Two premature babies have died from a deadly bacterial infection linked to contaminated industrial dish soap at San Maurizio Hospital in Bolzano, northern Italy, prompting an urgent recall and criminal investigation into the tragic deaths that occurred within hours of each other.
The infants, who each weighed approximately 700 grams (1.54 pounds), died on the night between 12 and 13 August from sepsis caused by Serratia marcescens, a bacterium traced to the hospital’s dishwashing detergent. The South Tyrolean Health Authority has ordered the immediate removal of all industrial dish soap from the Bolzano hospital system.
A criminal investigation led by the National Anti-Corruption Unit of the Carabinieri military police (NAS) is now underway, with the Bolzano Public Prosecutor’s office considering whether to order autopsies to determine if charges of malpractice or manslaughter are warranted.
Vulnerable Victims of Hospital-Acquired Infection
Both babies were born three weeks ago at San Maurizio Hospital, with one delivered at 23 weeks gestation and the other at 27 weeks. Their extreme prematurity made them particularly vulnerable to infection due to their underdeveloped immune systems.
Dr Josef Widmann, medical director of the South Tyrolean Health Authority, confirmed at a Thursday press conference that the bacterium had been linked to the hospital’s dishwashing soap. “In addition to the serious problems resulting from their extreme prematurity, both children were diagnosed with an infection by Serratia marcescens,” he stated.
Hospital director Pierpaolo Bertoli explained that whilst the bacterium is widespread in the environment, appearing in water, soil, plants, animals and humans, it poses a particular threat to vulnerable patients. The presence of this bacterium is not unique because it constantly poses a risk to neonatal intensive care units,” Bertoli said, adding that the danger stems “not so much because of the type of germ but because of the particular vulnerability of these little patients due to their immature immune systems.
Immediate Safety Measures and Hospital Response
Following the deaths, San Maurizio Hospital implemented emergency protocols to prevent further tragedies. The facility immediately ceased accepting high-risk premature babies, with all such cases now being diverted to hospitals in Trento, approximately 40 miles from Bolzano.
Dr Monika Zaebisch, the hospital’s medical director, assured that comprehensive preventive measures had been implemented. “At the Bolzano hospital, we have implemented all preventive measures to prevent the transmission of germs,” she said on Thursday. “The ward staff strictly adheres to hygiene measures. Unfortunately, these two cases could not be prevented.”
The South Tyrolean Health Authority issued a directive suspending the use of the potentially contaminated detergent across all hospitals in the province. According to an official statement, the decision was made “upon instructions from the judicial authorities, through the NAS, as a precaution and pending further investigation.”
Understanding Serratia Marcescens: A Persistent Hospital Threat
Serratia marcescens is a gram-negative bacterium belonging to the Enterobacteriaceae family, known for its distinctive red-orange pigmentation. First described in the nineteenth century by Paduan pharmacist Bartolomeo Bizio, the microorganism has become recognised as one of the top ten causes of hospital infections, particularly in intensive care units.
The bacterium’s ability to colonise medical instruments, surfaces and even supposedly sterile devices such as catheters and respiratory equipment makes it particularly dangerous in hospital settings. In premature infants, it can cause sepsis, meningitis and pneumonia, with mortality rates reaching as high as 45 per cent according to scientific studies.
Medical experts note that Serratia marcescens functions as an opportunistic pathogen, remaining harmless to healthy individuals but potentially lethal to those with compromised immune systems. The bacterium’s high antibiotic resistance further complicates treatment, often requiring targeted antibiotics administered only after careful microbiological analysis.
Investigation Focuses on Contamination Source
The ongoing investigation is examining multiple theories about how the bacterium contaminated the dish soap. According to reports, investigators are considering whether the bacterium was introduced by an infected person, if the dispenser was already contaminated, whether the microorganism was present in the detergent before opening, or if it developed due to improper storage and the addition of contaminated water.
The tragedy has highlighted the critical importance of infection control in neonatal intensive care units, where extremely premature babies face heightened vulnerability to hospital-acquired infections. Sources familiar with the investigation indicate that samples have been collected from various areas of the hospital, including floors, walls, air conditioning systems, medical equipment and staff hands.
Broader Context of Italian Food Safety Concerns
The Bolzano hospital deaths come just weeks after three people died from suspected botulism poisoning in southern Italy, raising broader concerns about contamination and public health safety measures across the country.
The earlier incident involved toxic vegetable and sausage sandwiches sold from a food truck near Diamante in Calabria, resulting in the deaths of Tamara D’Acunto, 45, and Luigi Di Sarno, 52, with more than a dozen others hospitalised.
Current Hospital Status and Ongoing Precautions
Despite the crisis in the neonatal intensive care unit, hospital officials emphasise that other departments continue operating normally. The Obstetrics Department and all other services at San Maurizio Hospital remain unaffected and are functioning at full capacity.
Ten premature babies currently hospitalised in the neonatal intensive care unit are reported to be in stable condition, with enhanced monitoring and preventive measures in place. The hospital has strengthened its hygiene protocols and increased staffing levels to ensure the safety of all patients.
Health authorities continue to monitor the situation closely whilst awaiting the results of the criminal investigation. The incident serves as a stark reminder of the vulnerabilities faced by premature infants in hospital settings and the critical importance of maintaining rigorous hygiene standards in medical facilities.
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