Pseudomonas aeruginosa vaccine and pseudomonas antiserum in the treatment and prevention of infections in burned patients

Burns, 7. l-9

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Pseudomonas aeruginosa vaccine and pseudomonas antiserum in the treatment and prevention of infections in burned patients Agr. lonescu, Stela Vasiliu and S. Milicescu Clinic of Plastic and Reconstructive Surgery, Bucharest

Eugenia Meitert, T. Meitert, F. Sima and C. Savulian Cantacuzino Institute, Bucharest

Summary Two hundred and ten patients with various severe bums were followed up clinically, bacteriologically and immunologically; 162 patients received a polyvalent pseudomonas vaccine (23 for treatment, 139 preventively), 5 patients received combined immunotherapy (polyvalent pseudomonas vaccine and serum) and 43 patients were not vaccinated (control group). Of the 23 patients treated immediately after the onset of pseudomonas infection, 18 recovered clinically and bacteriologically, the other 5 patients died after 39-137 days from Pseudomonas aeruginosa septicaemia (1 case) or other causes (4 cases). In the control group (25 non-vaccinated patients) 5 patients died from P. aeru&nosn infections. The combined immunotherapy applied in 5 patients with severe bums predominantly infected with P. aeruginosa led to conspicuous improvement of their general condition and progress towards clinical and bacteriological recovery. Polyvalent pseudomonas vaccine applied preventively 2 years consecutively (1977, 1978) in the same hospital lowered the incidence of P. aeruginosa both in the vaccinated and non-vaccinated patients (from 47.6 per cent in 1977 to 7.2 per cent in 1978 in the vaccinated patients, and from 76 per cent in 1977 to 33.3 per cent in 1978 in the non-vaccinated patients). Active anti-pseudomonas immunity induced by the polyvalent pseudomonas vaccine (prepared from 1I different P. aeruginosa serotypes) in burned patients, systematically followed up in 167 cases, was confirmed by the steadily rising curve of serum immunoglobulin values (IgG, IgA, IgM) and seroprotection titres.

INTRODUCTION IN view of the increased resistance to antibiotics of Pseudomonas aeruginosa strains and the fre-

quent failure of chemoprophylaxis and chemotherapy in patients with severe bums infected with P. aeruginosa, new therapeutic and preventive means had to be found for the control and prevention of these infections (Ionescu et al., 1965, 1978; Bocanegra et al., 1966; Feller, 1966; Feller and Pierson, 1968; Fajardo and Laborde, 1968; Jones, 1968, 1972; Alexander et al.. 1969; Alexander and Fisher, 1970; Jones et al., 1970, 1973; Sachs, 1970; Fajardo et al., 1971; Hanessian et al., 1971; O’Neill et al., 197 I; Jones and Lowbury, 1972; Laborde and Fajardo, 1972; Berche et al., 1976; Meitert E. et al.. 1976c, 1977a,b; Miller et al., 1977). The success of immunotherapy and immunoprophylaxis in infections with P. aeruginosa depends upon several factors, including knowing the characteristics of the P. aeruginosa strains isolated from the patients, their immune response to pseudomonas infection and to the specific bioproducts. On the basis of our knowledge of the distribution of P. aeruginosa serotypes in Romania (Meitert T., 1964; Meitert E. and Meitert T.. 1972; Meitert E. et al., 1974, 1976c, 1978a) and testing of some bioproducts (sera and vaccines) in animals (Meitert E. and Meitert T.. 1968:

Burns Vol. ~/NO. 1

2

Meitert T. et al., 1971; Meitert E. et al., 1975, 1977a, 1978b) and volunteers (Meitert E. et al., 1976a,b), penta- and hexavalent sera and corpuscular monovalent P. aeruginosa vaccines were prepared for therapeutic use and a polyvalent pseudomonas vaccine containing eleven different ‘0’ serotypes (according to the MeitertMeitert scheme) was prepared for the prevention of pseudomonas infections in hospitals with high risks ofinfection. The present study reports on the results obtained in the Clinic of Plastic and Reconstructive Surgery in the treatment and prevention of pseudomonas infections in burns following the application of a polyvalent pseudomonas vaccine and immune P. aeruginosa antisera, prepared in the Cantacuzino Institute. MATERIALS

AND

METHODS

During 1977 and 1978 210 patients with various severe burns were followed up clinically, bacteriologically and immunologically; 162 of these patients received a polyvalent pseudomonas vaccine (23 for treatment, 139 preventively) immediately after admission to hospital; 5 patients were treated with polyvalent pseudomonas vaccine and serum, and 43 nonvaccinated patients represented the control group. The polyvalent P. aeruginosa vaccine, prepared from eleven different ‘0’ P. aeruginosa serotypes (I, II, III, IV, V, VI, VIII, XIII, XIV, XV, XVI)-the most frequently encountered in Romanian hospitals-was administered on 4 consecutive days (total dose, 1 ml) for the basic vaccination and continued at 3-5-day intervals in progressive doses of 0.3-l ml vaccine during the patient’s stay in hospital. The total amount of polyvalent pseudomonas vaccine administered varied between 1.3 and 27.7 ml and it was well tolerated by 97 per cent of patients, the remaining 3 per cent presenting minor local reactions and transient mild bouts of fever. The purified and concentrated P. aeruginosa antisera (penta- and hexavalent), prepared in horses against the serotypes contained in the polyvalent pseudomonas vaccine, was administered on 3 consecutive days in total doses of 48 000-l 20 000 AIU (anti-infectious units), and was very well tolerated. In order to consolidate the treatment with specific immune serum the polyvalent pseudomonas vaccine was administered concomitantly. Utilization of the polyvalent pseudomonas vaccine for therapeutic purposes became pertinent because of consecutive contamination

of the same patient with 2-4 P. aeruginosa serotypes during hospitalization (34 per cent of patients). In each patient the clinical course and immunological state, microbial flora of the burned areas and characteristics of the P. aeruginosa strains (serotype, sublysotype, virulence, sensitivity to chemotherapeutics) isolated on admission and during hospitalization were followed up periodically. Samples for detecting P. aeruginosa carriers (nose, throat, groin, axillas and anus) were taken on admission; study of the microbial flora in the bums and of the state of immunity (serum immunoglobulins IgG, IgA, IgM, anti-H and anti-0 agglutinating antibodies, seroprotection titre) was performed on admission and at 7-day intervals throughout the patient’s stay in hospital. Isolation, identification, lysotyping, serotyping and assessment of virulence of the P. aeruginosa strains were performed on the basis of a methodology previously described (Meitert T., 1964; Meitert E., 1965; Meitert T. and Meitert E., 1971; Meitert E. and Meitert T., 1975). Sensitivity to chemotherapy was tested by a diffusometric method in Chabert medium, using microtablets for antibiogram (Uzina de Medicamente Bucuresti). Serum immunoglobulins (IgG, IgA, IgM) were studied by the Mancini method on immunoplates prepared in the Cantacuzino Institute. The presence of agglutinating anti-H antibodies in the patients’ sera was determined by the twofold serum dilution technique (l/10-1/2560), to which were added equal amounts of suspension of the P. aeruginosa strain isolated from the patient in a concentration of lo9 cells/ml. Incubation was at 37 ‘C for 24 h. The serum agglutinating titre was given by the dilution presenting +t agglutination at the agglutinoscope. Anti-O agglutinating antibodies were investigated by the same technique, using boiled antigen (2.5 h); the serum antigen mixture was incubated at 52 ‘C for 24 h. The seroprotection text was performed in Rockland All Purpose mice, weighing 18-20 g, each serum dilution being inoculated by the S.C. route to 4 mice, to which one LD,,, of the homologous virulent strain was inoculated i.p., 4 h after administration of the serum. Survival of the mice was followed up for 4 days. The seroprotection titre was given by the serum dilution that protected all the mice against one

lonescu et al.: P. aerughosa

Vaccine

LD,,, and was expressed in anti-infectious (AIU).

3

units

RESULTS

In the patients studied the incidence of burns was more frequent among men (67 per cent) and in the 20-40 years (55.5 per cent) and 41-50 years (21.2 per cent) age groups. The burned area extended from 8 to 10 per cent of the body surface in 28.2 per cent of patients, 1 l-20 per cent in 32.5 per cent, 2 l-30 per cent in 15.3 per cent, to over 31 per cent of the body in 23.9 per cent of patients. The depth of the bums, estimated according to the method of Ionescu et al. (1970), was first-degree in 7 per cent, second/third-degree in 39 per cent, second/ third/fourth-degree in 49 per cent and fourthdegree in 5 per cent. Study of the microbial flora on admission revealed a proportion of 4.3 per cent P. aeruginosa carriers (3 pharyngeal, 2 nasal, 2 nasopharyngeal, 2 digestive), whose burns subsequently became contaminated with the same phage and serologic type as that of the carried strain. Within the first 7 days after admission the burns were predominantly (46.6 per cent) or non-predominantly infected with P. aeruginosu, in association with other organisms (proteus, haemolytic Staphylococcus aureus, or both etc.). All the 207 P. aeruginosa strains isolated from the burned patients were listed in sublysotypes and distinct serotypes. The predominant sublysotypes in both 1977 and 1978 were: la, (I 3 per cent), la, (7.8 per cent). 3 1, (7 per cent), 3n, (6 per cent), la, (3.6 per cent), 3p, (3.1 per cent) etc. Apart from the great variety of the sublysotypes isolated from the patients with burns, a great variety of sublysotypes was found in the same patient (57 per cent) during hospitalization. The predominant serotypes in 1977 and 1978 were the same: XV (36 per cent and 32 per cent respectively) and 11 (26 per cent and 19 per cent respectively), followed by serotypes I, IV (14 per cent each), III (10 per cent), V (7 per cent) etc. As with the sublysotypes, a great variation was noted in the serotypes (45 per cent) during hospitalization. In 34 per cent of cases, consecutive contamination of the burn with two to four different P. aerugino,sa lysoserotypes was observed in the same patient. Virulence of the P. aeruginosa strains for white mice varied from one strain to another,

59.5 per cent of strains exhibiting various degrees of virulence (10.3 per cent of which were exceptionally virulent) while 40.5 per cent were not virulent. All the P. aeruginosa strains were sensitive to polymixin and Colomycin, 99.9 per cent to gentamicin and fewer sensitive to tetracycline (31 per cent), streptomycin (30 per cent), neomycin (26.5 per cent), Pyopen (carbenicillin) (17.8 per cent), kanamycin (15.5 per cent), chloramphenicol(3.8 per cent) and Negram (0.5 per cent). All the strains were resistant to sulfathiazole, furazolidone, nitrofurantoin, Septrin (co-trimoxazole) and rifampicin (Table I). In the bums, P. aeruginosa was more frequently associated with haemolytic S. aureus (30 per cent) and proteus (25 per cent) or with both organisms (12 per cent). P. aeruginosa was also associated with 1, 2 or 3 of the following organisms: E. coli, klebsiella, enterococcus, haemolytic and/or non-haemolytic, betahaemolytic streptococci (between 0.7 and 10 per cent). The sensitivity to antibiotics of these microbial species differed from that of the P. aeruginosa strains (Table I). Serum immunoglobulins presented normal values in all the patients on admission to hospital. Following prophylactic and therapeutic vaccination of the burned patients with polyvalent pseudomonas vaccine, there was an increase in serum immunoglobulin titres starting from day 7 after the first vaccine dose, IgG and IgA increasing more than twofold after 21 days and IgM, 1.8 times the initial titre (Fig. I ), in contrast to the non-vaccinated patients in whom immunoglobulin titres increased slightly (IgG and IgA) or not at all (IgM). Similarly, the vaccinated patients developed infection. against pseudomonas protection manifested by progressive increase in the seroprotection titre, so that 14 days after the first vaccine dose mean values greater than 50 AIU/ml were attained and after 20-28 days, mean values of 80 AIU/ml (Fig. 2). In the nonvaccinated patients the seroprotection titre remained at relatively low values not exceeding 8.5 AIU/ml, even 28 days after the onset of pseudomonas infection. Anti-H agglutinins were detected in all the vaccinated patients (l/640-1/2560) but in only 43 per cent of the non-vaccinated patients with P. aeruginosa infection at low titres (l/201/640). Anti-O agglutinins were detected in small titres (l/20-1/80) and only in 5 per cent of the vaccinated patients. No relationship was noted between the titres of the two agglutinin

BurnsVol.7/No.l

4 T&e

1.Sensitivity (%) to chemotherapy

Chemotherapeutics

of P. aeruginosa strains and associated microbial flora

P. aaruginosa (207 strains)

Proteus (52 strains)

E. coli (29 strains)

S. aureus (55 strains)

S. albus (38 strains)

100 100 99.9 31 30 36.5 17.8 15 3.8 0.5 0 0 0 0 0 0

4.3 13 86.5 4.3 9.6 27 13.4 19.2 44.2 60 17.3 3.8 3.8 0 3.8 7.2

44 55.5 100 0 55.5 55.5 0 55.5 0 z:

0 0 95.2 9.5 24 33 43 33 29 4.7 23.8 4.7 4.7 9.5 76.1 14

12 0 62 62 50 25 37 62 25 0 12 12 25 12 100 37

0 3.8 0 0 0 0

1 0I.1

0 61.9 76.1 57.1 35.2 19

;: 62 100 100 12

Polymixin Colomycin Gentamicin Tetracycline Streptomycin Neomycin Pyopen (carbenicillin) Kanamycin Chloramphenicol Negram Septrin (co-trimoxazole) Sulfathiazole Furazolidone Nitrofurantoin Rifampicin Ampicillin Penicillin Novobiocin Lincocin Pristinamycin Erythromycin Oxacillin

0 0 0 0 0

0 44 0 1 I.1 0

: 0 0 AlUlml

100 90

_

+-

80 Nonvacanated

vaccinated nonvacc~nated

70 60

go-

--

50

80-

40

70-

30

60-

20

JO-

IO

40-

L

30-

Days afteradmwon

ZO-

titre in vaccinated and nonvaccinated patients infected with P. aeruginosa (mean titres).

Fig. 2. Seroprotective

10l-6 7-14 Days afterburn

Fig. I. Serum immunoglobulins (IgG, Ig.4, IgM) in patients vaccinated against P. aeruginosa and in non-

vaccinated patients (variations initial titre).

per cent in terms of

types and serum immunoglobulin values or seroprotection titre. Of the 23 patients treated with polyvalent pseudomonas vaccine (Table II), 18 (78.3 per

cent) treated immediately after the onset of infection recovered clinically and bacteriologically, presenting moreover high seroprotection values and a one and a half to fourfold increase in serum immunoglobulins. The other 5 patients died after 39-137 days in hospital: 1 (with incomplete vaccinotherapy) died from l? aeruginosa septicaemia and the other 4 (with deep burns of over 40-63 per cent of the body surface) died from causes other than pyocyaneus

lonescu et al.:P aaruginosa Vaccine

5

Tab/e /I. History of 23 patients infected with P. aeruginosa, treated with polyvalent P. aeruginosa vaccine

No. of cases 4 9 4 6

Burned surface (%I

Degree of burn

age lyr)

Min/max

Mean stay

IO-17 20-30 40-45 60-63

3/4 3/4 3/4 2/3/4

41 38 28 30

38/79 55/l 05 39/75 36/l 37

50 56 47 89

Mean

Days in hospital

Condition at discharge Died from P. aeruginosa Other infection Recovering causes 4 9 2 3

0 0 1 0

(781.!%,

(4G%,

0 0 1 3 (1743%)

Table/f/. History of 25 patients infected with P. aeruginosa, not treated by polyvalent P. aeruginosa vaccine

No. of cases

Burned surface l%)

Degree of burn

age lyr)

Min/max

Mean stay

6 10 5 4

21-30 1 O-20 31-45 57-63

2/3/4 2/3/4 2/3/4

32 38 36 40

19/l 67 52 13/l 12/134 1 O/l 08

79 38 62 81

Mean

Days in hospital

Condition at discharge Died from P. aeruginosa Other Recovering infection causes

Tab/e/V. Comparative evolution of patients infected treated or not treated with P. aeruginosa vaccine Recovering Patients Treated

No. of cases

No.

%

23

18

78.3

6 9 2 0

01 3 1

(687%)

(2Z%,

with P. aeruginosa

Died from P. aeruginosa infection No. % Significance 1

4.3

: 0 3

Other causes No. % 4

17.3

3

12

n.s. Not treated

25

17

68

5

20

ns., Not significant.

infection, i.e. cardiorespiratory failure because of burns of the upper respiratory tract (1 patient), renal failure (1 patient, incompletely vaccinated), septicaemia due to haemolytic S. uwws and proteus (1 patient) and hepatorenal failure (1 patient). In the control group of 25 non-vaccinated patients, P. aeruginosa infection was fatal in 5 patients (20 per cent), in spite of the intense treatment with antibiotics (Table ZZr). However, the difference in the mortality from P. aerugino.su infection between the vaccinated and non-vaccinated patients is not statistically signi-

fkant because of the relatively small number of patients (Table IV). Combined immunotherapy (polyvalent pseudomonas vaccine and serum) applied in 5 patients with medium and severe burns, predominantly infected with P. ueruginosu (60-100 per cent), led to conspicuous improvement of their general condition and evolution towards clinical and bacteriological recovery (Table V). The patients vaccinated prophylactically with polyvalent P. ueruginosu vaccine on admission (42 patients in 1977 and 97 in 1978) presented fewer infections with P. uerugino.su (Tables VI

Burns Vol. ~/NO. 1

6 Table V. History of 5 patients infected with P. aeruginosa, treated P aeruginosa serum and vaccine

Burned No. of surface cases /%I 1 4

Degree of burn

12 30-40

No. of days in hospital

3/4 3/4

Condition at discharge Recovering Died

79 49-72

Organic* deficiency

0 0

:

with

1 1

?? , Chronic hepatitis. Tab/e V/. History of 139 patients vaccinated prophylactically with polyvalent P. aeruginosa vaccine Days in hospital Mean age (yr) Min/max Mean

No. of cases

Burned surface PSI

Degree of burn

48 47

8-10 1 l-20

2/3/4 2/3/4

38 38

7/55 9/52

20 25

18 11

21-30 31-40

2/3/4

39 34

8’ 8’/103 /61

35 34

10 4 1

41-50 51-60 80

2/3/4 3/4

37 29 17

25/55 21/104 12’

38 70 0

stay

Condition at discharge Contamination Died from with P. aeruginosa Other infection Recovering causes P. aeruginosa 0 10 17 10 10 4 0 136 (98%)

0

:;

!

0 :

0 15

z 1

(23l %I

?? , Day of death; t, pulmonary embolism; +, septicaemia with proteus; 5, cardiorespiratory failure. Tab/e V/f Comparative seruginosa in 1977-78

evolution

of patients

vaccinated

and not vaccinated

Recovering

Died from P. aeruginosa infection

No.

%

No.

%

98

0

0

preventively

against

P.

Contamination with P. aeruginosa

Other causes

No. of Patients Vaccinated preventatively

cases

139

136

Significance

No.

%

No.

%

3

2.1

27

19.4

x*=12.5 P < 0.001 Not vaccinated

43

35

81.4

5

11.6

and VIII) than (Tables VIZ and

the non-vaccinated patients VIII). Thus, in 1977, in the patients vaccinated preventively, P. aeruginosa was detected in 47 per cent as against 76 per cent in the non-vaccinated patients, and in 1978, the proportion of infections with P. aeruginosa was only 7.2 per cent in the vaccinated patients as against 33.3 per cent in the non-vaccinated cases (Table

IX).

In the patients vaccinated

preventively

infec-

Significance

x2=22.2 P < 0.001 3

6.7

25

58.1

tion with P. aeruginosa was short-lived (l-2 weeks) and involved a reduced number of bacteria(lOi-102). There were no deaths from P. aeruginosa infections among the preventively vaccinated patients (Tables VI and VII), recovery occurring in all cases and the hospitalization was much shorter than that of the controls (Tables VI and VZ10. Statistically, the differences in the mortality rate from P. aeruginosa infection and

lonescu et al.: P. aeruginosaVaccine

7

Table VIII. Evolution of 43 non-vaccinated patients (control group) Days in hospital No. of cases

11 16 6 10

Burned surface /o/o)

Degree of burn

6-8 lo-20 21-30 31-63

2/3/4 2/3/4 2/3/4 2/3/4

Mean age

Min/max

(vr) 44 39 32 33

Mean

stay 12/34 13/167 19/152 lo/134

27 28 79 72

Condition at discharge Died from Contamination P. aeruginosa Other with Recovering infection causes P. aeruginosa 11 15 6 3 (813:%,

0 :, 4

0 3

(1 156%)

(6.37%)

Table IX. Frequency of P. aeruginosa infections in non-vaccinated vaccinated preventively against P. aeruginosa in 1977-78

Patients Vaccinated preventatively

No. of cases 1977 1978

42

97

No.

20

:

25

18

19

Contamination with P. aeruginosa 1977 1978 % Significance No. % Significance

47.6

76

in the rate of burn contamination with this organism, between the vaccinated and nonvaccinated patients, was significant (Tables VIII and IX). DISCUSSION

AND

(5:?%)

patients and patients

7

7.2

x2 = 4.08 P < 0.05 Not vaccinated

3 10 6 6

CONCLUSIONS

The good results obtained with polyvalent P. aeruginosa vaccine and sera in the treatment and prophylaxis of pseudomonas infection in burned patients, in the group studied, and the absence of adverse reactions, permit the introduction of P. aeruginosa vaccine and sera in the routine prophylaxis of burns and their treatment in association with other methods. These bioproducts, which are well tolerated by the patients, protect against 95 per cent of P. aeruginosa serotypes isolated in the hospitals of Romania, as is manifested immunologically by increased serum immunoglobulin values and seroprotection titres. The success of immunotherapy and immunoprophylaxis in pseudomonas infections in burned patients with specific bioproducts depends upon a number of factors, important among which are the extent and depth of the

x2=7.8 P < 0.01 6

33.3

lesions, the patient’s age and past history and the moment at which the bioproducts were applied. The earlier combined immunotherapy (P. aeruginosa serum and vaccine) and immunoprophylaxis with polyvalent pseudomonas vaccine are applied in cases of severe burns, i.e. from the moment of admission of patients with burns covering more than 10 per cent of the body surface, the more favourable are the results in the prevention and management of pseudomonas infection of burns. Passive immunization combined with active immunization applied as soon as pseudomonas infection developed proved particularly efftcient even in the cases with a reserved prognosis. Favourable results in severe pseudomonas infections of burned patients by immunotherapy with P. aeruginosa antisera or the concomitant application of sera and pseudomonas vaccine were also obtained by Feller (1966) Jones et al. ( 1970) Pierson and Feller (1970) and Fajardo et al. (1971). Good results in the management of declared P. aeruginosa infection of burned patients in the group investigated, in whom the concomitant

Burns Vol. ~/NO. 1

8

application of pseudomonas antiserum was contraindicated, were obtained by early vaccination with the polyvalent P. aeruginosa vaccine (78.3 per cent), necessitating, however, a certain interval for the onset of specific immunity. Late or incomplete vaccinotherapy of burned patients with severe pseudomonas infection led to a longer survival but not to recovery of the patients. Similar results have been reported by Alexander et al. (1969) Alexander and Fisher (1970) and Sachs (1970). Polyvalent pseudomonas vaccine applied preventatively for 2 years running (1977, 1978) in the Clinic of Plastic and Reconstructive Surgery lowered the incidence of P. aeruginosa both in the vaccinated and the non-vaccinated patients (from 47.6 per cent in 1977 to 7.2 per cent in 1978 in the vaccinated patients, and from 76 per cent in 1977 to 33.3 per cent in 1978 in the non-vaccinated patients). Active anti-pseudomonas immunity induced by the polyvalent pseudomonas vaccine (prepared from eleven different P. aeruginosa serotypes) in burned patients, systematically followed up in 167 cases, was confirmed by the steadily rising curve of serum immunoglobulin values and seroprotection titres, by the evolution towards clinical and bacteriological recovery of more than 95 per cent of patients, by the small number (19.4 per cent) of P. aeruginosa contaminations (for a short period and with a small number of organisms) and by the minimal mortality from infection with P. aeruginosa (0.6 per cent). Similarly, hospitalization of the vaccinated patients was of much shorter duration than the non-vaccinated cases. In 43 per cent of non-vaccinated patients and 100 per cent of vaccinated patients, anti-H agglutinins proved not to be related to the seroprotection titre or serum immunoglobulin values, as did the anti-0 agglutinins which were only present in 5 per cent of the vaccinated cases and absent in the non-vaccinated ones. From these favourable results obtained with polyvalent pseudomonas vaccine and sera in the prevention and control of P. aeruginosa infec-

tions in burned patients, combined with antibiotics and measures for controlling the spread of P. aeruginosa strains, we recommend the use of these bioproducts in other areas of pseudomonas infection, with a view to reducing inhospital infections with these bacteria.

249.

Berche P., Veron M. and Tirelli R. (1976) A cellular vaccine from P. aeruginosa. Ann. Inst. Past. (Paris) 127 (A/2), 247.

Bocanegra M., Minostroza F., Bazan A. et al. (1966) Convalescent bum plasma for severely burned children. Ann. Surg. 163,46 1. Fajardo C. L. and Laborde H. F. (1968) Pseudomonas vaccine. J. Bacterial. 95, 1968. Fajardo C. L., Zaidenberg A. J. and Laborde H. F. (1971) Anti-pseudomonas serum in the control of Pseudomonas aeruginosa infection in children’s wards. In: International Symposium on Enterobacterial Vaccine (Beme, 1968) Basle, Karger, pp. 253-258.

Feller I. (1966) The use of pseudomonas vaccine and hyperimmune plasma in the treatment of seriously burned patients. In: Wallace A. B. and Wilkinson A. W. (ed.) Research in Burns. Edinburgh, Livingstone, pp. 470-80. Feller 1. and Pierson C. (1968) Pseudomonas vaccines and hyperimmune plasma for burned patients. Arch. Surg. 97,225.

Hanessian S., Regan W., Watson D. et al. (1971) Isolation and characterization of antigenic components of a new heptavalent pseudomonas vaccine. Nature (New Biol,) 229,209.

Ionescu Agr., Meitert E., Vasiliu S. et al. (1978) Vaccinul si serul anti-Pseudomonas aeruginosa Pn tratamentul si prevenirea infectiilor la arsi (AntiPseudomonas aeruginosa vaccine and serum in the treatment and prevention of infection in burned patients). Bull. Acad. St. Med. No. 2,37. lonescu Agr., Radulescu V. and Vasiliu A. (1970) Arsurile:

Clinica’

Fiziopatologie.

Tratament.

Bucharest, Edit. Medical& pp. 88-9 1. Ionescu Agr., Vasiliu A., Petrovici V. et al. (1965) Immunotherapy in the management of infected bums. Plast. Reconstr. Surg. 35,39 1. Jones C. E., Alexander J. W. and Fisher M. W. (1970) Clinical evaluation of pseudomonas hyperimmune globulin and plasma. Surg. Forum. 21,238. Jones C. E., Alexander J. W. and Fisher M. W. (1973) Clinical evaluation of pseudomonas hyperimmune globulin. J. Surg. Res. 14,87. Jones R. J. (1968) Protection against P. aeruginosa infection by immunization with fractions of culture filtrates of P. aeruginosa. Br. J. Exp. Pathol. 49,4 11. Jones R. J. (1972) Specificity of early protective responses induced by pseudomonas vaccines. J. Hyg. (Camb.) 70,343.

Acknowledgement

The authors wish to thank technical assistance.

REFERENCES

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for

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lonescu et al.: P. aeruginosaVaccine

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Meitert E., Meitert T., Savulian C. et al. (1976a) Cercetari privind imunogenitatea vaccinului corpuscular polivalent P. aeruginosa la voluntari (Investigations on the immunogenicity of the polyvalent P. aeruginosa corpuscular vaccine in volunteers). Scientific Session of the Cantacuzino Institute (Bucharest) XIV, 18.

Meitert E., Petrovici M., Meitert T. et al. (1976b) Cercetarea valorii protectoare a serului imun polivalent anti-P. aeruginosa de provenienta umana (Investigations on the protection value of the polyvalent anti-P. aeruginosa immune serum of human origin). Scientific Session of the Cantacuzino Institute (Bucharest) XIV, 149.

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therapeutical value of the immune P. aeruginosa antiserum in experimental infections). Scientific Session of the Cantacuzino xv, 102.

Institute

(Bucharest)

Meitert E., Meitert T., Sima F. et al. (1977b) la Imunoterapia infectiilor cu P. aeruginosa bolnavii cu arsuri (Immunotherapy of P. aeruginosa infections in burned uatients). Scientific Session of the Cantacuzino

’

Institute (Bucharest) XV, 108.

Meitert E., Meitert T., Sima F. et al. (1978a) New P. aeruginosa serotypes following the individualization of new antigenic ‘0’ structure. Arch. Roum. Pathol. Exp. Microbial. 31, 16 I.

Meitert E., Meitert T., Petrovici M. et al. (1978b) Experimental investigations of the immunogenicity of some P. aeruginosa corpuscular vaccines. Arch. Roum. Pathol. Exp. Microbial. 37,25 1. Meitert T. (1964) Contribution a l’itude de la structure antigenique des b. pyocyaniques. II. Individualisation des groupes serologiques au moyen des antigenes ‘0’. Arch. Roum. Pathol. Exp. Microbial. 23,679.

Meitert T. and Meitert E. (1971) Virulence pour la souris blanche de quelques souches de Pseudomonas aeruginosa provenant de cas sporadiques et d’infections nosocomiales. Arch. Roum. Pathol. Exp. Microbial. 30,37.

Meitert T., Meitert E., Sulea 1. et al. (1971) Studiul experimental al propriet&ilor antiinfectioase si antitoxice ale serului imun antipiocianic (Experimental study of the antiinfectious and antitoxic properties of the immune pseudomonas antiserum). Scientific Session of the Cantacuzino Institute (Bucharest) VIII, 2 1.

Miller J. J., Spilsbury J. F., Jones R. J. et al. (1977) A new polyvalent pseudomonas vaccine. J. Med. Microbial. 10, 19.

O’Neill J. A., Nance J. F. C. and Fischer M. W. (197 I ) Heptavalent pseudomonas vaccination in seriously burned children. J. Pediatr. Surg. 6,547. Pierson C. and Feller 1. (1970) A reduction of pseudomonas in burned patients by the immune processes. Surg. Clin. North Am. 50, 1331. Sachs A. (1970) Active immunoprophylaxis in bums with a new multivalent vaccine. Lancer 2.959.

55,83.

Meltert E., Petrovici M. and Savulian C. (1977a) C‘ercetarea valorii terapeutice a serului imun anti-P. aeruginosa in infectia experimental& (Study of the

Paper accepted I I May 1978.

Keqruws for rrprino should hr addrerred to. Prof Agr. Ionescu. Clinic of Plastic and Reconstructive Mincu 7. Bucharest. Romania.

Surgery. Str. Arhitect

Ion