title: Hospital Outbreak of Pulmonary and Cutaneous Zygomycosis due to Contaminated Linen Items From Substandard Laundry.
abstract: BACKGROUND
  Healthcare laundry-related infection is rare, and pulmonary zygomycosis due to contaminated hospital linens has never been reported.
  
  
  METHODS
  We reported an outbreak investigation of zygomycosis in a university-affiliated teaching hospital. Air samplers, sponge swabs and Replicate Organism Detection and Counting (RODAC) contact plates were used for environmental sampling. The fungal isolates from clinical and environmental samples were identified by morphology, MALDI-TOF MS, and ITS1-5.8S-ITS2 rRNA gene cluster sequencing.
  
  
  RESULTS
  From 2 June 2015 to 18 July 2015, 6 immunosuppressed patients developed pulmonary (n = 4) and/or cutaneous (n = 3) infection by a spore-forming mold, Rhizopus microsporus, through direct inhalation and skin contact of contaminated linen items supplied by a designated laundry. Seventy (27.8%) of 252 freshly laundered clothing and 15 (3.4%) of 443 nonclothing laundered linen items (pillow case, bed sheet, draw sheet) were contaminated by R. microsporus, which was significantly higher than those from other hospital laundries (0%, n = 451; P < .001) supplying linen to hospitals with no cases of zygomycosis reported during the same period. The fungal isolates from patients and linens were phylogenetically related. In sum, 61% of environmental samples and 100% of air samples at the designated laundry were also positive for zygomycetes, suggesting heavy environmental contamination. RODAC contact plates revealed mean total viable bacteria counts of freshly laundered items (1028 ± 611 CFU/100 cm(2)) far exceeded the "hygienically clean" standard of 20 CFU/100 cm(2) set by the US healthcare textile certification requirement.
  
  
  CONCLUSIONS
  Suboptimal conditions of washing, drying, and storage contributed to the massive linen contamination and the outbreak of zygomycosis.
authors.affiliation: Department of Microbiology, Queen Mary Hospital.|Infection Control Unit, Queen Mary Hospital.
authors.forename: Vincent C C
authors.initials: VCC
authors.lastname: Cheng
authors.affiliation: Department of Microbiology, Queen Mary Hospital.
authors.forename: Jonathan H K
authors.initials: JHK
authors.lastname: Chen
authors.affiliation: Department of Microbiology, Queen Mary Hospital.
authors.forename: Sally C Y
authors.initials: SCY
authors.lastname: Wong
authors.affiliation: Department of Microbiology, Queen Mary Hospital.
authors.forename: Sally S M
authors.initials: SSM
authors.lastname: Leung
authors.affiliation: Department of Microbiology, Queen Mary Hospital.
authors.forename: Simon Y C
authors.initials: SYC
authors.lastname: So
authors.affiliation: Centre for Health Protection, Department of Health.
authors.forename: David C
authors.initials: DC
authors.lastname: Lung
authors.affiliation: Infection Control Unit, Queen Mary Hospital.
authors.forename: Wan-Mui
authors.initials: WM
authors.lastname: Lee
authors.affiliation: Department of Pathology, Queen Mary Hospital.
authors.forename: Nigel J
authors.initials: NJ
authors.lastname: Trendell-Smith
authors.affiliation: Adult Intensive Care Unit, Queen Mary Hospital.
authors.forename: Wai-Ming
authors.initials: WM
authors.lastname: Chan
authors.affiliation: Head Office, Hospital Authority.
authors.forename: Desmond
authors.initials: D
authors.lastname: Ng
authors.affiliation: Centre for Health Protection, Department of Health.
authors.forename: Liza
authors.initials: L
authors.lastname: To
authors.affiliation: Department of Medicine, Queen Mary Hospital, Hong Kong Special Administrative Region, China.
authors.forename: Albert K W
authors.initials: AKW
authors.lastname: Lie
authors.affiliation: Department of Microbiology, Queen Mary Hospital.
authors.forename: Kwok-Yung
authors.initials: KY
authors.lastname: Yuen
mesh_terms: D000328:Adult; D000368:Aged; D001512:Bedding and Linens / Q000382:microbiology*; D002681:China / Q000453:epidemiology; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology; D004196:Disease Outbreaks; D005260:Female; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006785:Hospitals, University; D006801:Humans; D016867:Immunocompromised Host; D007847:Laundry Service, Hospital / Q000592:standards*; D008168:Lung / Q000382:microbiology*; D008297:Male; D008875:Middle Aged; D010802:Phylogeny; D012233:Rhizopus / Q000235:genetics / Q000302:isolation & purification*; D017422:Sequence Analysis, DNA; D020096:Zygomycosis / Q000453:epidemiology / Q000382:microbiology*
keywords: Rhizopus microsporus; laundry; linens; outbreak; zygomycosis