Antenatal pyelonephritis: a three-year retrospective cohort study of two Irish maternity centres.

Pyelonephritis affects 1-2% of pregnant women, and is associated with significant maternal and fetal morbidity. Antenatal pyelonephritis has been associated with PPROM (preterm premature rupture of membranes), preterm labour, low birth weight (LBW) and prematurity. A three-year retrospective dual-centre cohort study of antenatal pyelonephritis cases was conducted in two neighbouring Irish maternity hospitals - the Rotunda Hospital (RH) and the National Maternity Hospital (NMH). Patient demographics, clinical presentation, investigations, management and maternal/neonatal outcomes were recorded. A total of 47,676 deliveries (24,768 RH; 22,908 NMH) were assessed. 158 cases of antenatal pyelonephritis were identified (n = 88 RH, n = 70 NMH), with an incidence of 0.33%. The median age was 28 years. The median gestation was 27 + 6 weeks, with 51% presenting before 28 weeks' gestation. Risk factors included; obesity (18.4%), diabetes mellitus (13.3%) and self-reported clinical history of recurrent urinary tract infection (28.5%). Rate of relapse with UTI in the same pregnancy was 8.2%. Renal ultrasound was performed in 30.4%. Predominant uropathogens were Escherichia coli (60%), Klebsiella pneumoniae (11%) and Proteus mirabilis (5%). 7.5% of cases had a concurrent bloodstream infection, 13.3% of cases were complicated by sepsis and 1.9% with septic shock. Complications including PPROM (6.3%), preterm delivery < 37 weeks' gestation (11%), LBW < 2,500 g (8.2%) were comparable between sites. Delivery within 72 hours of diagnosis was noted in 7% (n = 11) of patients, of which three were preterm and one had LBW. Appropriate and prompt investigation and management of antenatal pyelonephritis is essential given the associated maternal and neonatal morbidity.

The etiology of stillbirth over 30 years: A cross-sectional study in a tertiary referral unit.

INTRODUCTION: Stillbirth remains an often unpredictable and devastating pregnancy outcome, and despite thorough investigation, the number of stillbirths attributable to unexplained causes remains high. Placental examination has become increasingly important where access to perinatal autopsy is limited. We aimed to examine the causes of stillbirth in normally formed infants over 30 years and whether a declining autopsy rate has affected our ability to determine a cause for stillbirths. MATERIAL AND METHODS: All cases of normally formed singleton infants weighing ≥500 g that died prior to the onset of labor from 1989 to 2018 were examined. Trends for specific causes and uptake of perinatal autopsy were analyzed individually. RESULTS: In all, 229 641 infants were delivered, with 840 stillbirths giving a rate of 3.66/1000. The rate of stillbirth declined from 4.84/1000 in 1989 to 2.51 in 2018 (P < .001). There was no difference in the rate of stillbirth between nulliparous and multiparous women (4.25 vs 3.66 per 1000, P = .026). Deaths from placental abruption fell (1.13/1000 in 1989 to 0 in 2018, P < .001) and the relative contribution of placental abruption to the incidence of stillbirth also fell, from 23.3% (7/30) in 1989 to 0.0% (0/19) in 2018 (P < .001). Stillbirth attributed to infection remained static (0.31/1000 in 1989 to 0.13 in 2018, P = .131), while a specific causal organism was found in 79.2% (42/53) of cases. Unexplained stillbirths decreased from 2.58/1000 (16/6200) in 1989 to 0.13 (1/7581) in 2018 (P < .001) despite a fall in the uptake of perinatal autopsy (96.7% [29/30] in 1989 to 36.8% (7/19) in 2018; P < .001). Placental disease emerged as a significant cause of stillbirth from 2004 onwards (89.5% [17/19] in 2018). CONCLUSIONS: The present analysis is one of the largest single-center studies on stillbirth published to date. Stillbirth rates have fallen across the study period across parity. A decrease in deaths secondary to placental abruption contributed largely to this. Infection-related deaths are static; however, in one-fifth of cases a causative organism was not found. Despite a decreasing autopsy rate, the number of unexplained stillbirths continues to fall as the importance of placental pathology is increasingly recognized.

To screen or not to screen for asymptomatic bacteriuria in pregnancy: A comparative three-year retrospective review between two maternity centres.

BACKGROUND: Current national guidance in Ireland states that asymptomatic bacteriuria (AB) should be screened for at 12-16 weeks' gestation and treated with a seven-day course of antimicrobials, due to the potential risk of preterm birth and low birth weight infants (LBWI), however, this is based on low quality evidence. METHODS: Over a three-year period (2018-2020), a retrospective review was undertaken in two neighbouring maternity hospitals; one of which screens for AB (Rotunda hospital (RH)) and one which does not (National Maternity Hospital (NMH)). Patients were included on the basis of fulfilling the IDSA definition for pyelonephritis and requiring admission for intravenous antibiotics. Rates of antenatal pyelonephritis were compared between hospitals, and between screened and unscreened populations. Secondary outcomes including rates of preterm births and LBWI were compared across sites. RESULTS: A total of 47,676 deliveries between the two centres (24,768 RH; 22,908 NMH) were assessed, of which 158 patients met inclusion criteria for antenatal pyelonephritis (n = 88 RH, n = 70 NMH). There was no statistically significant difference in the rate of antenatal pyelonephritis (p = 0.34) or preterm births (p = 0.21) across sites. RH had a significantly higher rate of LBWI at 6.45% versus 5.68% of all births in NMH (p=<0.004). Given the screening rate in RH was below 100%, this cohort was further subdivided into 'RH screened' and 'RH unscreened'. There was no statistically significant difference in the rate of antenatal pyelonephritis both between the 'NMH unscreened' group (n = 70) versus the 'RH screened' group (n = 62) (p = 0.53), or in the 'RH screened' group (n = 62) versus the 'RH unscreened' group (n = 26) (p = 0.53). CONCLUSION: Omission of a screening programme for AB in NMH did not result in higher rates of antenatal pyelonephritis, preterm birth or LBWI. Our findings may inform decision-making on screening protocols and whether selective screening (i.e. screening in high-risk patients only) could be more cost-effective without compromising best quality of care.

In vitro study examining the effectiveness of antiseptic prophylaxis for antibiotic-resistant bacterial endophthalmitis.

PURPOSE: To assess the effectiveness of current antiseptic agents on multidrug-resistant (MDR) isolates in an in vitro setting. SETTING: Department of Microbiology, The National Maternity Hospital, Dublin, Ireland. DESIGN: Organisms were selected based on current review of endophthalmitis literature: methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE), Pseudomonas aeruginosa, carbapenem-resistant and extended-spectrum ß-lactamase Klebsiella pneumoniae, and vancomycin-resistant (VRE) Enterococcus faecalis. METHODS: Samples were exposed to povidone-iodine (PVI) 5% and chlorhexidine (CHX) 0.05% for 0.5 minutes, 1 minute, 3 minutes, and 5 minutes. After inactivation, organisms were incubated under standard conditions and growth assessed after 16 hours. RESULTS: MRSA and MRSE responded to 3-minute PVI exposure. CHX eradicated MRSA growth after 5 minutes but failed to completely suppress MRSE. Pseudomonas and Klebsiella required 3-minute CHX exposure and 5-minute PVI exposure for complete clearance. Eradication of enterococci (VRE positive and negative) was not achieved at 10 minutes of CHX or PVI exposure. Comparison of PVI vs CHX showed a benefit for PVI in MRSA (P < .01) and MRSE (P < .001) eradication at 3 minutes. CONCLUSIONS: Current recommendations of 3 minutes of antisepsis prior to intraocular surgery are not sufficient for complete eradication of MDR organisms from the ocular surface. A bespoke approach is suggested to patients at risk for carriage of MDR organisms to minimize the risk of endophthalmitis.

Clinical and microbiological characteristics of Moraxella keratitis.

BACKGROUND/AIMS: To describe the risk factors, clinical features, bacterial subspecies characteristics and treatment outcomes of Moraxella keratitis in a single centre. METHODS: A retrospective review of all patients diagnosed with Moraxella keratitis between November 2012 and December 2017 at the Royal Victoria Eye and Ear Hospital, Dublin, Ireland was performed. Matrix-assisted laser desorption ionisation time-of-flight (MALDI-TOF) mass spectrometry was used to identify Moraxella subspecies. RESULTS: Forty-one cases of Moraxella keratitis were identified. Previous ocular surgery and diabetes were the most common local and systemic risk factors. The most common appearance on presentation was an oval-shaped paracentral infiltrate with a mean diameter of 4.2 mm. Mean presenting and final logarithm of minimal angle of resolution visual acuity were 1.307±0.74 and 0.99±1.01, respectively. Surgical procedures, including penetrating keratoplasty, corneal glueing or evisceration, were required to manage nine (22%) patients. Mean time to complete corneal epithelialisation was 32 (range, 7-109) days and mean duration of topical antibiotic therapy was 54 (range, 9-124) days. MALDI-TOF analysis revealed the following Moraxella subspecies: nonliquifaciens (16; 39%), lacunata (15; 36%), osloensis (4; 10%) and catarrhalis (2; 5%). In four cases (10%), subspecies analysis was inconclusive. M.nonliquifaciens and M. lacunata were associated with larger infiltrates on presentation (p<0.05), required more surgical intervention and longer treatment duration (p<0.001). CONCLUSION: In this large series of patients from Ireland, Moraxella keratitis was notable for its severity on presentation, slow response to antimicrobial therapy, high risk of surgical intervention and poor visual outcome. We have demonstrated the value of subspecies identification using MALDI-TOF by reporting significant differences in the clinical features and prognosis of M. nonliquifaciens and M. lacunata compared with other subspecies.

Clinical impact of rapid polymerase chain reaction (PCR) test for group B Streptococcus (GBS) in term women with ruptured membranes.

BACKGROUND: Early-onset group B Streptococcus (EOGBS/GBS) infection remains a significant cause of neonatal morbidity and mortality. AIMS: Aiming to improve antimicrobial stewardship and reduce unnecessary maternal and infant exposure to intrapartum antibiotic prophylaxis (IAP), this study assessed the clinical use of a commercially available GBS polymerase chain reaction (PCR) assay for term women with pre-labour rupture of membranes. METHODS: This was a retrospective study in a tertiary level maternity unit of term women with pre-labour rupture of membranes (ROM), without any clinical suspicion of infection performed between November and December 2017. GBS PCR tests were cross-referenced with patient clinical data. PCR test results, the impact of testing on antibiotic administration, pyrexia in labour, induction, interventional delivery rates and neonatal outcomes were analysed. RESULTS: Of 200 patients included in the study, 29 were positive (14.5%) and 166 were negative (83%), with five invalid results (2.5%). One hundred and twenty three women had > 18-h ruptured membranes and 86 women (70%) who would have been eligible for IAP based on risk factors avoided antibiotic therapy following a negative PCR test. There were no significant differences in induction or interventional delivery rates between GBS-positive and GBS-negative women following PCR testing. During the study period, there were no cases of EOGBS. CONCLUSIONS: In a centre adhering to a risk-factor-based GBS policy, the introduction of limited rapid GBS screening for term women with pre-labour rupture of membranes resulted in a clinically significant reduction in prophylactic antibiotic use.

2% chlorhexidine-70% isopropyl alcohol versus 10% povidone-iodine for insertion site cleaning before central line insertion in preterm infants: a randomised trial.

OBJECTIVE: To determine whether 2% chlorhexidine gluconate-70% isopropyl alcohol (CHX-IA) is superior to 10% aqueous povidone-iodine (PI) in preventing catheter-related blood stream infection (CR-BSI) when used to clean insertion sites before placing central venous catheters (CVCs) in preterm infants. DESIGN: Randomised controlled trial. SETTING: Two neonatal intensive care units (NICUs). PATIENTS: Infants <31 weeks' gestation who had a CVC inserted. INTERVENTIONS: Insertion site was cleaned with CHX-IA or PI. Caregivers were not masked to group assignment. MAIN OUTCOME MEASURES: Primary outcome was CR-BSI determined by one microbiologist who was masked to group assignment. Secondary outcomes included skin reactions to study solution and thyroid dysfunction. RESULTS: We enrolled 304 infants (CHX-IA 148 vs PI 156) in whom 815 CVCs (CHX-IA 384 vs PI 431) were inserted and remained in situ for 3078 (CHX-IA 1465 vs PI 1613) days. We found no differences between the groups in the proportion of infants with CR-BSI (CHX-IA 7% vs PI 5%, p=0.631), the proportion of CVCs complicated by CR-BSI or the rate of CR-BSI per 1000 catheter days. Skin reaction rates were low (<1% CVC insertion episodes) and not different between the groups. More infants in the PI group had raised thyroid-stimulating hormone levels and were treated with thyroxine (CHX-IA 0% vs PI 5%, p=0.003). CONCLUSIONS: We did not find a difference in the rate of CR-BSI between preterm infants treated with CHX-IA and PI, and more infants treated with PI had thyroid dysfunction. However, our study was not adequately powered to detect a difference in our primary outcome and a larger trial is required to confirm our findings. TRIAL REGISTRATION: This study was registered with the EU clinical trials register before the first patient was enrolled (Eudract 2011-002962-19). (https://www.clinicaltrialsregister.eu).

Incidence of congenital cytomegalovirus infection in Ireland: implications for screening and diagnosis.

BACKGROUND: Congenital cytomegalovirus (cCMV) causes serious intrauterine infection and is the leading cause of sensorineural hearing loss. In the absence of routine screening, asymptomatic infections, which constitute approximately 90% of all cCMV cases, remain undiagnosed; however many clinical abnormalities manifest later in childhood. OBJECTIVES: The aims of the present study were to determine, for the first time, the incidence of cCMV infection in a large maternity hospital in Dublin city and the optimal sampling method for neonatal screening. STUDY DESIGN: A pilot screening study of asymptomatic infants born was conducted over a 12-month period. Mothers were consented and neonates screened for evidence of CMV infection (n=1044). Urine or saliva was tested for the presence of CMV DNA and reactive results were confirmed with follow-up testing and clinical evaluation. RESULTS: cCMV incidence in the asymptomatic neonates screened was 0.19%. An overall cCMV incidence was extrapolated based on the total number of live-births and data from those infants routinely screened for cCMV during the study period, and estimated as 0.23%. Neonatal urine collection proved prohibitive to mass screening. However, testing of saliva for CMV DNA was rapid, sensitive and suitable for screening. Furthermore, in a low prevalence population, pooling of patient samples proved effective and cost-efficient. CONCLUSIONS: The present study concluded that there is a significant burden of undiagnosed cCMV infection in Ireland. The introduction of neonatal CMV DNA testing of saliva is viable, and could be considered as part of the national newborn screening programme, following a cost-benefit analysis.