Zygomycosis Outbreak Associated with Hospital Linens · ͵ the pre-intervention linen company’s...
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J Duffy 1 , J Harris 2 , E Newhouse 1 , A Balajee 2 , C Neal 2 , J Noble-Wang 1 , L Sehulster 1 , S Gilbert 1 , M Howard 1 , H O’Connell 1 , E Stanley 3 , C Rao 1 , T Chiller 2 1 Division of Healthcare Quality Promoon, CDC; 2 Mycoc Diseases Branch, CDC; 3 Louisiana Office of Public Health The findings and conclusions in this report are those of the authors and do not necessarily represent the official posion of the Centers for Disease Control and Prevenon. Contact Informaon: 1600 Cliton Road, NE MS A-24 Atlanta, GA 30333 Phone: 404-639-4353 Fax: 404-639-2647 jduff[email protected] CS211357 ABSTRACT Background: Zygomycosis is an invasive fungal infecon caused by mucormycetes (formerly zygomycetes), a ubiquitous group of molds including Rhizopus species. Infecons are rare, usually occur in people with an underlying medical condion, can affect various body sites, and have a case fatality rate of > 50%. Objecve: We invesgated an outbreak of Rhizopus among Hospital A paents to idenfy the environmental source and prevent further infecons. Methods: A case was defined as illness consistent with mucormycete infecon confirmed by culture or histopathology. Retrospecve case-finding was performed by reviewing hospital databases starng from 1993. Case-paent medical records were reviewed for clinical course and exposure to items and locaons within the hospital. Environmental samples were collected from air and surfaces at Hospital A and the laundry facility of its linen supply company. Fungal species isolated from paents and the environment were idenfied and subtyped using DNA sequencing and Inter Simple Sequence Repeat (ISSR) methods, respecvely. Results: Nine cases were diagnosed at Hospital A since 1993, with six cases temporally clustered from August 2008 to July 2009. One of these was a community-associated case of meningoencephalis, but five were hospital-associated cutaneous infecons in paents ranging in age on admission from 0 days to 13 years. Hospital length of stay at first sign of infecon was 20 – 51 days. Adming diagnosis categories were: cardiac (2), hematologic (2), preterm birth (1). All five had established risk factors for zygomycosis, including acidosis (4) and bone marrow transplantaon (1). Cases occurred on different wards served by different air handling systems. Hospital linens (sheets, pillowcases, gowns) were the only items common to all the cases. Environmental cultures taken at Hospital A demonstrated Rhizopus species from 26 (40%) of 65 swabs of clean linens and areas in contact with clean linens, and from 1 (4%) of 25 samples from items not in contact with linens. Hospital A changed linen supply companies, replaced all linens, and disinfected linen storage areas. Hospital air and surface cultures (n=29) taken 3 weeks later were negave. All specimens available for tesng (13 environmental and 4 paent) were idenfied as Rhizopus oryzae. One paent isolate was available for subtyping and was genotypically related to an isolate from a clean linen transport cart. Non-Rhizopus oryzae mucormycetes were recovered from 7 (88%) of 8 surface cultures from the linen company laundry facility. Conclusions: Hospital linens likely acted as a vector bringing Rhizopus in contact with suscepble paents in this outbreak. Rhizopus might have contaminated linens at the laundry facility or during delivery to the hospital. Hospital linens should be laundered, shipped, and stored in a manner that minimizes exposure to environmental contaminants. BACKGROUND Mucormycetes (formerly known as zygomycetes) are a taxonomic group of ubiquitous molds found in soil, dust, decaying food or vegetaon ͵ include human pathogens classified into several genera including ͵ Rhizopus, Absidia, and Mucor Rhizopus ͵ species are the most common pathogens Zygomycosis (also known as mucormycosis) is the clinical term for an invasive fungal infecon caused by these pathogens Zygomycosis can manifest as different types of infecon including: sinus ͵ rhinocerebral ͵ pulmonary ͵ cutaneous ͵ gastrointesnal ͵ renal ͵ Zygomycosis has been associated with underlying medical condions including: diabetes, malignancy, solid organ and bone marrow transplantaon, deferoxamine therapy, injecon drug use, ͵ low birth weight in infants, AIDS, burns, and metabolic acidosis Zygomycosis is rare even among paents with these condions Case fatality rate varies by body site and extent of infecon for all cases it is about 50% ͵ for cutaneous infecon it ranges from 10% to 94% ͵ Previous hospital outbreaks have been associated with mold present on medical supplies or in the hospital environment OBJECTIVE An outbreak of zygomycosis caused by Rhizopus species among paents of Hospital A was recognized in June 2009 We invesgated the outbreak to idenfy an environmental source of the mold and to prevent further infecons METHODS Case definion: an illness consistent with mucormycete infecon confirmed by culture or histopathology in a paent of Hospital A since 1993 Hospital-associated cases were defined as infecon onset ≥ 14 days aſter admission Retrospecve case-finding: based on review of Hospital A pathology, microbiology, and billing records Case-paent underlying medical condion and hospital environment exposure assessment reviewed medical records ͵ interviewed clinical staff ͵ Observed linen handling and laundering procedures hospital linens include: sheets, pillow cases, blankets, paent gowns, towels, and ͵ washcloths Environmental fungal cultures sampling at Hospital A and off-site laundry facility ͵ air samples: SAS air microbiological sampler ͵ surface samples: premoistened sponge swabs ͵ dust and linen surface samples: filter cassees using vacuum pump ͵ Fungal laboratory analysis done for paent samples (culture isolates and samples extracted from ͵ biopsy ssue preserved in paraffin blocks) and environmental culture isolates species idenficaon: by comparave genec sequence analysis of ͵ porons of the rRNA regions subtyping: by inter simple sequence repeat (ISSR) PCR ͵ RESULTS (connued) Paent environmental exposures examined: paent locaon (ward, room, and trips off ward) ͵ surgery and procedures ͵ radiology exams ͵ biomedical devices (lines and tubes) ͵ medicaons (topical and systemic) ͵ bandages and dressings ͵ bathing and personal care products ͵ linens ͵ Linens were the only item idenfied that came in contact with the paents’ skin that the five cases shared in common Hospital A’s linen is provided by a company that operates a laundry facility remote from the hospital. Each day, clean linen is delivered and dirty linen is removed from the hospital. Hospital Linen Daily Cycle Intervenon: Inial Control Measures Based on the results of the inial invesgaon, Hospital A implemented the following intervenons seven days aſter the case triggering the invesgaon was diagnosed changed to a different linen supply company ͵ started using a different entrance for linen deliveries and a different linen bin holding area ͵ removed all linen in use at the me ͵ disinfected the linen storage room ͵ Hospital A Post-Intervenon Environmental Cultures Were all negave for Rhizopus air samples (n=17) from six different wards, linen storage room, central supply room, and outside ͵ swab samples (n=8) from linen storage room, linen cart, linen bin holding area, central supply room, and one ͵ ward filter cassee samples (n=4) from linen storage room ͵ Laundry Facility Site-Visit the pre-intervenon linen company’s laundry facility used commercial washers, dryers, irons, and a work flow ͵ consistent with typical laundry industry processes Environmental Cultures air samples (n=5): all negave ͵ swab samples (n=4): ͵ Rhizopus microsporus (3), Mycocladus corymbifer (1) filter cassee samples (n=4): ͵ Rhizopus microsporus (2), Mycocladus corymbifer (1), negave (1) Fungal Laboratory Analysis Paent Specimens Environmental Culture Isolates only 13 pre-intervenon culture isolates were saved and available for reference lab tesng ͵ linen bins (9), linen (1), linen storage room area (2), Ward A linen closet (1) all 13 were idenfied as ͵ Rhizopus oryzae Fungal Species Subtyping Only culture isolate specimens were sufficient for genec subtyping This dendrogram shows that the Rhizopus oryzae isolated from Paent #5 is closely genecally related to an isolate from a clean linen bin Paent 1 2 3 4 5 Specimen type available ssue none ssue ssue culture isoalte Fungal species Rhizopus oryzae unknown Rhizopus oryzae Rhizopus oryzae Rhizopus oryzae ISSR Subtyping Unrooted Dendrogram Patient #5 isolates Linen bin swab isolate RESULTS Five hospital-associated cases occurred in a cluster from August 2008 to July 2009 The hospital wards involved are served by different air handling units / air intakes located on opposite sides of the building, making airborne disseminaon of mold from a common source unlikely All five case-paents died 0 1 2 3 Jul- 98 Jan-99 Jul-99 Jan-00 Jul-00 Jan-01 Jul-01 Jan-02 Jul-02 Jan-03 Jul-03 Jan-04 Jul-04 Jan-05 Jul-05 Jan-06 Jul-06 Jan-07 Jul-07 Jan- 08 Jul- 08 Jan-09 Jul-09 Number of Cases Month and Year (1998 – 2009) Cases Diagnosed at Hospital A by Month Unknown association Community- associated Hospital - associated Characteriscs of the Five Hospital-Associated Cases Paent 1 2 3 4 5 Age 0 days 1 day 13 years 10 years 11 years Date of diagnosis 8/22/2008 3/25/2009 3/11/2009 6/22/2009 7/2/2009 Adming Diagnosis Premature birth Dextrocardia and TAPVR Hisocytosis Mitral valve insufficiency Graſt versus host disease Zygomycosis risk factors Acidosis ͵ Low birth ͵ weight Acidosis ͵ Acidosis ͵ Chronic steroids ͵ Acidosis ͵ Chronic steroids ͵ Bone marrow ͵ transplant Locaon of cutaneous lesion Groin Upper back and posterior neck Axila and sacrum Face Periumbilical Length of stay at infecon onset (days) 35 47 20 51 33 Ward NICU CCU ICU CCU ICU CONCLUSIONS Rhizopus oryzae was isolated from four of the five case-paents in this outbreak, and in the one sample sufficient for tesng, was genecally related to Rhizopus oryzae isolated from a clean linen bin. The hospital linens are the most likely vehicle to have brought the Rhizopus in contact with the paents in this outbreak, who were all suscepble to infecon due to underlying medical condions. The length of me and the intervals over which the cases occurred indicates that contaminaon of clean linens with Rhizopus happened repeatedly, but might have been intermient or persistent. The linens could have become contaminated at the laundry facility, in route, or during delivery at the hospital. The point at which contaminaon occurred could not be determined. Negave cultures do not prove the absence of Rhizopus oryzae at specific locaons. Hospital linens should be laundered, shipped, and stored in a manner that minimizes exposure to environmental contaminants. Hospital A Pre-Intervenon Environmental Cultures Linen Related Areas and Items Cultured Non-linen Related Areas and Items Cultured Category Rhizopus Posive Samples Tested Category Rhizopus Posive Samples Tested Linen storage room 6 8 Skin adhesives 0 9 Clean linen delivery bins 10 22 Wound cleaner 0 1 Clean linen in bins 1 3 Ward C 0 8 Linen delivery truck (inside) 1 1 Pharmacy 0 2 Linen bin holding area 1 1 Respiratory equipment room 1 2 Ward A linen closet 2 4 Air handling unit 0 1 Ward B linen closet 3 4 Service entrance 0 1 Ward C linens 0 9 OR linen closet 2 10 Linen rewashed in hospital 0 3 Total 26 (40%) 65 Total 1 (4%) 24
Transcript of Zygomycosis Outbreak Associated with Hospital Linens · ͵ the pre-intervention linen company’s...
Zygomycosis Outbreak Associated with Hospital LinensJ Duffy1, J Harris2, E Newhouse1, A Balajee2, C Neal2, J Noble-Wang1, L Sehulster1, S Gilbert1, M Howard1, H O’Connell1, E Stanley3, C Rao1, T Chiller2
1Division of Healthcare Quality Promotion, CDC; 2Mycotic Diseases Branch, CDC; 3Louisiana Office of Public Health
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Contact Information:1600 Cliton Road, NEMS A-24Atlanta, GA 30333Phone: 404-639-4353Fax: [email protected]
CS211357
ABSTRACTBackground: Zygomycosis is an invasive fungal infection caused by mucormycetes (formerly zygomycetes), a ubiquitous group of molds including Rhizopus species. Infections are rare, usually occur in people with an underlying medical condition, can affect various body sites, and have a case fatality rate of > 50%.Objective: We investigated an outbreak of Rhizopus among Hospital A patients to identify the environmental source and prevent further infections.Methods: A case was defined as illness consistent with mucormycete infection confirmed by culture or histopathology. Retrospective case-finding was performed by reviewing hospital databases starting from 1993. Case-patient medical records were reviewed for clinical course and exposure to items and locations within the hospital. Environmental samples were collected from air and surfaces at Hospital A and the laundry facility of its linen supply company. Fungal species isolated from patients and the environment were identified and subtyped using DNA sequencing and Inter Simple Sequence Repeat (ISSR) methods, respectively.Results: Nine cases were diagnosed at Hospital A since 1993, with six cases temporally clustered from August 2008 to July 2009. One of these was a community-associated case of meningoencephalitis, but five were hospital-associated cutaneous infections in patients ranging in age on admission from 0 days to 13 years. Hospital length of stay at first sign of infection was 20 – 51 days. Admitting diagnosis categories were: cardiac (2), hematologic (2), preterm birth (1). All five had established risk factors for zygomycosis, including acidosis (4) and bone marrow transplantation (1). Cases occurred on different wards served by different air handling systems. Hospital linens (sheets, pillowcases, gowns) were the only items common to all the cases. Environmental cultures taken at Hospital A demonstrated Rhizopus species from 26 (40%) of 65 swabs of clean linens and areas in contact with clean linens, and from 1 (4%) of 25 samples from items not in contact with linens. Hospital A changed linen supply companies, replaced all linens, and disinfected linen storage areas. Hospital air and surface cultures (n=29) taken 3 weeks later were negative. All specimens available for testing (13 environmental and 4 patient) were identified as Rhizopus oryzae. One patient isolate was available for subtyping and was genotypically related to an isolate from a clean linen transport cart. Non-Rhizopus oryzae mucormycetes were recovered from 7 (88%) of 8 surface cultures from the linen company laundry facility.Conclusions: Hospital linens likely acted as a vector bringing Rhizopus in contact with susceptible patients in this outbreak. Rhizopus might have contaminated linens at the laundry facility or during delivery to the hospital. Hospital linens should be laundered, shipped, and stored in a manner that minimizes exposure to environmental contaminants.
BACKGROUNDMucormycetes (formerly known as zygomycetes) are a taxonomic group of ubiquitous molds �
found in soil, dust, decaying food or vegetation ͵include human pathogens classified into several genera including ͵ Rhizopus, Absidia, and Mucor Rhizopus ͵ species are the most common pathogens
Zygomycosis (also known as mucormycosis) is the clinical term for an invasive fungal infection caused by these �pathogensZygomycosis can manifest as different types of infection including: �
sinus ͵rhinocerebral ͵pulmonary ͵cutaneous ͵gastrointestinal ͵renal ͵
Zygomycosis has been associated with underlying medical conditions including: �diabetes, malignancy, solid organ and bone marrow transplantation, deferoxamine therapy, injection drug use, ͵low birth weight in infants, AIDS, burns, and metabolic acidosis
Zygomycosis is rare even among patients with these conditions �Case fatality rate varies by body site and extent of infection �
for all cases it is about 50% ͵for cutaneous infection it ranges from 10% to 94% ͵
Previous hospital outbreaks have been associated with mold present on medical supplies or in the hospital �environment
OBJECTIVE
An outbreak of zygomycosis caused by � Rhizopus species among patients of Hospital A was recognized in June 2009
We investigated the outbreak to identify an environmental source of the mold and to prevent further infections �
METHODSCase definition: an illness consistent with mucormycete infection confirmed by culture or histopathology in a �patient of Hospital A since 1993Hospital-associated cases were defined as infection onset ≥ 14 days after admission �Retrospective case-finding: based on review of Hospital A pathology, microbiology, and billing records �Case-patient underlying medical condition and hospital environment exposure assessment �
reviewed medical records ͵interviewed clinical staff ͵
Observed linen handling and laundering procedures �hospital linens include: sheets, pillow cases, blankets, patient gowns, towels, and ͵washcloths
Environmental fungal cultures �sampling at Hospital A and off-site laundry facility ͵air samples: SAS air microbiological sampler ͵surface samples: premoistened sponge swabs ͵dust and linen surface samples: filter cassettes using vacuum pump ͵
Fungal laboratory analysis �done for patient samples (culture isolates and samples extracted from ͵biopsy tissue preserved in paraffin blocks) and environmental culture isolatesspecies identification: by comparative genetic sequence analysis of ͵portions of the rRNA regionssubtyping: by inter simple sequence repeat (ISSR) PCR ͵
RESULTS (continued)
Patient environmental exposures examined: �patient location (ward, room, and trips off ward) ͵surgery and procedures ͵radiology exams ͵biomedical devices (lines and tubes) ͵medications (topical and systemic) ͵bandages and dressings ͵bathing and personal care products ͵linens ͵
Linens were the only item identified that came in contact with the patients’ skin that the five cases shared in �commonHospital A’s linen is provided by a company that operates a laundry facility remote from the hospital. Each day, �clean linen is delivered and dirty linen is removed from the hospital.
Hospital Linen Daily Cycle
Intervention: Initial Control MeasuresBased on the results of the initial investigation, Hospital A implemented the following interventions seven days �after the case triggering the investigation was diagnosed
changed to a different linen supply company ͵started using a different entrance for linen deliveries and a different linen bin holding area ͵removed all linen in use at the time ͵disinfected the linen storage room ͵
Hospital A Post-Intervention Environmental CulturesWere all negative for � Rhizopus
air samples (n=17) from six different wards, linen storage room, central supply room, and outside ͵swab samples (n=8) from linen storage room, linen cart, linen bin holding area, central supply room, and one ͵wardfilter cassette samples (n=4) from linen storage room ͵
Laundry FacilitySite-Visit �
the pre-intervention linen company’s laundry facility used commercial washers, dryers, irons, and a work flow ͵consistent with typical laundry industry processes
Environmental Cultures �air samples (n=5): all negative ͵swab samples (n=4): ͵ Rhizopus microsporus (3), Mycocladus corymbifer (1)filter cassette samples (n=4): ͵ Rhizopus microsporus (2), Mycocladus corymbifer (1), negative (1)
Fungal Laboratory AnalysisPatient Specimens �
Environmental Culture Isolates �only 13 pre-intervention culture isolates were saved and available for reference lab testing ͵
linen bins (9), linen (1), linen storage room area (2), Ward A linen closet (1) �all 13 were identified as ͵ Rhizopus oryzae
Fungal Species SubtypingOnly culture isolate specimens were sufficient for genetic subtyping �This dendrogram shows that the � Rhizopus oryzae isolated from Patient #5 is closely genetically related to an isolate from a clean linen bin
Patient 1 2 3 4 5Specimen type available
tissue none tissue tissue culture isoalte
Fungal species
Rhizopus oryzae unknown Rhizopus oryzae Rhizopus oryzae Rhizopus oryzae
ISSR Subtyping Unrooted Dendrogram
Patient #5 isolates
Linen bin swab isolate
RESULTS
Five hospital-associated cases occurred in a cluster from August 2008 to July 2009 �
The hospital wards involved are served by different air handling units / air intakes located on opposite sides of the �building, making airborne dissemination of mold from a common source unlikely
All five case-patients died �
0
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Jul-9
8Ja
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Jul-9
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Jul-0
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1Ja
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2Ja
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Jul-0
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n-04
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4Ja
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Jul-0
5Ja
n-06
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6Ja
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Num
ber o
f Cas
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Month and Year (1998 – 2009)
Cases Diagnosed at Hospital A by Month
Unknown association
Community-associated
Hospital-associated
Characteristics of the Five Hospital-Associated Cases
Patient 1 2 3 4 5Age 0 days 1 day 13 years 10 years 11 yearsDate of diagnosis 8/22/2008 3/25/2009 3/11/2009 6/22/2009 7/2/2009Admitting Diagnosis
Premature birthDextrocardia and
TAPVRHistiocytosis
Mitral valve insufficiency
Graft versus host disease
Zygomycosis risk factors
Acidosis ͵
Low birth ͵weight
Acidosis ͵ Acidosis ͵
Chronic steroids ͵
Acidosis ͵ Chronic steroids ͵
Bone marrow ͵transplant
Location of cutaneous lesion
GroinUpper back and posterior neck
Axila and sacrum Face Periumbilical
Length of stay at infection onset (days)
35 47 20 51 33
Ward NICU CCU ICU CCU ICU
CONCLUSIONS
Rhizopus oryzae � was isolated from four of the five case-patients in this outbreak, and in the one sample sufficient for testing, was genetically related to Rhizopus oryzae isolated from a clean linen bin.The hospital linens are the most likely vehicle to have brought the � Rhizopus in contact with the patients in this outbreak, who were all susceptible to infection due to underlying medical conditions.The length of time and the intervals over which the cases occurred indicates that contamination of clean linens �with Rhizopus happened repeatedly, but might have been intermittent or persistent.The linens could have become contaminated at the laundry facility, in route, or during delivery at the hospital. The �point at which contamination occurred could not be determined. Negative cultures do not prove the absence of Rhizopus oryzae at specific locations.Hospital linens should be laundered, shipped, and stored in a manner that minimizes exposure to environmental �contaminants.
Hospital A Pre-Intervention Environmental Cultures
Linen Related Areas and Items Cultured Non-linen Related Areas and Items Cultured
CategoryRhizopus Positive
Samples Tested
CategoryRhizopus Positive
Samples Tested
Linen storage room 6 8 Skin adhesives 0 9
Clean linen delivery bins 10 22 Wound cleaner 0 1
Clean linen in bins 1 3 Ward C 0 8
Linen delivery truck (inside) 1 1 Pharmacy 0 2
Linen bin holding area 1 1 Respiratory equipment room 1 2
Ward A linen closet 2 4 Air handling unit 0 1
Ward B linen closet 3 4 Service entrance 0 1
Ward C linens 0 9
OR linen closet 2 10
Linen rewashed in hospital 0 3
Total 26 (40%) 65 Total 1 (4%) 24
