Clinical sepsis and death in a newborn nursery associated with contaminated parenteral medications--Brazil, 1996.

In October 1996, a total of 35 newborn infants died in a 26-bed nursery of a 200-bed hospital in Roraima, Brazil; these deaths represented a significant increase over the baseline mortality rate in the nursery (6.0 versus 1.7 per 100 live births; p<0.01). Twenty of the deaths were attributed to sepsis. Fatal episodes of sepsis began 24-72 hours after birth. Although an investigation by the Roraima Health Department resulted in an improvement of infection control, increased episodes of fever and clinical sepsis persisted. As a result, in November 1996, the Secretary of Health of Roraima, Brazil Ministry of Health, requested that CDC assist in the investigation. This report summarizes this investigation, which implicated locally produced intravenous (IV) solutions as the source of the outbreak and underscores the need to assure proper quality control of parenteral medications and the importance of nosocomial infection surveillance.