636
BRITISH MEDICAL JOURNAL
5 MARCH 1977
COR RES PONDENCE Hexachlorophane-yes or no? Beryl D Corner, FRCP, and others; E G McQueen, FRCP, and D G Ferry, MSC ...... 636 Experiments with computers J G Gray, FRCS, and others; N G Pearson, MB, and J Sparrow; J F N Sidebotham, MB, and others ............................ 637 Cigarette smoking and cancer of bladder and lung T A W Edwards, FRCP .................. 637 Staffing in hospital laboratories F J Baker, FIMLS and J K Fawcett, FIMLS .... 638 Chemotherapy for varicella-zoster infections B E Juel-Jensen, DM .................... 638 Royal College of General Practitioners A S Hatch, MRCGP; J D E Knox, FRCGP .... 638 Metabolic effects of salbutamol S P Deacon, MB ........................ 639 Respiratory distress syndrome L B D Courtney, MRCOG ....... ........... 639 Rising incidence of childhood diabetes J 0 Craig, FRCPED, and others ............ 639
Salbutamol-induced acidosis in pregnant diabetics M G Chapman, MB ...................... 639
Jejunoileal bypass for obesity R M Baddeley, FRCS .................... 640 Diabetic feet I H J Bourne, FRCGP; Margaret R Witting, FCHS
..
640
Lumbar epidural analgesia in labour FRCS .................................. 644 J McQueen, FRCS, and Linda Mylrea, SCM; S Bakhoum, MB, and others .............. 640 Drug compliance in the elderly H G Nicol, BM .......................... 644 Vitamin D status in different subgroups Administrative staff in the NHS of British Asians L C Crane ............................ 644 Sandra P Hunt, BSC, and others ..... ....... 641 Loss of doctor in the course of duty Future of child health services P A Jones, MB; R D France, MB; E E Penny, D G E Alldridge, MB ....... ............. 641 LHA .................................. 644 Pentazocine addiction: a warning World Medical Association E Waldmann, MB, and P A L Horsfall, FRCP. 642 H A Constable, MRCS ....... ............. 645 "Specialist" and hospital practitioner Surgery for Meniere's disease grades G G Browning, FRCSED, and J F Plantenga, D I Williams, MRCGP .................... 645 MD .................................... 642 GP specialists Child health and environmental lead K J Bolderi, MRCGP ...................... 646 A Goldberg, FRCP, and M R Moore, PHD.. .. 642 Ileostomy Association Appeal Molar solutions and molar concentrations B N Brooke, FRCS, and others . 646 J Cloyd, PHARMD; S E Williams, MRCP ...... 643 Points from letters Organs for transplant (T D Patients' awareness of melaena Houlding); Diagnosis of allergy (j W Speight); M Ross, FRCGP ...... .................. 643 Tourist hepatitis (F Morgan); Bedside comfort Teaching leprosy to medical students (A S Watts); Quebec, Wales, Scotland (D J D C L Crawford, MRCP .................... 643 Stevenson) ............................ 646
Correspondenits are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors.
Hexachlorophane-yes or no?
SIR,-Your leading article (5 February, p 337) raises various points on which we would comment. (1) There has undoubtedly been a marked reduction in the incidence of clinical staphylococcal infection in the newborn during the past 18 years and, although this might be attributed to various factors but especially earlier discharge of mothers and babies from hospital, this practice was not widespread until 1968, whereas topical chemoprophylaxis for staphylococci came into general use 10 years before. The implication that asepsis might now replace antisepsis ignores the fact that even with good aseptic techniques, which experience indicates cannot invariably be maintained for routine newborn care, staphylococci will still colonise and rapidly multiply on carrier sites (umbilicus, flexures, nostrils) to a significant extent as early as 48 h after birth and this is the source of most newborn epidemics of clinical infection. The value of chemoprophylaxis with hexachlorophane (or chlorhexidine) is to restrict this multiplication of organisms.' The need for chemoprophylaxis for staphylococci in the newborn still seems to be well established both on epidemiological evidence and on the experience of a resurgence of staphylococcal sepsis in newborn infants when hexachlorophane prophylaxis was withdrawn.2-4
CMV retinitis H B Chawla, FRCSED, and others .......... 643 Hip fractures up to date R R J Dinley, FRCS ...................... 643 Cimetidine and surgery J D Thomson, FRCSED, and J B W Galloway,
(2) Your article refers only to the use of 3,", hexachlorophane solution for washing babies, but since 1958 0-33% hexachlorophane in sterilised dusting powder has been used in routine newborn infant skin care in Bristol. The efficacy of this preparation was shown by a marked reduction in the incidence both of staphylococcal sepsis in babies and of breast abscess in mothers immediately after it was introduced in the maternity units.5 6 Further epidemiological studies also showed a significant reduction in colonisation and staphylococcal sepsis in infants during the first six months of life when hexachlorophane powder prophylaxis was used in the first 14 days.7 This powder has proved to be adequate for the prophylaxis of staphylococcal colonisation, simple to use, and safe for all infants, but in these respects we do not claim that it is superior to the solution when both methods are correctly used. The use of 0 33",, hexachlorophane powder has, however, some advantages over the solution: (a) the concentration of hexachlorophane is nearly 10 times less, (b) the powder assists desiccation and separation of the umbilical cord, and (c) powder can be applied immediately after birth when bathing of the baby might be undesirable-for example, for immature and sick infants. (3) Despite the reports of harm done by hexachlorophane absorption when it was clearly
incorrectly used in greatly excessive quantities or on damaged skin, especially in premature infants, enormous numbers of children have been treated without any evidence of harm in many centres. We have reported blood levels at eight days for mature babies treated by correct technique with 0 33", hexachlorophane powder in hospital which were all well below the presumed toxic levels found in animal experiments." 9 A recent series of low-birth-weight, including preterm, infants has been reported. Some of these were treated for up to 49 days in hospital and maintained blood levels well below the presumed toxic experimental level."9 We therefore urge that it would be a retrograde step to discontinue the use of hexachlorophane for prevention of neonatal sepsis under medical supervision and with more stringent precautions-for example, avoidance of use on damaged skin-until a safer and equally effective agent becomes available. BERYL D CORNER GEORGE ALDER DAVID BURMAN WILLIAM A GILLESPIE Bristol Maternity Hospital, Bristol
Gillespie, W A, Simpson, K, and Tozer, R C, Lancet, 1958, 2, 705. Ayliffe, G A J, et al, Lancet, 1972, 2, 479. Alexander, G M C, and Pitkewicz, J S. Pediatrics, 1973, 5, 360. 4 Dixon, R E, et al, Pediatrics, 1973, 51, 413. Corner, B D, Crowther, S T, and Eades, S M, British Medical Journal, 1960, 1, 1927 6 Plueckhahn, V D, and Baulis, J, British Medical Jfournal, 1964, 2, 414. Baber, K 6J, et al, Jrournal of Hygietne, 1967, 65, 381. Alder, V G, et al, Lancet, 1972, 2, 384. Gillespie, W A, et al,oournal of Hygiene, 1974, 73, 311. 0 Gillespie, W A, et al, Chemotherapy, 1976, 3, 361.
2 3
BRITISH MEDICAL JOURNAL
5 MARCH 1977
COR RES PONDENCE Hexachlorophane-yes or no? Beryl D Corner, FRCP, and others; E G McQueen, FRCP, and D G Ferry, MSC ...... 636 Experiments with computers J G Gray, FRCS, and others; N G Pearson, MB, and J Sparrow; J F N Sidebotham, MB, and others ............................ 637 Cigarette smoking and cancer of bladder and lung T A W Edwards, FRCP .................. 637 Staffing in hospital laboratories F J Baker, FIMLS and J K Fawcett, FIMLS .... 638 Chemotherapy for varicella-zoster infections B E Juel-Jensen, DM .................... 638 Royal College of General Practitioners A S Hatch, MRCGP; J D E Knox, FRCGP .... 638 Metabolic effects of salbutamol S P Deacon, MB ........................ 639 Respiratory distress syndrome L B D Courtney, MRCOG ....... ........... 639 Rising incidence of childhood diabetes J 0 Craig, FRCPED, and others ............ 639
Salbutamol-induced acidosis in pregnant diabetics M G Chapman, MB ...................... 639
Jejunoileal bypass for obesity R M Baddeley, FRCS .................... 640 Diabetic feet I H J Bourne, FRCGP; Margaret R Witting, FCHS
..
640
Lumbar epidural analgesia in labour FRCS .................................. 644 J McQueen, FRCS, and Linda Mylrea, SCM; S Bakhoum, MB, and others .............. 640 Drug compliance in the elderly H G Nicol, BM .......................... 644 Vitamin D status in different subgroups Administrative staff in the NHS of British Asians L C Crane ............................ 644 Sandra P Hunt, BSC, and others ..... ....... 641 Loss of doctor in the course of duty Future of child health services P A Jones, MB; R D France, MB; E E Penny, D G E Alldridge, MB ....... ............. 641 LHA .................................. 644 Pentazocine addiction: a warning World Medical Association E Waldmann, MB, and P A L Horsfall, FRCP. 642 H A Constable, MRCS ....... ............. 645 "Specialist" and hospital practitioner Surgery for Meniere's disease grades G G Browning, FRCSED, and J F Plantenga, D I Williams, MRCGP .................... 645 MD .................................... 642 GP specialists Child health and environmental lead K J Bolderi, MRCGP ...................... 646 A Goldberg, FRCP, and M R Moore, PHD.. .. 642 Ileostomy Association Appeal Molar solutions and molar concentrations B N Brooke, FRCS, and others . 646 J Cloyd, PHARMD; S E Williams, MRCP ...... 643 Points from letters Organs for transplant (T D Patients' awareness of melaena Houlding); Diagnosis of allergy (j W Speight); M Ross, FRCGP ...... .................. 643 Tourist hepatitis (F Morgan); Bedside comfort Teaching leprosy to medical students (A S Watts); Quebec, Wales, Scotland (D J D C L Crawford, MRCP .................... 643 Stevenson) ............................ 646
Correspondenits are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors.
Hexachlorophane-yes or no?
SIR,-Your leading article (5 February, p 337) raises various points on which we would comment. (1) There has undoubtedly been a marked reduction in the incidence of clinical staphylococcal infection in the newborn during the past 18 years and, although this might be attributed to various factors but especially earlier discharge of mothers and babies from hospital, this practice was not widespread until 1968, whereas topical chemoprophylaxis for staphylococci came into general use 10 years before. The implication that asepsis might now replace antisepsis ignores the fact that even with good aseptic techniques, which experience indicates cannot invariably be maintained for routine newborn care, staphylococci will still colonise and rapidly multiply on carrier sites (umbilicus, flexures, nostrils) to a significant extent as early as 48 h after birth and this is the source of most newborn epidemics of clinical infection. The value of chemoprophylaxis with hexachlorophane (or chlorhexidine) is to restrict this multiplication of organisms.' The need for chemoprophylaxis for staphylococci in the newborn still seems to be well established both on epidemiological evidence and on the experience of a resurgence of staphylococcal sepsis in newborn infants when hexachlorophane prophylaxis was withdrawn.2-4
CMV retinitis H B Chawla, FRCSED, and others .......... 643 Hip fractures up to date R R J Dinley, FRCS ...................... 643 Cimetidine and surgery J D Thomson, FRCSED, and J B W Galloway,
(2) Your article refers only to the use of 3,", hexachlorophane solution for washing babies, but since 1958 0-33% hexachlorophane in sterilised dusting powder has been used in routine newborn infant skin care in Bristol. The efficacy of this preparation was shown by a marked reduction in the incidence both of staphylococcal sepsis in babies and of breast abscess in mothers immediately after it was introduced in the maternity units.5 6 Further epidemiological studies also showed a significant reduction in colonisation and staphylococcal sepsis in infants during the first six months of life when hexachlorophane powder prophylaxis was used in the first 14 days.7 This powder has proved to be adequate for the prophylaxis of staphylococcal colonisation, simple to use, and safe for all infants, but in these respects we do not claim that it is superior to the solution when both methods are correctly used. The use of 0 33",, hexachlorophane powder has, however, some advantages over the solution: (a) the concentration of hexachlorophane is nearly 10 times less, (b) the powder assists desiccation and separation of the umbilical cord, and (c) powder can be applied immediately after birth when bathing of the baby might be undesirable-for example, for immature and sick infants. (3) Despite the reports of harm done by hexachlorophane absorption when it was clearly
incorrectly used in greatly excessive quantities or on damaged skin, especially in premature infants, enormous numbers of children have been treated without any evidence of harm in many centres. We have reported blood levels at eight days for mature babies treated by correct technique with 0 33", hexachlorophane powder in hospital which were all well below the presumed toxic levels found in animal experiments." 9 A recent series of low-birth-weight, including preterm, infants has been reported. Some of these were treated for up to 49 days in hospital and maintained blood levels well below the presumed toxic experimental level."9 We therefore urge that it would be a retrograde step to discontinue the use of hexachlorophane for prevention of neonatal sepsis under medical supervision and with more stringent precautions-for example, avoidance of use on damaged skin-until a safer and equally effective agent becomes available. BERYL D CORNER GEORGE ALDER DAVID BURMAN WILLIAM A GILLESPIE Bristol Maternity Hospital, Bristol
Gillespie, W A, Simpson, K, and Tozer, R C, Lancet, 1958, 2, 705. Ayliffe, G A J, et al, Lancet, 1972, 2, 479. Alexander, G M C, and Pitkewicz, J S. Pediatrics, 1973, 5, 360. 4 Dixon, R E, et al, Pediatrics, 1973, 51, 413. Corner, B D, Crowther, S T, and Eades, S M, British Medical Journal, 1960, 1, 1927 6 Plueckhahn, V D, and Baulis, J, British Medical Jfournal, 1964, 2, 414. Baber, K 6J, et al, Jrournal of Hygietne, 1967, 65, 381. Alder, V G, et al, Lancet, 1972, 2, 384. Gillespie, W A, et al,oournal of Hygiene, 1974, 73, 311. 0 Gillespie, W A, et al, Chemotherapy, 1976, 3, 361.
2 3
