TABLE OF CONTENT

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1. EPIDEMIOLOGICAL AND ETIOLOGICAL ASPECTS RELATED TO AEROBIC BACTERIAL SURGICAL SITE INFECTION

A. Kirtcheva, D. Radev, T. Kantardjiev, l\1. Todorova, M. Petrov, Tz. Velinov, A. Bachvarova

ABSTRACT
Nosocomial infections (N1) and surgical site infections (SSI) in particular constitute a serious problem in infectious pathology. Surgical wound infection (SWI) occupies constantly the first place among nosocomial infections in the Multi-profile Hospital for Active Therapy (MPHAT) „St.Anna“ - Varna AD, varying from 35.29% to 51.09%. Gram-negative microorganisms predominate as major etiologic agents - 67.43%. The leading causative agents are E.coli - 17.78%, Staphylococcus aureus - 17.25%, Enterobacter spp -9.15%, Pseudomonas spp - 8.98%, Proteus spp - 8.01%.

Data are reported as regards the dominating resistance and susceptibility to antibiotics of the isolated microorganisms for the 1994-2001 period. The results are presented of a conducted cross-sectional study, comprising 114 patients from First Surgical Ward having developed SWI, a relation being made with wound class according to CDCP.


2. INFECTION CONTROL IN BULGARIA: AN OVERVIEW AND PERSPECTIVES OF THE ONGOING BULGARIAN SWISS PROGRAM

V. Voynova, N. Gatcheva

ABSTRACT
In Bulgaria, in parallel with recognition of the need to control nosocomial infections (N1), since the early 1950s a national infection control program has been gradually developed. This report summarizes the information on the key strategies implemented and the lessons learnt from the past experience. Based on the historical background the perspectives of the ongoing Bulgarian Swiss Hospital Hygiene Program (BSHHP) are presented. The following periods are considered: 1952-1974 with efforts focused primarily on the widespread classic infections, 1975-1989 with establishment of the national infection control system, and the 1990s with collapse of the socio- economic infrastructure, incl. health care system and a negative impact on the infection control program. By implementing the BSHHP principles for new professional qualifications and development of quality care standards integrated into clinical practice a future sustainable improvement in the Nl prevention and control is expected.


3. EPIDEMIOLOGIC CONTROL OF METHICILLIN-RESISTANT STAPHYLOCOCCI IN SURGICAL WARDS

A. Kirtcheva, D. Radev, T. Kantardjiev, M. Petrov, M. Todorova, Tz. Velinov, A. Bachvarova

ABSTRACT
The general trend of increasing the relative frequency of staphylococci as an etiologic agent of nosocomial infections and surgical site infection (SSI) in particular, as confirmed by our and foreigh authors, is being established in MPHAT „St.Anna“ - Varna as well - 56.40% of all grampositive microorganisms isolated. Of importance for this is the increased rate of isolation of methicillin-resistant staphylococci (MRS) - 31.81 % of all clinical materialstested forthe 1996-2001 period, and in SSI - 21.20%. The present study examines the rate of determination of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagu-lase-negative staphylococci (MR-CNS) on the background of all methi-cillin-sensitive isolates, an attempt is made of clarifying the specificities of the epidemic process and the risk factors for MRS-associated SSI development. We examined likewise the resistance of the isolated MRS strains to antibiotics routinely used, and the characteristics of the multiply resistant MRSA and MR-CNS strains.


4. EVALUATION OF CELL-MEDIATED IMMUNE FUNCTION IN THERAPY FREE PATIENTS WITH M. TUBERCULOSIS INFECTION

R. Drenska, V. Terzieva, Y. Todorova, S. Nikolaeva, E. Sapundjieva, D. Stefanova, V. Dimitrov, M. Nikolova, R. Markova

ABSTRACT
Protective immunity against Mycobacterium tuberculosis is T-cell mediated and requires strong T-cell lymphoproliferative activity and IFN-gamma production. The clinical outcome following TB infection is largely determined by the host immune response. To correlate the degree of impairment of the immune function two groups of patients were set up according their disease stage. Patients with advanced disease demonstrated highly suppressed T-cell responses measured in vitro by unstimulated and stimulated IFN-gamma production and T - lymphocyte proliferation, whereas patients with mildly expressed limited disease showed more preserved immune function. The neutrophil function measured by NBT-test of patients with advanced disease have been found suppressed but the degree of impairment was less expressed in comparison with T-cell function. A positive correlation between cutaneuos induration diameter after Mantoux test and specific IFN-gamma responses have been detected in bought groups of patients.


5. ASSESSMENT OF CELL - MEDIATED IMMUNITY IN HIV-1 INFECTED PATIENTS BEFORE THE ONSET OF SPECIFIC ANTIRETROVIRAL THERAPY

Y. Todorova, V. Terzieva, R. Drenska, I. Elenkov, M. Yankova, K. Kostov, H. Taskov, R. Markova

ABSTRACT
The hallmark of HIV-1 infection is the progressive loss of CD4+T cells together with functional impairment of the remaining lymphocyte populations: chronic immune activation, failure in T-cell proliferative responses to recall, specific antigens and mitogens as well as a critical Th1 - Th2 switch in cytokine profile. The aim of this study was to analyze T-cell function in therapy-naive chronically HIV-1-infected patients before inclusion in HAART. 29 individuals were set up in two groups following CD4+T-cell count. Each group consisted of two subgroups according to lymphoproliferative responses to PHA: group A with SI(PHA)< 3.0 and group B with SI(PHA)>3.0. The degree of chronic immune activation was measured by the short-term (1 hour) spontaneous lymphocyte proliferation and the non-stimulated IFN-gamma pro-duction. Functional activity of CD4+ T cells was assessed by lymphoproliferative and IFN-gamma responses to PHA, PPD M. tuber-culosisand the specific HIV-1 p24 antigen. An increased spontaneous T-cell activation was found in all patients and the highest values were measured in those with lowest CD4+T cell count and SI(PHA)<3.0. An impaired T - cell function was determined in all individuals, which correlated inversely with the spontaneous lymphocyte activation, as a marker of chronic immune activation.


6. IS THERE A PREVENTIVE EFFECT OF LACTOBACILLUS BULGARICUS IN YOGHURT TO THE CLINICAL OUTCOME OF H. PYLORI INFECTION?

I. Mladenova-Hristova

ABSTRACT
Lactobacilli exert inhibitory effects on H.pylori in vitro. The aim of this study was to link the clinical outcome of H.pylori infections with the consumption of Lactobacillus bulgaricus (found in yoghurt). We investigated serum samples of 307 blood donors aged over 20 years: 151 donors from a town with a lower consumption of yoghurt and 156 donors from a rural area in front of Balcan Mountains with a higher consumption of the same milk product, derived from the vilagers themselves. They were tested for anti-H. pylori IgG antibodies with an ELISA (Roch Diagnostic). A questionnaire for sociodemographic and lifestyle possible risk factors of acquisition of H.pylori infection and about the quantity of milk consumption was also administrated. The observed overall seropositivity rate was 88% in Stara Zagora and 92% in the rural area of Balkan Mauntains. The educational level of the parents was associated with a seropositivity of blood donors in the same region (OR 6.00; 95%CI: 1.31-55.38; p<0.009). Sociodemographic variables showed that the manual profession (OR 6.58; 95%CI: 1.01 -25.62; p<0.02), the consumption of uncooked milk (OR 5.91; p<0.01), the contact with animals (OR 6.58; p<0.004), the eating from communal bowls (OR 3.54; p<0.03) are strong predictors of H. pylori seropositivity in the Balkan rural area as in the region of Stara Zagora. Although the seroprevalence of H. pylori is higher, the prevalence of the gastroduodenal diseases is significantly lower in the Balkan area than in Stara Zagora: 46 of 151 donors have duodenal ulcer in Stara Zagora and 10 of 156 patients - in the Balkan area (p<0.000001); 98 of 156 blood donors have not complains about the gastroduodenal tract in the rural area and 50 of 151- in the town of Stara Zagora (p<0.000002). Therefore the growth and clinical outcome of H. pylori may be suppressed by Lactobacilli and their fermented food products, (esp. Lactobacillus bulgaricus in yoghurt) in vivo.


7. SUPPURATIVE-DESTRUCTIVE PNEUMONIA IN CHILDHOOD: TREATMENT EXPERIENCE

K. Kalinova, P. Stefanova

ABSTRACT
Despite the new antibiotics the problem of suppurative-destructive pneumonia in childhood is still valid at present and needs timely and thorough diagnostics. Infection of a pleura! effusion, particularly as consequence to an underlying pneumonia, results in significant morbidity to the patient and health care costs to the family and payers. A considerable group of children has been directed to surgical treatment from pediatric wards of peripheral hospitals too late and in bad condition, with destructive pulmonary processes and severe intoxication effect. The problem of the treatment of children with suppurative-destructive pneumonia in Bulgaria is one of the basic issues in pediatric surgery and pulmonology. Early surgical intervention has been demonstrated to hasten recovery and reduce morbidity.


8. COURSE OF SURGICAL WOUND HEALING PROCESS IN PATIENTS WITH DIFFERENT LOCAL AND GENERAL PHYSICAL STATUS

A. Kirtcheva, E. Softova, T. Kantardjiev, M. Todorova, M. Petrov, Tz. Velinov, A. Bachvarova

ABSTRACT
Surgical cutaneous wound healing submits to both the general regularities of wound healing process, and the influence of a number of risk effects. The general risk factors related to patient and surgical procedure are being extensively examined and evaluated. The local factors, inhibiting or stimulating regeneration are being still only mentioned, but there lack studies of their detailed research and objectification. In the present work we investigated 24 operated patients of different surgical diagnosis, age, surgical wound class and physical status. After the termination of operation we took a biopsy material for histological evaluation of wound tissues’ status. On this ground we made a general conclusion of the course of the healing process in the four patients groups as regards surgical wound class.


9. FREQUENCY AND ETIOLOGICAL STRUCTURE OF CENTRAL VENOUS CATHETER-RELATED INFECTIONS IN CRITICALLY ILL PATIENTS

T. Strateva, R. Vatcheva, I. Mitov

ABSTRACT
To determine the frequency and etiological structure of central venous catheter (CVC)-related infections among critically III patients, hospitalized in a surgery-trauma Intensive Care Unit in Sofia (2001, March - 2002, June). Patients, materials and methods: 90 CVC from 71 patients, mean age 51.4 (range 18-81) and APACHE II averaged sum 14 (2-29), were studied. The used catheters were: Cavafix (76.6 %), Balton (16.8 %) and Vygon (6.6 %). Microbiological methods: (1) A semiquantitative culture method of Maki et al.: rolling the distal catheter segment across blood agar. (2) Determination of the time to growth of blood cultures taken simultaneously from the CVC and a peripheral vein, or „differential time to positivity“ of paired samples. CVC-colonization- 47 catheters (52.2 %); CVC-sepsis- 22 episodes (24.4 %). Etiology: (1) CVC-coloni-zation- gram-negative bacteria (mainly K. pneumoniae and P. aeruginosa) - 40.3 %, coagulase-negative staphylococci (CNS)-29.8 %, S. aureus - 17 %, Candida spp. - 8.5 %, and E. faecalis - 4.3 %. (2) CVC-sepsis- Gram-negative bacteria (mainly K. pneumoniae)- 45.4 %, S. aureus - 32 %, CNS- 13.6 %, and E. faecalis - 9%. The frequency of CVC-related infections in the present study was above 3 times higher than that worldwide. The major etiological pathogens were Gram-negative bacteria, different from the leading pathogens in the USA and Europe (CNS, S. aureus and Candida spp.). In the base of these considered differences is an underestimation of the role of this serious complication for the increasing mortality among critically ill patients and thence the absence of contemporary strategy for the prevention of intravascular catheter-related infections in Bulgaria.


10. IN VITRO EVALUATION OF THE LINEZOLID ACTIVITY IN GENERAL TYPE BULGARIAN HOSPITAL

R. Vacheva-Dobrevski, E. Savov

ABSTRACT
Treatment of hospital-acquired infection is made difficult by increasing incidence of Gram-positive bacteria, many of them resistant to available therapy. Linezolid is a novel oxazolidinone antibiotic that has a bacteriostatic activity against staphylococci and enterococci, and bactericidal activity against streptococci. We performed a study to assess the in vitro activity of linezolid against common Gram-positive clinical isolates in our hospital. A total of 301 nosocomial isolates from the last two years were included: Staphylococcus aureus - 79 MSSA and 86 MRSA; Coagulase negative Staphylococcus - 37 CoNMS and 43 CoNMR; Enterococcus faecalis- 52; Enterococcus faecium - 24. We used Mini API (Bio Merrieux, France) System and conventional Kirby-Bauer disk diffusion test according NCCLS. We presented comparative susceptibility data about oxacillin, clindamycin, ampicillin,erythromycin, levofloxacin, vancomycin, teicoplanin, quinipristin/ dalfopristin. All tested strains exhibited 100% linezolid susceptibility. The results demonstrated linezolid to be active against most important Gram-positive cocci in our hospital, including those resistant to other antibiotics.


11. FIRST PCR DETECTION OF FRANCISELLA TULARENSIS IN RESERVOIR ANIMALS FROM ENDEMIC AREA IN BULGARIA

T. Gladnishka, I. Christova, T. Kantardjiev

ABSTRACT
PCR method is a new, sensitive, rapid, and specific method for diagnosis and identification of microorganisms. It eliminates risk for personnel of working with bacteria at high risk, such as Francisella tularensis. PCR investigation of rodents in endemic for tularemia region was conducted and 21% positive for F. tularensis rodents were detected. There were some differences in positivity of different organs: higher in spleen and liver samples, lower in kidney, heart and lung. Positive PCR reaction in considerable number of rodents suggests their epidemiological role in transmission of the infection. Our data correlate with results from serological studies on domestic animals.


12. DEVELOPMENT OF AFLP AND RAPD METHODS FOR TYPING OF CLINICALLY SIGNIFICANT CANDIDA SPECIES

T. Kantardiiev, V. Levterova, S. Panaiotov, I. Ivanov

ABSTRACT
Two molecular epidemiology typing approaches RAPD (Random Amplified Polymorphic DNA) and AFLP (Amplified Fragment Length Polymorphism) have been applied for better evaluation of genetic diversity among Candida isolates with clinical significance. Main objectives of the study were to develop typing methodologies and to investigate the reproducibility, discriminatory power and typeability of each method applied. By using six short oligomer primers (10-15 mers) with arbitrary chosen sequences, distinctive and reproducible sets of RAPD products were observed. The AFLP technique was applied by amplifying specific Pstl/BamHI restriction fragments. With the applied typing methods it was found that the isolates obtained from a single person with chroniocal recurrent vaginal candidosis, but isolated from different body sites show polymorphic fragments. We performed an attempt to study possible transmission of Candida strains in hospitalized HIV positive patients. In conclusion, AFLP is a method with good reproducibility, but laborious. RAPD needs strict performance criteria.


13. CHEMOTHERAPY OF CYSTIC EHINOCOCCOSIS-INDICATION AND REVIEW OF LITERATURE

K. Kalinova

ABSTRACT
Chemotherapy is a noninvasive treatment and is less limited by the patient s status than surgery or PAIR but is not ideal when used alone. Albendazole, the drug most often used, appears to have the greatest eficacy of any agent used so fan nevertheless, apparent cure (shrinkage or disappearance of cysts) rangeds only between 20% and 30%. Another important indication for chemotherapy is the prevention of secondary echinococcosis. There is not yet formal consensus, as the efficacy and safety of some of the methods require further evaluation before we can establish comprehensive guidelines for the medical treatment of hydatidosis.


14. ASYMPTOMATIC CASES OF HUMAN HYDATIDOSIS

K. Kalinova

ABSTRACT
The diagnosis of uncomplicated hydatid cyst depends on clinical suspicion. Nonspecific symptoms may also be present. There exist scarce information about the natural history of the illness in non-treated patients. At the present time, these aspests in non-symp-tomatic carriers detected by ultrasonography (US) are studied. Ultrasonography, a noninvasive, readily available, sensitive, cost-effective imaging technique, should be the diagnostic method of choice. 47 of these cases are detected in 331survey by US made in South-Eastern Bulgaria between 1990 and 2003 years. 40 of these are investigated by way of interviews, review of clinical histories, clinical control, US and serology; and other cases - only by US. 75% did not present clinical evidence of hydatidosis. 15 asymptomatic cases between 1992 and 2003 were evaluated by US detecting an average increase of the (QH) of 1,2 cm, with substantive changes in the type of image and in the serological response. 20% of the asymptomatics had been operated on before appearing the symptoms. The results are analysed in function of the age, of the propable individual susceptibility and of the echogenic image of the (QH), evaluating the pertinence of the current of the treatment.


 

Editorial Board

Editorial-in-Chief
Prof. B. Petrunov, MD, DSc

Executive Editor
Prof. H. Taskov, MD, DSc
Assoc. Prof. R. Kurdova, MD, PhD
Assoc. Prof. R. Kotzeva, MD, PhD
Assoc. Prof. N. Gatcheva, MD, PhD
Assoc. Prof. T. Kantardjiev, MD, PhD
Prof. P. Nenkov, MD, DSc

Production Manager
Dr. V. Gatcheva

Technical Assistance
T. Koshev

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