1202

count, per 1000 thymic lymphocytes, of flagellin-binding lymphocytes from fetal to adult life. Are

antigens other than flagellin better represented in theadult thymus, or is there " dilution " as a result ofsomatic mutation? Alternatively the thymocytes ofthe adult thymus may be " blanks " with no capacityfor reactivity with antigen; there is some evidencethat mature thymus lymphocytes lack surface

receptors.15Our observations imply that the human thymus may

function as does the avian bursa of Fabricius in

regard to the genesis of cells concerned in humoralantibody production. Against this, it may be that thethymic cells recognised by our technique are con-cerned only with delayed hypersensitivity reactions,although flagellin seems more associated with humoralantibody than delayed-hypersensitivity responses. Interms of the " two-cell " theory,16 it could be proposedthat humoral antibody function depends on the colla-borative activity of a specifically patterned thymus-derived cell and a marrow-derived partner whichmay or may not have antigenic specificity. The

irregular seeding of such specifically patterned cellsfrom the thymus in fetal life would explain theinconsistent effects of experimental neonatal thymec-tomy on antibody production. 1 Also relevant is theobservation by Lischner and DiGeorge 18 that aninfant with total failure of thymic development hadcomplete failure of antibody production: their claimis that in man the thymus is essential for the

development of capacity for antibody production.The present relatively simple technique of counting

antigen-binding lymphocytes opens up numerous

pathways of investigation, including comparativecounts of antigen-binding lymphocytes in the chickenthymus and bursa, relative counts in the thymus ofcells reactive with various extrinsic and intrinsic (auto)antigens, and counts of cells in blood in various

immunodeficiency diseases.We thank Miss Dorothy Hutchieson for technical assistance,

Mr. John Pye for help with isotope labelling, and Dr. PatriciaMackay, Mr. Ian McDonald, Mr. George Westlake, and Mr.Peter Clarke for their collaboration. We acknowledge discussionsof the manuscript with Sir Macfarlane Burnet, F.R.S., Dr. IanWood, Prof. G. J. V. Nossal and Dr. Jacques Miller, F.R.S.

J. M. D. was aided by a Drug Houses of Australia researchfellowship, and 1. R. M. by a grant from the National Health andMedical Research Council of Australia.

Requests for reprints should be addressed to 1. R. M.

REFERENCES

1. Naor, D., Sulitzeanu, D. Nature, Lond. 1967, 214, 687.2. Dwyer, J. M., Mackay, I. R. Lancet, 1970, i, 164.3. Byrt, P., Ada, G. L. Immunology, 1969, 17, 503.4. Humphrey, J. H., Keller, H. V. in Developmental Aspects of

Antibody Formation (Prague Symposium, 1969). (In the press.)5. Miller, J. F. A. P., Mitchell, G. F. Transplant. Rev. 1969, 1, 3.6. Ada, G. L., Nossal, G. J. V., Pye, J., Abbot, A. Aust. J. exp. Biol.

med. Sci. 1964, 42, 267.7. Kauffmann, F. Enterobacteriaceæ. Copenhagen, 1954.8. Sulitzeanu, D., Naor, D. Int. Archs Allergy, 1969, 35, 564.9. Ada, G. L., Byrt, P. Nature, Lond. 1969, 222, 1296.

10. Burnet, F. M. Cold Spring Harbor Symp. quant. Biol. 1967, 32, 1.11. Lennox, E. S., Cohn, M. A. Rev. Biochem. 1967, 36, 365.12. Rowley, M. J., Mackay, I. R. Clin. exp. Immun. 1969, 5, 407.13. Martin, W. J., Miller, J. F. A. P. Int. Archs. Allergy, 1969, 35, 163.14. Burnet, F. M. Personal Communication.15. Raff, M. C., Sternberg, M., Taylor, R. B. Nature, Lond. 1970,

225, 553.16. Miller, J. F. A. P., Mitchell, G. F. J. exp. Med. 1968, 128, 801.17. Goldstein, G., Mackay, I. R. The Human Thymus. London, 1969.18. Lischner, H. W., DiGeorge, A. M. Lancet, 1969, ii, 1044.

HEXACHLOROPHANE FOR TREATING

CARRIERS OF STAPHYLOCOCCUSAUREUS

PAUL NOONE ROSE J. GRIFFITHSC. E. D. TAYLOR

Public Health Laboratory and Department of Microbiology,Central Middlesex Hospital, London N.W.10

Summary Twenty nasal carriers of epidemicstrains of Staphylococcus aureus, most

of which were resistant to several antibiotics, includingsome resistant to cloxacillin, were treated with 2%hexachlorophane cream applied to the nose twice dailyfor 7 days. Staph. aureus was eradicated from them allprovided that 2% hexachlorophane soap was usedconcurrently. After treatment, coagulase-negativestaphylococci were isolated from each one. In addition,Proteus mirabilis was isolated from three, and Pr,mirabilis and Pseudomonas œruginosa from one of them.

Introduction

IN this hospital, 10-20% of strains of Staphylococcusaureus isolated from septic wounds are resistant tocloxacillin (methicillin is used for laboratory tests) aswell as to other antibiotics including benzylpenicillin,tetracycline, and erythromycin.During the investigation of outbreaks of staphylo-

coccal sepsis, members of the staff and patients werescreened for nasal and skin carriage of the epidemicstrains. In the past, nasal carriers of antibiotic-resistant strains of staphylococci which caused infectionin the hospital were treated topically with neomycinpreparations, but the results were not very encourag-ing. We decided, therefore, to investigate the effect ofapplying hexachlorophane as a nasal cream.

Methods

The noses of suspected carriers were sampled by means ofExogen (Exogen Ltd., Glasgow) serum-tipped swabs whichwere moistened in sterile peptone water before beingapplied to each nostril. Cultures of these swabs were madeon 5% horse-blood agar at 37 °C.

All strains of staphylococci isolated were tested forcoagulase production in plasma broth, and those whichproduced a clot within 4 hours were accepted as beingcoagulase-positive.

Antibiotic sensitivities were tested on Oxoid DST agarat 30°C, using ’Oxoid Multodisks’ containing penicillin(1-5 -g.), tetracycline (10 -g.), erythromycin (10 -.g.),methicillin (10 (-g.), fusidic acid (10 fLg.), lincomycin (2 -g.,neomycin (10 -g.), and gentamicin (10 4g.). After over-night growth (approximately 15-21 hours) zone sizes werecompared with those produced in relation to a fully sensitivecontrol strain of Staph. aureus (NCTC 6571).

Methicillin-resistance was confirmed and phage-typingcarried out in the Cross Infection Reference Laboratory atthe Central Public Health Laboratory, Colindale.

Carriers of multiply antibiotic (including methicillin)resistant strains of Staph. aureus were treated twice dailyfor 7 days with applications of 2% hexachlorophane creamto the anterior nares. The preparation was formulated as2% hexachlorophane powder B.P.C. in aqueous cream B.P.dispensed in tubes containing 5 g. Concurrently, hexa-chlorophane soap was used for bathing and washing. Noseswabs were taken 2 days after the end of the nasal treatment,

1203

at weekly intervals for a month, and at monthly intervalsfor up to 6 months.

Results

Among twenty nasal carriers of Staph. aureus amongstaff and patients treated with 2% hexachlorophanecream and soap the resistance pattern was:

Among carriers of strains resistant to penicillincarriage was associated with sepsis (e.g., furunculosis)either in the carrier or in someone else in the ward

(e.g., a premature nursery-unit nurse whose nasalstrain of Staph. aureus was of the same phage-type asthat found in two infants under her care both of whomhad septic staphylococcal lesions).2 days after completing the application of hexa-

chlorophane cream, Staph. aureus was not isolatedfrom any of the twenty carriers. On the other hand,coagulase-negative staphylococci were isolated fromall of them, and Proteus mirabilis (resistant only tosulphonamides and tetracycline) was isolated fromfour. Pr. mirabilis had not been demonstrated in pre-treatment nose swabs. Pseudomonas ceruginosa wasisolated from one person, along with Pr. mirabilis.

Sixteen of the carriers who remained in the hospitalenvironment were followed up, and Staph. aureus wasnot isolated subsequently from the noses of ten of them.In one, a fully antibiotic sensitive Staph. aureus wasisolated a month after treatment ended. It was not

thought necessary to treat this carrier, and a similarstrain of Staph. aureus was isolated during a furtherperiod of 6 months. In three people, Staph. aureusresistant only to penicillin was isolated between 6weeks and 2 months after treatment; it was decidednot to treat them. In two, cloxacillin-resistantstrains were isolated a month after treatment. In oneof these, this followed treatment for a strain resistantonly to penicillin and tetracycline, and in the other itwas the re-emergence of a strain of the same phage-type in a nurse treated for carriage of a cloxacillin-resistant strain. Inquiries revealed that this nurse

had failed to use the hexchlorophane soap during theperiod when she was applying hexachlorophane nasalcream. Both these cloxacillin-resistant strains wereeliminated by a further week’s course of hexachloro-phane cream combined with the continued exclusiveuse of hexachlorophane soap. During the next 6months, nose swabs from both persons yielded onlycoagulase-negative staphylococci.Neither allergy nor any other form of intolerance to

hexachlorophane was observed.

Discussion

The emergence in hospitals of strains of Staph.aureus, resistant to many antibiotics including thepenicillins, cephalosporins, and members of the amino-glucoside group of antibiotics, gives cause for concern.

The very old and the very young, and patientsdebilitated by serious illness or major surgical pro-cedures are extremely vulnerable. It would appearthat widespread and often indiscriminate use of

penicillin selects not only for penicillinase-producingstaphylococci but also for cloxacillin-tolerant strains.1These pathogens, often resistant to other antibiotics,are readily carried by hospital staff, and may colonisepatients after admission to hospital. Because thesestaphylococci are frequently carried in the anteriornares and on the skin, they are readily transmitted tosusceptible patients, especially by the hands duringoperations and other procedures such as catheterisa-tion, venepuncture, and wound dressing.2 2

In the past, attempts to control carriage of Staph.aureus have been made with nasal creams containingantibiotics such as neomycin and gentamicin. This

approach has suffered from two main drawbacks-emergence of neomycin-resistant and gentamicin-resistant strains,3 and the sensitisation of patients tothe topically applied antibiotics.4The use of hexachlorophane, at a concentration of

2% in a simple base, avoids these two problems. Sofar, it has not shown any serious defects in use and,provided that hexachlorophane soap is used con-

currently, there have not been any failures. One

potential drawback is the possible colonisation of theanterior nares by hexachlorophane-resistant, patho-genic, Gram-negative organisms. In four of the

twenty people treated with hexachlorophane, Pr.mirabilis was isolated from each of them, and Ps.aeruginosa from one. Even so, it would seem that the

application of 2% hexachlorophane can eradicate

Staph. aureus from the anterior nares, from the skin,and from any site where topical application is feasible.We thank Dr. M. T. Parker, Cross Infection Reference

Laboratory, Colindale, for help with this investigation; Prof.G. W. A. Dick for advice in the preparation of this paper;Mr. D. Hawney, Central Middlesex Hospital pharmacy forformulating and dispensing the hexachlorophane nasal cream;and the medical and nursing staff for their cooperation.

Requests for reprints should be addressed to C. E. D. T.

REFERENCES

1. Dyke, K. G. H., Jevons, M. P., Parker, M. T. Lancet, 1966, i, 835.2. Williams, R. E. O., Blowers, R., Garrod, L. P., Shooter, R. A.

Hospital Infection: Causes and Prevention; chaps 3 and 6.

London, 1966.3. Lacey, R. W., Mitchell, A. A. B. Lancet, 1969, ii, 1425.4. Kirton, V., Munro-Ashman, D. ibid. 1965, i, 138.

" The voices for humanizing the health service have sofar been medical. The architect has still to state his

position. That the architect is something of a pawn in thisgame might be deduced from the fact that the same firmthat designed the monster of Northwick Park produced thesensitive proposals for Milton Keynes which are firmlyrooted in a series of ’ front line medicine’ health centresbacked up by a modern hospital-community based insteadof hospital based care. The impression is bound to beconfirmed when we realize that the Bonham-Carter reporton The Functions of the District General Hospital wasproduced without a single architect member-yet it wasthat report more than anything that might have enmeshedthe architect called upon to design a new hospital in aformula for medical efficiency devoid of human scale."-The Architectural Review, April, 1970, Manplan 6, p. 324.

1204

∈-AMINOCAPROIC ACID IN

PREOPERATIVE CORRECTION OF

HÆMOSTATIC DEFECT IN CYANOTIC

CONGENITAL HEART-DISEASE

HARVEY R. GRALNICK

Hematology Service, Clinical Center, National Institutes ofHealth, Bethesda, Maryland 20014, U.S.A.

Summary Preoperatively four patients (twochildren and two adults), with cyanotic

congenital heart-disease (C.C.H.D.) were found to

have increased fibrinolytic activity. Preoperativetreatment with ∈-aminocaproic acid (E.A.C.A.) correctedthe fibrinolytic abnormality. The patients receivedE.A.C.A. through the operative procedure and for 6hours postoperatively. Although increased fibrino-

lytic activity was found during the surgical procedure,operative and postoperative blood-loss was insignificant.A preoperative therapeutic trial is warranted in patientswith C.C.H.D. with hæmostatic defects. If successful,treatment should be started before the operation toreduce potential bleeding.

Introduction

MULTIPLE coagulation deficiencies have been des-cribed before and after operation in patients withcyanotic congenital heart-disease (C.C.H.D.), and bleed-ing and thrombosis are serious hazards duringsurgery. 1,2 2 Preoperative identification and correctionof any coagulation defect should result in a surgicalprocedure and postoperative period free of the risk ofuncontrolled bleeding. I describe here the use of

e-aminocaproic acid (E.A.C.A.) in an attempt to correctthe haemostatic mechanism and to diminish post-operative bleeding in four patients with C.C.H.D. andincreased fibrinolytic activity.

Methods

Coagulation and fibrinolytic tests were done on four

patients with C.C.H.D. After increased fibrinolysis had beendetected E.A.C.A. (’Amicar’) was given orally in the

following regimen-a loading dose of 4 g. in adults and 2 g.in children followed by hourly doses of 0.75-1 g. in adultsand 250-500 mg. in children. On the night before surgery,at operation, and postoperatively E.A.C.A. was given at thesame hourly dose by intravenous infusion in 5% dextroseand water.

Blood was collected through 19-gauge needles into plasticsyringes and transferred to plastic tubes containing onepart of 40% sodium citrate to 100 parts blood (v/v), or one

part 20% potassium oxalate to 50 parts blood, if thehmmatocrit was less than 60 volumes %. When thehsematocrit was greater than 60 volumes %, half the amountof anticoagulant was used. After centrifugation at 4°C and4000 r.p.m. for 15 minutes, the plasma samples were keptat 40C and tested immediately or frozen at -30°C andtested later. Serum was collected from samples clotted inthe presence of E.A.C.A. (final concentration 0-2M). The

samples were allowed to stand at 37°C for 4 hours, centri-fuged, decanted, and tested.The following tests were done on citrated plasma

samples:(1) One-stage prothrombin-time 3 using rabbit brain thrombo-

plastin (Ortho Pharmaceutical Co.).(2) Partial thromboplastin-time 4 using ’ Celite ’ as the plasma

activator (Warner-Chilcott Laboratories).

(3) Factor V5, factors VII- X,6 and factors VIII and IX 7 alldone on a semiautomated coagulation timer (’ Fibrometer’, ’,BioQuest, Cockeysville, Maryland).

(4) Plasminogen assay,8 fibrinogen,9 and euglobulin clot lysiswere done on oxalated plasma samples. The plasminogen assaywas modified by using alpha-casein (Worthington Biochemical,Freehold, New Jersey) as substrate and measuring perchloric-acid non-precipitatable peptides at 275 µ.

(5) Serum from whole blood clotted at 37°C in the presence ofE.A.C.A. was tested for fibrinogen-breakdown products by the agardouble-diffusion technique 11 with anti-fibrinogen antibodyprepated in rabbits.

(6) Platelet-counts.12(7) Packed-cell volume.13Results

Preoperatively, all four patients had shortened

euglobulin lysis-times, decreased plasminogen levels,fibrinogen-degradation products and prolonged pro-thrombin and partial thromboplastin times (see table).In three patients the factor-V level was decreased.Factors VII-X, VIII, and IX and fibrinogen were normalin all cases. All four patients had abnormally highhaematocrits.

2, 4, 6, and 24 hours after E.A.C.A. therapy wasstarted all tests were repeated. After 6 hours of treat-ment all four patients had normal euglobulin clot-lysistimes, normal plasminogen concentrations, and nofibrinogen-degradation products. Factor v activityrose in the three patients who had had low values. Theprothrombin and partial thromboplastin times re-

turned to normal in all four patients. The fibrinogenrose in one patient but did not change significantlyin the other three. Factor VII-X, vIII, and ix, plateletcounts, and heamatocrit were not significantly changed.

10 hours before surgery E.A.C.A. therapy was startedintravenously and was continued through surgery and6-8 hours postoperatively. In three patients sampleswere taken before the operation, after throacotomy

COAGULATION AND FIBRINOLYTIC STUDIES BEFORE AND AFTER EACA THERAPY