During a 23-day period in April 1991, nine infants in a neonatal ward were found to be colonized with Salmonella senftenberg. All were asymptomatic on detection and all except one (who developed septic ileus) remained asymptomatic on follow-up. The affected babies were isolated and subsequently discharged from the ward as soon as possible. These measures, along with emphasis on handwashing and intensification of cleaning and disinfection, were able to prevent spread to other babies. Despite extensive sampling of the environment, mothers and staff, the source of the organism could not be identified.
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