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      Remediation of Mucorales-contaminated Healthcare Linens at a Laundry Facility Following an Investigation of a Case Cluster of Hospital-acquired Mucormycosis

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          Abstract

          Background

          In an investigation of hospital-acquired mucormycosis cases among transplant recipients, healthcare linens (HCLs) delivered to our center were found to be contaminated with Mucorales. We describe an investigation and remediation of Mucorales contamination at the laundry supplying our center.

          Methods

          We performed monthly RODAC cultures of HCLs upon hospital arrival, and conducted site inspections and surveillance cultures at the laundry facility. Remediation was designed and implemented by infection prevention and facility leadership teams.

          Results

          Prior to remediation, 20% of HCLs were culture-positive for Mucorales upon hospital arrival. Laundry facility layout and processes were consistent with industry standards. Significant step-ups in Mucorales and mold culture-positivity of HCLs were detected at the post-dryer step (0% to 12% [P = .04] and 5% to 29% [P = .01], respectively). Further increases to 17% and 40% culture-positivity, respectively, were noted during pre-transport holding. Site inspection revealed heavy Mucorales-positive lint accumulation in rooftop air intake and exhaust vents that cooled driers; intake and exhaust vents that were facing each other; rooftop and plant-wide lint accumulation, including in the pre-transport clean room; uncovered carts with freshly-laundered HCLs. Following environmental remediation, quality assurance measures and education directed toward these sources, Mucorales culture-positivity of newly-delivered HCLs was reduced to 0.3% (P = .0001); area of lint-contaminated rooftop decreased from 918 m2 to 0 m2 on satellite images.

          Conclusions

          Targeted laundry facility interventions guided by site inspections and step-wise culturing significantly reduced Mucorales-contaminated HCLs delivered to our hospital. Collaboration between infection prevention and laundry facility teams was crucial to successful remediation.

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          Most cited references13

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          Epidemiology and outcome of zygomycosis: a review of 929 reported cases.

          M M Roden, T. E. Zaoutis, W L Buchanan … (2005)
          Zygomycosis is an increasingly emerging life-threatening infection. There is no single comprehensive literature review that describes the epidemiology and outcome of this disease. We reviewed reports of zygomycosis in the English-language literature since 1885 and analyzed 929 eligible cases. We included in the database only those cases for which the underlying condition, the pattern of infection, the surgical and antifungal treatments, and survival were described. The mean age of patients was 38.8 years; 65% were male. The prevalence and overall mortality were 36% and 44%, respectively, for diabetes; 19% and 35%, respectively, for no underlying condition; and 17% and 66%, respectively, for malignancy. The most common types of infection were sinus (39%), pulmonary (24%), and cutaneous (19%). Dissemination developed in 23% of cases. Mortality varied with the site of infection: 96% of patients with disseminated disease died, 85% with gastrointestinal infection died, and 76% with pulmonary infection died. The majority of patients with malignancy (92 [60%] of 154) had pulmonary disease, whereas the majority of patients with diabetes (222 [66%] of 337) had sinus disease. Rhinocerebral disease was seen more frequently in patients with diabetes (145 [33%] of 337), compared with patients with malignancy (6 [4%] of 154). Hematogenous dissemination to skin was rare; however, 78 (44%) of 176 cutaneous infections were complicated by deep extension or dissemination. Survival was 3% (8 of 241 patients) for cases that were not treated, 61% (324 of 532) for cases treated with amphotericin B deoxycholate, 57% (51 of 90) for cases treated with surgery alone, and 70% (328 of 470) for cases treated with antifungal therapy and surgery. By multivariate analysis, infection due to Cunninghamella species and disseminated disease were independently associated with increased rates of death (odds ratios, 2.78 and 11.2, respectively). Outcome from zygomycosis varies as a function of the underlying condition, site of infection, and use of antifungal therapy.
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            Microbial Cellulose Utilization: Fundamentals and Biotechnology

            L. R. Lynd, P. J. Weimer, W H Van Zyl … (2002)
            Fundamental features of microbial cellulose utilization are examined at successively higher levels of aggregation encompassing the structure and composition of cellulosic biomass, taxonomic diversity, cellulase enzyme systems, molecular biology of cellulase enzymes, physiology of cellulolytic microorganisms, ecological aspects of cellulase-degrading communities, and rate-limiting factors in nature. The methodological basis for studying microbial cellulose utilization is considered relative to quantification of cells and enzymes in the presence of solid substrates as well as apparatus and analysis for cellulose-grown continuous cultures. Quantitative description of cellulose hydrolysis is addressed with respect to adsorption of cellulase enzymes, rates of enzymatic hydrolysis, bioenergetics of microbial cellulose utilization, kinetics of microbial cellulose utilization, and contrasting features compared to soluble substrate kinetics. A biological perspective on processing cellulosic biomass is presented, including features of pretreated substrates and alternative process configurations. Organism development is considered for "consolidated bioprocessing" (CBP), in which the production of cellulolytic enzymes, hydrolysis of biomass, and fermentation of resulting sugars to desired products occur in one step. Two organism development strategies for CBP are examined: (i) improve product yield and tolerance in microorganisms able to utilize cellulose, or (ii) express a heterologous system for cellulose hydrolysis and utilization in microorganisms that exhibit high product yield and tolerance. A concluding discussion identifies unresolved issues pertaining to microbial cellulose utilization, suggests approaches by which such issues might be resolved, and contrasts a microbially oriented cellulose hydrolysis paradigm to the more conventional enzymatically oriented paradigm in both fundamental and applied contexts.
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              Trends in Hospitalizations Related to Invasive Aspergillosis and Mucormycosis in the United States, 2000–2013

              Snigdha Vallabhaneni, Kaitlin Benedict, Gordana Derado … (2017)
              Abstract Background. Invasive aspergillosis (IA) and mucormycosis contribute to substantial mortality, especially among immunocompromised persons, including those with hematopoietic stem cell transplant (HSCT), hematologic malignancy (HM), and solid organ transplant (SOT). Methods. Using International Classification of Diseases, Ninth Revision codes available in the National Inpatient Sample, a hospital discharge database, we estimated IA-related hospitalizations (IA-RH), mucormycosis-RH (M-RH), HSCT-RH, HM-RH, and SOT-RH during 2000–2013. United States census data were used to calculate overall M-RH and IA-RH rates and present trends; estimated annual numbers of HSCT-RH, HM-RH, and SOT-RH served as denominators to calculate M-RH and IA-RH rates occurring with these conditions. Weighted least-squares technique was used to test for linear trends and calculate average annual percentage change (APC). Results. There were an estimated 169 110 IA-RH and 9966 M-RH during 2000–2013. Overall, IA-RH and M-RH rates per million persons rose from 32.8 to 46.0 (APC = +2.9; P < .001) and 1.7 to 3.4 (APC = +5.2%; P < .001), respectively, from 2000 to 2013. Among HSCT-RH, there was no significant change in M-RH rate, but a significant decline occurred in IA-RH rate (APC = −4.6%; P = .004). Among HM-RH, the rate of M-RH increased (APC = +7.0%; P < .001), but the IA-RH rate did not change significantly (APC = +1.2%; P = .073). Among SOT-RH, M-RH (APC = +6.3%; P = .038) and IA-RH rates (APC = +4.1%; P < .001) both increased. Conclusions. Overall IA-RH and M-RH rates increased during 2000–2013, with a doubling of M-RH. Mucormycosis-related hospitalization occurring in conjunction with certain comorbidities increased, whereas IA-RH rates among patients with the comorbidities, decreased, remained stable, or increased to a lesser extent than M-RH.
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                Author and article information

                Journal
                Title: Clinical Infectious Diseases
                Publisher: Oxford University Press (OUP)
                ISSN (Print): 1058-4838
                ISSN (Electronic): 1537-6591
                Publication date Created: April 15 2022
                Publication date Created: April 28 2022
                Publication date Created: July 20 2021
                Publication date Other: April 15 2022
                Publication date (Print): April 28 2022
                Publication date (Electronic): July 20 2021
                Volume: 74
                Issue: 8
                Pages: 1401-1407
                Affiliations
                [1 ]University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
                [2 ]University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
                [3 ]University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
                [4 ]University of Minnesota Department of Environmental Health and Safety, Duluth, Minnesota, USA
                [5 ]University of Virginia Division of Infectious Diseases and International Health, Charlottesville, Virginia, USA
                Article
                DOI: 10.1093/cid/ciab638
                SO-VID: 967e685e-36e7-425e-98d5-4339370cd78a
                Copyright © © 2021
                License:

                https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model

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