Characterisation of an echovirus type 11' (prime) epidemic strain causing haemorrhagic syndrome in newborn babies in Hungary.

Echovirus 11' (prime) isolates from an epidemic of haemorrhagic syndrome in departments of obstetrics in Hungary have been characterised. The leading component of the clinical disease was carditis and its lethal outcome occurred in 13 newborn babies. Maternal immunity was found to be absent even in women of 41 years of age. The application of monovalent oral poliovirus type 1 vaccine prevented the progress of the epidemic within two weeks. Nevertheless, a serological survey among primovacinees of 3-15 months of age revealed that 20% of the babies seroconverted without clinical symptoms during the epidemic. Serological evidence showed that the echovirus 11' infection was unable to interfere with the efficacy of oral poliovirus vaccine (OPV), since seroconversion rates of primovaccinees did not differ significantly from those in the group seroconverted also to echovirus 11' during the vaccination campaign. A 440 nucleotide (nt) fragment of the 5'-non-translated region of 12 epidemic echovirus 11' isolates and 26 echovirus prototype strains was amplified by a nested reverse transcription-polymerase chain reaction (RT-PCR) and analysed using three different restriction endonucleases. The 5'-regions of the echovirus 11' isolates were found to be identical to each other but different from that of the prototype echovirus 11 (Gregory) strain. The results indicate that echovirus 11' isolates underwent genetic changes in the 5'-end and P1 region of the genome before the onset of the epidemic.

[Incidence of post-transfusion hepatitis in Hungary 1987-1993]. / Posttransfusiós hepatitisek elöfordulása magyarországon 1987-töl 1993-ig.

The authors describe the epidemiological characteristics of hepatitis cases occurred after administration of blood or blood-preparations in Hungary, based on data collected between January 1987 and December 1993. The epidemiologists of the public health network reported 868 acute posttransfusion hepatitis within this seven years period. The number of the cases decreased year by year, and in accordance with the rapid development of virological diagnostics the rate of cases with uncovered aetiology increased gradually. Nevertheless the aetiology of more than half of the reported cases (466 patients, i.e. 53.6%) remained unknown. The results of the examinations were negative in 167 cases (19.2%), and no etiological examinations were carried out in 299 cases (34.4%). Hepatitis A was reported in 17 cases (2%), hepatitis B in 129 cases (14.9%), whilst non-A, non-B hepatitis was diagnosed in 188 cases based on examinations with an experimental NANB antigen and antibody tests or by exclusion of hepatitis A and B infectious (21.7%); from 1991 67 cases (7.7%) were diagnosed by standard tests as hepatitis C, and Epstein-Barr virus infection was reported in 1 case (0.1%). During the seven years 11 patients of the 868 (1.3%) died in the acute phase of the illness.

[Questions about re-sterilization and reuse of sterile disposable devices]. / Diszpozibilis steril eszközök újrasterilizálásának és ismételt használatának kérdése.

Authors deal with the problems of restilization and reuse of sterile disposable devices on the basis of literary data, their own experiences, and the standpoints offered on the Fourth Symposium of the Canadian Office for Health Technology Assessment. They state, though the reuse of sterile disposable items is possible to work out, it needs a very sophisticated technology, its thriftiness is often doubtful, and the related legal and ethical problems are mostly unsettled. The personal, material and legal preconditions assuring a safe reuse do not exist in Hungary at present.

Marketing management enhances customer relations.

The implementation of automated marketing management systems in hospitals across the United States can change dramatically the way in which a hospital builds business by managing relationships with prospective customers.

[Management of gas gangrene in Hungary during 1979-1988 based on data from Public Health Centers]. / A gázgangréna kezelése Magyarországon 1979-1988-ban a KOJAL-ok adatai alapján.

Authors present data on the therapy of 223 gas gangrene cases between 1979-1988, a ten years period, based on the reports of Public Health Stations in Hungary. Of the 223 patients 150 died, thus lethality was 67.3%. In lack of surgical intervention there was no chance of survive. Merely wound exposure resulted in a much higher fatality rate than necrectomy of the wound. Local hydrogen-hyperoxide treatment improved survival essentially. Specific antitoxin therapy did not influence the survival rate. The effect of a single antibiotic was poor; combined antibiotic treatment gave a significantly better result. As for combination, the most effective were erythromycin, the lincosamids and chloramphenicol. According to the data presented, it would be possible to reduce to the half the fatality rate of gas gangrene in Hungary.

[Information data on the incidence of nosocomial infections in Hungary]. / Tájékoztató adatok a nosocomialis fertözések hazai elöfordulásáról.

Authors registered the occurrence of nosocomial infections in altogether 1000, randomly selected case records at the surgical, gynecological, urological and intensive care wards of four county hospitals plus one large hospital in the capital in 1988. They found the proof of a total of 117 nosocomial infections occurring in 100 case records. The three most common infections in diminishing order were: urogenital-, wound- and respiratory infections. Twenty three infected patients developed sepsis, with a fatal outcome in every second among them. A nosocomial infection extended the period of hospital treatment in average by a week. In more than half of the cases microbiological examination for detecting the causative agent failed. Four fifth of the isolated bacteria were Gram-negative. Presented data of informatory nature suggest more decades arrearagement compared to the highly-developed countries.

[Gas gangrene cases in Hungary 1979-1986]. / Gázgangraena megbetegedések Magyarországon 1979-1986-ban.

The authors evaluate epidemiologic data of 182 patients suffering from gas gangrene during an eight year period from 1979 to 1986. Of the patients surveyed 127 died; thus lethality reached 69.2%. The average age of the survivors was 49.9 year as opposed to the 66.1 year of the fatal cases. More than half of the illnesses followed amputation of extremities, and a quarter of them was a consequence of an accident. Samples of the bacteriologically examined wound discharges yielded in 93.1% bacteria from the Clostridium genus. Hygiene was poor in operation theatres and in the hospital environment in 1/4-th of the cases. Sixty six patients died within 24 hours after diagnosis. The presented data suggest that in Hungary the number of gas gangrene cases and deaths surpass those of tetanus.

Phases of the serological response in Pseudomonas aeruginosa infections.

Sixty-four infections due to Pseudomonas aeruginosa in patients of a respiratory intensive care unit were studied. The length of serologically latent period following the appearance of P. aeruginosa decreased with the growing severity of the infection, however, the longest latent period occurred in lethal cases. As the phase of development of peak anti-LPS antibody titres was constant in each group, in fatal infections the serological response developed too late when sepsis had already started. The duration of the persistence of peak titres was also stable. In consequence of a close negative correlation between these two latter parameters, the period from the onset of antibody increase till the beginning of decrease was especially constant, independent of the severity of infection, the duration of the antigenic stimulus and the intensity of the serological response. The rate of decrease was an another stable value. All these refer to an endogenous, time-dependent regulation which, despite existing clinical symptoms and the presence of P. aeruginosa, starts anti-LPS antibody level to decline. Pseudomonas carrier state in convalescence was observed in cases with prolonged persistence of peak titre and with a lower rate of titre decrease.

Anti-LPS antibody response in Pseudomonas aeruginosa infections. I. Kinetics of the serological response.

A continuous survey of the serological response in 59 Pseudomonas aeruginosa infections of 30 patients treated in a respiratory intensive care unit revealed that anti-LPS antibody production paralleled the intensity of the infection from the early onset. In lethal cases the immunological response was depressed from the start of the P. aeruginosa complications, probably as a consequence of a too intensive antigenic stimulus exerted by a massive infection. Septic shock was always accompanied by a marked fall in antibody titres. The loss was more expressed in the most effective IgG class antibodies.

Immunoserology of Pseudomonas aeruginosa infections in man. III. Site of infection, duration of the presence of Pseudomonas aeruginosa and antibody response.

In 39 patients of a respiratory intensive care unit the intensity of the serological response to the purified LPS of the causative Pseudomonas aeruginosa was found to change according to the site of infection. The highest titres were found in septic cases, when the antigenic assault reached all the immune-competent cells in the body. Short presence (only one positive bacteriological culture) of P. aeruginosa at the site of inflammation resulted in a low or moderate rise in antibody titre. Ten days were enough for the development of a maximum total antibody (approximately IgM) response, while IgG type antibodies moderately grew further when the presence of P. aeruginosa lasted more than 10 days. Only a 16-fold increase in total antibodies per se or a 4-fold rise in both total (approximately IgM) and IgG antibodies confirmed the pseudomonas infection.

Serial determination of complement and specific antibody titres in Pseudomonas aeruginosa infection.

Serial examination of the complement system and specific antibody titre of 12 surviving patients and 8 lethal cases suffering from Pseudomonas aeruginosa infection showed that except the onset of infection, until the development of septic shock, the level of the complement components corresponded to or exceeded the average normal value. In reversible septic shock the complement titre decreased significantly and in irreversible shock the values were even lower. Activation of the complement system occurred on 10 occasions via the classical and on 42 occasions via the alternative pathway. The number of activations grew parallel with the severity of the infection. Activation through the classical way was generally more intensive. During the whole infectious process not the individual characteristics of the P. aeruginosa present unbroken, but the pathological events and the specific antibody level determined the mode (alternative or classical pathway) of complement activation. The specific antibody level of the surviving patients significantly surpassed the titres of the lethal cases until the development of shock. Not an insufficiency of the complement system but the relative lack of specific antibodies was mainly responsible for the fatal outcome of P. aeruginosa infections.

Immunoserology of Pseudomonas aeruginosa infections in man. II. effect of natural and immune anti-LPS antibodies on pseudomonas colonization and infection.

In 39 acute patients of a respiratory unit a comparatively high Pseudomonas aeruginosa anti-lipopolysaccharide antibody level present on admission prevented colonization by the homologous pseudomonas serogroup. At lower natural antibody titres symptomless colonization occurred, and in patients with the lowest initial titres, later P. aeruginosa complications developed. A low antibody level also predisposed to pseudomonas infection in 9 chronic patients. When colonization occurred at high antibody titres, the presence of P. aeruginosa was only transient; however, the titre had no effect on the further duration of harbouring P. aeruginosa. Anti-LPS antibodies may play an important role not only in the outcome of pseudomonas infection, but also in other respects of pseudomonas-man interaction.

Immunoserology of Pseudomonas aeruginosa infections in man. I. Four types of interaction between host and bacterium.

Continuous survey of clinical symptoms, bacteriological findings and anti-LPS antibodies in 39 acute and 9 chronic patients at a respiratory department revealed four interaction-types between Pseudomonas aeruginosa and host: I, clinical complications with a serological response; II, the same without serological answer; III, rise of specific antibodies without clinical symptoms; and IV, no clinical or serological reaction despite the presence of P. aeruginosa. Exogenous factors like massiveness or mode of infection (e.g. instrumental) determined mainly the type of interaction in the absence of immune-antibodies. P. aeruginosa colonization longer than a few days turned generally into manifest or subclinical infection. The lack of antibody production in severe infection was likely a consequence of an immune-paralysis, elicited by a massive infection. Antibody production was lower in subclinical than in manifest infection, yet IgG-type antibodies increased not only in the latter, but always in the former, too.

Effect of Pseudomonas aeruginosa lipopolysaccharide on phytohaemagglutinin induced lymphocyte transformation.

Examination of the mitogenic response of lymphocytes in 50 blood samples from 17 patients suffering from Pseudomonas aeruginosa infection and on 5 occasions from 5 healthy persons revealed that a Pseudomonas lipopolysaccharide unfamiliar to the lymphocytes decreased, whereas the purified O-antigen of the infection causing Pseudomonas serogroup increased the effect of phytohaemagglutinin on parallel lymphocyte cultures prepared from the same blood samples during the whole infectious process. After complete recovery, however, the lipopolysaccharide of the infection causing P. aeruginosa strain inhibited again the phytohaemagglutinin response as if the lymphocytes had never met it. The model seems to offer a possibility to follow up in vivo the signs of the changes in the cellular background during the reaction given on Pseudomonas lipopolysaccharides.

Origin and spread of Pseudomonas aeruginosa, Proteus and Klebsiella during twenty years in an infectious hospital.

Bacteriological examinations carried out in an infectious hospital revealed that the occurrence of Pseudomonas and Proteus grew 4-fold, and the rate of Klebsiella positive cultures 3.5-fold between 1958 and 1977. On the other hand, the occurrence of Staphylococcus aureus decreased to the half since 1961. The occurrence of Gram-negative facultative pathogens started to increase in the surgical wards in the fifties and the rise lasted until the mid-sixties. Pseudomonas aeruginosa was the most frequent among them. In contrast, Escherichia coli dominated and P. aeruginosa was the least frequent in the non-surgical wards. Here the Gram-negative facultative pathogens showed a more rapid increase and the incidence of P. aeruginosa and Proteus kept rising throughout the whole examination period. When Gram-negative facultative pathogens of hospital origin were colonizing, the proportion of sick persons versus symptomless carriers was significantly higher than in the case of extrahospital colonization on the basis of the records of 300 P. aeruginosa, 300 Proteus and 300 Klebsiella positive patients. This proportion changed parallel with the rate of the strains of hospital origin. The number of patients who acquired P. aeruginosa, Proteus or Klebsiella extrahospitally, kept continuously rising between 1958 and 1971. Thus, the advance of Gram-negative facultative pathogens is due not ony to nosocomial causes.

Extrahospital and intrahospital factors predisposing to the spread and colonization in patients of Pseudomonas aeruginosa, Proteus and Klebsiella in an infectious hospital.

The number of patients admitted to hospital who harbour Pseudomonas aeruginosa, Proteus and Klebsiella, keeps rising. Of the factors predisposing to colonization, only diabetes and antibiotic therapy exert their effect equally in extrahospital and intrahospital environment. Malignant diseases, immune suppressive therapy and instrumental interventions play a predominant role in the hospital. In extrahospital environment, infancy and old age, poor general condition as well as in almost half of the cases, an inflammatory process caused by viruses or bacteria was found to create favourable conditions for the colonization of facultative pathogens. One of the main sources of the Gram-negative facultative pathogens studied was the faeces of enteric patients in the hospital. The frequency of P. aeruginosa, Klebsiella and Proteus positive cultures rose parallel in the faecal and non-faecal bacteriological samples in the period 1958 to 1977. The seasonal changes observed in the frequency of positive cultures revealed that the Gram-negative facultative pathogens had increased in number first in the enteral wards, spreading subsequently to the medical and paediatric wards, and finally they appeared in a high number in the surgical wards, originating from patients transferred there from the medical or paediatric wards.

Serum IgG, IgA and IgM changes during infectious complications induced by facultative pathogenic gram-negative bacteria.

IgG, IgA, and IgM concentrations were measured at 40 acute and 9 chronic patients continuously during complications induced by facultative pathogenic Gram-negative bacteria, primarily by Pseudomonas aeruginosa. On the basis of the results the sudden decrease of Ig concentrations at the onset of complications, during shock, and before death was, beside the consuming effect of antigen-antibody reactions, most probably a consequence of increased capillary permeability and haemodinamic disorders due to antigen-antibody reactions and the effect of endotoxin. It was conspicuous, that a correlation could be found between the concentration of IgM and the development or final outcome of the complications: IgM values in cases of lethal complications in the acute patients were essentially lower than in the other patients surviving severe complications, even at the early period of complications still without any clinical signs of the outcome.

Natural antibodies in Pseudomonas aeruginosa infections.

Studying 347 sera of 49 patients suffering from Pseudomonas aeruginosa infection the mean titre value (MTV) calculated from the exponent of the binary logarithm of natural antibody (NA) titres, was found suitable to characterize the humoral immune status. As long as the organism is in equilibrium with the infection, the NA level rises. In septic shock, before death or at the development of a massive infection, the NA titre decreases rapidly. The decrease may be due partly to the permeability increasing effect of endotoxin and antigen-antibody reactions exerted on the capillaries. Consequently, in the most severe phase of sepsis, when bacteria enter the circulation less NA is available to fight against them. This might be a cause of the still very high lethality of septic shock due to Gram-negative bacteria. Finally, when applying the MTV one always has to consider that despite its advantages it gives less information than the Backhausz immunogram.