Mucormycosis as a HALO Event: Skin as the First Line of Defense

Unintentional extubation is a challenge in neonatal intensive care. Endotracheal tube securement may involve either taping or using an endotracheal tube securement device for infants born extremely preterm. An unplanned extubation is a physiological stressor for the infant as well as a psychological stressor for both the family and the healthcare team. Beyond the potential for respiratory decompensation with an unplanned extubation, skin integrity may be compromised with recurrent application of an adhesive or unplanned adhesive removal as occurred for the newborn featured in the Visual Diagnosis section in the August 2024 issue of NeoReviews, A Necrotic Ulcer in an Extremely Premature Infant.

Disrupted skin integrity complicated by mucormycosis may be life-limiting¹ or life-altering.² These cases share the common thread of life-supporting or vital sign monitoring equipment routinely used for the care of critically ill neonates (i.e., endotracheal tube and temperature probe) contributing to a rare but potentially deadly healthcare-associated infection, mucormycosis. As neonatal clinicians increasingly care for infants born early in the periviable period, there is a need for heightened attention to skin integrity. The skin is a key barrier to infection that cannot be taken for granted in the extremely preterm population, as discussed in the January 2025 issue of NeoReviews, Skin Care of Infants Born at 21-23 Weeks’ Gestation.

In recent decades there has been a decline in Candida infections in the neonatal intensive care setting with fungal prophylaxis and antibiotic stewardship.³ While Candida albicans remains the most common fungal infection in neonatal intensive care, the morbidity and mortality of non-Candida albicans fungal infections in neonates is greater.⁴ Neonatal clinicians and trainees may never care for an infant with mucormycosis; however, its early recognition and management are critical. Arguably, mucormycosis may fall into a class of infections that could be handled as high acuity, low occurrence (HALO) events⁵ similar to pericardial tamponade. HALO events require directed education and preparation to ensure multidisciplinary teams are prepared to make the diagnosis, intervene, and potentially save a life.

References

1. Chmelova K, Tinnion R, Zalewski S. Cutaneous mucormycosis in an extremely premature infant. Arch Dis Child Fetal Neonatal Ed. 2023;108(6):661
2. Brooks D, Abdessalam S, Davies HD, Aldrich AM, Bedrnicek J, Gollehon N. Invasive cutaneous mucormycosis in an extremely preterm infant. J Pediatr Surg Case Rep. 2018;35:52-6
3. Dermitzaki N, Baltogianni M, Tsekoura E, Giapros V. Invasive Candida infections in neonatal intensive care units: risk factors and new insights in prevention. Pathogens. 2024;13(8):660
4. Ribeiro M, Ruiz LDS, Gandra RF, et al. Bloodstream infection in a neonatal intensive care unit: epidemiology, antifungal susceptibility, and new drug delivered strategies. J Mycol Med. 2025;35(1):101535
5. Ali N, Schierholz E, Reed D, Hightower H, Johnson BA, Gupta R, et al. identifying gaps in resuscitation practices across level-IV neonatal intensive care units. Am J Perinatol. 2024;41(S01):e180-6