A study of the bacterial flora among infants, mothers, staff (nursing and medical), and the environment of a neonatal unit is outlined. On admission to the unit, 60,5% of babies were already infected, presumably from contact with medical staff. By day 15 this number had increased significantly. A large number of mothers (40% on day 1, and 91% on day 15) were found to be carrying pathogenic organisms, providing a significant bacterial reservoir in the unit. Few pathogens were isolated from the environment.S. Afr. Med. J., 48, 1165 (1974)

Cruickshank, J.G.

Lunat, M.

Singer, B.

Wolfsdorf, J.

English

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8 June 1974 S.A. MEDICAL JOURNALHazards of HandlingA STUDY OF FLORA IN AN OPEN NEONATAL UNIT1165M. LUNAT, B. SINGER, J. G. CRUICKSHANK, J. WOLFSDORFSUMMARYA study of the bacterial flora among infants, mothers, staff(nursing and medical), and the environment of a neonatalunit is outlined. On admission to the unit, 60,5% of babieswere already infected, presumably from contact withmedical staff. By day 15 this number had increased sig-nificantly. A large number of mothers (40% on day 1, and91 % on day 15) were found to be carrying pathogenicorganisms, providing a significant bacterial reservoir inthe unit. Few pathogens were isolated from the environ-ment.s. Air. Med. l., 48, 1165 (1974).The indefinable bond between mother and child is probablyformed before delivery, and clinical observations haveshown that separation of mother and child immediatelyafter delivery adversely affects both.' In the infant,detrimental effects on motor and mental developmenthave been de.scribed, while a mother who is deprived ofhandling her infant may subsequently be less attached tothe child compared with one who experienced earlycontact.There are two further considerations governing ad-mission policies for neonatal units serving lower socio-economic communities in underdeveloped countries.Firstly, the birth rate is high in these groups, necessitatinga more rapid turnover, and secondly, the number ofavailable nursing staff handling these neonates is fre-quently small. As a result of these factors. more neonatalunits are now permitting mothers to feed, clean andhandle their babies.'" One of the main factors that haspreviously led to the exclusion of mothers from nurserieshas been the fear of the spread of infection. In the de-veloped countries, with the present methods of control, thepresence of the mother has not led to an increase in therat:': of colonisation or the occurrence of neonatal in-fection.'" No studies exist, however, for nurseries in under-developed countries, where conditions are often not opti-mal. Neonatal infections under these circumstances arestill common.'Departments of Paediatrics and Medical Microbiology,Godfrey Huggins School of Medicine, University of Rho-desia, Salisbury, RhodesiaM. LUNAT, :\oLB. B.CH., B.SC.B. SINGER. :\'l.B. B.CH., M.R.C.P., D.e.H.l G. CRUICKSHANK, :\o'LD., M.R.C. PATH.J. \VOLFSDORF, M,B. B.CH., B.SC., DIP. PA.ED" F,R.C.P.Dale received: 7 December 1973,Reprint requests: Professor J. Wolfsdorf. Department of Paediatrics andChild Health. University of Rhodesia, Salisbury, Rhodesia,It was thus the purpose of this study to: (a) determinethe incidence of infection in a random group of babies,mothers and staff (nursing and medical) in a nursery forthe newborn; (b) determine the types of infection present;(c) determine whether, and how much, transfer of bacterialinfection from staff/mother to baby occurs; and (cl)examine the bacterial flora of the environment.PATIENTS AND METHODSA total of 159 pre-term infants weighing less than 2000 gwere admitted to the neonatal unit of Harare Hospitalin the 2 separate months during which the study wasundertaken (November 1972 and February 1973). Ofthese, a statistically random sample of 38 babies (24,5%)and 36 mothers (there were two sets of twins). plus allstaff, i.e. doctors and nurses, was studied.During the survey, nasal, umbilical and rectal swabswere taken from the babies on admission. while' nasal,throat and re:::tal swabs were similarly taken from mothersand medical staff. All swabs were repeated on an averageof 15 days later (range 3 - 29 days). Swabs were broth-moistened and plated within 30 minutes onto conventionalmedia, including nutrient, blood, chocolate and MacCon-key's agar. After incubation at 3rC for 24 hours, colonieswere picked and identified by standard methods. Anaerobicculture was not undertaken.Swabs were also taken from the environment. whichincluded special care. isolation, transitional and normalpre-term wards, plus the kitchen area. Floors. walls. wallcracks, window sills, lampshades, cots and apparatus ofvarious sorts were similarly examined,RESULTSIncidence of InfectionTable r summarises the number of pOSItive swabs ob-tained from each of the 3 groups studied.On day I, 23 (60.5°0) of the babies had positive swabs,but of these only 4 (10,5°,,) showed evidence of clinicalinfection, By day 15, a further 12 babies had been infectedfor the first time, and of the first group, 10 had acquireda second organism on culture, making a total of 45organisms isolated (118,4 O~), Thirty-one babies (81 ~~) hadevidence of clinical infection. Fifteen mothers (41,60{,)had positive swabs on admission. This increased to 33(91,6°0) by day 15, Only one mother had clinical infection,and a Shigella organism was cultured from her stool.] 166 S.-A. MEDIESE TVDSKRIF 8 Junie 1974TABLE I. NEONATAL SURVEY: PRE-TERM INFANTS/MOTHERS, NURSING AND MED:CAL STAFFDay 1 Day 15+ve org. CI"nical +ve org" ClinicalNo. on swabs % infection % on swabs 'Yo infection 'Yo CommentBabies 38 23 60,S 4 10,5 45 118,4 31" 81,0 10/38 had 2ndorganismMothers 36 15 41,6 33 91,6 2,1 ShigellainfectionStaff 44 20 45,4 25 56,8• 23 (13 T 10) had 5taph. pyogenes or E. coli (74%); conjunctivitis. umbilical sepsls. gasrro-enteriti s.Forty-four staff members were examined. On dayI, 20 (45,4?o) were shown to be positive for a pathogenicorganism, and the number of positive swabs rose to 25(56%) by day 15.Types of InfectionTable II lists the diagnoses and outcome of the babieswho were infected. The major pathology was umbilicalsepsis, gastro-enteritis and pneumonia. There were 5deaths (10,3%): two died from necrotising enterocolitis,2 from pneumonia with gastro-enteritis, and one fromrecurrent pneumonia with a congenital hean lesion. Theremainder recovered and were discharged well.TABLE 11. INFECTIONS FOUND IN BABIES IN THIS SEr.::-CNo. Infection Outcome17" Umbilical sepsis Well15" Gastro-enteritis 2 diedt6" Pneumonia 3 diedt2 Pemphigus neonatorum Well2 Conjunctivitis Well1 Congenital syphilis Well43 5 deaths.. 12 babies our of 31 had two infections.t Postmortem examinations were done on all these cases.Transfer of InfectionTable HI lists the organisms cultured from the babies.mothers and staff. The most common organism isolatedwas Staph. pyogenes and 46°b of these organisms wereresistant to penicillin. On day I, STaph. pyogenes wasfound in 16 babies, 7 mothers and 17 staff members.This increased to 25, 17 and 22 respectively by day 15.Pathogenic (typable) E. coli was the next most commonorganism isolated. There were 10 types, of which types]27, 119 and ] 14 were most frequently found. On· ad-mission, 4 infants, 6 mothers and 3 staff members carriedthese organisms, whle 15 days later the total number hadincreased to 13 and 9 in infants and mothers respectively.no E. coli being isolated from staff members at this time.Table HI also summarises other organisms found: theseincluded, in order of frequency, STrep. faecalis. PrOTeus.Pseudomonas, Shigella, Strep. pneumoniae, Klebsiella andH. injluenzae. It is interesting to note that Shigellaorganisms were isolated from 3 mothers. One wa presenton day I, while the other 2 were cultured on subsequentdays during the time that the mothers were in hospitalnursing their infants. However. only one baby waclinically infected.The number of concomitant infections in mother andbaby is shown in Table IV. On day 1,8 out of 4S (17.ro)organisms were found in both mother and child. Therewere 4 Staph. pyogenes, 2 £. coli and 2 Pseudol11onllscases. After ± 15 days, 30 out of 94 organisms (31.8 00)were present in both mother and baby.g June 1974 S.A. MEDICAL JOURNAL 1167TABLE IV. MOTHER AND BABY CORRELATIONOrganism Day % Day 15 %Staphylococcus 4 8,8 24 25,SE. coli 2 4,4 2 2,1Shigella 0 2 2,1Proteus 0 2 2,1Pseudomonas 2 4,4Total 8 17,7 30 31,8EnvironmentThe organisms recovered from the environment werechiefly non-pathogens, and included spore-bearing bacilli,micrococci, diphtheroids and Neisseria catarrhalis. Of thefew pathogens isolated, most were Staph. pyogenes (57%penicillin-re,istant) cultured from the floor.DISCUSSIONThere are 3 main sites from "hich bacterial colonisationof the newborn arises: nasopharyngeal spread of theorganisms, contaminated handling, and an infected en-vironment. In normal circumstances (i.e. excluding respi-rators, etc.) the most important method of bacterialtransmission is by handling.'" 1 his study outlines theimportance of medical staff in the aetiology of earlyinfection of the newborn. In spite of all the babieshaving been removed from their mothers directly afterbirth, precluding maternal contact as a source of infection,60,5% of the babies were infected by the end of the firstday. These organisms could only have come from contactwith medical staff. By 2 weeks of age, though maternalstaphylococci did not increase significantly in number, 25babies (an increase of 56°~) were found to be infected.These data ~trongly suggest that the increase in infectionrate came mostly from the medical staff.Though the help of mothers in the nursery has manyadvantages, avoiding as it does the separation of motherfrom child and providing much-needed 'manpower', thedata dem0n,trate the high percentage of mothers carryingpathogenic organisms. On day lover 40°6 of mothers hadpathogenic organisms isolated, which increased to 91 %by day 15. The potential hazard of babies being exposedto this significant maternal bacterial re,ervoir requiresto be stres,ed, while the absolute increase in the numbersof babies becoming infected during their stay in hospital,as compared with other units,'" emphasises the need forcareful monitoring of mothers from the lower socio-economic groups, and medical staff, before they arefreely admitted to the neonataJ unit.All m:-mbers of staff working in the neonatal uniteither roll their sleeves, remove jewellery, wash theirhands and use a 0,04°6 Hibitane solution before handlingany baby, or wear theatre-type shirts, similarly washingtb{'ir hands as above. Caps, boots and ma,ks are notworn. Mothers are a1!owed freely into the unit but allare reouired to remove their normal hospit~l-i,st:ed blouse.wash their hands and breast" and put on a c!ean gownand overshoes. A Hibitane solution is applied to theirhands before handling their babies. Any ill mother orstaff member is excluded from the unit until she or hehas recovered.Although the wearing of masks and gowns does notreduce the infection rate," encouraging the mothers to gothrough the motions of aseptic techniq ues reinforces theimage of 'cleanliness in the unit' which is so desirable.In addition, these mothers do not usually wear shoes; thusthe wearing of canvas overshoes reduces significantlythe amount of dust brought into the unit.eonates are not bathed. After birth, babies are simplydried and all blood, vernix, etc. gently wiped away. whiletheir cords are treated with a 0,04°6 Hibitane-in-spiritsolution. No prophylactic antibiotics are used, nor arecords dressed. Though bathing infants with 3°~ hexa-chlorophene reduces the colonisation rate of staphylo-cocci,'" Forfar et al." have shown that the use of this agentincreases infection caused by Gram-negative organismsand there is evidence that this substance gives rise toneurotoxic complications in both animals and man."Artificial colonisation of infants with selected strains ofStaph. at/rells of low resistance has resulted in terminationof hospital outbreaks of infection." However, this methodcan only be used in the face of an epidemic and cannotbe recommended as a routine. As the umbilical cord isreadily colonised at birth and is a direct portal of entry oforganisms into the blood, and since umbilical sepsis wathe most common clinical condition present, many mightadvocate the use of daily prophylactic Polybactrin· sprayuntil the cord falls off.'" If no topical antibiotics are used,an occlusive dressing has been found to be preferable toleaving the cord exposed." As nasal carriage and infectionrate by Staph. allrells have been found to be reduced by theuse of Naseptin na,al cream," this too might be beneficialand worth a triaLThough some pathogens were isolated from the nurseryenvironment. these were surprisingLy few in number andinsignificant in type. This tends to diminish environmentalfactors, but rather underlines the importance of staff andmothers as the major source of infant contamination inthis, a neonatal unit in an underdeveloped country.We wish to thank the Secretary of Health, Rhodesia, forpermission to publish.REFERE 'CESI. Klaus. M. and Kennel, J. (1970): Pediat. Clin. N. Amer., 17. 1015.2. ~~d?a~~ti;".C45. 79~derman, P.. Grab <ein, R. and Klaus, M. (1970):3. Williams. C. and Tho:nas. 0. (1969): Ibid., 44, 640.4. Kahn. E.. Wayburn, S. and Fouche, M. (1954): S. Afr. Med. l., 28,453.). Singer. B. and \Volfsdorf. J. (1973): Personal communication andunpublished data.6. MO!limer. E.. Lipsitz. P .. Wolinsky. E .. Couzaga. A. and Rummel-kamp, G. (1962): Amer. J. Dis. Childh., 104, 289.7. Wolinsky. E .. Lipsitz, P .. Monimer. E. and Rummelkamp, G. (1960)'Lancet, 2, 620. .8. WJiliams. R. (1961): Ibid .. 2. 176.9. Forfar, J. 0. and MacCabe, A. F. (1958): Brit. Med. l., I, 76.10. Gluck. l. and Wood, H. F. (1961): New EngL l. Med., 265, 1177.11. Forfar, J. 0 .. Gould, J. C. and MacCabe, A. F. (1968): Lancet, 2,177.12. James. l. S. (1972): Pediatrics, 49, 492.13. Shinefield. H. R .. Ribble. J. C., BoTis M and Eichenwald H F(1963): AmeT. l. Dis. Childh., 105. 646.' . , . .14. Davies, P. (1971): Arch Dis. Child., 46, l.15. Humingford. P .. Welch. G .. Ursula. G. and Wetherby-Mun G (1961)'J. Obstet. Gynaec. Brit. Cwlth. 68. 179. , '.16. Stokes. E. l., Simpson. R. and Tozer, R. C. (1962): l. Hyg. (Lond.),60. 209.

Hazards of handling

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Hazards of handling

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