r a fte r 10-30 years
i. T-cell leukaemia
ii. Tropical spastic paraparesis