After a long and exhaustive investigation, the deaths of two infants and the sickening of a third at Miami Children's Hospital is a medical mystery.

The infants, born extremely prematurely, their immune systems compromised, were in the hospital's Neonatal Intensive Care Unit when two of them died of a common yet lethal bacterium in March.

County health investigators found 23 strains of the bacteria Pseudomonas aeruginosa in faucets, sinks and drains throughout the unit, but said Wednesday that none matched the strains that killed a 7-day-old boy and a 21-day-old girl, said Dr. Vincent Conte, the Miami-Dade Health Department's principal investigator.

''Through all our testing, we never did find the source of the infection,'' said Dr. Vincent Conte, the Miami-Dade Health Department's principal investigator.

''Pseudomonas is found everywhere in the environment -- in the water, in the soil; if you tested your own water at home, you might find it,'' Conte said.

A report issued by the county on Tuesday criticized the hospital's water sanitation procedures, saying it lacked policies for routine inspections of plumbing, did not systematically flush the system and didn't take part in the county's annual free chlorine-purge program that is aimed at cutting such infections.

BACTERIA WIDESPREAD

The bacteria's spread in the intensive-care unit was wider than initially reported.

In addition to the three infants who died or became ill, it colonized 11 of 36 infants, the report said. In medical terms, a person is ''colonized'' when a microorganism is on or in the body without causing a disease.

The health department's report said investigators found the bacteria in half of the 22 samples it took on March 26.

New tests on May 11, after the hospital had purged the unit's water supply, still found traces in 25 percent in the area sampled, the report said. Investigators concluded that the problem was limited to Room 2 of the NICU -- where all three of the infected infants were cared for -- and recommended that it be closed.

At the county's request, the hospital then tore out the three sinks, faucets and drains in Room 2 and and put in new ones and super-chlorinated the water supply, the report says. The area later got a clean bill of health.

At Wednesday's news conference, reporters pressed the health officials to say whether the bacteria came from the Lawnwood Hospital in St. Lucie County, where the two babies who died were born, the helicopter that brought them to Miami, or at the Miami hospital, since the infants never went anyplace else.

''It had to come from one of the three,'' Conte agreed. ``But since we have no environmental matches, we can't say it came from point A, B or C.''

REPORT FINDINGS

The report cleared the hospital's health practices in the infection. ''The health department found no evidence to suggest that specific patient care practices were associated with infection,'' Conte wrote.

It recommended that the hospital initiate monthly checks of water quality, train its staff in infection control, closely monitor chlorine levels and use the county's annual chlorine purge.

Miami Children's Hospital, in a statement e-mailed to news media, said: ``We're pleased to report that many of the recommendations made by the Miami-Dade County Health Department were already routine practices. The remaining recommendations are being reviewed and will be acted upon as appropriate.''

''We take all recommendations from the county health department seriously and, in a spirit of cooperation, plan to do everything we can to comply with those recommendations,'' read a hospital statement. ``In fact, many of the recommendations have been completed or were part of our routine operations. We have been conducting post chlorination tests since April and the results from each test have been excellent.''

The statement said the hospital will implement the county's chlorine purge program.

The problem began when two babies died in the hospital's intensive care unit on March 14 and 15, and a third became ill but survived.

All three underwent various surgeries and were on ventilators.

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