title: Mucormycosis outbreak associated with hospital linens.
abstract: BACKGROUND
  Mucormycosis is an invasive fungal infection with a high fatality rate. We investigated an outbreak of mucormycosis in a pediatric hospital to determine routes of pathogen transmission from the environment and prevent additional infections.
  
  
  METHODS
  A case was defined as a hospital-onset illness consistent with mucormycosis, confirmed by culture or histopathology. 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. Fungal isolates collected from case-patients and the environmental samples were identified using DNA sequencing.
  
  
  RESULTS
  Five case-patients had hospital-associated cutaneous mucormycosis over an 11-month period; all subsequently died. Three case-patients had conditions known to be associated with susceptibility to mucormycosis, while 2 had cardiac conditions with persistent acidosis. The cases occurred on several different wards throughout the hospital, and hospital linens were the only exposure identified as common to the case-patients. Rhizopus species were recovered from 26 (42%) of 62 environmental samples from clean linens and associated areas and from 1 (4%) of 25 samples from nonlinen-related items. Case-patients were infected with Rhizopus delemar, which was also isolated from cultures of clean linens and clean linen delivery bins from the off-site laundry facility.
  
  
  CONCLUSIONS
  Hospital linens were identified as a vehicle that carried R. delemar into contact with susceptible patients. Fungal species identification using DNA-based methods is useful for corroborating epidemiologic links in hospital outbreak investigations. Hospital linens should be laundered, packaged, shipped and stored in a manner that minimizes exposure to environmental contaminants.
authors.affiliation: From the *Epidemic Intelligence Service; †Division of Healthcare Quality Promotion; ‡Mycotic Diseases Branch; and §Epidemiology Elective Program, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Duffy
authors.forename: Julie
authors.initials: J
authors.lastname: Harris
authors.forename: Lalitha
authors.initials: L
authors.lastname: Gade
authors.forename: Lynne
authors.initials: L
authors.lastname: Sehulster
authors.forename: Emily
authors.initials: E
authors.lastname: Newhouse
authors.forename: Heather
authors.initials: H
authors.lastname: O'Connell
authors.forename: Judith
authors.initials: J
authors.lastname: Noble-Wang
authors.forename: Carol
authors.initials: C
authors.lastname: Rao
authors.forename: S Arunmozhi
authors.initials: SA
authors.lastname: Balajee
authors.forename: Tom
authors.initials: T
authors.lastname: Chiller
mesh_terms: D000293:Adolescent; D000818:Animals; D001512:Bedding and Linens / Q000382:microbiology*; D002648:Child; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission; D004271:DNA, Fungal / Q000737:chemistry / Q000235:genetics; D004196:Disease Outbreaks; D005260:Female; D006651:Histocytochemistry; D006776:Hospitals, Pediatric; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D008828:Microbiological Techniques; D009091:Mucormycosis / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission; D012233:Rhizopus / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D017422:Sequence Analysis, DNA
chemical_list: D004271:DNA, Fungal