Basic Microbiology and Infection Control for Midwives

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Elisabeth Presterl
Magda Diab-El Schahawi • Jacqui S. Reilly
Editors

Basic Microbiology
and Infection Control
for Midwives
Editors
Elisabeth Presterl Magda Diab-El Schahawi
Department of Hygiene and Infection Department of Hygiene and Infection
Control Control
Medical University of Vienna Medical University of Vienna
Vienna Vienna
Austria Austria

Jacqui S. Reilly
Glasgow Caledonian University
Glasgow
UK

ISBN 978-3-030-02025-5    ISBN 978-3-030-02026-2 (eBook)

https://doi.org/10.1007/978-3-030-02026-2

Library of Congress Control Number: 2018964062

© Springer Nature Switzerland AG 2019

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Preface

According to the 2017 Revision of the World Population Prospects published by the
UN Department of Economic and Social Affairs, every year there are about 139
million births worldwide, and the WHO estimates that about 830 women die from
pregnancy- or childbirth-related complications every day. Of these, 99% occur in
developing countries. Infections are one of the major complications that account for
these maternal deaths. The access to quality healthcare before, during, and after
childbirth is a key to save the lives of women and their newborn babies. Midwives
are frontline providers of care for pregnant women. They are in a powerful position
to significantly contribute and increase the health of future mothers and their babies
among other things by reducing the burden of infectious diseases. The principles of
infection prevention and control are essential for all healthcare settings.
Understanding the fundamental processes behind infection transmission is the basis
for setting appropriate actions which are intended to protect the health of patients as
well as healthcare workers. This book focuses on “hygiene and microbiology for
midwives” in high- and middle-income countries and is meant to enhance the
knowledge and role of midwives regarding infections and infectious diseases, their
transmission routes, and finally their prevention and control. A chapter dedicated to
midwifery in low-income countries will briefly summarize relevant international
literature and WHO documents.

Vienna, Austria Elisabeth Presterl

Vienna, Austria  Magda Diab-El Schahawi
Glasgow, UK  Jacqui S. Reilly

v
Foreword I

Infections play a major role in the morbidity and even mortality in obstetrics.
Knowledge about existing guidelines is an important prerequisite for quality assur-
ance; therefore, publications about these topics are of utmost importance. I con-
gratulate the authors for this extensive overview to address the midwives.
Midwife-led care for physiologic deliveries will become more important in the
future based on excellent data demonstrating good quality care and high patient
satisfaction. The present textbook should be of integral part of midwives’ education
in the future.

Peter Husslein
Chief of the Department of Obstetrics and Gynecology
Medical University of Vienna
Vienna, Austria

vii
Foreword II

Ignaz Philipp Semmelweis was the first doctor to identify the mode of transmission
of puerperal fever (sepsis) in the General Hospital in Vienna 170 years ago. He rec-
ognized the difference in maternal mortality in two clinical departments. One
department only employed midwives and students in midwifery; the other was also
staffed by obstetricians and medical students who conducted autopsies. His intro-
duction of washing hands with chlorinated lime solution was a highly effective and
preventive measure which reduced maternal mortality substantially. Knowing about
this history is important for midwives and doctors alike. The knowledge of hygiene
and microbiology as is presented in this textbook is therefore vital in the contempo-
rary as well as future education of midwives. I wish to thank the authors for their
excellent task in compiling this essential work!

Brigitte Kutalek-Mitschitczek, MSc

Head of Bachelor’s Degree Program Midwifery
Vienna FH Campus, University of Applied Sciences
Vienna, Austria

ix
History

The word hygiene originates from the Greek, ὑγιεινή [τέχνη] (hygieine téchne),
meaning “healthy art.” Hygeia is the name of the Greek goddess of health. Hygiea
is the daughter of the god and physician Asclepius, who is a son of the god of medi-
cine Apollo. In the Roman Empire, the knowledge of hygiene was well developed.
Already at that time, the Roman physician Marcus Terentius Varro knew that dis-
eases are caused by microorganisms. It was known that quarantine (isolation) could
prevent the spread of infectious diseases. In Christian Europe in 1670, Antoni van
Leeuwenhoek discovered the first “micro-creatures” seen using his self-built micro-
scope. He saw in human secretions (saliva, dental plaque) “little animals”
(microorganisms).
One of the pioneers of hygiene in Central Europe/Austria was Gerard van
Swieten (1700–1772), who was the personal physician of Maria Theresia and
founded the older Vienna School of Medicine. His successor Johann Peter Frank
(1745–1821) was a professor at the Vienna General Hospital, Vienna, and founded
the so-called public hygiene, today called public health (Public Health). He intro-
duced strict guidelines for the protection of the population against infectious dis-
eases. Further extensions of this institution are public health departments and
regulatory reporting for infections that have the protection of the public against
epidemics goal.
Ignaz Semmelweis (1818–1865) was an assistant doctor at the University
Hospital in Vienna. As such, he made the observation that substances are transmit-
ted to other people through contact with corpses, which can cause serious diseases
(sepsis). He witnessed the death of his friend Jacob Kolletschka following an injury
during autopsy of a septic corpse. Due to the similar clinical picture of the sepsis
seen in women with puerperal fever and the sepsis of his friend, he concluded that
there may be same cause and that there may be a transfer of infection via the hands
of doctors and students working on postmortems of corpses and then going to the
ward and treating pregnant women. He therefore called for hand hygiene prior to
any examination of patients.
He performed the first epidemiological study comparing the mortality rates of
two obstetric wards. At the Vienna University Hospital, there were two obstetric
wards for the care of pregnant women. In one the care was in the hands of midwives
and student midwives; the other was run by medical doctors, medical students, and
midwives. In a meticulous investigation, he showed that the mortality rate at the

xi
xii History

medical ward was much higher than the mortality rate at the ward with the mid-
wives. Then he performed the first intervention study. The medical students and
medical doctors had to disinfect their hands with chlorinated lime solution before
contact with the postnatal women. It really came to a sharp drop in the death rate,
which was finally identical on both wards. Nevertheless, there was considerable
controversy, so Semmelweis finally had to leave Vienna. He received a professor-
ship in Budapest. The mortality rate increased again.
Quite late in his life, he summed up his scientific findings in the scientific essay
“The Etiology, the Concept and the Prophylaxis of Puerperal Fever.” Semmelweis
died eventually after a serious illness in Oberdöbling near Vienna.
The great period of medical microbiology came in the nineteenth century. Louis
Pasteur (1822–1895) and Robert Koch (1843–1910) are considered to be the found-
ers of clinical microbiology. Microbiology is the science of microorganisms includ-
ing bacteria, fungi, and viruses. Louis Pasteur was the first to detect bacteria using
the microscope and culturing them. He developed methods of clinical microbiology
for the diagnosis of infectious diseases. Robert Koch discovered the pathogen of
tuberculosis, Mycobacterium tuberculosis. He also established the so-called Koch’s
postulates for the general definition of a pathogen. Paul Ehrlich (1854–1915) was
the founder of anti-infective therapy. He discovered and developed the drug
Salvarsan. Salvarsan was used for the treatment of syphilis. Ilya Metchnikoff
(1845–1916) developed basic microbiology and immunology. Immunology is the
science of the immune system and its reaction to infection but increasingly to many
other triggers. Metchnikoff also set milestones for the diagnosis and therapy of
infectious diseases.

Infection Prevention in Hospital: Tasks of Hospital Hygiene

Infection prevention and control (IPC) in hospitals aims to streamline processes and
care actions with respect to avoid the transmission and/or spread of infections and/
or microorganisms. Measures include the advice of medical personnel and the
involvement of the management of hospitals to implement the advice given, the
choice of adequate technology and medical devices for use in patients, and the
establishment of standards and guidelines. Additionally, the infection prevention
and control team is consulted when building or rebuilding hospitals or parts of it.
In hospitals, specialist IPC advice is given by the IPC team. The IPC team con-
sists of IPC nurses, IPC doctors, sometimes other IPC professionals, supporting
assistants, epidemiologists, scientists, etc. IPC nurses, IPC doctors, and IPC profes-
sionals have special training in infection prevention and control. The IPC team cre-
ates the so-called IPC plan of the hospital. This plan includes IPC guidelines,
disinfection and sterilization rules, surveillance (epidemiology) of healthcare-­
associated infection, etc. In some European countries, including Austria, IPC is
legally endorsed.
History xiii

Other tasks of the IPC team are surveillance and epidemiology of healthcare-­
associated infections (HAI) and detection of infectious outbreaks and transmission
of pathogens.
Frequency and descriptive statistics on the antibiotic susceptibility of the most
common pathogens in the hospital are usually supplied by the microbiological labo-
ratory. These together with national and international guidance are the basis for the
antibiotic policy within a healthcare institution. Additionally, these data give insight
for the spectrum of pathogens, the change of susceptibility pattern, and also the
mechanisms of antibiotic resistance.
In Austria hygiene and infection control are endorsed in three laws: the Act on
Healthcare Institution, the Act on Physicians, the Act on Nursing, and indirectly the
Act on Midwifery – “Midwives have to practice their profession conscientiously
without distinction of person. The welfare and health of pregnant women, women
giving birth, new mothers, newborns, mothers and infants have to be treated on the
basis of statutory provisions and in accordance with the technical and scientific
knowledge and experience….”
Contents

1 General Definitions������������������������������������������������������������������������������������   1

Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
2 Infections and Infectious Doctrine ����������������������������������������������������������   3
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
3 Hand Hygiene �������������������������������������������������������������������������������������������� 17
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
4 Medical Instruments and Devices������������������������������������������������������������ 29
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
5 Reprocessing: Cleansing, Disinfection, Sterilization������������������������������ 35
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
6 Basic Principles and Introduction to Disinfectants and Antiseptics for
Skin, Mucosa, and Wounds ���������������������������������������������������������������������� 51
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
7 Basics of Medical Microbiology���������������������������������������������������������������� 59
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
8 Bacteriology: Selected Bacteria and Diseases������������������������������������������ 67
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
9 Hospital Infections ������������������������������������������������������������������������������������ 85
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly

xv
xvi Contents

10 Antimicrobial Agents (Antibiotics)���������������������������������������������������������� 93

Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
11 Multiresistant Microorganisms and Infection Control�������������������������� 97
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
12 General and Specific Virology������������������������������������������������������������������ 107
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
13 Specific Virology: Viruses as Diseases������������������������������������������������������ 113
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
14 Gastroenteritis: Gastrointestinal Infections�������������������������������������������� 131
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
15 Blood-Borne Viruses: HIV, Hepatitis B, and Hepatitis C���������������������� 143
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
16 Puncture Wounds and Needle-Related Injuries�������������������������������������� 151
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
17 Medical Mycology: Fungal Infections������������������������������������������������������ 155
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
18 Parasites and Parasitic Diseases �������������������������������������������������������������� 161
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
19 Epidemiology���������������������������������������������������������������������������������������������� 171
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
20 Basic Immunology�������������������������������������������������������������������������������������� 183
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
21 Immunizations�������������������������������������������������������������������������������������������� 185
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
22 Household Hygiene������������������������������������������������������������������������������������ 191
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
Contents xvii

23 Disinfestation���������������������������������������������������������������������������������������������� 199
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
24 Environmental Medicine �������������������������������������������������������������������������� 207
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly
General Definitions
1
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly

In the German-speaking parts of the world, hygiene is the science of the preserva-
tion of health and prevention of disease. According to the more up-to-date defini-
tion, hygiene comprises all measures for prevention and control of infections.
The World Health Organization (WHO) definition of health (1946) is: “Health is
a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity”.
In other parts of the world, hygiene mainly focuses on cleaning, disinfection and
sterilization. All other parts are summarized under “infection prevention and
control”.

Infection Prevention and Control or Hygiene Comprises the Following:

• Any measures to combat and destruct pathogenic microorganisms, e.g. disinfec-

tion, sterilization, antimicrobial therapy, etc.
• Protection against and prevention of infections by laws and regulations in hospi-
tals, the public health system, enforcing quality in the medical environment and
vaccinations.
• Communication and networking to disseminate knowledge and information to
protect against infection.

E. Presterl (*) · M. Diab-El Schahawi (*) · L. S. Lusignani · H. Paula

Department of Hygiene and Infection Control,
Medical University of Vienna, Vienna, Austria
e-mail: [email protected]; [email protected];
[email protected]; [email protected]
J. S. Reilly
Glasgow Caledonian University, Glasgow, UK
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 1

E. Presterl et al. (eds.), Basic Microbiology and Infection Control for Midwives,
https://doi.org/10.1007/978-3-030-02026-2_1
2 E. Presterl et al.

• Teaching, educating and training of all people working in the health-care sys-
tems and beyond.
• Epidemiology: Description of the incidence, distribution and control of a disease
in a population including the detection of the source and cause of epidemics of
infectious diseases. Epidemiology is the study of the occurrence of diseases,
their course and their distribution in a population. Epidemiological descriptive
numbers to measure the burden of (infectious) causes of disease are mortality,
morbidity, incidence and prevalence of a disease (see Chap. 24 on epidemiology).
Infections and Infectious Doctrine
2
Elisabeth Presterl, Magda Diab-El Schahawi,
Luigi Segagni Lusignani, Helga Paula, and Jacqui S. Reilly

2.1 Definitions

Infection
Infection is defined as the invasion and propagation of a pathogen in an organism
and the (immune) reaction of the organism to the pathogen.
Any microorganisms, e.g. bacteria, viruses, fungi, etc., causing infection are
referred to as pathogens. Microorganisms that cause no disease in healthy persons
but cause disease in immunocompromised or otherwise severely ill patients are
called “opportunistic pathogens”. In contrast all other pathogens are obligatory
pathogens. To cause infection, a pathogen must penetrate into the body (invasion).
The pathogen must multiply, and the host organism must show an immune response,
e.g. fever.
The immune response may be generalized, e.g. sepsis with fever, low blood pres-
sure and a pulse more than 100 beats/min. The local immune response depends on
the site of infection, e.g. cough for lung infection or diarrhoea for bowel infection.
The most common skin infection and infections of a surgical site present most com-
monly with redness, swelling, pus, warmth, pain and impaired function. For acqui-
sition of an infection, a so-called chain of infection is common. The knowledge
about this “chain of infection” is pivotal for infection prevention.

E. Presterl (*) · M. Diab-El Schahawi (*) · L. S. Lusignani · H. Paula

Department of Hygiene and Infection Control, Medical University of Vienna, Vienna, Austria
e-mail: [email protected]; [email protected];
[email protected]; [email protected]
J. S. Reilly
Glasgow Caledonian University, Glasgow, UK
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 3

E. Presterl et al. (eds.), Basic Microbiology and Infection Control for Midwives,
https://doi.org/10.1007/978-3-030-02026-2_2
4 E. Presterl et al.

The chain of infection is the basic model for the transmission of pathogens.
There is the source of infection and then the propagation (transmission) by either
direct or indirect contact with vehicles, vectors or items to the target of infection
(usually the patient).
Horizontal transmission of infection means that a pathogen is transmitted from
host/source to a host of the same generation. Vertical transmission of infection
means that a pathogen is transmitted from one host/source to its descendants.
Examples for vertical transmission include:

• Prenatal or transplacental infection when a pathogen is transmitted via the pla-

centa to the embryo or foetus before birth (in utero)
• Perinatal infection when the transmission of a pathogen occurs during
childbirth
• Postnatal infection when the transmission of a pathogen occurs after birth, e.g.
through breast milk or vaginal secretions

Common sources of infection are persons (patients, staff, visitors), animals

(insect vectors, but also pets) or inanimate objects or materials (surfaces in the envi-
ronment of the patient, liquids, instruments, old disinfectants, etc.). Most common
sources of infection in the hospital are unclean hands of the healthcare staff, cloth-
ing (especially abdominal/stomach area, sleeves), urinary or vascular catheters,
instruments, body bowls, dust and particles in the air and near and even distant
surfaces in the patient environment.

2.2 Risks of Infection for Healthcare Personnel

Sources of infection are infectious patients, patient material (blood, secretions,

stools, urine, tissue, etc.), contaminated objects and surfaces and medical waste.
The most common occupational pathogens for the healthcare personnel are hepatitis
B virus, hepatitis C virus and HIV in countries with high prevalence (see Chap.
15—Blood-Borne Viruses: HIV, Hepatitis B, and Hepatitis C).
The risk of infection even exists when a person or a patient is only colonized with
a pathogen without any symptoms or has very little symptoms.

2.3 Classification of Infections and Infectious Diseases

There are several classifications for infections:

(a) Pathogen-related classification, e.g. bacterial, viral and fungal infection.

(b) Organ related (lung, pneumonia; urinary tract, urinary tract infection; skin/tis-
sue, abscess soft tissue infections; bowel, diarrhoea).
(c) Immune response: systemic or localized infection. In a localized infection, only
one organ/body site/space is affected, e.g. pneumonia. Classic systemic infec-
tion is sepsis, e.g. puerperal sepsis with severe illness.
2 Infections and Infectious Doctrine 5

(d) Epidemiological classification.

(e) Vector-borne infectious disease classification: vectors are, for example, insects
(ticks, malaria mosquitos, etc.) that transmit the agents of infection (malaria
parasites) to a susceptible host (human, animals).
(f) Behaviour-related infectious diseases, e.g. sexually transmitted diseases when
omitting any precaution.
(g) Classification according to the clinical course. These are divided into acute
(occurring suddenly), subacute (slowly occurring over weeks), chronic (dura-
tion 3 months) and recurrent (still healthy intervals repeatedly sweeping)
infections.
(h) Classification according to the immune status of the host, e.g. infections in
immunocompromised patients (e.g. after transplantation, cancer patients, leu-
kaemia patients, rheumatic patients) that have often obscure symptomatology
different to that in patients with normal immunity. These patients should be
cared for in specialized centres and undergo advanced microbiological diagnos-
tics including cultures and serology.
(i) Classification according to the origin of the pathogen: exogenous infection is
the transmission of the disease through pathogens from the environment.
Endogenous infection is an infection of the human body’s own flora.

The most common infections in humans are infections of the upper respiratory tract
(common cold: rhinitis, cough, otitis media, sinusitis). These can occur up to ten times/
person/year. Nearly all of these infections are caused by viruses. Diarrhoeal diseases
are in second place and occur one-two times/person/year. Also these diarrhoeal dis-
eases are also commonly of viral origin (e.g. Norovirus) and rarely caused by bacteria.
Skin infections (folliculitis, boils, impetigo) are in third place, followed by urinary tract
infections in women. Skin infections are mostly due to bacteria (e.g. Staphylococcus
aureus) and controlled by local disinfectant treatment and strict hygiene (handwash-
ing). Up to 70% of all women have at least one UTI in their lifetime.

2.4 The Basics of Clinical Diagnosis

The causative agents of infectious diseases are microorganisms: bacteria, viruses,

fungi, protozoa (single-celled organisms), worms and insects (see Chap. 18—
Parasites and Parasitic Diseases).
The goal in the treatment of infectious diseases and infections is a rapid diagno-
sis and pathogen identification followed by immediate antimicrobial therapy.
The common procedure to admit a sick patient must include the accurate medical
history and a clinical examination and taking blood pressure, pulse and temperature
for fever. For diagnosis of infection, microbiological testing must be done: sample
material is taken from the site of infection, e.g. blood cultures to detect bacteraemia,
urine culture for urinary tract infections, chest X-Ray for pneumonia (note: only for
particular indications in pregnant women), stool cultures for diarrhoea, wound
swabs, etc. Biochemical blood tests, e.g. the increased numbers of leukocytes or the
elevated C-reactive protein, may indicate infection.
6 E. Presterl et al.

2.5 Clinical Syndromes of Infection

Sepsis/Septicaemia/Bacteraemia
Sepsis is a systemic reaction triggered by infection that affects the entire body.
Commonly this syndrome is blood poisoning. A typical example of a sepsis is puer-
peral fever. Typical symptoms of a systemic infection are fever, chills, low blood
pressure, rapid pulse (tachycardia) and rapid breathing (tachypnoea). The most seri-
ous condition of sepsis is septic shock. Sepsis may have a primary or secondary
focus site and associated symptoms. Local symptoms of skin, tissue or wound infec-
tions and abscesses are redness, warmth, swelling, heat, pain and impaired function.
Organ-specific signs of infection depend on the affected organ as cough in pneumo-
nia or headache in meningitis. Sepsis is a most serious type of infection. Therefore,
it is pivotal to recognize sepsis in a patient as soon as possible. Based on several
studies, there are definitions of sepsis particularly for emergency and intensive care
medicine. Because of the high fatality of sepsis, the World Health Organization
(WHO) has launched an entire programme on sepsis involving several many differ-
ent institutions (http://www.who.int/sepsis/en/).
Laboratory testing (full blood count) reveals an increase of the white blood cells
(leucocytosis) is found typically as well as the increase in C-reactive protein. In
addition, the detection of bacteria or fungi in the microbiological results of the
patient samples (e.g. blood, urine, bronchial secretions, stool, smears, aspirates)
confirms the diagnosis of infection.
Fever is defined as a body temperature >38 °C. Temperatures below 38.2 °C are
referred to as elevated body temperature. Nevertheless, an infection is not necessarily
associated with fever. Old patients, patients who have swallowed antipyretic or analge-
sic tablets, may have a normal temperature despite serious signs of infection. However,
note other causes of fever except infections are other inflammatory diseases, e.g. rheu-
matism, malignant tumours, postoperative fever, trauma and idiopathic hyperthermia.
Symptoms of sepsis include fever (38.2 °C), hypotension, tachycardia (heart rate
over 100 beats/min), tachypnoea (respiratory rate 20/min), confusion, nausea, vom-
iting, coughing, fatigue, confusion, weakness and frailty. Septic shock can result in
organ failure and coma. The detection of bacteria in the blood in the blood culture
is called bacteraemia or septicaemia. Other signs of sepsis are changes in the blood
count (leucocytosis above 10 G/L, thrombocytopenia <100 G/L).
The most frequent pathogens of sepsis are Escherichia coli, Staphylococcus
aureus, Klebsiella pneumoniae, Enterobacter species, beta-haemolytic streptococci
group A or group B, Enterococcus faecalis, Streptococcus pneumoniae and
Pseudomonas aeruginosa, and the fungus Candida albicans, E. coli, K. pneumoniae
and Enterobacter sp. are referred to as “enterobacteria” because they are most fre-
quently found in faeces.
Puerperal fever has the clinical signs and symptoms of sepsis. Puerperal fever
occurs immediately to a few days after delivery. Pathogens are beta-haemolytic
streptococci of groups A and B, respectively, enterobacteria and the so-called anaer-
obic bacteria. Early identification and management of this are critical to the out-
come. The patient must be necessarily taken to the hospital immediately.
2 Infections and Infectious Doctrine 7

Urinary Tract Infection

Urinary tract infection is the most common infection during pregnancy. In young,
non-pregnant women, the urinary tract infection is considered to be as uncompli-
cated. Uncomplicated urinary tract infection requires only 3 days of treatment.
Urinary tract infections in pregnancy are complicated because of the anatomical
changes of the body during pregnancy. Any urinary tract infections in men, in
patients with kidney stones, in immunocompromised patients and in patients with
indwelling urinary catheters are complicated infections requiring accurate diagnosis
and prolonged treatment.
The symptoms of lower urinary tract infection (infection of the bladder, cystitis)
include burning (alguria), frequent voiding, blood in urine (haematuria), cloudy
urine (proteinuria), pain and fever.
The symptoms of upper urinary tract infection (infection of the kidney, pyelone-
phritis) include the symptoms of lower urinary tract infection plus high fever, flank
pain and pain. Pyelonephritis may be accompanied by the signs and symptoms of
sepsis.
Most common pathogens of urinary tract infection are enterobacteria (Escherichia
coli, Proteus mirabilis, Klebsiella pneumoniae), Staphylococcus saprophyticus,
Enterococcus faecalis and group B beta-haemolytic streptococci.
Diagnostics of urinary tract infection are the chemical urine analysis for leuko-
cytes, protein, nitrite (produced by some bacteria) and blood. For pathogen identifi-
cation urine culture (midstream urine) should be done. Urine culture is recommended
after at least two urinary tract infections within a short period or treatment failure.
The treatment of urinary tract infection in pregnant women is limited to antibiot-
ics that are safe for pregnant women. However, the resistance to these antibiotics
may be up to 50%. For intravenous therapy for pyelonephritis with sepsis, there are
still beta-lactam antibiotics available. Thus, urine culture is mandatory in pregnant
women with urinary tract infections. In non-pregnant women, quinolones (cipro-
floxacin, levofloxacin), trimethoprim or fosfomycin trometamol can be used.

Vaginal Infection, Vaginosis and Vaginitis

Symptoms of vaginal infection (vaginitis, colpitis) include vaginal discharge, pain
during intercourse, itching and redness. During pregnancy and particularly after
intake of antibiotics, fungal infections of the vagina and external genitalia frequently
occur. Signs and symptoms include burning and itching, redness and typical white
friable discharge. Local antifungal cream or vaginal troches are the therapy of
choice (see Chap. 17—Medical Mycology and Fungal Infections).
Other frequently occurring vaginal infections are trichomoniasis and bacterial vagi-
nosis. Trichomoniasis is vaginal infection caused by the protozoon Trichomonas vagi-
nalis. It is typically associated with foul-smelling discoloured discharge. The diagnosis
is rapidly done by direct microscopy of the vaginal smear showing slowly moving
Trichomonas vaginalis cells. During pregnancy, topical therapy is recommended.
Bacterial vaginosis is caused by Gardnerella vaginalis, a small Gram-labile rod
(staining red and blue) sticking in dense numbers on squamous cells of the vagina
epithelium (so-called clue cells).
8 E. Presterl et al.

Infections of the Skin, Soft Tissue and Wounds

Frequent skin infections are erysipelas, boils and abscesses. Symptoms include
swelling, redness, pain, warmth, loss of function and pus.
Erysipelas is caused by beta-haemolytic group A streptococci. Erysipelas pres-
ents as a typical sharply demarcated redness. Entry points may be minor injuries.
Pre-existent damage of the lymph drainage of the skin may lead to the occurrence
of recurrent erysipelas. Occasionally, other beta-haemolytic streptococci of group
B, C and G may cause cellulitis.
Boils are abscesses of the hair follicles. Wound infections occur after injuries but
also after surgery (surgical site infections). Surgical site infections are considered as
healthcare-associated infections (nosocomial infections). Common pathogens of
boils, wound and surgical site infections are Staphylococcus aureus, beta-­haemolytic
streptococci group A and enterobacteria (e.g. Escherichia coli). Wound infections
acquired in the hospital or after contact with long-term care patients may be caused
by methicillin-resistant Staphylococcus aureus (MRSA). However, meanwhile
MRSA may be even isolated in patients who had had no contact with healthcare
(so-called community-acquired MRSA, CA-MRSA).
For microbiological sampling, the wound should be cleansed with sterile saline
before sample collection. From boils and abscesses, pus can be aspirated with a
sterile syringe.
A local wound cleansing with an antiseptic is necessary. For severe symptoms,
systemic antibiotic treatment is necessary.

Respiratory Tract Infections: Infections of the Respiratory Tract

Frequent respiratory tract infections are pharyngitis (sore throat, “sore throat”),
sinusitis (sinusitis), middle ear infection (otitis media), tonsillitis (tonsillitis) and
bronchitis. Classic symptoms are cough and pain in the affected area. Bacterial
tonsillitis is generally caused by beta-haemolytic streptococci group A with flaming
redness of the tonsils. Scarlet fever may be a toxic complication of the infection
with beta-haemolytic streptococci group A.
The pneumonia is the most severe form of respiratory tract infection. Pneumonia
is an inflammation of the lung tissue with a high fever, painful breathing and cough-
ing. In pneumonia purulent sputum is rare. Excessive purulent sputum is usually a
sign of bronchitis. The majority of respiratory tract infections are of viral origin.
Thus, antibiotic therapy has to restrict to bacterial infection because it is effective
against viral infection.
The clinical examination of pneumonia includes auscultation (listening to breath-
ing) with the stethoscope and chest X-Ray (care: only in strictly limited indications
in pregnant women!). Microbiological samples include blood cultures (in pneumo-
nia), sputum and serological tests (e.g. for Mycoplasma pneumoniae).
Common causative agents of pneumonia are Streptococcus pneumoniae,
Mycoplasma pneumoniae, Chlamydophila pneumoniae, Staphylococcus aureus,
Haemophilus influenzae and Klebsiella pneumoniae.
2 Infections and Infectious Doctrine 9

Diarrheal Diseases: Infections of the Gastrointestinal Tract

Infectious diarrhoea is defined as more than three unformed stools per day, evi-
dence of a pathogen and at least one symptom such as fever, nausea, vomiting and
abdominal pain. Duration of acute diarrhoea is less than 14 days, and duration of
persistent diarrhoea is more than 14 days. Usually there is a diarrheal episode per
person per year.
The most common bacterial pathogens of diarrhoea are Salmonella species,
Campylobacter species (only in travellers to hygienically questionable areas, travel
history), Clostridium difficile, Yersinia enterocolitica (children, pregnant women),
Escherichia coli (enterohemorrhagic Escherichia coli EHEC – children) and Vibrio
cholerae (tropical disease, travel history).
In most developed countries, the following pathogens cause notifiable diseases.
Any cases have to be reported to the public health authorities, e.g. Salmonella,
Campylobacter, Shigella, Yersinia enterocolitica, Escherichia coli EHEC, Vibrio
cholerae and many more.
Microbiological diagnosis of bacterial diarrhoea is done by culture of stool (2 ml
liquid stool to be sent to the microbiology laboratory in tightly closed vials). Most
commonly only Salmonella, Campylobacter and Shigella are reported, for all other
pathogens indicate a special request.
The treatment of choice for acute diarrhoea is oral rehydration. The oral hydra-
tion fluid according to the World Health Organization (WHO) can be self-prepared
and consists of 1/2 teaspoon salt (3.5 gm), 1 teaspoon soda (2.5 gm NaHCO3), 8
teaspoons of sugar (40 gm) and 250 ml orange juice (1.5 gm potassium chloride,
KCl) diluted to 1 l with boiled and cooled water.
It is also commercially available products. In addition to oral rehydration and the
observance of hygiene measures (handwashing, cleaning the toilet with normal toi-
let cleaners), Antibiotics are generally not indicated. They may only be necessary in
critically ill infants with adequate rehydration, in the very old persons, in immuno-
suppressed patients and in patients with sepsis (typhoid fever) or bacterial dysentery
due to Shigella dysenteriae.

Clostridium Difficile Infection (CDI) CDI is a special entity in patients with fre-
quent contacts with healthcare institutions. General risk factors include intake of
antibiotics or cytotoxic chemotherapy, age more than 65 years and kidney disease.
Small children until the age of 2 years are usually asymptomatic carriers without
illness. Thus, thorough handwashing and cleaning of the surrounding surfaces are
essential after changing diapers or handling stool or stool-contaminated items.
Clostridium difficile-associated colitis has different clinical pictures; it primarily
affects the large intestine. The symptoms range from watery stools to severe colitis
with bloody mucous stools and sepsis due to intestinal perforation and ileus.
Sometimes CDI may be relapsing, most often in elderly and very ill patients.
Hygienic measures include the washing of hands and adequate cleaning of the
patient’s environment with sporicidal disinfectants. Measures to avoid transmission
10 E. Presterl et al.

are strict hand hygiene of clinical staff, patients and visitors, a private toilet, protec-
tive clothing for the staff (e.g. apron or gown, gloves, mask, cap, even goggles
depending on the risk of contamination and local hygiene standards) and isolation
in single room during the duration of diarrhoea.

Listeriosis Listeriosis is a bacterial infection caused by Listeria monocytogenes

that is generally acquired through intake of contaminated food. Listeria monocyto-
genes can normally found in the excretions and in the gastrointestinal tract of ani-
mals. Food at risk to be contaminated by Listeria include raw meat, smoked fish
(salmon), raw milk, raw milk cheese and other contaminated foods.
Most commonly listeriosis can manifest as diarrhoea but as sepsis or abscesses
in elderly or immunocompromised patients.
Pregnant women may acquire listeriosis via contaminated food, be asymptom-
atic or have just an episode of diarrhoea. But, infection of Listeria leads to a placen-
titis (febris infantiseptica) and abortion. To diagnose human listeriosis, Listeria
monocytogenes can be detected in stool, blood or aspirates of abscesses.
The symptoms are fever, signs and symptoms of sepsis, weakness, diarrhoea,
headache and delirium. Brain abscesses may cause seizures. Pregnant women may
have premature labour and miscarriage.
Listeriosis in pregnant women and their offsprings may occur as a pre- and peri-
natal infection. The early-onset type may have common cold-like symptoms or
fever of the pregnant women. Depending on the gestational age of the child, there
may be septic abortion in first months of pregnancy or septic preterm birth in the
second half of pregnancy. Premature babies are severely ill and show the signs and
symptoms of sepsis, livid skin, microgranulomata, hepatosplenomegaly and respi-
ratory insufficiency.
The delayed type is the so-called infant listeriosis. This is a perinatal infection
through the contaminated birth canal of pregnant women. The infants develop signs
and symptoms of meningitis from the second to fifth week after birth. The diagnosis
is made by culture of the vaginal smear or a stool sample to prove the colonization
of the mother or by blood cultures of the mother when she has systemic symptoms
like fever, headache and fatigue. In the diseased infant blood cultures, culture of
cerebrospinal fluid and/or stool cultures or rectal swabs are diagnostic.

2.6 Infections During Pregnancy

Pregnant women are particularly at risk for certain infections. Either the infection
affects the pregnant woman only or it affects the foetus or the newborn with severe
sequelae. Infection occurs either via the bloodstream and the placenta or during
birth.
The most important infections impairing the child include the following:

• Viral infections
–– Rubella
–– Human immunodeficiency virus (HIV) infection
2 Infections and Infectious Doctrine 11

–– Parvovirus B19 infection (“fifth disease”)

–– Varicella (chickenpox)
–– Cytomegaly (cytomegalovirus CMV)
–– Herpes simplex infection
–– Hepatitis B
–– Lymphocytic choriomeningitis
• Bacterial infections
–– Syphilis
–– Listeriosis
–– Gonorrhoea
–– Sepsis and meningitis of the newborn by beta-haemolytic streptococci
group B
–– Chlamydia infection
–– Tuberculosis
–– Sepsis and meningitis of the mother and newborn by Escherichia coli,
Staphylococcus aureus and anaerobes
• Parasitic infections
–– Toxoplasmosis
–– Malaria

Infection during pregnancy may result in malformations, defects and develop-

mental disorders of unborn child. Infection during the first 3 months may cause
embryopathy because of impaired organogenesis. Later infection is referred to as
fetopathy. The main causes of these prenatal infections and their respective
pathogens are syphilis (Treponema pallidum), listeriosis (Listeria monocyto-
genes), toxoplasmosis (Toxoplasma gondii), rubella (Rubella virus), cytomegaly
(CMV), varicella (varicella zoster virus), HIV infection (HIV), lymphocytic cho-
riomeningitis (lymphocytic choriomeningitis virus) and parvovirus B19 infec-
tion (parvovirus B19).
Perinatal infections occur during, shortly before or shortly after birth. Common
infections and their respective pathogens are sepsis or meningitis due to Listeria
monocytogenes, sepsis or meningitis due to beta-haemolytic streptococci group B
(Streptococcus agalactiae), sepsis or meningitis due to Escherichia coli, eye infec-
tion or sepsis due to Neisseria gonorrhoeae, eye infection due to Chlamydia tracho-
matis, hepatitis B, primary genital herpes simplex and primary varicella.
To control these infections, many countries worldwide have a special monitoring
programme for pregnant women. In Austria, this is the “mother-child pass” which is
similar to the Torch programme in the United States. The following examinations
for infections are carried out until the end of the 16th week of pregnancy: blood tests
for syphilis, toxoplasmosis, rubella and HIV. In the pregnancy weeks 25–28, hepa-
titis B serology is performed. If there is any clue for these infections, appropriate
further tests and treatment are initiated and carried out.
The most common infections in pregnant women are urinary tract infections and
diarrhoea due to common intestinal pathogens Salmonella or Campylobacter.
Tuberculosis is a rare disease in the developed countries but frequent in countries
with poverty and uncontrolled HIV infections.