Neonatal staphylococcal disease occurred in the nurseries of a university hospital three weeks after discontinuation of routine, daily, whole-body bathing of newborns with hexachlorophene. Of 16 infants who had clinical manifestations within a two-week period, 11 cases were confirmed bacteriologically. Shortly after onset of the outbreak, daily clinical and microbiologic surveillance and control measures on all infants and personnel were inaugurated. Clinical surveillance after the outbreak did not yield any new case. Average incidence of cultures positive for coagulase-positive Staphylococcus aureus was highest (13% per week) during the first three weeks of microbiologic surveillance (when hexachlorophene was not used). This is lower than that reported in most previous studies. These findings indicate the importance of scrupulous hand washing before and after handling each infant and of enforcement of other basic nursery techniques.