Poor Infection Control Leads to Deaths of 3 Premature Infants

January 7, 2020

Pennsylvania health officials have ruled that Geisinger Medical Center failed to follow standard infection control procedures, which led to the death of 3 premature infants last year, the Associated Press reported.  

The findings are the result of a surprise state inspection that occurred in October, which determined that the bacterium Pseudomonas was behind the outbreak at Geisinger’s hospital in Danville, Pennsylvania. The facility was cleared to begin treating premature infants in its neonatal intensive care unit again on December 6 after it corrected the problems. 

Those problems included failing to keep donor breast milk at the correct temperature and routinely testing equipment for bacteria. In addition, Geisinger stored equipment within the “splash zone” of a sink and didn’t have written instructions for routine cleaning of brushes, blenders, cylinders, and other equipment used to prepare infant formula and breast milk.

Pseudomonas aeruginosa bacteria are common but can pose a hazard to vulnerable patients, including “severe nosocomial infections, life-threatening infections in immunocompromised persons, and chronic infections in cystic fibrosis patients,” according to the US Centers for Disease Control and Prevention. “The bacterium’s virulence depends on a large number of cell-associated and extracellular factors. Cell-to-cell signaling systems control the expression and allow a coordinated, cell-density–dependent production of many extracellular virulence factors.”

When contacted by Infection Control Today, Geisinger spokesperson Matthew Van Stone said that “due to ongoing litigation, it would be inappropriate for us to comment at this time.”

Frank Maffei, MD, Geisinger’s chair of pediatrics, said at a news conference in October that “our neonatal intensive care unit has never seen a situation involving infections like this. Our neonatal intensive care unit has been a cornerstone of our children's hospital for 25 years. The unit has provided excellent care for the tiniest of babies.”

Geisinger has issued apologies for the infection, which state health inspectors said happened as a result of the hospital not routinely sanitizing the equipment used to prepare donor breast milk. 

According to the AP, Geisinger’s actions placed vulnerable patients in “immediate jeopardy,” a legal finding that means risk of serious injury or death. 

Matt Casey represents the families of 2 of the babies who died. He said: “This is an institution that holds itself out as a facility that has specific expertise in caring for premature babies, and this report demonstrates that there was a flagrant disregard of the most basic infection control policies.”

Geisinger said in a statement: “The teams at Geisinger Medical Center look forward to providing high-quality, life-saving care to our communities’ most fragile infants.”