(COMMENT BY DR. JAMES SUTHERLAND)

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SUPPLEMENT 357

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

Boston.

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

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358 HEXACHLOROPHENE

TABLE I

TECHNIQUPIS USED TO CONTROL NURSERY EPIDEMICS OF STAPHYLOCOCCAL DISEASE

Technique

Recurrence

Selected References Colonization Disease

Least effective

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.

Moderately effective

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.

Most effective

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

al-TABLE II

1. Staphylococcal epidemics occur despite hexachioro-phene bathing.

. Hexachiorophene bathing of newly born babies has

usually been ineffective in control of staphylococcal

outbreaks.

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

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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

staphylococcal disease.

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1973;51;357

Pediatrics

(COMMENT BY DR. JAMES SUTHERLAND)

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1973;51;357

Pediatrics

(COMMENT BY DR. JAMES SUTHERLAND)

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