Ventilator-Associated Pneumonia in Neonates Admitted to a Tertiary Care NICU in Bulgaria.

Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection (HAI) among neonatal patients in the intensive care units (ICUs) and is a serious challenge for neonatologists because it affects critically ill patients who need prolonged mechanical ventilation. In Bulgaria, there is no detailed data at regional and national levels on the characteristics of VAP in newborns, which imposes a necessity for specific studies of risk factors and etiology of VAP. The aim of the study was to analyze the frequency, characteristics and risk factors for the occurrence of VAP in newborns hospitalized in intensive care unit. This was a prospective study, conducted between January 2017 and June 2018 in the NICU of University Hospital "St. George" Plovdiv, Bulgaria. The sample consisted of 507 neonates, followed up prospectively, 107 of whom were placed on mechanical ventilation for ≥48 h. VAP was diagnosed in 33 out of 107 neonates (31%). The VAP incidence rate was 35.06/1.000 ventilator days. We confirmed differences between the median birth weight (1,310 vs. 1,690 g, p = 0.045) and average gestational age (31.08 g.w. vs. 33.08 g.w, p = 0.04) of the patients with and without VAP. The average stay of patients with VAP in the NICU was statistically significantly longer than the hospital stay of non-VAP patients (35.70 ± 21.84 days vs. 21.77 ± 17.27 days (t = 3.241, p = 0.002). In neonates with VAP, the duration of mechanical ventilation was statistically significantly longer compared with non-VAP patients (16.88 ± 11.99 vs. 5.42 ± 4.48; t = 5.249, p = 0.000). A statistically significant prevalence of Gram-negative bacteria among VAP patients was demonstrated (91%) compared to the Gram-positive (9%), p < 0.05. The leading causative agent of VAP was Klebsiella pneumoniae ESBLs + (27%), followed by Acinetobacter baumannii (14%), Pseudomonas aeruginosa (12%) and Escherichia coli (12%). In multivariate logistic regression, mechanical ventilation >7 days was established as an independent risk factor for VAP (OR 3.6; 95% CI: 1.7-6.5, p = 0.003). VAP remains a serious and outstanding issue in pediatric and neonatal intensive care units. The findings of the current study emphasize that the birth weight, gestational age, and duration of hospital stay have a significant association with ventilator-associated pneumonia.

Bisphosphonate-associated Osteonecrosis of the Jaws: a Survey of the Level of Knowledge of Dentists about the Risks of Bisphosphonate Therapy.

INTRODUCTION: Bisphosphonate-associated osteonecrosis of the jaws (BAONJ) is a side effect of treatment with bisphosphonate (BP). Reports of this complication have increased recently. AIM: To evaluate the level of knowledge of dentists from Plovdiv, Bulgaria, about possible complications of bisphosphonate therapy of patients in dental practice. MATERIALS AND METHODS: Three hundred and twenty-three dental practitioners from Plovdiv, Bulgaria, took part in an anonymous survey containing 25 questions, designed to evaluate the knowledge of dentists about the complications of BP therapy. RESULTS: Oral and maxillofacial surgeons have the best knowledge about the indications and side effects of BP therapy, while dentists with a specialty in Pediatric Dentistry and General Dentistry have insufficient knowledge. Of the respondents, 17.03% are absolutely uninformed about BP and their side effects, and 1/2 declare that they have never had a patient with complications from BP therapy in their practice, probably due to a lack of awareness of the problem. Approximately half of the dentists we surveyed agree to carry out prophylactic examinations of patients receiving BP and know what the prophylactic examination includes. Only 15.48% of the respondents have correctly responded that in order to be treated as clinically healthy, patients should have stopped taking BP for more than 10 years. CONCLUSION: With the exception of specialists in Oral and Maxillofacial Surgery, dental practitioners in Plovdiv and the region are poorly informed about the complications associated with BP therapy. Therefore, efforts must be made to make these dentists better informed about BAONJ, especially about the methods and means of preventing this condition.

Booster immunity - diagnosis of chronic hepatitis B viral infection.

INTRODUCTION: Diagnosis of chronic hepatitis B virus (HBV) infection particularly its occult form requires monitoring and repeat serological and molecular studies. The aim of the study was to investigate the possible relation between the case of a family outbreak of hepatitis A and the finding that a member of this family was diagnosed with chronic hepatitis B. METHODOLOGY: A mother and her two sons, one previously diagnosed with chronic HBV infection, were hospitalized due to suspected acute hepatitis. Serological markers for hepatitis A, hepatitis B and hepatitis C were assessed. Additionally, HBV DNA was tested with a sensitive PCR. Hepatitis B vaccine was administered to the mother to differentiate resolved from occult HBV infection. RESULTS: A family outbreak of hepatitis A was confirmed, alongside a focus of chronic HBV infection. The serological profile for two brothers was HBsAg(+), anti-HBcIgM(-), anti-HBc(+), HBcAg(-)/anti-HBe(+). The mother was negative for all HBV markers except anti-HBc. HBV DNA was detected at a level of 461 IU/mL in the elder brother, 3647 IU/mL in the younger brother and was negative in the mother on two occasions. Her anti-HBc alone, having two sons with chronic HBV infection, and her lack of antibody response to hepatitis B vaccine despite being negative for HBV DNA, led to the diagnosis of probable occult HBV infection. CONCLUSION: Our results confirmed that a vaccination approach could facilitate diagnosis of chronic HBV infection in the presence of isolated anti-HBc. If it were not for a family outbreak of hepatitis A, this unexpected family HBV focus would not have been revealed.

A Technical Problem in Diagnosis Clarity of Solitary Spinal Cord Neurofibroma in an Eleven-month-old Boy.

Spinal neurofibroma is one of the rarest of the neoplasms involving the spinal cord or roots and occurs much less often than neurinoma, meningioma or glioma. The sixth pediatric case of solitary intramedullary tumor was described in 2013, according to B. Eljebbouri et al. We present a rare, difficult to diagnose and may-be the seventh pediatric case of solitary neurofibroma of the cauda equine in an 11-month-old infant. The patient underwent a laminectomy of T12, L1, L2 and L3, extirpation of intradural, intramedullary and extramedullary spinal cord tumor. The patient is fully recovered for 5 years of monitoring. Although rare, spinal neurofibromas in children should be diagnostically considered and radically treated for a favorable outcome.

A survey of occupational risk exposures and behaviour of healthcare workers.

UNLABELLED: To reduce the risk of transmission of microorganisms standard precautions are taken for all patients expected to be exposed to blood, body fluids, or have contacts with mucous membranes and non-intact skin. These preventive measures are by far the best way to protect healthcare workers from adverse infections. AIM: To analyze occupational risk exposure of healthcare workers occurring when the latter come into contact with blood or other potentially infectious liquid in order to assess some aspects of the application of standard preventive measures. PATIENTS AND METHODS: 680 healthcare workers (186 physicians, 330 nurses, and 164 hospital orderlies) were included in an anonymous survey conducted at St George University Hospital, Plovdiv in 2009. The questionnaire consisted of 14 questions grouped in 3 clusters. Occupational risk exposure was defined as recommended by the Centers for Disease Control and Prevention (CDC). We used descriptive statistics, parametric and non-parametric analysis. RESULTS: Occupational exposure was reported by 81% of the respondents for the last year with predominance of percutaneous injuries (62%). Nurses sustained the most risk exposures (86%). We found a correlation between the job category and the occupational exposure (chi2 = 14.3, df = 2, p < 0.001). No correlation was found between length of service and injury intensity (chi2 = 1.69, df = 2, p > 0.05). Immunisation against hepatitis virus B infection received 64.3 +/- 3.8% of the healthcare personnel. Immunization covered 48.2% of the ancillary workers, which is less than the mean coverage for the respondents. Job position was found to correlate with the immunisation coverage (chi2 = 24.41, df = 2, p < 0.001). Ninety-two percent of the healthcare workers used personal protective equipment (disposable gloves), but only 74.6% of them did this during emergencies (p < 0.001). CONCLUSION: Post-exposure follow-ups and the overall behaviour pattern after occupational risk exposure are random and non-systematic in nature. A better prevention of healthcare personnel would require a long-term training with constant knowledge upgrading, invasive procedures perfection and permanent control.

Immune response and immunologic memory in medical personnel vaccinated with hepatitis B vaccine.

UNLABELLED: The occupation-related nature of Hepatitis B viral infection in medical personnel has been well documented in a lot of studies. The only reliable way of prevention of this infection is immunisation with hepatitis B vaccine. AIM: To follow-up the primary immune response after immunisation with recombinant vaccine and its duration in adult immunocompetent subjects. MATERIALS AND METHODS: One hundred sixty-five health-care workers working at St. George University Hospital, Plovdiv in 2009/2010 were included in the study and allocated to two groups. Group 1 (N1 = 70) was followed up for the primary immune response after immunization; group 2 (N2 = 95) was with documented immunization in 1998/1999 (n = 81) and in 1994/1995 (n = 14). Tests based on ELISA for quantitative determination of anti-HBs in mIU/ml were used. The measurement were performed at the National Reference Laboratory of Viral Hepatitis at the NCIPD, Sofia. Descriptive statistics, non-parametric and parametric tests, qualitative correlation were used to analyse data. RESULTS: Group 1 mean age was 40.3 +/- 2.6 years; anti-HBs concentration of > or = 10 mIU/ ml was found in 92.8%. No association between the immune response and the commonly involved factors such as gender, age, overweight, smoking, etc., was found. In group 2, anti-HBs concentration of > or = 10 mIU/ml was found in 77.9%: it was in 75.3% in those immunized 10 years before, and in 92.9% in those immunized 15 years before (t = 0.24, p > 0.05). A booster dose of the vaccine was received by 15/21 subjects from group 2 (those immunized 10 years before that) with anti-HBs < 10 mIU/ml. After the booster, 9/15 produced anti-HBs in protective concentrations (anamnestic immune response). The actual level of seroprotection among the immunized more than 10 years ago was 92%. CONCLUSION: This study and the documentation of the primary postvaccinal immunity in high-risk medical personnel will help specify if additional hepatitis B vaccine shots are needed.

Immunological and microbiological investigations of patients with burn injuries.

UNLABELLED: Susceptibility of patients with burn injuries to infections is associated with disturbances of the humoral and cell-mediated immunity. The aim of the present study was to investigate the dynamics of phagocytic indices and serum immunoglobulin levels in patients with burn injuries as there is a high risk of colonization and infection of the burn wound. PATIENTS AND METHODS: Between December 2004 and April 2005, we studied the dynamics of the following indices of the phagocytic system and humoral immunity of 30 burned patients: phagocytic index, phagocytic number, nitro blue tetrazolium chloride test, leukocyte number in the peripheral blood, the percentage of the neutrophilic leukocytes from the differential blood count, serum levels of immunoglobulins A, G and M and the percentage of lymphocytes. In addition, microbiological tests of the wound secretions were performed using conventional microbiological methods. RESULTS: The changes in the phagocytic indices suggested that it is the decreased phagocytic index and number that are important for the evaluation of wound infection risks. The increased total number of leukocytes and elevation of the neutrophil levels usually observed in burned patients indicate the presence of bacterial infection and the prompt involvement of the phagocytic mechanisms. The lower percentage of lymphocyte in comparison with the healthy controls was indicative also of a possible involvement of the cell-mediated immune response. The characteristic humoral mechanisms of the immune response (serum immunoglobulins) in patients with thermal injuries altered only slightly. CONCLUSIONS: The analyzed data may be of help in evaluating the risk of colonization and infection of the burn wound in patients with burn injuries. We would like to recommend a compulsory battery of microbiological tests and several immunological investigations phagocytic index, phagocytic number, leukocyte number, differential blood test and serum immunoglobulins with a view to applying an adequate antimicrobial and immune modulating treatment.