WHAT IS THE EVIDENCE THAT HEXACHLOROPHENE IS NOT EFFECTIVE?

(1)

345

WHAT

IS THE

EVIDENCE

THAT

HEXACHLOROPHENE

IS NOT

EFFECTIVE?

Irwin

J. Light, M.D.,

and

James M. Sutherland, M.D.

From the University of Cincinnati College of Medicine, Children’s Hospital Research Foundation in Cincinnati,

and the Crosley Memorial Nurseiy of the Cincinnati General Hospital

ABSTRACT. Routine daily bathing of newborn infants with hexachlorophene, if meticulously perfonned, can alter the frequency of colonization and endemic disease caused by Staphylococcus aureus. However, the recent decrease in the occurrence of epidemics of severe disease caused by Staphylococcus aureus 80/81 innewborn in-fants is related to a decrease in colonization of infants with this epidemic strain unrelated to the use of

hexa-chiorophene bathing. In fact, in the presence of epidemic strains of staphylococci, hexachlorophene bathing has repeatedly been unsuccessful in either preventing or controlling disease. In addition, antistaphylococcal

topi-cal agents including hexachlorophene have a profound effect on the total bacterial flora pennitting an increase

in colonization with gram-negative bacilli. Routine daily

hexachlorophene bathing of newborn infants results in an increase in both colonization and disease caused by

gram-negative organisms. In view of the effects of hexa-chiorophene on the total well-being of the newborn in-fant, routine daily bathing with hexachlorophene should be used with caution.

Pediatrics, 51:345, 1973, STAPHYLOCOCCUS AUREUS,

GRAM-NEGATIVE BACILU; HEXACHLOROPHENE; NURSERY EP-IDEMICS.

OUTINE daily hexachlorophene bathing

of newborn infants has been a widely

accepted practice in many nurseries during

the past 10 years. The data regarding the

effect of hexachlorophene bathing on

staphy-lococcal colonization and disease has been

presented.’ It is significant that these effects

occur only if meticulous care is taken in

fol-lowing the details of the bathing procedure.2

This procedure requires that the newborn

infant be washed as soon as possible after

delivery while still in the delivery room and

that the bath be repeated upon admission to

the nursery. Undiluted 3% hexachiorophene

must be used. Particular care must be paid to

the umbilical stump using a cotton-tipped

applicator to cleanse the trough at the

skin-cord margin. Alcohol is to be avoided for cord

care. Complete baths with hexachlorophene

must be given daily during the entire nursery

stay. As frequently performed in many

nur-series, modifications of this procedure include

omission of the delivery room bath, delay of

the admission bath, bathing on alternate days

during the nursery stay, hexachlorophene

bathing only on admission to the nursery, the

use of diluted hexachlorophene, and omission

of careful attention to the umbilical stump.

These modified procedures are not known to

alter the incidence of either colonization or

disease caused by Staphylococcus aureus.

At-tention to the umbilical site is of special

im-portance and the omission of this detail or

persistence of the tradition of applying

alco-hol to the umbilical stump makes the bathing

procedure an ineffectual method of

decreas-ing staphylococcal colonization.3

DECREASED COLONIZATION WITH 80/81

It is widely recognized that the epidemics

of severe staphylococcal disease which

plagued newborn infants and mothers in the

late 1950’s and early 1960’s are not occurring

in present-day nurseries. These ‘epidemics

characterized by breast abscesses,

osteomyeli-tis, pneumonia and other deep pyogenic

le-sions were frequently caused by

Staphylococ-cus aureus of the phage type 80/81. Although

it has been suggested that the decrease is a

result of the suppression of staphylococci by

hexachiorophene this decrease may also be

explained by cyclic changes in the

staphylo-coccal flora which colonize newborn infants.

Decreases in the incidence of severe disease

could result from a decrease in colonization

with highly virulent strains of

Staphylococ-cus, such as 80/81. In order to examine the

changing pattern of staphylococcal

coloniza-tion in newborn infants, routine surveillance

cultures obtained over the past 12 years from

newborn and premature infants in the

nurser-ies at the Cincinnati General Hospital5 have

(2)

2/60 6/61 6/63 6/65 6/67 6/69 1/72 346

FIG. 1. Frequency of colonization of full-term and pre-mature infants with Staphylococcus aureus 80/81.

been reviewed. In the full-term nursery,

cul-tures are obtained on a given day of each

week from all infants being discharged on

that day and from all infants more than 7

days of age. In the premature nursery

speci-mens are obtained at weekly intervals from

all infants. Specimens obtained with

cotton-tipped applicators from the external nares

and the umbilical site are streaked directly

onto mannitol-salt agar. All staphylococci are

tested for coagulase production by a standard

slide test with rabbit plasma.

Mannitol-posi-tive coagulase-positive organisms are

desig-nated Staphylococcus aureus and are phage

typed. Staphylococcus aureus lysed by either

of the phages 80 or 81 are designated 80/81.

During this 12-year period a total of 25,662

cultures were obtained from 9,216 newborn

and premature infants. Any infant harboring

Staphylococcus aureus at any time from

ei-ther the nasal or umbilical site was

consid-ered to be positive for this organism.

Staphy-lococcus aureus was isolated from 3,450

in-fants; of these, 328 infants harbored

Staphy-lococcus aureus of the phage type 80/81.

Hexachlorophene handwashing has been

employed throughout the entire 12-year

study period. Daily hexachlorophene bathing

was used in the full-term newborn nursery

between June, 1965 and June, 1967. In the

delivery room, as soon as possible after birth,

a gauze pad soaked with undiluted 3%

hexa-chlorophene was wrapped about the

umbili-cal cord. On admission to the nursery, the

gauze pad was removed and the infant was

bathed with undiluted hexachlorophene.

Spe-cial attention was paid to the application of

hexachlorophene to the skin margin of the

umbilical cord; cotton-tipped applicators

were used for this purpose. The

hexachioro-phene was allowed to dry on the skin and was

not removed with water. The bathing

proce-dure was repeated once daily throughout the

hospital stay. Hexachlorophene for each bath

was dispensed in individual single-unit

auto-claved bottles.

Staphylococcal colonization of infants

dur-ing the 2-year hexachlorophene period was

compared to the three 2-year periods

preced-ing and the two 2-year periods following the

hexachlorophene bathing period (Fig. 1). The

frequency of colonization with 80/81 is

ex-pressed as the proportion of infants colonized

with 80/81 relative to the total number of

infants colonized with coagulase-positive

sta-phylococci during the 2-year period under

study. The 19-week period from May 12,

1963 to October 8, 1964, when purposeful

colonization with Staphylococcus a ureus

502A was employed has been omitted from

this study. In the premature nursery routine

daily hexachlorophene bathing was not used.

Staphylococcal colonization of infants in this

nursery was compared to that in the full-term

newborn nursery.

In the full-term newborn nursery, during

the first three periods, colonization with

Staphylococcus aureus decreased from a high

of 17.8% to a low of 6.5%. Because the

colo-nization rate of 17.8% may be unduly high

the 1963-65 period was compared to the

average colonization rate during the entire

period from 1960 to 1963. The decrease in

colonization with 80/81 from 15.3% during

this period to 6.5% in the 1963-65 period

remains highly significant (p less than 0.001).

This decrease in colonization with 80/81

rela-tive to total colonization with Staphylococcus

aureus occurred prior to the introduction of

hexachlorophene bathing. Similar results are

(3)

SUPPLEMENT

NS = Concentration not specified

80/81 is calculated per total number of

in-fants cultured. During the 2-year period of

hexachlorophene bathing there occurred a

further small, although statistically

insignifi-cant, decrease in colonization of infants with

80/81. During the 4 years following cessation

of hexachlorophene bathing the rate of

colo-nization with 80/81 remained unchanged.

In the premature nursery routine daily

hexachiorophene bathing has never been

used. In this nursery a similar significant

de-crease in colonization with 80/81 has

occur-red. Colonization decreased from an average

of 10.7% during the period prior to 1965, at

which time hexachlorophene bathing was

started in the newborn nursery, to an average

of 6.4% after this time (p less than .02).

The data indicates that colonization of

newborn infants with Staphylococcus aureus

80/81 decreased during the 12-year period

from 1960 to 1972. This decrease was

unre-lated to the use of hexachlorophene bathing

of newborn infants since the decrease began

prior to the use of hexachlorophene bathing

in this nursery, and remained low during the

4 years following cessation of this procedure.

In addition, a similar decrease in colonization

of newborn infants with 80/81 occurred in

the premature nursery, although daily

hexa-chlorophene bathing was never employed in

this nursery.

The data suggest that the recent decrease

in occurrence of epidemics of severe

staphy-lococcal disease in newborn nurseries is

re-lated to a spontaneous disappearance of this

epidemic strain which has occurred

indepen-dent of the use of hexachlorophene bathing.

FAILURE TO CONTROL STAPHYLOCOCCAL EPIDEMICS

In fact, in the presence of epidemic strains

of Staphylococci nursery epidemics have

been reported in which hexachlorophene

bathing has failed to either prevent or control

the epidemic. Although meticulous daily

hexachlorophene bathing will decrease

colo-nization with Staphylococcus aureus and will

decrease the incidence of endemic

staphylo-coccal disease, the data supporting the

effi-cacy of this procedure in controlling

epidem-ics of staphylococcal disease in newborn

in-fants is sparse. Nine such epidemics’’3

re-ported in the literature between 1960-71

have been summarized (Table I). Five

epi-TABLE I

FAILURE OF HEXACHLOROPHENE TO PREVENT EPIDEMICS OF STAPHYLOCOCCAL DISEASE

Newborn

Nursery

Hexachiorophene . Preparation

. .

(Liquid)

.

Le.nons

. Epidemic

.

Strain Comment

Wisconsin, 19606 0.75% Pustules 80/81 Failed to prevent

Georgia, 1961 3% Impetigo 80/81 Failed to prevent

Louisiana, 1968 NS Pneumonia,

Septicemia Breast Abscesses

Osteomyelitis

80/81 Failed to prevent

Milwaukee, 1963 NS Ritter’s disease SC/71 Failed toprevent

Indiana, 1964b0 3% Pustules

Breast Abscesses Pneumonia

80/81 Failed to prevent

Ohio, I969 3% Bullous Impetigo 3B/71 Failed to prevent

Chicago, 1971” 3% Pustules

Mastitis Parotitis

Grey strain Failed to prevent

Ohio, 19542 3% Pustules

Breast Abscesses

42B/47C/44A/5 Failed to control

(4)

TABLE II

EFFECT OF IIF;xAcIILoIs0PHENF: BATHING ON MICROBIAL FLORA IN NESVBORN INFANTs

Colonization of infants Disease

Nravitz, et al.*lb

l)ugdale, et a!.”

Sarkai,y, et a!.’7

Simon, et a!.2 8/9 cases of mastitis in mothers

caused by coliformns

CULTURES FROM UMBILICAL SITE

308 356

II

FIG. 2. Umbilical cultures for staphylococci and gram-negative bacilli obtained from infants in the full-term nursery (Light, et at’).

Ligl,t, et al.*b Increase gram-negative bacilli

(pseudomonas)

Forfar, et al.014 Increased gram-negative infections

in infants Increased E. (‘oh at skin umbilical

and penile sites

Increased gram-negative rods at

anterior nares

Increased proteus

“Heavy contamit,ation of perineal cultures with cohiforms

Plueckhali et a!.” Increased candela

* Statistically significant

demics caused by Staphylococcus aureus 80/

81 were associated with pustules, breast

ab-scesses, and occasional deep lesions including

osteomyelitis and pneumonia. Two epidemics

caused by group II staphylococci were

associ-ated with localized exfoliation of bullous

im-petigo or generalized exfoliation of Ritter’s

disease. Liquid hexachlorophene preparations

were used in all nine nurseries; the

concen-tration specified as undiluted 3% in six

nur-series, 0.75% in one nursery, and unspecified

in two nurseries. In seven of these nurseries

hexachiorophene bathing failed to prevent

the epidemic, since the frequency of

staphy-lococcal disease increased despite the use of

hexachlorophene bathing. In the two

remain-ing nurseries hexachlorophene bathing was

instituted to control established epidemics

and in both instances this control measure

failed. In one of these epidemics’2

hexachloro-phene bathing was instituted to control an

epidemic of pustules in newborn infants. This

control measure proved successful only to the

extent that skin manifestations of infection

were suppressed while the infants were in the

hospital. However, nasal colonization with

the epidemic strain of Staphylococcus

contin-ued to take place, with 32% of the infants

harboring the organism at the time of

dis-charge from the nursery at 3 to 6 days of age.

The hazards of nasal colonization were

em-phasized by the appearance of pyoderma in

STAPHYLOCOCCI

E]No growth

Coogulos. nigotive

_

Coagulate

positne

I

E

-Hexochlorophene hondwothiflg

-Hexochlorophene bathlng-_-_l

(5)

many of these infants 3 to 7 days after

dis-charge from the nursery and by infection in

many family members in the home. In the

recent nursery staphylococcal epidemic

re-ported by Hart, et aL’3 tightening of nursery

procedures including careful attention to

hexachlorophene bathing failed to alter the

course of the epidemic.

INCREASED COLONIZATION WITH GRAM-NEGATIVE BACILLI

Much of the interest in hexachiorophene

has focused on the problem of staphylococcal

colonization and disease. However,

appropri-ate evaluation of the effects of

hexachloro-phene bathing on the total well-being of the

infant must be extended to include a broader

spectrum of the bacterial flora of the

new-born infant. Although many components of

the newborn microbial flora have not been

examined, in recent years abundant data has

been accumulated regarding the effect of

hexachlorophene on gram-negative flora

(Ta-ble II). In studies in the newborn nurseries at

the Cincinnati General Hospital5 the effects

of hexachlorophene bathing on colonization

of newborn infants with gram-negative bacilli

and staphylococci have been examined (Fig.

2). This study was divided into four periods

during 29-week periods from late December

to early July of four consecutive years.

Dur-ing the first period, hexachlorophene for

handwashing was the only antibacterial agent

employed. Tap water was used for infant

bathing. During the second period, the

bath-ing procedure was changed to include

hexa-chlorophene as previously described. During

the third period, an antibacterial foam

(Inter-sept) selected for its broad antibacterial

spec-trum was added to the handwashing

proce-dure. Hexachlorophene infant bathing was

continued during this period. During the

fourth period, hexachlorophene bathing was

omitted, and hexachlorophene handwashing

plus antibacterial foam were continued.

During the first period of hexachlorophene

handwashing alone, coagulase-positive

sta-phylococci were isolated from 50% of the

umbilical sites and gram-negative bacilli from

45% of the sites. With the addition of

hexa-chlorophene bathing, the frequency of

cob-nization with coagulase-positive

staphybo-cocci decreased significantly from 50% to 4%,

concurrent with a significant increase in

gram-negative bacilli from 45% to 78%.

When antibacterial foam was added, no

change was noted in the frequency of

colo-nization with either coagulase-positive

sta-phylococci or gram-negative bacilli.

Follow-ing the cessation of hexachborophene bathing,

colonization with coagulase-positive

staphylo-cocci increased from 6% to 14%, concurrent

with a significant decrease in colonization

with gram-negative bacilli from 81% to 53%.

The changes in colonization at the nasal

site during these same periods were similar to

those at the umbilical site. During the period

of hexachborophene handwashing alone,

coag-ulase-positive staphylococci were isolated

from 54% of the nasal sites and gram-negative

bacilli from 36% of the sites. When

hexachbo-rophene bathing was added, colonization

with coagulase-positive staphylococci

de-creased significantly, concurrent with a

signif-icant increase in colonization with

gram-neg-ative bacilli. The addition of antibacterial

foam resulted in an additional small decrease

in colonization with Staphylococcus aureus

concurrent with a significant decrease in

gram-negative bacilli. This was the only

pe-riod during which changes in

coagulase-posi-tive staphylococci were not associated with

reciprocal changes in colonization with

gram-negative bacilli. The cessation of

hexachloro-phene bathing resulted in an increase in

coag-ulase-positive staphylococci from 2.5% to

14.5%, in association with a decrease in

gram-negative bacilli.

This data indicated that colonization with

Staphylococcus aureus and gram-negative

ba-cilli are inversely related. To define this

rela-tionship better, identification of specific

gram-negative organisms was begun during

the period of hexachborophene handwashing

plus hexachiorophene bathing. All cultures

obtained from that time to the end of the

study were examined to determine the

pro-portion of sites colonized with Pseudomonas,

(6)

Escheric-350

hia coli in the presence or absence of

Staphy-lococcus aureus. Frequently isolated, but

rel-atively nonpathogenic, gram-negative bacilli

including paracobon organisms and Bacterium

anitratum were not similarly examined. The

index of colonization with these particular

gram-negative organisms at sites without

Staphylococcus aureus, in contrast to sites

with Staphylococcus aureus were calculated.

Pseudomonas was more than three times as

frequent at sites without Staphylococcus

au-reus than at sites with Staphylococcus aureus.

For the other gram-negative bacilli, the index

was only slightly greater than 1.0.

A specific inverse relationship existed

be-tween Staphylococcus aureus and

Pseudomo-nas. Of the total 3,336 cultures obtained,

Staphylococcus aureus was isolated from 306

sites. Pseudomonas was isolated from only

four of these sites. In contrast, Pseudomonas

was isolated from 130 sites without

Staphylo-coccus aureus.

These studies indicate that certain nursery

procedures including hexachborophene

bath-ing influence colonization of newborn infants

with both Staphylococcus aureus and

gram-negative bacteria. Daily inunction of

new-born infants with hexachlorophene resulted

in a striking decrease in colonization with

Staphylococcus aureus. However, changes in

colonization with Staphylococcus a ureus

were associated with inverse changes in

colo-nization with gram-negative bacteria. A

spe-cific inverse relation existed between

Staphy-lococcus aureus and undefined Pseudomonas

species. These findings are in agreement with

those of Forfar, et aL’ who examined the

effect of routine daily hexachborophene

bath-ing on colonization and disease caused by

both staphylococci and gram-negative bacilli

in two newborn nursery units. During the

10-year period from 1954 to 1964 staphybococcal

infection was common in these units. In one

unit hexachlorophene was not used at all in

the newborn nurseries. In the other unit

hexachborophene was not used at all during

FIG. 3. Yearly rate of colonization and disease in newborn infants caused by

Staphylo-coccus aureus and gram-negative bacilli before and during routine daily

(7)

p

HOSPITAL E HOSPITAL W

954-60 1960-64

FIG. 4. The infection rate in infants caused by Staphylococcus aureus and

gram-negative bacilli in two different hospitals with and without hexachiorophene bathing (Forfar, et al.’).

the first 63, years but was used extensively

during the next 33 years. The effect of

hexa-chborophene was assessed by comparing a

period of use with a preceding period of

non-use in the same nurseries, and with preceding

and concurrent periods of non-use in another

hospital. Staphybococcal colonization was

measured by periodic swabbing of selected

sites on the babies. Staphybococcal infection

was defined as purulent lesion from which

coagubase-positive staphylococci were

cul-tured and a gram-negative lesion as a similar

lesion from which gram-negative organisms

were cultured. Most of these lesions were of a

minor nature such as conjunctivitis, skin

sep-sis, and umbilical infection. The

gram-nega-tive organisms cultured were predominantly

E. coli, Proteus, Pseudomonas, and other

coli-form bacilli.

The introduction of hexachborophene

bath-ing resulted in an immediate fall in the

inci-dence of staphybococcal infection (Fig. 3)

from greater than 10% to bess than 3%

coinci-dent with a decrease in the colonization rate

with coagulase-positive staphylococci. There

was no appreciable change in the incidence

of gram-negative infection for the first 6

months, but in the next 6 months

gram-nega-tive infection increased significantly from

0.9% to 5.0%. During the next 6 months,

when the use of hexachborophene on babies

was discontinued, the incidence of

staphybo-coccal infection rose and the incidence of

gram-negative infection began to fall. The

reintroduction of hexachborophene bathing

resulted in another decrease in the incidence

of staphybococcal infection concurrent with

an increase in the gram-negative infection

rate. The incidence of disease in this hospital

was compared to that in the other hospital

where hexachborophene was not used in the

newborn nursery (Fig. 4). The introduction of

hexachborophene bathing in the first hospital

resulted in a fall in the incidence of

staphylo-coccal infection from 11.1% in the

pre-hexa-chborophene period to 2.8% during the

hexa-chborophene period. This was associated with

(8)

infec-HC = Hexachlorophene

tion from 1.4 to 3.8%. In contrast, during the

same time period in a second hospital where

hexachiorophene was not used the infection

rate for both staphylococcal disease and

gram-negative infection remained unchanged.

This data confirms the observations of the

previous study demonstrating a reciprocal

re-lationship between Staphylococcus aureus

and gram-negative bacilli and demonstrates

that these changes in bacterial flora are

asso-ciated with differences in the incidence of

disease caused by these organisms.

Similar data has also been provided by

Kravitz, et al.’ who reported that

hexachboro-phene bathing resulted in a marked decrease

in colonization of infants with

coagulase-posi-tive staphylococci associated with a

signifi-cant increase in colonization with E. coli at

skin, umbilical, and penile sites. In contrast

there was no change in colonization with E.

coli in the control nursery where infants were

not bathed with hexachlorophene during the

hospital stay.

The preceding three studies provide data

indicating a statistically significant increase in

gram-negative bacilli in association with

hexachborophene bathing of newborn infants.

Other studies provide further data in support

of this observation (Table II). Simon, et al.,2

in an early documentation of the effect of

daily hexachborophene bathing on

staphybo-coccal infection in newborn infants, observed

that coliform micro-organisms were readily

recoverable from these infants. Heavy

con-tamination with coliforms required the

addi-tion of polymxin to the blood agar plates to

allow selection of staphylococci. Although no

increase in gram-negative infection in infants

was reported, nine cases of mastitis occurred

in mothers during this 19-month period.

Eight of these nine cases were associated

with coliform bacteria. Dugdale, et al.,16 in

studying the effect of hexachborophene

bath-ing on skin bacteria, reported 5% colonization

with gram-negative rods in the absence of

coagulase-positive staphylococci in contrast

to 0% colonization with gram-negative rods in

the presence of coagulase-positive

staphylo-cocci. These differences were not statistically

significant due in part to the small number of

sites cultured. Sarkany and Arnold’7 reported

a marked suppression of Staphylococcus

au-reus and diphtheroids following the use of

hexachborophene in association with an

in-crease in colonization with Proteus.

Pleuk-hahn and Banks” noted no changes in

gram-negative bacilli but did note an increase in

the incidence of positive cultures for Candida

species from skin lesions of newborn infants

following the use of hexachlorophene.

The use of topical antibacterial agents in

situations other than bathing of newborn

in-fants results in similar increases in the

gram-negative flora (Table III). The long-term use

of topical antimicrobial agents including

hexachlorophene in patients with acne

vu!-garis” is associated with a shift in the normal

bacterial flora with an overgrowth of

gram-negative organisms resulting in gram-negative

rod superinfection of facial pustules. The use

of hexachborophene in the treatment of

recur-rent superficial staphybococcal infections

re-TABLE III

EFFECT OF ANTIBACTERIAL TOPICAL AGENTS ON GRAM-NEGATIVE FLORA

Topical Agent

.

Site Bacterial . Flora

Fulton, el at.” HC Acne vulgaris Superinfection with gram-negative rods

Stratford2#{176} HC Skin Increased gram-negative bacilli

Crowder, et al.’2 HC Operative site Increased cohiforms

Evans, et al.2’ HC Toe-web Increased gram-negative bacilli(Kiebsiella, Enterobacter, and pseudoinonas)

(9)

sults2#{176}in suppression of Staphylococcus

au-reus and recolonization with gram-negative

organisms. Repeated washing of the toe-web

area with hexachborophene results2’ in

in-creased colonization with gram-negative

bac-teria including Pseudomonas. In a study” of

the bacterial flora of operative sites following

preparation of the skin with

hexach!oro-phene, the isolation of coliforms increase

from 10% to 20%.

Similar changes in the gram-negative

bac-terial flora have been reported with topical

antibacterial agents other than

hexachboro-phene. The repeated application of Safeguard

soap (containing a mixture of halogenated

salicylanilides and a carbanilide) to the

toe-web area results” in an increase in

coloniza-tion with gram-negative bacilli including

Pseudomonas. The daily application of

Inter-sept (containing dequalinium acetate and

ce-tylpyridinium acetate in 50% alcohol) to the

umbilical cord area in newborn infants

re-sults2 in a marked decrease in colonization

with staphylococci associated with an

in-crease in the occurrence of pure cultures of

gram-negative organisms, including

Kieb-siella-aerobacter.

The total data on the use of

hexachloro-phene and other topical antibacterial agents

indicates a widespread effect of these agents

on the bacterial flora. An inverse relationship

exists between Staphylococcus aureus and

gram-negative bacilli. This biologic

phenome-non is not peculiar to the use of

hexachioro-phene in newborn infants, but the data

dem-onstrates that the use of hexachborophene for

infant bathing results in suppression of

Staph-ylococcus aureus with concomittant increases

in both colonization and disease caused by

gram-negative bacilli.

REFERENCES

1. Cezon, H.: Control of staphylococcal infections and disease in the newborn through the use of hexa-chlorophene bathing. PEDIATRICS, (Suppl.) 51:331, 1973.

2. Simon, H. J., Yaffe, S. J., and Cluck, L.: Effective control of staphylococci in a nurseiy. New Eng. J. Med., 265:1171, 1961.

3. Neumann, L L., Rager, R., Brickman, A., and Co-hen, S. N.: Cram positive umbilical flora in a nursery using alcohol cord care. Abstracts of

American Pediatric Society and Society for Pedi-attic Research, Atlantic City, N.J., April 28-May 1, 1971, p. 258.

4. Albert, S., Baldwin, R., Czekajewski, S., van Soest-bergen, A., Nachman, R., and Robertson, A.: Bul-bus impetigo due to group II Staphylococcus Aureus. Amer. J.Dis. Child., 120:10, 1970. 5. Light, I. J., Sutherland. J. M., Cochran, M. L., and

Sutonus, J.: Ecologic relation between staphylo-coccus aureua and pseudomonas in a nursery pop-ulation. New Eng. J.Med., 278:1243, 1968. 6. Zupanc, E.: Control of a staph epidemic in a small

nursery. Amer. J.Dis. Child., 101:434,1961.

7. Shinefield, H. R., Boris, M., Bibble, J. C., Cale, E. F., and Eichenwald, H. F.: Bacterial interference: Its effect on nursery-acquired infection with

Staphylococcus aureus:III. The Georgia

Epi-demic. Amer. J.Dis. Child., 105:663, 1963. 8. Boris, M., Shinefleld, H. R., Eichenwald, H. F.,

Hauser, C. H., and Caraway, C. T.: Bacterial interference: Its effect on nursery-acquired infec-tion with Staphylococcus Aureus:IV. The Louisi-ana Epidemic. Amer. J. Dis. Child., 105:674, 1963.

9. Pequet, A. R., and Westley, W.: Bitter’s disease. Lancet, 231, 1965.

10. Light, I. J., Walton, R. L., Sutherland, J. M., Shine-field, H. R., and Brackvogel, V.: Use of bacterial interference to control a staphylococcal nursery outbreak. Amer. J. Dis. Child., 113:291, 1967. 11. Subramanyam, R., Corbach, S. L., and Pildes, R. S.:

Nursery epidemic caused by a non-typable “grey” colony variant of Staphylococcus aureus, read be-fore the Society for Pediatric Research, Washing-ton, D.C., May 22-26, 1972. (Abst.) Pediat. Res., 6:385, 1972.

12. Shaffer, T. E., Baldwin, J. N., Rheins, M. S., and Sylvester, R. F.: Staphylococcal infections in new-born infants: I. Study of an epidemic among in-fants and nursing mothers. PEDIATRICS, 18:750, 1956.

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1971. (Abst.)J. Pediat., in press.

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18. Pleuckhahn, V. D., and Banks, J.: Antiseptic skin care of newborn infants with hexachiorophene. Med. J.Aust., 1:247, 1968.

19. Fulton, J. E., McCinley, K., Leyden, J., and Mar-ples, R.: Cram-negative folliculitis in acne vul-garis. Arch Derm., 98:349, 1968.

20. Stratford, B. C.: The investigation and treatment of recurrent superficial staphylococcal infection. Med. J.Aust., 1:308, 1963.

21. Evans, Z. A., Rendtorff, R. C., and Rosenberg, E. W.: Efficacy of dermal antisepsis. New Eng. J. Med., 284:675, 1971 (Letter).

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Acknowledgment

The authors wish to thank Barbara Doty, Jonni Bran-non, and Harry Atherton for their assistance in the prep-aration of this manuscript.

DISCUSSION FOLLOWING PAPER BY DR. LIGHT IN WHICH EVIDENCE WAS PRESENTED THAT HEXACLOROPHENE

IS NOT EFFECTIVE

Dr. Shinefield: Stated that at Cornell in the

late 50’s serious newborn infections

oc-curred with 8(}-81 staph. The technics

employed at that time affected neither

colonization nor disease. No special

at-tention was given to the umbilical area.

In the early 1960’s the colonization rate

with 80-81 was about 40%, but the

orga-nism began to disappear spontaneously.

At this point, with hexachborophene data

available, it was decided that

hexachboro-phene would not be used and the

stan-dard technics were employed. The

nur-sery had no infections for the next 2

In San Francisco he has studied 17,000

newborn infants who as a result of the

Kaiser plan are well followed. He found

40 to 80% colonization rates and

inde-pendently of the technics used; 4 per

1,000 babies developed pustules but no

serious staph infections. He felt that

colo-nization by itself may not be harmful

unless one is dealing with “hot” strains.

He believes that if ordinary aseptic

tech-nics can change colonization rates from

40 to 80%, their average rates, down to 5

to 10%, and change infection rates from 4

to 1 per 1,000, one should be cautious

about additional measures. He believes

that a 4/1,000 pustule rate in a

nonepi-demic period is not alarming and that

intensive intervention may give rise to

difficulty. He asked Dr. Light about the

inverse relation between staph and

gram-negative organisms raising the question

as to whether it is staph or

nonpatho-genic micrococci which holds down

gram-negative bacteria.

Dr. Light: Replied that studies showed

the inverse relationship between

coagu-base-positive staph and pseudomonas. As

the staph fell, pseudomonas rose. He

sug-gested that coagulase-negative

coloniza-tion diminishes but does not eliminate

coagulase-positive organisms.

Dr. Klein: Requested further information

about gram-negative infection.

Dr. Light: Replied that in some studies

colo-nization changes only were investigated.

In others there were indications that as

staph colonization was decreased there

was an increased frequency of

gram-neg-ative infections. He pointed out that in

Forfar’s studies the decrease in staph

in-fections isn’t equalled by the rise in

in-fections caused by gram-negative

infec-tions.

Dr. Sutherland: Reported on the joint study

organized by Dr. McCracken to

investi-gate gram-negative infections in

neo-nates. Data appear to indicate that

sup-pression of staph results in a rise in

gram-negative infection. He summarized the

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1973;51;345

Pediatrics

Irwin J. Light and James M. Sutherland