A study of surface bacteria of the newborn and the comparative values of cleansing agents

POTTER-ABEL:

SURFACE BACTERIA

OF NEWBORN

loo:l

reports in fatal and nonfatal cases of puerperal infection attested the virulence of Strep. hemolyticus and Strep. viridans, although a number of deaths occurred due to the aerobic nonhemolytic and anaerobic varieties. The incidence of Staph. uureus infection was four times and of thta colon bacillus twice as great in the fatal cases as compared to a series of ‘7’71 cultures routinely obtained in patients with clinical puerperal itIfectioll. The Welch bacillus was found as a major illvader in l.‘,.:N per cent of the total cases. 7. Fever, if not present during labor, usually manifested itself ea.rIy in the fatal cases, and in most instances rose to a high level. Fhen death was due to septicemia or peritonitis the average number of days elapsing between delivery and the fatal termination was 10, and in thrombophlebitis 30. 8. In view of t,he present knowledge of the etiology, prophylaxis. and treatment of puerperal infection it is our opinion that approximately t,mo-thirds of the maternal deaths due to ibis condition arfb preventable.

A STTJDY OF SURFACE THE COMPARATIVE RAYMOND (From

BACTERIA OF THE NEWBORN AND VALUER OF CLESNSING AGENTS

T. POTTER, B.S., M.D., F.A.(~‘.S., AND ARTFWR R. -ABET,, M.A., M.D., EAST ORANGE, ;?;. J.

the Departments

of

Obstetrics

and

CGnical Pathology,

Oran.ge

MemoM

Hospital) VERY hospital that includes in its service an obstetric departmenl faces, sooner or later, the problem of care and prevention of skin infections of the newborn. Those who have had the responsibility of treating sporadic or epidemic cases of severe types of cutaneous infections of infants realize the problems involved. By the severe types we refer to that disease synonymously t,ermed impetigo cont,agiosa, impetigo neonatorum, and pemphigus neonat0rum.l Lacking such experiehce, one has only to read the report of McCandlish2 or that of Cole and Ruh3 to learn the seriousness of the disease, its tendency to become epidemic, the difficulty in checking epidemics and the havoc it can cause in hospital wards. aandy, in a recent report, furnishes a vivid account of his cxperiencc in two such epidemics. Treatment of impetigo or pemphigus neonatorum begins not, with the onset of the disease but at birth when proper and adequate measures should be instituted in a.n endeavor to l)revtnt its occurrence. Each hospital has its own, or some approved, m’etbod of init.ial cleaning and daily care of the newborn. Whatex-er method is employed the

E

1004

AMERICAN

JOURNAL

OF

OBSTETRICS

AND

GYNECOLOGY

aim should be, first, to clean mechanically the body surface without irritation and, second, to protect that surface from bacterial invasion. If this protection can be given by means of some application which dors not injure nor irritate the infant,‘s skin, we feel that, the incidence of troublesome, not to say dangerous, cutaneous infections can be definitely reduced or prevented. At the Orange Memorial Hospital various routines hare been employed. TJntil 1927, babies were given an initial cleansing with olive oil followed by daily soap and water baths. 5 per cent, ammoniated mercury ointment, was used following, in a general wa\T, the suggestions of Chadwell.” Finally, in 1933, a routine was adopted which has been in force since then. This consists of an initial, prepared soap hat,h, drying and completely anointin, m with 3 per cent ammoniated mercury ointment as soon after birtli as possiblr. Each day following, during t,llcl entire st,ay in tlic hospild, t,lle babies oiled with a IlldiCilttYl, l)ltWdtd oil. No water is used after t.hc initial bath. During the period from March, 1931, to January, 1935, among 1,310 newborn babies, the total number of skin infections was 26 (0.019 per cent). Of this number, twelve (0.009 per cent) were impetigo. 01~ baby was born with a single lesion, the remaining eleven were postnatal in origin. Table I shows the incidence of skin infections since the adoption of the present routine. JJater,

i11’C

TABLE

I.

INCIDENCE

0~

SKIK

INFEOTI~NS.

MAY, --

CASES OF IMPETIGO

1933 1934 ; 1 1935 Total incidence, 0.016% ; impetigo

1933

TO X45',

1935 (651

RABIES)

I_PI'ONIMPETIGENOUS ERUPTIONS

1 B 2 incidence, 0.007%

Our comparative freedom from sporadic cases of impetigo and the absence of any recent epidemics has afforded us much satisfaction in, and reliance upon, the technic used. So satisfactory have been our results we were prompted to learn by experiment, if possible, the relative value, particularly the bactericidal value, of different applications made on the surface of the skin. Since skin or mucous membrane invasion by the staphylococcus is the accepted route of infection in impetigo, it was decided, as a basis for this study, to determine by bacterial examinat,ion the number and characte1 of organisms present on the surface of the babies at birth. With this

fact established we could then test the effectiveness of different cleansing agents commonly used on infants by noting the increase or decrease of the bacterial flora. The

sterile,

procedure decided upon was a@ follows: cultures were taken by means of a rigid, Nichrome loop from three prominent areas on the baby (1) im-

POTTER-ABEL

:

SURFACE

BACTERIA

OF

NEVCTBORN

1005

mediately after delivery; (2) the first day following birth, after the initial cleaning but before t,he routine daily care was started; and (3) on the third day postpartum. The areas on the body selected were (A) the chin in head presentations (the saprum, in breech births), (B) the right side of the neck, and (C) the right groin. Tll4i cultures were taken by gently scraping the loop over a rectangular skin surfac:ra. roughly 8 by 13 mm. in area. The loop was then dipped a:nd agitated in a tul)f8 of brain Infusion broth. This liquid media was added to melted agar in a Petri dish which, after solidifying, was incubated for forty-eight hours. A colony count was then made with identification of the different types of colonies present. When the colonies mere great in number they were enumerated 17~ means of a Lafnr counting plate. The first was carried out by taking There were three series of experiments. the c~ultures as outlined above, using our standard technic with the babies, i.t$., initial soap and water bath followed by 3 per cent ammonia.tetl mercury ointment, then daily applications of the medicated, blended oil. With this routine t,he first cultures were taken directly after birth before any applications haa been made to the skin; the second cultures on the day following birth, after the soap bath and ammoniated mercury treatment but before the use of the medicated oil; t,hc third cultures on the third day after birth, medicated oil alonr haPLug been used since the primary cleansing. In the second series the cultures were taken at the same :respect,ive intervals anIl frolu the same areasbut the soap bath and ammoniated mercury ointment were deleted. The medicated oil was the only preparation used ou the skin. The, procedure in the third series was the same as in the t,wo preceding ex(‘Ppt that sterile cotton seed oiI was the rleansing agent used.

Fifty-two babies mere examined and a minimum ot’ nine cultures taken from each. In t,he first, series there were 14 babies. in the second series 24, and in the third series, 14. A separate -record was kept. 4’01 each child on which was tabulated fhe na.mr, (late of birth, the nurnbc>J anti tplje of colonies obtained from cnch ;Irc’:l, A\, 13. am1 C! ;I ftcr (b;~~t~ 1 lrcb numhcr of rrt+al or whwl cnlturt~ 1. 2, and 3, the length of labor, cxaminat,ions matlc 011 the mother, thtl t\j)ti oi’ dclivt ry, and tlic t~rtWtw.! or ahsenc~~of mat,ernal, vaginal tlisc~harg~~. The first tabulation was for cacll groul) or wk. The total number of colonies from each site in thr respecti\-(1 series was added and a composite graph prepared. In this manner we were able to determine the number of bacteria present at birth and rvaluat,e the bactericidal effect of the difRrent, pregarations subsequently used on the baby. Figs. 1. 2, and 3 show the composite gral>hs of the fhrcc srries. In reading the graphs, it must IX>rcmcmlw~~~tl t hat they indicate thcl findings oi’ the groups as a whole. Tn a nnmlh~r 0I’ I'ilSW, in Series 1 and 2, \v<’

found

ill1

initial

sterility

011 iIll

thrtsv

ill’(‘ilS

u.tikh

Wt’

were

ilhlC

t.0

maintain t,hroughout the st,udy. In others, where bacteria were Ikrrsent on the first cultures, we were ahlc t,o reduce the number of colonies 01 render the areas sterile. In the third series, however, when bacteria were found t,hel\- usually continued to increase in number and, il’ an area was sterile at birth, subsequent cultures invariably grew colonies.

1006

AMERICAN

JOURNAL

OF OBSTETRICS

AND

GYNECOLOGY

The similarity between the graphs of Series 1 and 2 is striking. Although in neither is “group sterility” of the skin obtained, there is considerable reduction in the number of surface bacteria on those parts of Site

41ts 6.

3. (nsck)

Jaw 2860 26W 2400 2m - 2000 ;lem 1: 1600 $ 1400 v l200 L moo t 800 2 600 400 2ou 0 CUltlUW

E‘ig.

(grdn)

(2940)

4

(1513)

(1275)

‘\

:844)

016) L 1

2

1

3

Sits

(589)

(3%)

2

I.-Composite graph of bacterial colonies. in Series 1: soap bath, ammoniated JO00

(1117)

3.

First series, 14 cases. Cleansing mercury, and medicated oil.

agents

situ c. (groin)

91ts 3. (nsck)

*. (chin)

2

1

3

2800

2600 2400 g 2200 ‘$ 2000 2 l&JO 8 1600 % 1400 g 1200 = 1000 2 800 600 400 200 0 culturea

Fig.

Z-Composite

i ;

45000 42cQo JPCOO 36000 33000

(2319)

(1184) ( 935)

J

(968)

(976)

(490) \, (39Z) 1

2

graph 9ita.A.

3

1

2

1

J

of bacterial colonies. Second series, agent in Series 2: medicated oil.

Sits 3.

(chin)

2

3

24 cases.

Cleansing

site c. (groin)

(neck)

(~.190) I

(30,575)

Jooo" 27Goo 24000 % 21000 :

*

dg P

lf3300

15000 lx)(K) 9000 6000

/

( 3166) 1

Fig.

3.-Composite

graph of bacterial agent in Series

colonies. 3 : sterile

Third series, cottonseed oil.

2

14 cases.

3

Cleansing

the body, i.e., (A) chin and (B) neck, which can be easily and readily kept clean. In Area C, the groin, there was an increase in the number of colonies in both series after the second culture due, we believe, to reimplantations from diapers. This supposition is substantiated by the

POTTER-ABEL

:

SURFACE

BACTERIA

OF

lOOi

NEWBORN

fact that a majority of the colonies from the groin were identified as B. c&i, while in Areas A and B (chin and neck) staphylococci predominated. Sltr

i ; ';: * : * f

Sit0

A. (ohin)

m ml 260 240 220 zoo 1fn 160 140 1x0 1cQ ,"

(w \

(91) (79)

(61)

J \ 2

1

3

First series. and medicated

colonies on individual babies. bath. ammoniated mercury,

2

Cleansing oil.

A. (chin)

sits

1 colonies

on

2

Site

(4’)

J

individual babies. medicated oil.

3

agents

: soap

0. (pi.)

W)

(64) ---@-+40) k--Bacterial

(9

24)

1

Site

Fig.

0. (gmln)

(210)

40 20 0 Culturea

Bib? 4.-Bacterial

SlU

8. (neck)

Second

J

‘;

(W 2

series.

Cleansing

5

'

agent

site c. (groin)

8. (neck)

(20700)

Fig.

&-Bacterial

colonies

on

individual babies. sterile cottonseed

Third oil.

series.

Cleansing

agent:

In Fig. 3, the graph compiled from patients treated only with sterile cotton seed oiI, we find an entirely different picture. From the first eulture there is an uninterrupted increase of surface bacteria in all areas

:

1008

AMERICAN

JOUR.NAL

OF

OBSTETRICS

AND

GYNECOLOCY

cultured. The colonies, in many instances, reached a considerable number-as many as 5,000 to 6,000 were present on numerous plates. Reducing the group findings to an average, individual basis, gives the results shown in Figs. 4, 5, and 6. These curves were plotted because of the unequal number of’ cases in the three series. The curves in these graphs follow the same general course as corresponding curves in Figs. 1, 2, and 3. In Fig. 4, the graph for Series 1, in which ammoniated mercury was used, we find a reduction in the number of colonies, after its use, of 53 per cent. Following this, at the time of the next culture, there is an increase in the number of colonies of over 100 per cent. In Fig. 5, showing the results in that group where only the medicated oil was used, although the reduction in the number of colonies from the original count was but 32 per cent, the increase following this was only 34 per cent. The total number of bacterial colonies on babies in this group, not including the original count over which we had no control, was 32’ per cent less than those found on infants in the first group. It is reasonable to conclude that, of the two procedures, the routine which employs medicated oil alone better inhibits the growth of bacteria on the skin of infants. If, as (iandy has reported, ammoniated mercury ointment is objectionable, the use of this unguent as a bacterial inhibitor is not necessary if medicated oil is used. The graphs in Fig. 6 need scarcely be considered since they, like those in Fig. 3, show a steady increase in the bacterial count. It indicates clearly that cotton seed oil has no value, other than a mechanicrtlcleansing agent, as a preparation to prevent or inhibit the growth of bacteria on the skin surface.

The organisms cultured were practically all staphylococci and B. co%. Occasionally a spore-forming organism was grown. Both staphylococci and B. coli were found, at various fimcs, on all three areas at birth. On subsequent cultures, when bacteria were grown, the staphylococcus predominated on the chin and neck while B. coli was most cornman on t,hc groin. No cutaneous lesions occurred on ilIly of the infants st~udicd, and it, is apparent that, the mere presenrc of bact,eria on t,hc skin is not the O@ factor predisposing to skin infections. Whatever other considerations may be involved (and we recognize that many are), the use of SOIIN cleansing substance or agent capable of reducing the number, or inhibiting the growth, of surface bacteria is desired. In considering the length of labor, the time of rupture of the amniot,ic sac, and the number of rectal or \aginal exwminat,ions in reference to surface bacteria, we found there was no definite relationship. The presence of a vaginal discharge in the mother was associated, almost invariably, with a considrrablr nmnbt~r of 4onies in the first. plate CII~tures taken from her baby. Two of the babies were twins, and it is interesting to note t,hat cultures from all three areas on the first child showed numerous colonies, while the second baby was sterile in two areas and had but a few bacteria (staphylococci) on the third.

HARR,IR ET AT,. :

MECHANICS

OF UTERINE

1009

SuPPORT BND POSITION

CONCLUSIONS

1. Although a few babies showed surface sterility at birth, in the areas cultured, the majority were nonsterile. 2. 1nitia.l cultures from babies born of mothers with a vaginal discharge invariably showed many bacterial colonies. 3. The majorit,y of organisms cultured were Stnphy7ococczls nlb~s and R. coli. A few (mlt,ures from 5 babies’) grew a large spore-forming bacillus. 4. The use of an antiseptic in the cleansing agent reduces t,he number 01’ suri’ace barteria. 5. The use of a sterile, nonantiseptic oil does not, tlwrease the numhel of surface bact,eria. 6. 31edicated oil, used alone, has great,er inhibiting powers on surfaet? l~aetrrial growth than when used with ammoniated mercury ointment. 7. it is probable ihal oil, in itself, has n beneficial t+fwt nn t,he skill :tnct increases it.s resistance to infection. REFERENCES (1) Ma t~emnher, R. : H.

S.:

AX

J.

OBST.

&

Wien. klin. Wehnschr.

13: 1077, 1900.

GYNEC.

(3)

9:

234,

1925.

Cole,

H.

N.,

(2) OCCUR% and

J. A. IM. A. 63: 1159, 1914. (4) Gandy. D. Tmett: Arch. Ped. 52: 15) Chndwll, 0. R.: New England J. Med. 199: 983. 19%.

MECHANICS

OF UTERINE

II. FACTORS INFLUENCING L. J. HARRIS, KD., the Department

POSITIOK

(k-z

TORONTO, CANADA, WILLIAM

E. D. (From

UTERINE

SUPPORT

M.D.,

PLASS,

of Obstetrics

and

IOWA

CITY,

Gynecology,

AND

Rzlh, NO.

H.

0.:

7, 1935.

POSITION*

EXYERIMENTAL

STIJDY)

F. MENGERT,

M.D.,

AND

IOWA

State

University

of Iowa)

UCCESSIVE gynecologic residents, acting as consultants at the State Sanatorium at Oakdale, Iowa, have discovered such an unusually high incidence of retroversion among patients who were examined for minor gynecologic complaints that some causative factor’, common to women confined to bed with pulmonary tuberculosis, was suspected. Obviously, there can be no relationship -between pulmonary tuberculosis and retroversion in women with otherwise normal pelvic viscera. The only common factors other than tuberculosis, discoverable in these patients, were confinement to bed and the supine posture, which is usually preferred to any other, especially during waking hours. If the posterior position of the uterus be due to the supine post,ure of the patient in bed, a shift to the prone posture should produce a COYs

and

*Read at the Gynecologists,

Seventh h?ld

Annual at Omaha,

Meeting Neb.,

of the October

Central Association 10 to 12. 193%

of

Obstetricians