When Too Much of a Good Thing Becomes Harmful: A Cluster of Aspergillosis in Premature Extremely Low Birthweight Neonates

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      The movement of premature Extremely Low Birthweight (ELBW) neonates imposes risk for brain hemorrhage. In response to this concern, the babies in the Neonatal Intensive Care Unit (NICU) were enrolled in the newly adopted Intraventricular Hemorrhage (IVH) Prevention Bundle, where infants were immobilized in supine position for the first seventy-two hours of life. Four neonates from the NICU were diagnosed with Primary Cutaneous Aspergillus (PCA) infection after exposure to this life-saving protocol.


      An internal multi-disciplinary team was convened to investigate these four cases. The case definition included infants who were enrolled in the IVH protocol starting in 2016. A review of the NICU's environment-of-care (EOC) elements was performed. This included retrospective air-quality culture surveillance data for molds available from 2016 to July 2017, internal incubator conditions, NICU construction and renovation activities, linen management, and the cleaning and disinfection of the infant immobilization/positioning device. During this investigation, air and surface samples were also collected to test for molds.


      The air sampling results were consistent with our facility's normal thresholds for air quality surveillance and the surface samples from linen, incubator, and all associated-IVH supplies were negative for molds. High humidity induced condensation was observed inside the incubators. Infection Control Risk Assessments were reviewed and were determined to be appropriate for unit-based construction activities. Subsequent mitigation strategies were instituted to include improvement in linen management, incremental decrease in humidity to reduce condensation, and more frequent patient re-positioning and incubator linen replacements. No additional cases were detected after the 4th case to-date.


      The use of prevention bundles is an important component in improving healthcare-associated outcomes. In the case of the IVH prevention bundle for premature ELBW neonates in this NICU, careful attention and fine adjustments to the infant's environment-of-care needs were essential to the successful application of this life-saving protocol.
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