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Bacterial “dispensers” in streptococcal disease
C o m m e n t s o n C u r r e n t Literature BACTERIAL " D I S P E N S E R S " IN STREPTOCOCCAL DISEASE A
STUDY undertaken to evaluate tile efficacy of triethylene glycol vapor as a means for .controlling cross-infections on the wards at Harriet Lane Home yielded extensive data relating to contamination of the environment with hemolytic streptococci and suggested the modes of spread of this infectious agent. Results of this exhaustive investigation, which covered a period from Nov. 1, 1945, to May 27, 1946, are presented in a paper entitled " T h e Transmission of Hemolytic Streptococcal Infections in Infant Wards With Special Reference to 'Skin Dispersers' " by Clayton G. Loosli, M.D., M. H. D. Smith, M.D., J. Cline, B.S., and L. Nelson, B.S., i n the September, 1950, issue of The Journal of Laboratory and Clinical Medicine. In their introduction the authors point up the fact that streptococcal disease manifests itself in a wide variety of illness, such as pharyngitis, tonsillitis, otitis media, cervical adenitis, scarlet fever, erysipelas, and suppurative skin and wound infections. They stress further that this diverseness of clinical manifestations of streptococcal disease (streptococcosis of Boisvert and others) is even more striking in infants and children than in adults. They emphasize especially that streptococcal infections of the skin are quite common in infants, particularly in patients with atopie eczema. This latter point is significant. The most striking findings of their study concerned the dispersal of a beta hemolytic streptococcus, Group A, Type 33, from a patient with infantile eczema whose skin was shown to be infected secondarily with this strain of streptococcus. This 6~-month-old infant with atopie eczema was admitted to the hospital on Oct. 16, 1945, and was discharged April 27, 1946. The hemolytic streptococcus, Group A, T y p e 33, was isolated repeatedly from skin lesions and from the nasopharynx of this patient. In the course of the clinical studies it became evident that the presence of the eczematous infant in various locations o f the study area determined to a striking degree the number of streptococci in the environment (air, dust, bedclothes, etc.) as well as the extent of infection with hemolytic streptococci in individuals who came in contact with the child. Transfer of this infected patient from one ward to another resulted in a marked clearing of streptococci from the air of the original ward and the extreme contamination of the air in the new ward. These changes occurred within forty-eight hours of transfer. It was considered of practical significance that adequate treatment of the patient with parenteral penicillin resulted in clinical improvement of the cutaneous manifestations of bacterial infection along with disappearance of streptococci on the skin and in the nasopharynx. Simultaneously, bacteriologic studies revealed that there was prompt disappearance of hemolytic streptococci from the environment (air, dust, bedclothes). As the studies progressed it was clearly shown that secondary streptococcal infections occurred when the ward was highly contaminated with hemolytic streptococci. By careful typing of the streptococci isolated from various sources, it was found that the skin of infected eczema patients and the purulent discharge from ears of patients with otitis media were common and important sources of ward contamination. It 938
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was also found that dried secretions eontaining millions of streptococci were dispersed into the air and eventually became ineorlSorated into the ward dust, settling on exposed surfaces. The role of contaminated dust was found to be extremely important in the spread of hemolytic streptococci. The authors conclude that "tile path of dispersal of the streptococcus appeared to be from the skin of the infected eczema patients and the pus from the ear of the otitis media patient to the bed clothes, then to the ward air and dust, then to other patients, hospital personnel and visitors." Even when aseptic techniques were meticulously carried out, it was impossible to keep the hands free of bacteria during I)eriods when the dust everywhere contained large numbers of streptococci. Nurses and doctors making rounds first on a ward highly contaminated with streptococci carried the organisms on their so-called " e l e a u " uniforms to other wards. When skin-infected patients were treated with intramuscular penicillin, 10,000 units every three hours, marked improvement in the oozing lesions was noted, and a simultaneous reduction in the number of organisms isolated from the environment observed. It was shown repeatedly that adequate treatment of bacterial "dispersers" resulted in stopping further contamination of the environment. Although the routine use of aseptic techniques is desirable and must be observed at all times, tile present report indicates that such measures failed to prevent the spread of hemolytic streptococci. The authors conclude that triethylene glycol vapor did not prevent the dispersion of streptococci through the ward. They believe that the role of contaminated dust is important and must be investigated thoroughly. As a practical approach to the over-all problem they suggest the prompt isolation of possible bacterial dispensers, especially the skin dispenser, employment of aseptic procedures, and prompt and adequate treatment of the infected patient with suitable antibiotics. These measures, along with adequate dust control, show promise of providing an effective means for controlling the spread of bacterial infections in hospital wards. Antibiotics employed prophylactically were suggested also as possible means for controlling the spread of secondary bacterial infections to otherwise susceptible individuals. These principles established for the control of streptococcal disease apply in a similar manner to other important infectious diseases, such as diphtheria, tuberculosis, and pneumoeoeeus infections. RUSSELL J . BLATTNER.
STUDY undertaken to evaluate tile efficacy of triethylene glycol vapor as a means for .controlling cross-infections on the wards at Harriet Lane Home yielded extensive data relating to contamination of the environment with hemolytic streptococci and suggested the modes of spread of this infectious agent. Results of this exhaustive investigation, which covered a period from Nov. 1, 1945, to May 27, 1946, are presented in a paper entitled " T h e Transmission of Hemolytic Streptococcal Infections in Infant Wards With Special Reference to 'Skin Dispersers' " by Clayton G. Loosli, M.D., M. H. D. Smith, M.D., J. Cline, B.S., and L. Nelson, B.S., i n the September, 1950, issue of The Journal of Laboratory and Clinical Medicine. In their introduction the authors point up the fact that streptococcal disease manifests itself in a wide variety of illness, such as pharyngitis, tonsillitis, otitis media, cervical adenitis, scarlet fever, erysipelas, and suppurative skin and wound infections. They stress further that this diverseness of clinical manifestations of streptococcal disease (streptococcosis of Boisvert and others) is even more striking in infants and children than in adults. They emphasize especially that streptococcal infections of the skin are quite common in infants, particularly in patients with atopie eczema. This latter point is significant. The most striking findings of their study concerned the dispersal of a beta hemolytic streptococcus, Group A, Type 33, from a patient with infantile eczema whose skin was shown to be infected secondarily with this strain of streptococcus. This 6~-month-old infant with atopie eczema was admitted to the hospital on Oct. 16, 1945, and was discharged April 27, 1946. The hemolytic streptococcus, Group A, T y p e 33, was isolated repeatedly from skin lesions and from the nasopharynx of this patient. In the course of the clinical studies it became evident that the presence of the eczematous infant in various locations o f the study area determined to a striking degree the number of streptococci in the environment (air, dust, bedclothes, etc.) as well as the extent of infection with hemolytic streptococci in individuals who came in contact with the child. Transfer of this infected patient from one ward to another resulted in a marked clearing of streptococci from the air of the original ward and the extreme contamination of the air in the new ward. These changes occurred within forty-eight hours of transfer. It was considered of practical significance that adequate treatment of the patient with parenteral penicillin resulted in clinical improvement of the cutaneous manifestations of bacterial infection along with disappearance of streptococci on the skin and in the nasopharynx. Simultaneously, bacteriologic studies revealed that there was prompt disappearance of hemolytic streptococci from the environment (air, dust, bedclothes). As the studies progressed it was clearly shown that secondary streptococcal infections occurred when the ward was highly contaminated with hemolytic streptococci. By careful typing of the streptococci isolated from various sources, it was found that the skin of infected eczema patients and the purulent discharge from ears of patients with otitis media were common and important sources of ward contamination. It 938
COMMENTS ON CURRENT LITERATURE
939
was also found that dried secretions eontaining millions of streptococci were dispersed into the air and eventually became ineorlSorated into the ward dust, settling on exposed surfaces. The role of contaminated dust was found to be extremely important in the spread of hemolytic streptococci. The authors conclude that "tile path of dispersal of the streptococcus appeared to be from the skin of the infected eczema patients and the pus from the ear of the otitis media patient to the bed clothes, then to the ward air and dust, then to other patients, hospital personnel and visitors." Even when aseptic techniques were meticulously carried out, it was impossible to keep the hands free of bacteria during I)eriods when the dust everywhere contained large numbers of streptococci. Nurses and doctors making rounds first on a ward highly contaminated with streptococci carried the organisms on their so-called " e l e a u " uniforms to other wards. When skin-infected patients were treated with intramuscular penicillin, 10,000 units every three hours, marked improvement in the oozing lesions was noted, and a simultaneous reduction in the number of organisms isolated from the environment observed. It was shown repeatedly that adequate treatment of bacterial "dispersers" resulted in stopping further contamination of the environment. Although the routine use of aseptic techniques is desirable and must be observed at all times, tile present report indicates that such measures failed to prevent the spread of hemolytic streptococci. The authors conclude that triethylene glycol vapor did not prevent the dispersion of streptococci through the ward. They believe that the role of contaminated dust is important and must be investigated thoroughly. As a practical approach to the over-all problem they suggest the prompt isolation of possible bacterial dispensers, especially the skin dispenser, employment of aseptic procedures, and prompt and adequate treatment of the infected patient with suitable antibiotics. These measures, along with adequate dust control, show promise of providing an effective means for controlling the spread of bacterial infections in hospital wards. Antibiotics employed prophylactically were suggested also as possible means for controlling the spread of secondary bacterial infections to otherwise susceptible individuals. These principles established for the control of streptococcal disease apply in a similar manner to other important infectious diseases, such as diphtheria, tuberculosis, and pneumoeoeeus infections. RUSSELL J . BLATTNER.