The June 2017 issue of the American Journal of Infection Control included a report from the Children’s Hospital of Philadelphia (CHOP) which described 23 infants in their intensive care unit (ICU) who contracted eye infections after eye examinations. In the report, CHOP attributed the cause of the outbreak to some medical staff not wearing gloves, and a “lack of standard cleaning practices” of equipment used in the exams.

This outbreak occurred in August 2016, and a recent lawsuit has been filed on behalf of a family who alleges their premature baby died as a result of her contracted infection at CHOP in September 2016. The premature infant had been transferred to CHOP in July, and by mid-August had tested positive for infection with an adenovirus and was suffering from respiratory symptoms. She eventually developed a bacterial infection on top of the viral illness, and died on September 11, 2016.

In the lawsuit, her parents accuse the hospital staff of negligence and failing to use proper hygiene. The lawsuit was originally filed in December 2016, but was amended this month after family learned of additional details in the hospital’s published case study.

In the Court of Common Pleas, CHOP denied that the infection was what specifically led to her death.

According to the case study published in the American Journal of Infection Control, 23 patients at CHOP were infected with a kind of microbe called an adenovirus. As a result of this infection, all the patients suffered respiratory symptoms, and 5 eventually developed pneumonia. Eleven of the 23 also experienced infectious symptoms in their symptoms in their eyes. In addition, 6 hospital employees and 3 parents of the sick infants also contracted viral infections.

The authors of the study were all pediatric or infection experts from CHOP or the University of Pennsylvania. They observed that the outbreak “revealed [a] lack of standard cleaning practices of bedside ophthalmologic equipment and limited glove use.” They examined the equipment that had been used on the infected patients and noted that “environmental sampling of two hand-held lenses and two opthalmoscopes revealed adenovirus DNA on each device.”

Specifically, the microbes on the lenses and scopes were identified as adenovirus type 3, which can cause both conjunctivitis and respiratory problems. The infection was transmitted at a high rate in the ICU, leaving more than half of the 43 infants who underwent eye exams in the neonatal intensive care unit to contract the virus in August 2016.

In the study, CHOP reportedly responded to this outbreak by reinforcing the importance of hand-washing, stepping up equipment cleaning, and instituting a “staff furlough.” The study did not specify the length of time or extent of the furlough.