Patient safety feature – TPN and infections with Bacillus cereus: important lessons for neonatal staff

The recent UK outbreak of Bacillus cereus infections associated with use of total parenteral nutrition (TPN) on neonatal units has again focused attention on the importance of strict quality assurance and good clinical governance procedures. At least 19 preterm infants became infected, with a further four possible cases, all occurring at the end of May and June 2014 in the south and east of England. Three of these infants died and it is not yet possible to know if any others have died directly as a consequence of this infection, or have suffered any long-term effects.

While there are many benefits of TPN, equally there are many potential risks, such as infection. The purpose of this article is to update neonatal staff on the incident and highlight important aspects of practice to all staff involved in prescribing or administering TPN to neonates.