dence of low grade mild staph infections in
the newborn are epidemics of “hot” strains of
staph which produce severe disease such as
pneumonia and osteomyelitis. There appears to be no clear indication that all such epidem-ics are prevented by or terminated by the use
of hexachborophene. Whether or not such
failure is related to inadequate application of hexachlorophene is not clear and will require further study. There is good evidence to sug-gest that such epidemics are cyclic in nature and may subside spontaneously or as a result of the use of antimicrobial agents. In all
likeli-hood such epidemics will reappear despite
the use of hexachlorophene.
3. There is suggestive evidence that gram-negative organisms increase in numbers when
gram-positive organisms are suppressed by
hexachborophene. Data indicating a concomi-tant increase in infections due to gram-nega-tive organisms are only’ suggestive and
per-haps circumstantial. They do not seem to be
sufficiently definite at least at the present to end attempts to control staphylococci in the newborn.
4. The infant himself is clearly the site on
which staphylococci thrive and from which
they spread. The umbilical stump and the
circumcision wound are the primary areas of
colonization and require the greatest atten-tion if staphylococci are to be controlled in their spread.
5. Until the possible untoward effects of
hexachborophene to the newborn infant are
fully explored, there appears to be no justifi-cation for the routine use of this agent in the newborn to lower the colonization rate in the face of interepidemic disease.
6. Further investigation with agents which
prove nontoxic to experimental animals yet
serve as deterrents to staphylococci is
needed. Until such agents are available,
thor-ough handwashing by nursery personnel with
3% hexachlorophene and attention to aseptic technic seem to be sufficient during
nonepi-demic periods. Much more work needs to be
done to elucidate the factors and their control
which underly the emergence of epidemics
due to pathogenic strains of staph which pro-duce severe infections.
(COMMENT BY DR. JAMES SUTHERLAND)
This preliminary data are on the subject of neonatal meningitis caused by gram-negative
organisms. During 1970 and 1971, Dr.
George Mc Cracken of Dallas designed a
study to investigate therapy of gram-negative
meningitis. Thirteen centers if the United
States and Canada were chosen on the basis
of their experience with the disease over the preceding few years. Together they had seen some 50 infants yearly with meningitis from
their cummulative population base of
100,000-150,000 births yearly. Participants of the study include centers in Dallas,
Birming-ham, Memphis, Atlanta, New Orleans,
Balti-more, Cleveland, Cincinnati, San Francisco,
Los Angeles, Salt Lake City, Montreal, and
The study began on September 1, 1971
with some of the 13 centers officially enroll-ing as late as December. Initially the number of patients enrolled in the study met expecta-tions. In 1972 enrollees fell off so severely that changes in study design were suggested at the last meeting of investigators in May.
The total number of infants entered in the
study from September through May is 15.
In examining the experience before
Decem-ber 8, 1971 compared to the experience after
December 8th the number of newborn
in-fants with meningitis fell from .09 per day to .05 per day. This highly significant change is in the face of a greater mean population base in the second period. The change is associ-ated, at least in time, with the decrease in use of hexachborophene bathing in nurseries (.32/ 1000 to .18/1000).
For my second topic, I’d like to review
some of the alternatives available to the clini-cian faced with a nursery outbreak of Staphy-lococcal disease.
Controlling an epidemic caused by a
dis-ease-producing Staphylococcus depends on
breaking the chain of infant-to-infant spread and at the same time assuring that adult-to-infant recolonization of nursery infants is pre-vented.
One would expect then that relative
TECHNIQUPIS USED TO CONTROL NURSERY EPIDEMICS OF STAPHYLOCOCCAL DISEASE
Selected References Colonization Disease
Establish new cohort
Close nursery No recurrence Ravenholt, cial, New Eng. J. Med.. 257:789. 1957. Specific tracking No recurrence Light, ci al, PEDIATRICS, 49:15, 197a.
Cord (groin) antimicrobials No recurrence Klainer, ci al, Amer. J. Die. Child., 103:7Q, 196Q.
Nasal antimicrobials Recurrence (1) Klein & Rogers, New Eng. J. Med., 260:lola, 1959. Environmental antimicrobials No recurrence Sutherland, ci al, Amer. J. Die. Child., 102:793, 1961. Hexachlorophqne bath Recurrence Rycheck, ci al, New Eng. .1. Med., 269:33a, 1963.
Systemic antimicrobials No recurrence No recurrence
Shaffer, ci a!, PzrnATaIcs, 18:750, 1956. Mortimer, Communication
Interference (50A) No recurrence Recurrence
Boris, ci a!, Amer. .1. Die. Child., 105:174, 1963. Light, cia!, J.A.M.A., 193:699, 1965.
staphylococcal outbreaks in nursuries is de-pendent upon three factors.
1. Ability to decrease rate of colonization with offending organism to a figure approach-ing zero. A few measures accomplish this.
2. Ability to decrease baby-to-baby
con-tact through intermediaries.
3. At the same time ability to identify and remove other sources of organism introduc-tion into the nursery. No personnel
surveil-lance system has yet been devised which
1. Staphylococcal epidemics occur despite hexachioro-phene bathing.
. Hexachiorophene bathing of newly born babies has
usually been ineffective in control of staphylococcal
3. Hexaehlorophene bathing of newly born infants increases colonization of infants with gram-negative organisms.
4. Hexachlorophene bathing of newly born infants in-creases the frequency of disease caused by gram-negative organisms.
5. Hexachlorophene bathing as usually carried out has only a modest effect on rates of nursery colonization
with Staphylococcus aureus and may delay the ap-pearance of staphylococcal disease.
6. Changes in frequency of staphylococcal disease in newborn infants are associated with spontaneous
ways accomplishes this successfully.
The types of procedures which have been
used and reported to have met with some
degree of success are listed in Table I. The list is not inclusive, the references are selec-tive, and the classification into categories of least, moderately, and most effective proce-dures could be questioned.
However, the first group of procedures, listed in Table I, measures establishing a new cohort, breaking infant-to-infant spread while not permitting time for surveillance, and
re-moval of offending personnel, might be
ex-pected to be the least effective of the various
procedures available. On the other hand,
these procedures would be effective when
personnel carriers were absent, transient, or incidental to infant colonization and disease
or when another new cohort could be
estab-lished after identification and removal of per-sonnel carriers. In fact, establishing a new cohort or tracking infants in a different way has occasionally been effective. Ravenholt
and co-workers presented such data from a
Seattle outbreak reported in 1957. More
re-cently Dr. Light reported the experience
sequen-SUPPLEMENT 359 ance of the bullous Impetigo/Bitter’s disease
type II outbreak.
The second category is comprised of
mea-sures which are moderately effective. They
are, or would be, expected to be frequently
ineffective. These measures decrease but
don’t abolish colonization. For instance a
measure decreasing overall colonization rate
from 30-40% to 5-10% would be effective
only fortuitously even if personnel sources of
reintroduction could be identified and
re-moved. In this category are measures
provid-ing an incomplete shield about each infant
primarily by substances applied to the surface or parts of the surface of the infant-local antibactenals and antimicrobials. Klainer and co-workers applied bacitracin ointment to the
cord and groin and thereby decreased
colo-nization from about 80% to about 20% and
apparently abolished the disease outbreak.
Klein and co-workers applied
neomycin-gramicidin to nares of infants and personnel and were able to abolish the disease outbreak. We repeated the study of Elek and Flemming
with an environmental antimicrobial and
were able to decrease colonization from 40 to
70% to less than 10% and were able to
pre-vent perpetuation of the offending organism.
Very likely the environmental substance
found its wa.y to surfaces of infants and per-sonnel, primarily to the nares and respiratory tract. Rycheck and co-workers used
hexachlo-rophene bathing to control an epidemic and
reduced colonization from 25 to 50% to less than 10%, although the offending organism returned when bathing was discontinued. Dr.
Light has indicated a number of other
epi-demics in which hexachiorophene has proved ineffective in epidemic control. Also the triple dye technique falls in this moderately
effec-tive category described by Jellard and
re-ported on again recently by Pildes.
The last group of procedures are those
cat-egonzed as most effective (Table I). These
are procedures which have been or would be
expected to be effective more frequently than
ineffective. The measures include those
which abolish offending organisms from
virtu-ally all infants while permitting surveillance of personnel and identification and removal or offenders. Yet nose cultures of personnel, for example, might not detect the rare pha-ryngeal carriers and therefore one would an-ticipate that even these most effective proce-dures would occasionally fail. In this category of the most effective measures are those ap-plied more than skin deep, that is, (1) sys-temic antimicrobials and (2) the procedure of colonization of infants with an interfering strain of organism of low pathogenicity. The effective use of erythromycin to prevent
colo-nization and thereby irradicate disease was
described by Shaffer in 1956. More recently Mortimer has effectively used methicillin on two occasions, while at the same time remov-ing carrier personnel from the nursery. In this category also is the technique of colonization of infants with a strain of organism of low pathogenicity. This procedure is effective in virtually abolishing colonization with other strains of organisms and in abolishing disease. That all procedures should eventually fail is apparent and therefore the work cited in the last reference indicated a recurrence of the offending organism after the period of pur-poseful colonization.
The purpose of presenting this very brief summary is not to defend the classification or the choice of references but only to indicate that while the subject of our conference is a single agent, there are a number of available alternatives, more or less effective, and each with its real or imagined hazards. The clini-cian is not faced with a single choice but in fact has a bulky bag of tricks with which to
meet the challenge of a nursery outbreak of