NEWS

• WORKSHOPS

• SITE VISITS

• FORTHCOMING EVENTS

ESBL: SOME INFORMATION FROM THE INTERNET

• Extended Spectrum Beta Lactamase (ESBL

• Frequency of Extended Spectrum Beta Lacrimase...

GABROVO PSBHI 2004 PROJECTS - COMPLETED OR IN ACTION

NEWS

WORKSHOPS

 A Problem Solving for Better Health Workshop on Nosocomial Infections took place in Pleven on April 1-3, 2005. The workshop was organized by Dreyfus Health Foundation, the Association for Better Health – Pleven, Medical University – Pleven and the University Hospital. The fifty-one participants were addressed by Assoc. Prof. Tashko Deliiski, MD, PhD, Dean of Faculty of Medicine and Director of the University Oncology Center Assoc. Prof. Dimitar Stoikov, MD, PhD, Executive Director of the University Hospital and Mrs. Yanka Tzvetanova, President of Association for Better Health and country coordinator. Participants were selected with the assistance of the hospital director, the chief nurses Mrs. Anelia Dimitrova and consulted prior the workshop by the hospital epidemiologist – Dr. Emilia Kanyovska, MD. General problems that were identified included hospital hygiene, control and registration of nosocomial infections, cost effectiveness of hospital care including antibiotic treatment, problems related to sterilization and availability of disposable protective gear, training of staff and patient education.

Dr. Assen Pachedjiev, coordinator of the Swiss-Bulgarian project on Hospital Hygiene, made a comprehensive introduction to the problems and issues of hospital hygiene and nosocomial infections, presenting information on the current status of the program, its achievements and perspectives. His organization – Hygia, also provided each participant with specialized literature on the problems.

With the assistance of facilitators – Dr. Daniel Levine, PhD (USA), and the local facilitators – Assoc. Prof. Maria Alexandrova, MD, PhD, Assoc. Prof. Angelika Velkova, MD, PhD, Mrs. Yanka Tzvetanova, Mrs. Polya Zhivkova, Mrs. Makretta Draganova and Mrs. Evgenia Dimitrova, they prepared the following plans of action:

·        Reduction of rate of complications due to nosocomial infections by introducing individual protective gear for health personnel working in a risk pregnancy clinic - Dr. Antoaneta Lyubomirova, Risk Pregnancy Clinic

·        Introducing of disposable sterile catheters for re-catheterization of patients undergone hysterectomy - Dr. Chavdar Tzvetkov, Clinic of Oncogynecological Surgery

·        A training program to improve compliance with proper hand disinfection protocol - Dr. Ghinka Ivanova, Clinic of Obstetrics

·        Introduction of routine antiseptic treatment of delivery pathways for women admitted to the clinic to prevent perinatal and postnatal infections n babies - Dr. Michail Tzvetkov, Clinic of Obstetrics

·        A health educational program for nursing staff to reduce the rates of superficial nosocomial phlebitis in patients with intravenous cannula - Dr. Milen Predovski, Cardiology clinic

·        A training program for link-doctors on definition and registration of nosocomial infections - Dr. Emilia Kanyovska, Hospital Epidemiologist

·        A training program for general practitioners on proper techniques of urinary cathetherization - Dr. Orlin Michailov, Urosurgery Clinic

·        Health education on the risks of promiscuous sex for 100 girls and 50 young women - Dr. Roumyana Koleva, Cytology Lab

·        Introduction of protocols for safe tonometry of non-infected eye surgery patients - Dr. Snezhana Mourgova, Eye Surgery Clinic

·        An information program to reduce non-compliance with disinfection of bronchoscopy equipment - Dr. Stefan Stanimirov, Pulmology Clinic

·        Health education for pregnant women to reduce rates of conjunctivitis, pyodermia and dermatitis in new-born babies - Dr. Yonka Marcheva, Neonatology Clinic

·        A training program on proper disposal of hazardous hospital waste - Mr. Ivailo Stefanov, Hospital Hygiene Inspector

·        Training medical students proper techniques of hand washing and disinfection during clinical practice - Mr. Tzvetko Andreev, Medical Student

·        Providing enough sterile cannulas for patients undergoing surgery at the eye clinic - Mrs. Boyanka Groshevska, Eye Disease Department

·        A health education program for on the hygiene and prevention of recurrent allergy attacks for newly diagnosed patients - Mrs. Christina Batolska, Allergology Consulting Room

·        A training program for improving compliance of staff with protocols for carrying out intravenous procedures on risk patients - Mrs. Daniela Georgieva, Clinic of Narcology

·        Health education program for new hemodialysis patients on proper hygiene of peritoneal catheter - Mrs. Dechka Nikolova, Nephrology Clinic

·        Introducing water proof sterile fixing pads for permanent infusion pathways for surgical patients - Mrs. Diana Koukova, Anesthesiology Department

·        Regulating the admission of visitors to surgical patients - Mrs. Emilia Minkova, Surgery Clinic

·        A program to introduce standardized system for control of hospital hygiene at Pleven University Hospital - Mrs. Erka Andreeva, Hospital Hygiene Nurse

·        Raising compliance of staff with standardized protocols for delivery of sterilized gear from sterilization unit to clinics - Mrs. Iliana Vitanova, Cental Sterilization Unit

·        Training patients and families for proper postoperative hygiene and daily regimen after discharge from hospital - Mrs. Izabella Georgieva, Eye Disease Department

·        A training program for nurses on proper cleaning, disinfection and handling of intubation equipment in the operating room - Mrs. Kamelia Ivanova, Anesthesiology Department

·        Health education for low-educated parents to reduce the rates of reinfections in children with pneumonia- Mrs. Katya Angelova, Pediatric Clinic II

·        Improving control on nosocomial infections in Pleven University Hospital         Mrs. Lilyana Slavkova -Hospital Hygiene Nurse

·        Prevention of decubital ulcers in ICU patients - Mrs. Margarita Yakova, Intensive Care Unit

·        A health education program on proper hygiene and diet for mothers accompanying infants during the hospital stay - Mrs. Maria Milanova – Zlatanova, Paediatric Clinic I

·        An educational program to increase compliance of staff for proper hand disinfection - Mrs. Maria Sankova, Neurology Clinic

·        Health education on proper hygiene for postoperative ENT clinic patients to prevent complications - Mrs. Mariana Dimitrova, ENT Clinic

·        Providing timely disinfection of bronchoscopy equipment -Mrs. Mariana Nedkova, Lung Disease Clinic

·        A health educational program on prevention of post operative infections for patients operated on in the surgery clinic -Mrs. Mariyana Dimitrova, Surgery Clinic II

·        A program to reduce the number of cases of contamination with blood among operating room staff - Mrs. Maya Tzvetkova, Surgery Department

·        A health education program for pregnant women to reduce the rates of infections of the newborn - Mrs. Miglena Petrova, Neonatology Clinic

·        A training program for nurses to improve management of permanent peripheral intravenous infusion pathway - Mrs. Minka Geteva, Cardiology Clinic

·        A health education for couples expecting babies to prevent birth-related infections due to low level of knowledge of hygiene of pregnancy - Mrs. Natasha Andreeva, Neonatology Clinic

·        Regulation of admission of diabetic patients with acute virus respiratory infections to reduce the number of infected staff and patients - Mrs. Nedyalka Andreeva, Endocrinology Clinic

·        Providing proper disinfection and handling of sterile dressing materials - Mrs. Nezabravka Lazarova, Urology Clinic

·        Introduction of updated standardized protocols for use of sterile gear for intracavitary brachytherapy - Mrs. Pepa Ivanova, Radiology Clinic

·        Providing proper fixing and transportation of biopsy materials to reduce the rate of infections among lab staff - Mrs. Raina Marinova, Department of Pathological Anatomy

·        A health education program on the hygiene of breast feeding roma mothers accompanying their babies in hospital - Mrs. Stefka Kancheva, Pediatric Clinic I

·        Improving on the skills of nursing and hygiene support staff to prevent pediculosis of frequently admitted psychiatric patients- Mrs. Stela Dyulgerova, Psychiatry Department Increasing the skills of department staff to observe high levels of hygiene during diagnostic procedures - Mrs. Temenouzhka Yatanska, X- ray Department

·        Introduction of check-list for disinfection control - Mrs. Tyulai Moustafova, Gynaecology Clinic

·        Introduction of transparent fixing pads for children with permanent infusion peripheral venous pathways - Mrs. Vanya Dobreva, Pediatric Clinic II

·        A training program to introduce standard protocols for proper hand washing and disinfection for health personnel of the risk pregnancy clinic - Mrs. Vanya Zacharieva, Risk Pregnancy Clinic

·        Reduction of permanent urinary catheter-related infections by introducing standardized protocol for cathetirization of stroke patients - Mrs. Vesselka Ivanova, Neurology Clinic

·        A training program on proper disinfection procedures for nurses and hygiene support workers at the clinic - Mrs. Yordanka Stoyanova, Gastroenterology Clinic

SITE VISITS:

On March 31, Dr. Daniel Levine, President of Children’s Help Net Foundation, USA, Mrs. Yanka Tzvetanova, country coordinator and Assoc. Prof. Angelika Velkova – country co-coordinator of PSBH in Bulgaria visited “Ivan Vasov” Comprehensive School in Pleven. There, a project started in 1999 for computer training of underprivileged children.  

After 10 laptops were donated by CHNF in 2001, other underprivileged children were included aged 7-11.  Since then, every year children are selected by the school psychologist Mrs. Malina Petzova, and she works together with class teachers and three teachers of informatics.

Alongside with computer training, children are individually assessed and followed up.  Results of the program are: better integration into the group of peers; self-confidence being able to work on the computer. As the children said themselves, they enjoyed the classes. Those who have no computers at home have a chance to learn.

As discussed during the meeting with the team and the school director, benefits from the donation of computers extended to the whole school:

·        the computer classroom gave a chance to all children aged 7-11 to have computer classes. Software designed for teaching maths and languages through computer games makes computer classes children’s favorite ones. Basic computer skills - Paint,  Excel, Word, Power Point, Internet are taught;

·        the computer room is still used 10 hours a day, and higher grades students have lessons in computer programming there;

·        the school managed to attract another donor for desktop computers;

·        a videoconference room is being installed, funding provided by the school and sponsors (appr. $18,000), and children will be able to communicate with other children around the world via the Internet..

On April 4^th, Dr. Daniel Levine, Mrs. Yanka Tzvetanova, and Assoc. Prof. Angelika Velkova visited Shtastlivo Detsvo crèche is Pleven.  Mrs. Emilia Taskova, a participant in the June 2004 PSBHN workshop, and her team have implemented a program aiming at prevention of flat foot deformities in 101 children aged 1.5 –3 years.

The project was started in September 2004, with assessment of the children by a specialist. Regular check ups are made by a pediatrician and a kinesitherapist, and records for each child are kept according to the requirements for crèches. Evaluation of results is to be made using the data concerning general health, physical fitness, presence/absence of deformities and motor capacity of the children from a final check up at the end of May 2005. Parents are kept informed about the activities, and provided with information what physical activities are recommendable for the time outside the crèche. Sports activities for parents and children are also organized.

The crèche staff, said Mrs. Tzenka Ivanova, Director, and Mrs. Raina Kouleva, trainer in kinesitherapy at the Nursing College in Pleven, plan to compile a manual with set of remedial gymnastics exercises adapted to the age of the children and presented in the form of games. The exercises are to cover prevention of spinal deformities, flat foot and incorrect posture in children up to 3 years, and are an integrated part of physical education to improve physical fitness and activities.

With the support of the municipality in Pleven, said Dr. Pacheva of Children’s Health Department, the manual will be printed and distributed to all 29 crèches, and the program for prevention of flat foot and spinal deformities is to become mandatory.

The team was provided with laptop computer by Children’s Help Net Foundation, USA, and with a printer by the municipality. The computer will also be used for preparing educational materials for the parents.

The scope of the project activities is even wider, in view of the fact that it is a training center for Nursing College students. After graduation, they carry out the program for prevention and rehabilitation in the places they later work: e.g.  the program is run in all 6 crèches in Svistov. 

Mrs. Antoaneta Zlatkova, a participant in the September 2004 PSBHN workshop started a project on dental hygiene, and timely detection/ treatment of dental caries for 140 children aged 3-6 attending Snezhanka kindergarten in Pleven.  Glaxo-Smith Kline company provided tooth pastes and brushes, Orbit provided leaflets, and a local software company helped with designing and printing of educational materials prepared by the project team. A dental center organized dental check up for all children, and a dentist gave consultations to parents of children with problems. The funds raised by the team exceeded $1,500.

Reports on project activities were published in the local papers, and the party to celebrate the completion of the first stage of the project was attended by Dr. Keremedchiev, Dr. Pacheva of the Municipality Health Department, by representatives of the sponsors and the Association for Better Health and parents.

The project was presented at the National Conference on pre-School Education in Sandanski. The results obtained and methods applied brought due recognition and provoked the interest of specialists. Mrs. Zlatkova’s participation expenses were covered by the municipality..

The plans of the team are to continue the program and organize further prevention of caries with fluoride tablets.

The project leader expressed her satisfaction with working on the project: “I have worked as a kindergarten nurse for 25 years, yet this is the first time I feel I have learned many new things myself. What pleased me most was that the results were better than I expected, and the response from sponsors and parents.”

In the afternoon, another PSBHN September 2005 project was visited. Mrs. Margarita Nikolova, a nurse started a project aiming to train parents of handicapped children to carry out rehabilitation at home. Skills and knowledge of parents are essential in the rehabilitation process.

The team of the project – the kindergarten staff, a rehabilitation specialist and a part-time paediatrician work in close collaboration with the general practitioners and specialists at the University Hospital in Pleven.

At present, the team works with parents of seven children with cerebral palsy and nine children with mild forms of locomotor deficiencies. Five children with hearing problems are on an early rehabilitation program, and a speech therapist works with 20 other children. Eight children with asthma also attend the kindergarten. All children are continuously assessed by specialists, and referred for hospital treatment when necessary.

Results:

·        the children with special needs have better chances for integration since the kindergarten is also attended by healthy children;

·        parents often spend hours with the kids and participate in the activities, which has proved useful to building confidence in the children

·        parents are instructed how to continue rehabilitation at home when the children do not attend, and on weekends;

·        parents readily collaborate with the team. 

The “School for parents of low birth weight children” was started in July 2004 by Mrs. Gorcheva and the team - Dr. Simov - pediatrician, Dr. Rosmanova – a pediatrician, consultant in neonatology and head of intensive neonatology unit at the University Hospital in Pleven, Dr. Yonov – pediatrician, Mrs. Bondjeva – a pedagogue, nurses and physical rehabilitation specialists.

The project was funded by Children’s Health Net Foundation, and was implemented on the premises of the home for medico-social care with an intensive care neonatology section. A room was renovated where parents come for training and individual talks and instructions as needed. The target group are biological and adoptive parents of low-birth weight and premature babies. The aim of the team is to prepare parents to give proper care to their children after discharge from intensive care. Individual approach to parents is applied, depending on the problem of children. Brochures were prepared by the team, and individual talks and training sessions for parents are organized. The team has organized continuous follow-up for medical and psychological assessment of children until they catch up with normal birth weight children.

Parents are given a chance to spend time with their babies, and the management of the home has also provided rooms so that mothers from outside Pleven can breast feed.

Results as of April 2005: parents of 70 children were included in the program, and recruitment for the program is an on-going process. The benefits of training are not need proofs further than meeting parents of babies not different from their peers. Unfortunately, proving benefits sometimes needs negative experiences: two of the ten children whose parents refused to be included in the program died after discharge.

The project was selected for presentation in the medico-social section of the National Congress in Neonatology in early June 2005.  The program providing organized training for parents of low birth-weight children starting while the children are still in intensive care is new for the country, and is expected to have a big impact in view of the increasing number of low birth-weight children.

FORTHCOMING EVENTS: 

·        A PSBHN workshop will be held on June 3-5, 2005 in Stara Zagora, with nurses taking a bachelor’s degree program at the Faculty of Medicine of Thracian University. Nurses from several other hospitals in South Bulgaria will participate. The workshop is organized by Dreyfus Health Foundation, Association for Better Heath, Pleven Medical University and Medical Faculty in Stara Zagora;

·         A follow-up workshop will be held in Gabrovo in June 6th 2005, for participants in the PSBHI June 2004 workshop, organized by Dreyfus Health Foundation, Association for Better Heath, Gabrovo Regional Hospital and Gabrovo NGOs;

·         A follow-up workshop will be held in Pleven on June 7th 2005, with participants from the June and September 2004 PSBHN workshops.  The workshop is organized by Dreyfus Health Foundation, Association for Better Heath and the Health Department of Pleven Municipality.

Note! You can visit www.livebg.net/psbh-digest, where you can see some pictures from both workshops and site visits.

Please send your suggestions and materials to abh-psbh-bg@el-soft.com

ESBL: Some Information from the Internet

Extended Spectrum Beta Lactamase (ESBL)

How is it spread?

How is it detected?

What do I look for?

How is it treated?

How can I protect myself?

What is it?

Extended spectrum beta lactamase (ESBL) microbes are specific bacteria that produce enzymes (extended spectrum beta lactamases) that can break down many common antibiotics, making the antibiotics ineffective.

ESBL microbes have been present in Europe and the USA for almost 20 years. Only recently have these bacteria been detected in Canada in significant numbers. The types of bacteria that are most commonly associated with ESBL are E. coli and Klebsiella.

E. coli is a bacteria found in the normal human bowel flora and is necessary for digestion. Sometimes E. coli will get into tissues or organs where it does not belong, such as the urinary tract, and can lead to infection. E. coli is the most common cause of bladder infection and is usually treated with antibiotics. Symptomatic infections that are caused by ESBL E. coli may not be effectively cured by some commonly used antibiotics.

NOTE: This is not the same E. coli that causes “hamburger disease” or caused the waterborne outbreak in Walkerton, Ontario.

How is it spread?

Poor personal hygiene, especially after using the washroom, can spread the bacteria from the bowel of one carrier or infected person to the mouth of another person. The spread of ESBL E. coli in a facility occurs most commonly through direct contact with someone with ESBL, a contaminated environment or on the hands of some care providers. Careful cleaning of areas that might be touched by hands is important to reduce the spread of this organism in a facility. Faucets, door handles, bedrails, bathrooms, and other surfaces that people touch must be cleaned regularly to prevent the spread of ESBL Ecoli..

How is it detected?

Currently, testing for ESBL E. coli is only done at specific hospitals. Testing can be arranged through the Health Department. For screening, a swab of the rectum is taken. For people with symptoms, urine, blood, wound area or phlegm samples may be required.

What do I look for

For most people, ESBL E.coli does not cause harm and does not cause any symptoms. People who are carriers of ESBL do not require antibiotic treatment since this could lead to increased resistance. For the few people who develop symptoms including symptoms of urinary tract, wound, pneumonia or blood infections, antibiotics should be used. These infections can be serious so knowing whether a person has ESBL E. coli is important to ensure the most appropriate treatments are prescribed.

Risk factors for ESBL infection for people in hospital include previous antibiotic use, catheters, length of stay, frail health, and admission to an intensive care unit. The risk of ESBL microbes to the general public is low. Appropriate use of all antibiotics is important to ensure effective treatments are available should the need arise.

How is it treated?

For people who carry ESBL E. coli but are not ill (i.e. carriers), no treatment is needed. Antibiotics to clear ESBL E.coli should only be taken if someone has symptoms of an infection. Not treating carriers of ESBL E.coli helps prevent further resistance and allows optimum treatment should the need arise. Carriers can frequently clear this organism without any treatment. Treatment should rely on culture and sensitivity of the test. Consultation with an infectious disease specialist should be considered for those with symptoms of infection from ESBL E. coli.

How can I protect myself?

·         Wash hands after going to the washroom and before eating or preparing food

·         Everyone working or visiting health care facilities must wash their hands prior to entering and upon leaving the resident’s room, and prior to assisting a resident with feeding. Wash hands using an antibacterial soap and/or alcohol hand sanitizer. Note: alcohol hand sanitizers should not be rinsed off.

·         All staff in health care facilities must wash their hands before and after every contact with residents.

·         Gloves should be worn when providing direct personal care or cleaning the environment. Gloves must be changed and hands washed between procedures and between resident contacts.

·         No masks are required. Gowns are only required if the environment is grossly contaminated and giving care may result in soiling the clothing of staff and family.

·         Good environmental cleaning and infection control procedures must be carried out in all facilities.

Adapted from FACTS About ESBL E.coli Durham Region Health Department

FREQUENCY OF EXTENDED SPECTRUM BETA LACTAMASE PRODUCING GRAM NEGATIVE BACILLI AMONG CLINICAL ISOLATES AT CLINICAL LABORATORIES OF ARMY MEDICAL COLLEGE, RAWALPINDI

Ali AM, Rafi S, Qureshi AH

Microbiology Department, Army Medical College Rawalpindi, Pakistan

Background: This study was carried out in Microbiology department of Army Medical College, Rawalpindi to find out the frequency of extended spectrum beta lactamase producing gram negative bacilli among clinical isolates recovered from clinical specimens received  from Military Hospital, Rawalpindi. Methods: This study was carried out from 1st Jan 2002 to 30th Dec 2002. A total of 812 consecutive Gram-negative bacilli were recovered during the study period from various samples including urine, blood, pus, sputum, high vaginal swab (HVS), aspirates, i/v canula/ Central venous lines (CVP), chest tubes and catheter tips. Extended spectrum beta lactamase detection in these isolates was carried out by Kirby Bauer disc diffusion method on Mueller Hinton agar. A susceptibility disk containing amoxicillin-clavulanate was placed as the inhibitor of beta lactamase in the center of the plate, and cefotaxime, ceftazidime, ceftriaxone and aztreonam disks were placed 30 mm (center to center) from the amoxicillin-clavulanate disk. Enhancement of the zone of inhibition of the oxyimino--lactam caused by the synergy of the clavulanate in the amoxicillin-clavulanate disk was considered as evidence of ESBL production. Escherichia coli ATCC 25922 and K. pneumoniae ATCC 700603 were used as control strains. Results: The frequency of ESBL producing gram negative bacilli among the clinical isolates was 45%.

Keywords: ESBL. Antibiotic. Nosocomial. Enterobacteriaceae

INTRODUCTION
ß-Lactam antibiotics are among the most frequently prescribed antimicrobial agents worldwide. The emergence of resistance to these agents in the past two decades has resulted in a major clinical crisis.^1,2 Gram negative bacteria resistant to agents such as extended-spectrum cephalosporins, monobactams, carbapenems and ß-lactam–ß-lactamase inhibitor combinations have emerged through the production of a variety of ß-lactamases, alterations in the penicillin-binding proteins, outer membrane permeability and combinations of multiple mechanisms of resistance. This increase has paralleled the introduction, administration and overuse of ß-lactam drugs.³

Resistance to ß-lactam antimicrobial agents, especially extended-spectrum cephalo-sporins and other antimicrobial agents among clinical isolates of gram negative bacteria is on the rise worldwide.^4,5 These antimicrobial resistant pathogens include extended-spectrum cephalosporin resistant Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens and Citrobacter freundii, Pseudomonas aeruginosa and Acinetobacter baumannii. Recent studies in Taiwan have demonstrated a high prevalence of these antimicrobial-resistant bacteria and a trend of increasing resistance under continued antibiotic selective pressure.⁶

The objective of this study was to determine the frequency of extended-spectrum ß-lactamase (ESBL) producing gram-negative bacilli recovered from clinical specimens in our set up.

MATERIAL AND METHODS

A total of 812 consecutive non duplicate gram-negative bacilli recovered from clinical specimens during the study period from 1^st Jan 2002 to 30^th Dec 2002 were included in the study. These were isolated from various samples including urine, blood, pus aspirate, sputum, chest tube, HVS, i/v canula/ CVP lines and catheter tips received from patients admitted in Military Hospital, Rawalpindi. The samples received were initially inoculated on Blood agar and MacConkey`s agar besides Chocolate agar (in case of sputum) where appropriate. Urine samples were cultured on Cystiene lactose electrolyte deficient agar (CLED). The samples were incubated at 37^oC under aerobic conditions for 24 hours. The organisms were primarily identified by standard techniques. Confirmation to the species level was done by API 20 E & API 20 NE where required. ESBL production was detected by placing a susceptibility disk containing amoxicillin-clavulanate (20/10 ug) as the inhibitor of beta lactamase in the center of the plate and cefotaxime (30ug), ceftazidime (30ug), ceftriaxone (30ug) and aztreonam (30ug) disks at 30 mm (center to center) from the amoxicillin-clavulanate disk. Enhancement of the zone of inhibition of the oxyimino--lactam caused by the synergy with clavulanate in the amoxicillin-clavulanate disk was considered as evidence of ESBL production.⁷ Escherichia coli ATCC 25922 and Klebsiella pneumoniae ATCC 700603 were used as control strains. The results were tabulated as frequencies.

RESULTS

Three hundred and sixty six isolates were ESBL producers making a frequency of 45 %. Enterobacter cloacae was the most frequent ESBL producer. Escherichia coli (45%) was the most frequent organism isolated followed by Klebsiella pneumoniae (21%), Pseudomonas aeruginosa (19.2%), Enterobacter cloacae (4.6%) and Acinetobacter baumannii (4.4%) (Table-1).

DISCUSSION

 Extended spectrum beta lactamase (ESBL) refers to beta lactamase enzymes produced by gram negative organisms that confer resistance against broad-spectrum beta-lactam antibiotics, normally having activity against gram-negative bacilli. Examples of such antibiotics are cefotaxime, ceftriaxone, ceftazidime and aztreonam.³

The first hospital outbreak of an ESBL producing gram-negative organism was reported in Germany in 1983.⁸ Within one year, nosocomial outbreaks caused by a multidrug resistant Klebsiella clone carrying a TEM-3 gene were described in France.⁹ Over the past decade, ESBL-producing Enterobacteriaceae have emerged as serious nosocomial pathogens throughout Europe.¹⁰ Outbreaks have occurred among the most critically ill patients in intensive care units (ICUs).¹¹

The prevalence of ESBL-producing bacteria in most hospitals remains unknown inspite of numerous reports of nosocomial outbreaks of infection due to these organisms. Important ESBL producing gram-negative bacilli include Klebsiella pneumoniae, Escherichia coli, and Proteus mirabilis, enterobacter species, Citrobacter freundii, Pseudomonas aeruginosa, Acinetobacter and Stenotrophomonas maltophilia.¹²

The percentage of isolates expressing ESBL production is variable although a recent study from the United States reported 83 ESBL-producing isolates from 906 consecutive isolates of Enterobacteriaceae over a 20 week period. Klebsiella pneumoniae and Escherichia coli were the most frequently associated with ESBL production in this study.¹²

 During a five-year surveillance study in northern France, the overall proportion of ESBL producers was 11.4% in the 6121 strains of Klebsiella species and 47.7% in the 2353 strains of Enterobacter aerogenes.¹³

In a national surveillance program conducted in 1996 in Argentina, resistance to extended-spectrum cephalosporins was shown in 48%, 26%, and 8% of K. pneumoniae, Proteus mirabilis, and Escherichia coli isolates respectively.¹⁴

In a study carried out in All India Institute of Medical Sciences, New Delhi during March to June 2001 out of the 678 isolates tested 68% were ESBL producers, which are  more than that found in our study. ESBL production was most common in Klebsiella spp. (80%).¹⁵

In our study Enterobacter cloacae (79%) was the most frequent ESBL producer followed by Acinetobacter baumannii (72%) and Klebsiella oxytoca (66.66%).

Table-1: Frequency of gram negative bacilli and ESBLS among the recovered isolates (n=812)

However these bacteria were infrequently recovered. The relative frequency of ESBL producing Gram negative bacilli in our study is similar to frequency reported from Islamabad, Pakistan¹⁶ with Escherichia coli (48%) being the most prevalent organism reported as was found in our study. 

The frequency of ESBL producing Gram negative bacilli (35 %) in nosocomial isolates reported from Armed Forces Institute of Pathology, Rawalpindi is lower than our study. Klebsiella spp. was the commonest ESBL producing organism reported followed by Enterobacter cloacae and Escherichia coli whereas Enterobacter cloacae was the most frequent ESBL producer in our study.¹⁷

The frequency of ESBL producing gram negative bacilli clinical isolates in our study was 45 %. Enterobacter cloacae (79%) was the most frequent ESBL producing organism detected followed by Acinetobacter  baumanii (72%) and Proteus mirabilis (61%) though Escherichia coli (45%) was commonest organism identified  followed by Klebsiella pneumoniae (21%) and Pseudomonas aerugenosa beside other gram negative rods

CONCLUSION

The resistance to beta lactam antimicrobial agents among gram-negative bacilli is on the increase in our setup. Laboratories can detect ESBL production by simple technique of Jarlier et al. Bacterial strains resistant to most classes of antibiotics will continue to emerge unless the inappropriate use of these drugs is curtailed. Clinicians should consider ESBL production as a possibility in case of treatment failure with -lactam antimicrobials.

REFERENCES

1. Wood AJ. Antimicrobial-drug resistance. N  Eng J Med 1996; 335: 1445–53. 

2. D'Agata FEMC. Antibiotic resistance and exposure to different generation cephalosporins. N Eng J Med 2000;28:2678-81.

3. Fridkin SK, Steward CD, Edwards JR, Pryor ER, McGowan JE Jr, Archibald LK, et al. Surveillance of antimicrobial use and antimicrobial resistance in United States hospitals: project ICARE phase 2. Clin Infect Dis 1999; 29 (2):245–52.

4. Pfaller MA, Jones RN. MYSTIC (Meropenem Yearly Susceptibility Test Information Collection) results from the Americas: resistance implications in the treatment of serious infections. J Antimicrob Chemother 2000; 46(Suppl ):25–37.

5. Goossens H. MYSTIC (Meropenem Yearly Susceptibility Test Information Collection) results from Europe: comparison of antibiotic susceptibilities between countries and centre types. J Antimicrob Chemother 2000;46 (suppl):39–52. 

6. Hsueh PR, Chen ML, Sun CC, Pan HJ, Yang LS, Ho SW  et al. Emergence of antimicrobial drug resistance of major pathogens causing nosocomial infections at a university hospital in Taiwan 1981–1999. Emerg Infect Dis 2002; 8(1):63-8

7. Jarlier V, Nicolas M, Fournier G, Philippon A. Extended broad-spectrum -lactamases conferring transferable resistance to newer -lactam agents in Enterobacteriaceae: hospital prevalence and susceptibility patterns. Rev Infect Dis 1988;10 (4):867-78.

8. Knothe H, Shah P, Krcmery V, Antal M, Mitsuhashi S. Transferable resistance to cefotaxime, cefoxitin, cefamandole and cefuroxime in clinical isolates of Klebsiella pneumoniae and Serratia marcescens. Infection 1983;11(6):315-7.

9. Brun-Buisson C, Legrand P, Philippon A, Montravers F, Ansquer M, Duval J et al. Transferable enzymatic resistance to third-generation cephalosporins during a nosocomial outbreak of multiresistant Klebsiella pneumoniae. Lancet 1987; 8(2): 302-6.

10. Livermore DM, Yuan M. Antibiotic resistance and production of extended spectrum b-lactamases amongst Klebsiella spp. from intensive care units in Europe. J Antimicrob Chemother 1996; 38(3):409-24.

11. Jacoby GA. Extended-spectrum b-lactamases and other enzymes providing resistance to oxyimino--lactams. Infect Dis Clin North Am 1997; 11(4):875-87.

12. Coudron PE, Moland ES, Sanders CC. Occurrence and Detection of Extended-Spectrum ß-lactamases in members of the family Enterobacteriaceae at a Veterans Medical Center: Seek and You May Find. J Clin Microbiol 1997; 35(10):2593-7.

13. Albertini MT. Surveillance of methicillin-resistant Staphylococcus aureus (MRSA) and Enterobacteriaceae producing extended-spectrum beta-lactamase (ESBLE) in Northern France: a five-year multicentre incidence study. J Hosp Infect 2002; 52(2): 107-13.

14. Bantar C, Famiglietti A, Goldberg M. Three-year surveillance study of nosocomial bacterial resistance in Argentina. The Antimicrobial Committee; and the National Surveillance Program (SIR) Participants Group. Int J Infect Dis 2000; 4(2):85-90.

15. Mathur P, Kapil A, Das B, Dhawan B. Prevalence of extended spectrum beta lactamase producing gram negative bacteria in a tertiary care hospital. Indian J Med Res 2002; 115:153-7

16. Shah AA, Hasan F, Ahmed S, Hameed A. Extended-spectrum beta-lactamases in enterobact-eriaceae: related to age and gender. New Microbiol 2002; 25(3): 363-6.

17. Zaman G, Karamat KA, Abbasi S, Rafi S, Ikram A. Prevalence of Extended-spectrum beta-lactamase (ESBL) producing enterobacteriaceae in nosocomial isolates. PAFMJ 1999: 49 (2): 91-6

Address for Correspondence:

Dr. Arif Maqsood Ali, House No. B- 889, Satellite Town, Rawalpindi, Ph :+92-51-4413383,4429514,4842055

Email: drarifmaqsood@hotmail.com

Gabrovo PSBHI 2004 Projects – Completed or in Action

A health educational program to promote breast feeding

Rositza Vassileva

During recent years, the number of primipara women who would not breast feed for different reasons has increased. Some of them express confidence in excellent quality of milk formulas, and some even believe that formulas surpass mother’s milk in quality and are more appropriate for feeding babies.

The project was started in August 2004 in Gabrovo Regional Hospital maternity ward, by a team of three midwives. After presenting the project to the management of the maternity ward, a questionnaire was prepared and the level of knowledge of mothers-to-be on the advantages of breastfeeding was measured. On the basis of the results from the study, a program was prepared for monthly talks with pregnant women visiting prenatal consulting rooms. Posters were prepared with information on the advantages of breastfeeding.

The target group is to include 200 women giving birth for the first time. During their stay at the ward, midwives have individual and group talks with the women, and hand them leaflets and other materials.

The results from the project are to be evaluated on the basis results from a second questionnaire. Current assessment shows that the level of satisfaction of those who breastfeed is high. The number of those who chose breastfeeding has encouraged the team to include obstetricians from primary health care to participate in the program.

Reduction of meticillin-resistant S. Aureus infections

Assiya Stefanova

The project was started in July 2004, at the microbiology laboratory of Gabrovo regional hospital, by a team of a microbiologist, a lab assistant and a biologist.   The target groups were staff from the maternity, pediatric and the surgical units.

After assessment of knowledge and skills of staff, they were provided with instructions and standard protocols how to act in cases of MRSA infections. In January 2005, a standard protocol was prepared and introduced for registering patients with proved MRSA. Posters and leaflets, focusing on prevention rather than on treatment, accompanied standard protocols of good practices. A UV sterilizer was provided.

The project is to be completed and finally evaluated in December 2005.

Reduction of aggressive behavior in student attending a school for children with special needs

Galina Koleva

During the last few years, aggression levels in children attending Nikola Palauzov school have increased. Using a psychotherapeutic program, the project aims to have a positive influence on 35% of the children and to reduce the number of acts of aggression.

Groups were formed according to the interests of the children, and individual sessions were organized. Project activities also include talks and discussions, e.g. “What can I do to be a better person”, painting in the open, talks with the families of the problem children. .

Initial results are encouraging. The project is to be completed in May 2005. In case the final results show the goals have been achieved, the program will be introduced in other schools with similar problems.

Health education on allergies for parents of children admitted for treatment in the pediatric unit

 Ganka Nedelcheva

Parents of children with allergies are not well informed on the problem, and often underestimate the importance of allergens in the household and how their elimination could contribute to treatment for the condition.     

The one-year program was started in July 2004, with a target group of parents of 30 children, and the program aimed to reduce complications in 15 of the children.

Brochures and posters were prepared after studying literature on the problem. Health education materials were given to the parents, visiting the allergology consulting room with their children.

The team plans to increase the number of children covered, inviting all of those visiting the consulting room to participate in the program.

A training program to improve communication skills of the nursing staff in Gabrovo regional hospital

Nelly Todorova

The nurse-patient communication process starts upon admission, continues throughout the hospital stay and often has to continue after discharge from hospital. A patient needs information concerning his/her health status, the outcome of the condition, on pain levels, results from various investigations, etc. which all makes the skills of nurses in rendering this information crucial.

Twenty-eight nurses participated in the training program, which included a two-day workshop with a lecturer – Mrs. Gergana Momova of the society of positive psychotherapy in Varna, and current discussions of various situations. Assessment of results showed 32% improvement of the target group’s communicative skills.

The positive effects of the project were also assessed by measuring patients’ satisfaction and that of the rest of medical staff. The results gave grounds for the hospital management to plan such training for senior medical staff.

Antismoking program for mothers of newborns

Dr. Zornitza Malinova

During the last three years, 60% of women who delivered at the maternity unit in Gabrovo were smokers. Studies showed that most of them have no sufficient knowledge on the extent of harm caused smoking inflicts on their babies. Some of them are not convinced they need to quit smoking.

Project activities of the team (4 doctors and 10 midwives) covered 60 smoking women who delivered at the maternity ward. The health-promotion department in Gabrovo provided health-education materials, and information that helped prepare brochures and posters. Three times a week, a talk on the harmful effect of smoking on the baby before and after birth, and the mother herself.

Evaluation was carried out on the basis of questionnaires. So far, a reduction of 25% has been achieved.

Final evaluation of results is to be made after April 2005.

An information program for stress reduction in patients scheduled for surgery at a urology unit

Nedyalka Tabakova

In August 2004, a consulting and information room was opened at the urology unit in Gabrovo regional hospital. There, patients scheduled for surgery received information about the essence of the operation, got brochures and filled in questionnaires.  

Results: due to the efforts of the team, pre-operative stress levels were reduced in 100 patients. The level of information of patients about their operations as to risks involved and the possible outcome became higher, as compared to patients in the past. All this contributed to the gradual adaptation to the situation of both patients and their families, and increased their confidence in the team involved in the surgical operation. The patients were also more compliant, which contributed to achieve better outcome.

One of the difficulties the team experienced was the need to apply individual approach to patients.

The results from the program motivated the team to continue with project  activities, and make them routine practice in the ward.

Social integration of blind children with additional disabilities

Stefka Pencheva

The project was implemented with the assistance of the Union of Blind People, Gabrovo and the Association of the Association of Children with Eye Disabilities. The Institute of Social Integration – Sofia also showed interest in the project activities.

The project team (a rehabilitation instructor, a social worker, a teacher specialized in working with blind students, pedagogues and parents) organized Saturday meetings with the families of 20 blind children with additional disabilities. The project aimed to help 6 of the children in their social integration.

The target group was selected using medical records, as well as on the basis of children’s visual and psychosomatic status.

Each month, one Saturday “party” was organized with the children: parties, modeling, concerts, and meetings with children with similar problems who had already been integrated. Competitions were organized and winners awarded small prizes.

Each months, parents attended meetings during which they got information about additional support they could get, legislative changes regarding possibilities for integration, the opportunities for their children to attend special or ordinary schools.

Parents and children actively participate in the activities organized. The ream expects to achieve its objectives, and to continue the project with the support of a German humanitarian organization.

Training everyday activity skills and rehabilitation for blind people with additional disabilities

Pena Yonkova

The association of blind people in Gabrovo has 215 members. Nearly half of them are classified with first grade disability, and have other disabilities, which makes them dependent on other people for everyday activities.

The aim of the project team (a rehabilitation specialist, a group of volunteers and a trainer for people with special needs) was to carry out a training program and rehabilitation for a group of 20 persons, so that in 5 of them independence in everyday activities could be achieved and the social isolation overcome for one year.

The project was started in September 2004. After the team was built. The group was selected on the basis of registers at the association and willingness to participate in the program. Depending on the participants’ abilities and interests, a training program was prepared, which included skills for mobility and orientation, visual rehabilitation, sports activities, outings, etc. Twice a week, trainings sessions were organized by a trainer in the respective skills.

So far, the effects of the program are increased satisfaction and active participation in the sessions organized. It should be noted that the families of the participants also find the program very useful. The project activities have proved useful to build confidence in the disabled people and make them feel less lonely.

Providing alternative care for lonely elderly disabled people

Joanna Boneva

The project was started in June 2004. The aim was to provide care for, and improve life quality of 10 lonely disabled elderly people.

The group was selected, and their needs identified. A schedule was prepared for the visits. The level of satisfaction of the activities carried out was measured by a questionnaire, filled in after each visit.  

One of the difficulties encountered was to make the visits when the weather was bad, especially in wintertime.

Final evaluation is to be made in June 2005, on the basis of criteria stated in the questionnaires.

Computer training for lung hospital staff

 Nelvena Christova

The aim of the project was to improve on the computer skills of 80 out of the 100 medical professionals employed by the Lung Disease Hospital in Gabrovo for one year.

The project was started in June 2004.

The level of IT knowledge of the 80 participants was measured, and they were divided into groups according to level. A program for the training sessions (four times a month) was prepared and carried out by a lecturer in informatics from the University School of Technology in Gabrovo. Guidelines for Microsoft Office and Excel were prepared and used during the practical sessions.

Final evaluation is to be made in June 2005 on the basis and comparison of knowledge before and after the training.

The team plans to include more staff members in the training program.

Prevention of acute virus and upper respiratory infection in lung disease hospital staff

Donka Dimitrova

During the autumn and winter, the number of patients with virus pneumonia increases, which increases the risk of virus infections among the hospital staff of the Lung Disease Hospital in Gabrovo. Absenteeism of staff due to infections makes it more difficult to carry out daily activities. The aim of the project was to include 50 members of the staff in the prevention program to reduce absenteeism due to virus infections by 40%. 

The prevention program includes dietary supplements to strengthen the immune system, providing protective gear and education for the staff. Brochures were prepared for the patients with virus pneumonia, with instructions how to reduce the risk of infecting the hospital staff.  

The program was implemented with additional funding from a Gabrovo Hospice (“Health”), “Vita” pharmacy – Gabrovo, Krassimira Angelova Ltd. After evaluation, the project team intends to run the prevention program every year.

A training program for factory workers and students in vocational schools

to give first aid in cases of accidents

Dimitar Dimitrov

The one-year program was started in June 2004, by a team of two doctors, an assistant doctor, two school nurses, four labor safety inspectors, and a specialist form Bulgarian Red Cross. The target group included 300 participants – factory employees and students of vocational schools in Gabrovo. A questionnaire was used to measure their level of knowledge on giving first aid in cases of accidents. The results served as a basis in the preparation of a number of different brochures, which included instructions how to act in cases of mild and severe burns in the home and place of work, and in road accidents. Training practical skills was also included in the program.

The results aimed at – 80% improvement of level of knowledge and practical kills of participants, will be measured by comparing the levels before and after the program. .

Health education on dangers of drug use for children aged 7-14

Radostina Petrova

The aim of the project was to prevent 200 children from School No 5 in Gabrovo from experimenting with and using drugs by organizing health education. Besides the children, parents were included in the program.

The team (a toxicologist, a psychologist and a nurse) chose an information program because statistical data show that one of the main reasons why children start experimenting with drugs is lack of information about the dangers of drug use.

Information was provided during meetings and talks, posters and brochures adapted for parents and children.

Evaluation at the end of the school year includes measuring the level of knowledge on the problem and the number of those still experimenting with drugs. In addition, the satisfaction with the program will be measured.

An information program to raise the level of knowledge on tuberculosis in the population of Gabrovo Region

Lyubka Dimitrova

The incidence of severe forms of tuberculosis in Gabrovo region is high, and this can be attributed, alongside with other factor, to low level of knowledge and underestimation of the problem by the general population, as well as to lack of timely and proper prophylactic measures taken for the risk groups. Another reason is that patients seek specialized medical help when the disease has advanced.

The target group of the program is the population over 15 years of age. The team of 5 doctors and seven nurses from the Lung Disease Hospital in Gabrovo have prepared and distributed brochures with information and instructions how to act in case one suspects tuberculosis. The information campaign helped carry out preventive check-ups in 18 settlements of Gabrovo region.

To organize the check-ups, the team was assisted by the media, Gabrovo Regional Health Center, Gabrovo regional administration, and social services in Sevlievo.

The effect of the program is to be evaluated by the end of June 2005, by comparing the number of patients from the region admitted for treatment with severe forms of tuberculosis to the numbers from the previous year. The increase in number of those who have been included in specific immunoprophylactic programs is also going to be measured.

The lung disease hospital management plans to continue with the program on a regular basis. The plans are strongly supported by the citizens of the region.

Health education for patients with primary hypertension

 Veska Pencheva

The project was started in June 2004, and aims to reduce the arterial blood pressure in 100 patients with primary hypertension by 20mmHg.

The educational program included measuring their level of knowledge regarding diet and risk factors. Two brochures were prepared and handed to the group. On a regular basis, their blood pressure is taken. The results are recorded and final evaluation in June 2005 is to be based on the level of knowledge after participating in the program and the values of blood pressure.

Health information program for prevention of Hepatitis B in hospital staff

 Zdravka Futkova

The aim of the health information program is to prevent hepatitis B infections among 100 members of hospital staff in the lung disease hospital in Gabrovo.  The project was started in September 2004.  

The level of knowledge of the participants was measured, and the team of two nurses and a doctor prepared brochures for the group. A schedule for talks was prepared, and the sessions started.

Final evaluation is to be made by comparing the level of knowledge, and comparing the number of those infected before and after the program.

A training program for families of 30 terminal patients to improve patients’ life quality

Kamelia Dragieva

The project aimed to train the families of 30 terminal patients to improve the quality of care and life quality of the patients. The team of five nurses from a hospice, a surgeon, three nurses from the lung disease hospital and a physiotherapist organized talks with the families, and prepared individual plans for rehabilitation and nursing for each patient. Consultations with specialist were also organized.

All patients and families were satisfied with the program, and 12 more were included in the program. However, the team proved too small to cover all patients.

The Union of Disabled People in Gabrovo and the Department of Social Services of Gabrovo Municipality became interested in the program and the effects achieved.

Plans for the future: to carry out the project on a larger scale in Gabrovo region, with the assistance of other organizations.

Patient education to reduce risks of reinfarction

Katerina Taneva

The aim of the project is to reduce by 20% the number of rehospitalizations for one year among 10 acute myocardial infarction patients (aged 50-70) treated at the intensive care cardiology unit of Gabrovo regional hospital.

With the help of a cardiologist and a nurse, a brochure was prepared with information on the risks of reinfarction and advice regarding diet and exercise. Once a month, a specialist examined the patients and paraclinical investigations were carried out.

Results are to be evaluated end of June 2005, by comparing rehospitalization rate among the target group with that of 10 other patients not included in the program.

Education in healthy life-styles for teenagers

Nedka Atanassova, National Aprilov High School

The project team of a nurse, a psychologist and two teachers aim to provide information on healthy life-styles for 55 students aged 14-15, and increase their motivation to change their attitude to their own health. The team has prepared a program for activities –talks, information brochures from health promotion department, which is meant to make student realize the risks and their responsibilities to their own health.

The program includes topics like general hygiene, healthy diet and risks implied in cigarette smoking and drug use.

Results are to be evaluated by measuring the changes in the students’ motivation to adopt healthy life-styles.

Education on risk factors for osteoporosis in early childhood

Dr. Ekaterina Boeva

The project was implemented at two kindergartens (approximately 120 children aged 3-7) in the town of Triavna, Gabrovo region. In addition to the health education program on proper diet for the staff and parents, various sports activities to improve fitness, immunity and proper posture were organized with the children.

The effect from the nine-month project will be measured by comparing the level of knowledge of staff and parents on the problem, and results from physical examinations of the children carried out at the beginning and end of the school year.

The project activities are made known to the public through a series of publications.

Health education for teenagers and their parents on bulimia and anorexia

Polina Pencheva

Anorexia and bulimia affect about 2% of teenagers, mostly girls, and studies showed that teachers and parents are not well informed on the problem.

After measuring the level of knowledge among the target group – 30 teachers, 100 parents and 200 teenagers from two vocational schools in Gabrovo, the team of two nurses, two psychologists and a health education specialist prepared materials for the program – brochures, CDs, lectures on the importance of early detection of signs of bulimia and anorexia, and the importance of early intervention.

The educational program was started in October 2004, and video demonstrations, talks twice a month, consultations with psychologists, and distribution of information on the problem (brochures, articles).

Results are to be evaluated in May 2005 by measuring the level of knowledge of persons in the target group after the program, and by comparing the number of those who sought medical advice to those who remained undetected before the program.

Prevention of spinal deformities in 60 children aged 7-10 years

Svetla Guteva, Ekaterian Boeva

The project was started in September 2004 at Elementary School No 3 in Gabrovo. The target group was selected after a physical examination of the children. Parents were informed about the results from the examination and the goals of the project.

A set of remedial gymnastics exercises was designed, and carried out with 60 children.

The program will last one school year, and the results will be evaluated on the basis of comparison of check-up before and after the program – the number of children with problems and the degree of deformities. година.

Reduction of aggression levels in schoolchildren aged 12-14

Tatyana Filipova, Otetz Paissi Elementary School, Gabrovo

The aim of the educational program was to reduce the level of aggression in problem children, identified by the team as having caused different traumas to their schoolmates.

The program was started in September 2004. The target group of 18 children (aged 12-15) was selected through psychological tests. With the assistance of the Municipality Educational Center, a psychologist and a nurse organize talks with the target group children every month. A focus group of three children from the group was formed for peer-education activities. The motivation of the focus group was increased by the training sessions organized with them.

As a result, the episodes of aggressive behavior became fewer. 50%.

The final results are to be evaluated at the end of the school year. The team plans to continue with the program and make it routine part of the activities with aggressive children. Project activities attracted pupils, parents and the members of the school board.

Education of acute myocardial infarction patients to comply with rules of diet and exercise regimen

Desislava Nenova

The aim of the health education program is to improve on the life-styles of 10 out of 20 patients who survived acute myocardial infarction.

The project was started in August 2004, when the team of three nurses and one doctor prepared adapted materials with information regarding diet and exercise regimen for patients with infarction. From the patients’ files, data is collected on risk factors such as high cholesterol levels, blood pressure levels, and harmful habits like cigarette smoking and alcohol consumption. During the stay at the hospital, patients are given information materials, and talked to about their life-styles after discharge.

Current and final evaluation of results is to be based on data regarding the presence of risk behavior in patients before and after discharge, and the results from routine follow-up examinations and investigations by their family doctors.

Prevention of and treatment for nursing staff

Stanka Raikova

The one-year program, which started in July 2004, targeted ten nurses aged 40-50, working at the Orthopedic Surgery unit of Gabrovo regional hospital.

The aim of the team (an orthopedic surgeon, and a physiotherapist) was to improve on the values of osteometric investigations through a specialized prevention and treatment program, which includes diet and exercise.

The results will be evaluated on the basis of comparison of osteometry before and after the program.

Education on the importance of proper diet for children aged 11-14

Plamen Dechev

The program aimed to reduce the number of cases of gastric pain attributable to improper diet among in half of 100 children aged 11-14, attending an elementary school in Gabrovo.

At the beginning of the school year, the project team had prepared a course of lectures on healthy diet, posters and booklets with the assistance of the school authorities and teachers. Video sessions and talks were organized. Some activities were organized outside the school. A group of four pupils from the target group volunteered and helped the team. Medical professionals from the Regional hospital and the Municipality Health Department assisted the team in its activities.

Final evaluation at the end of the school year is to be based on comparison the levels of knowledge of children on healthy diet, and the number of those who sought help for gastric pain episodes.

Health information program on proper diet for disabled people with chronic diseases

Tzonka Dyankova

The target group of 60 disabled people was divided into three groups – with hypertension and cardiac problems, with gastric ulcers and with diabetes. The aim of the program was to reduce by 20% the complications due to improper diet.

The five-month program was started in September 2004. Lectures and talks were organized with the three groups, and a diet plan for each group for one month was prepared.

Current evaluation has shown satisfaction of the participants with the program, and the team plans to include new people in the program.

A program to increase level of social activities of disabled people

Penka Gateva

The one-year program was started in June 2004, and its aim was to motivate disabled people to participate in social activities.

Three groups were formed according to field of interests: culture studies, youth section, and a singing group. Programs were prepared for the activities, which helped improve the confidence of participants in their abilities to participate in social life.

Meetings with groups of disabled people from other places, participation in singing competitions, outings are among the activities.

Results: satisfaction levels are high and participants are willing to continue with the activities.

Prevention of complications of chronic tonsillitis

Maya Christova

The project aimed at providing information to patients with chronic tonsillitis about possible risks of complication associated with lack of appropriate treatment. The target group initially selected included patients from rheumocardiology, nephrology and pediatric units of Gabrovo regiona hospital. The number of bilateral tonsillectomies was one way to measure the results from the program.

The team of the project – a nurse and an ENT specialist prepared the information materials and started with a group of 100 patients with chronic tonsillitis.

The project was completed in December 2004. However, due to interest on behalf of general practitioners, school nurses and the Regional Inspectorate of Public Health Protection in Gabrovo, project activities continued as a routine information program, with funding provided by donors from the private sector

Current results, as recorded at the ENT clinic, are: the number of patients who underwent tonsillectomy after recommendation by specialists was increased by 21%, during the period April 2004 – April 2005, as compared to the period April 2003-April 2004, and the increase was 29%, compared to the April 2002-April 2003 period.

Follow-up of patients from the pediatric, rheumatology and nephrology units showed there had been no complications, otherwise expected.

The team is grateful to the organizers of the workshop – Dreyfus Health Foundation, the Association for Better Health and the organizers form Gabrovo for the opportunity to participate in the program, for their support. The team is especially grateful for the chance they were given to learn how to see things from a different perspective. Being part of the program has given them confidence and, above all, they have found satisfaction in helping other people. Special thanks to Mrs. Gergana Momova for the friendly atmosphere in the group for training communicative skills, and the way she motivated them for work.

Providing information for patients eligible for endoscopic surgery

Iskra Koleva

Project activities carried out so far:

·        individual talks were given to patients indicated for laparoscopic surgery from the units of gynaecology and surgery;

·        information  brochures were prepared and handed to patients;

·        videos and compact disks were recorded , demonstrating gynaecological and surgical laparoscopic operations performed at the regional hospital in Gabrovo;

·        all patients who underwent laparoscopic surgery were asked to fill in questionnaires to measure their satisfaction/dissatisfaction with the surgical method.

·        As of April 2005, the results from project activities were as follows:

·        the number of patients undergone laparoscopic surgery between January 2004-June 2004 were 28;
the number of patients undergone laparoscopic surgery between June 2004 and April 30, 2005 were 104.

As compared to the patients operated per month before the project, the number has increased by 68.75%.

Questionnaires showed that 88 patients (84.61%) were satisfied with their choice, and 4 patients (3.84%) were not satisfied. Twelve patients (11.53%) did not give any answers.

Reduction of nosocomial infections due to bacteria produced by ESBL

Nona Redjova

By the end of April 2005, the following project activities have been carried:

·  information about the aims of the project was provided to the hospital management and the heads of the microbiogy laboratory, the surgery, othopedic and intensive care units;

·                 a conference was organized with the heads of units at risk on the problems of infections associated with ESBL and the risk factors;

·                 antibiotic treatment policies in the units was discussed;

·                 disinfection practices at the units were revised, and the staff got instructions regarding modes of action in case such infections were detected;

·                 the staff of the microbiology laboratory was trained to identify such infections;

leaflets with information were prepared and placed at the disposal of staff in units at risk;

·                 current lab control is carried out for the detection of ESBL, producing осъществява се текущ лабораторен надзор за откриване на ЕSBL and timely informing the units about the results;

·                 antimicrobial therapy in the risk units is monitored.