Allegation
Alleged failure to diagnose and treat bacterial infection in 2-month-old infant resulting in death.
Case Details
A premature male infant, born at approximately 34-35 weeks gestation with a birth weight of 4.8 pounds, had been followed by his pediatrician since birth. His early medical history was unremarkable, with routine pediatric assessments indicating normal growth and development.
At two-month-old the patient presented to the pediatric clinic with symptoms consistent with an upper respiratory infection (nasal congestion, mild irritability). The infant did not have a fever, nor any respiratory distress. The clinician diagnosed a viral upper respiratory infection and ordered a humidifier, hydration, and monitoring for any signs of deterioration. No labs or cultures were ordered at that time.
The patient returned to the clinic five days later for a well-child visit at approximately two months, seven days of age. At this visit, the infant was noted to be thriving, with normal examination findings. He received his scheduled immunizations, including DTaP, IPV, Hib, and pneumococcal vaccines. No abnormalities or concerns were documented.
The infant was brought to the clinic approximately one week later due to a two-day history of low-grade fever (axillary temperature of 100.4°F), mild cough, and rhinorrhea. The examination revealed a well-appearing infant with no tachycardia, tachypnea, or abnormal vital signs. Pulmonary auscultation was clear, and no signs of respiratory distress, lethargy, irritability, or focal neurological deficits were observed, and there were no clinical indicators of sepsis such as altered mental status, persistent high fever, poor feeding, or abnormal neurological findings noted by the pediatrician. The infant remained alert, well-hydrated, and active with minimal congestion. The clinical judgment was that the presentation was consistent with a benign viral infection, common in infants at this age.
In the days following this visit, the child’s condition deteriorated rapidly and the infant was brought to the ED of the local hospital and was admitted for observation. A complete CBC with differential and platelets were ordered. Initial results showed that the infants WBC was normal, but segs/bands were high with a left shift and elevated platelets. Blood cultures were processed and the patient was discharged just past midnight. However, at approximately 2:20 a.m., the lab called the ED physician and reported gram-positive cocci in the blood. The ED Physician called and left a voice message for the pediatrician, requesting that the parents be contacted and asked to return to the hospital or to call back. It is unclear whether the pediatrician or the parents received that message. Subsequently, the infant continued to deteriorate and was brought back to the ED the next day. He was transferred emergently via air ambulance to a tertiary pediatric hospital where clinical evaluation confirmed bacterial meningitis. Despite aggressive antimicrobial therapy, supportive care, and intensive monitoring, the infant succumbed to the infection later that day, approximately 60 hours after the initial visit. Autopsy findings confirmed bacterial sepsis with meningeal involvement caused by Streptococcus pneumoniae.
Laboratory analysis indicated that the infant was in the early stages of a bacterial infection, which was not clinically evident at the time of the first consultation. The blood cultures, taken after admission, documented the pathogen's presence, but earlier recognition or intervention was not initiated. The infant’s prematurity and low birth weight increased risk for bacterial infection, but there were no overt clinical signs during the last outpatient visit that indicated the seriousness of the situation.
This case was further complicated by a delay in communication of critical laboratory results. Blood culture findings were not relayed to the family nor the primary pediatrician promptly—taking approximately five hours—leading to allegations of delays in notifying caregivers and initiating potentially life-saving interventions.
Expert Testimony
Plaintiff experts opined that the infant’s prematurity and initial symptoms warranted earlier and more aggressive testing, including blood cultures, which could have identified the bacterial infection sooner and prevented progression to meningitis. Conversely, defense experts contended that the infant’s presentation was consistent with a viral illness, and the lack of severe symptoms or red flags justified the management plan. They stated the rapid progression of infection was unpredictable and that the delay in notification did not alter the outcome significantly.
Resolution
Defense counsel made a motion to dismiss for plaintiffs’ failure to provide an expert report. It was granted. The case was dismissed for procedural reasons; however, the essential elements of the case regarding diagnosis and treatment remain extremely relevant and important.
Risk Reduction Strategies
Thorough Documentation: Healthcare providers should ensure detailed and accurate documentation of all clinical findings, including subtle signs that could indicate bacterial infection.
Timely Laboratory Testing: To standardize and improve early recognition and management of neonatal sepsis, adoption of a standardized protocol, such as the one from the Cleveland Clinic is paramount.
Close Monitoring: High-risk infants with mild symptoms should be closely monitored, with clear plans for follow-up if symptoms persist or worsen.
Effective Communication: Hospitals and providers should establish protocols for rapid notification of critical lab results to ensure timely intervention.
Parental Education: Educate parents about warning signs of serious illness and the importance of prompt medical attention if symptoms worsen after visits. This is especially true with a premature infant.
References
Cohen, Robert, et al. “Neonatal bacterial infections: Diagnosis, bacterial epidemiology and antibiotic treatment.” Infectious Diseases Now, vol. 53,8S (2023): 104793. doi:10.1016/j.idnow.2023.104793
Meningitis Research Foundation. “Management of Bacterial Meningitis in Infants <3 Months.” November 2017.
U.S. Centers for Disease Control and Prevention. “Summary of Recommendations.” Infection Control. 4/12/2024.
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