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Mucormycosis Outbreak Associated With Hospital Linens

Duffy, Jonathan MD, MPH*†; Harris, Julie PhD, MPH; Gade, Lalitha M Pharm; Sehulster, Lynne PhD; Newhouse, Emily MD, CM§; O’Connell, Heather PhD; Noble-Wang, Judith PhD; Rao, Carol ScD, MS; Balajee, S. Arunmozhi PhD; Chiller, Tom MD, MPH

The Pediatric Infectious Disease Journal: May 2014 - Volume 33 - Issue 5 - p 472–476
doi: 10.1097/INF.0000000000000261
Original Studies

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.

Supplemental Digital Content is available in the text.

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.

Accepted for publication October 17, 2013.

Emily Newhouse, MD, CM is currently at School of Population and Public Health, University of British Columbia, Vancouver, British Columbia

Carol Rao, ScD, MS and S. Arunmozhi Balajee, PhD are currently at Division of Global Disease Detection and Emergency Response, CDC, Atlanta, Georgia

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.

L. Sehulster was a member of the Healthcare Laundry Accreditation Council at the time of this investigation and received no compensation for that activity. The authors have no other funding or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Address for correspondence: Jonathan Duffy, Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, 1600 Clifton Road NE, MS D-26, Atlanta, GA 30333. Email:

© 2014 by Lippincott Williams & Wilkins, Inc.