Environmental sources of pathogen organisms can sometimes be difficult to narrow down in a health care facility. One possible source of transmission is the laundry used, and not maintaining strict cleanliness attention can put both patients and workers at risk.
Do these linens have pathogens? (Adobe Stock)
The hospital is a busy place, full of myriad devices and complex situations. Preventing hospital-associated infections feels like it requires an encyclopedic knowledge of every new and complicated health care intervention. Potential sources of transmission in the hospital include a remarkable array of specialized risks, but there are mundane, everyday risks like health care laundry too.
Which textiles are reused and laundered varies from health care facility to health care facility. Typical health care linens include patient and staff bedding, towels, clothing (scrubs, coats, uniforms, patient pajamas, and gowns), surgical drapes, curtains, and reusable mop heads. Hospital linens can harbor a significant density of pathogenic organisms, from 106 to 108 colony-forming units/100 cm2. Those most commonly isolated include gram-negative organisms (Enterobacterales, Pseudomonadaceae) as well as Staphylococcus species. 1
Despite this noteworthy pathogenic burden, the significance of linens in health care transmission is unclear. When an infection occurs, it may not be possible to identify the exact environmental source of transmission because multiple potential environmental reservoirs exist in parallel. Although health care linens are not often implicated, it makes intuitive sense that they are a potential reservoir for transmissible organisms.
Workers who handle laundry are at increased risk of transmission, including gastrointestinal pathogens. 2-5 Definitive associations between linen contamination and patient infections are harder to parse. Nevertheless, there is a need for meticulous attention to maintaining linen cleanliness.
It may be simplest to separate hospital linen–associated risks into 3 distinct sections: 1) removal; 2) cleaning; and 3) storage.
Removal
Ensure linens are removed, stored (if necessary), and transported safely to the cleaning facility. Soiled linen poses a danger to health care staff and possibly to patients. All used linen should be considered potentially infectious. Linen should not be shaken or disturbed in a way that could aerosolize infectious particles. Personal protective equipment that would be worn around the patient should also be worn when removing and packaging soiled linen for transport. If there is gross contamination without transmission-based precautions, standard precautions will necessitate the use of additional personal protective equipment. 6 Some infections, including orthopoxviruses, are transmitted by contaminated linen. 7 Linen should be contained before removal from a patient’s room, taking care not to disturb or aerosolize any infectious particles. Note should be made that the exterior of bagged linens may become contaminated, even with double bagging. 8 In many health care settings, soiled linen must be gathered and transported to an off-site location.
Cleaning
Adequate cleaning and disinfection is essential. The 2003 Guidelines for Environmental Infection Control in Health-Care Facilities from the CDC and the Healthcare Infection Control Practices Advisory Committee provides detailed standards for health care laundering, including achieving minimum temperatures and disinfection concentrations that ensure pathogens will be inactivated. 6 In most cases, processing according to these standards should be effective, even with Monkeypox virus. 9 A few organisms may resist disinfection in the laundry. A study looking at the relative thermotolerance of enterococci showed that they were inactivated during the washing cycle, despite tolerance to the high temperatures alone. 10 Clostridioides difficile spores inoculated into cotton sheets and run through a simulated hospital linen washing cycle were noted to remain viable after cleaning. 11 An obvious potential pitfall during cleaning is failure to achieve intended time, temperature, or disinfectant concentration minimums. Excursions may be difficult to detect if laundry is managed off site or by a contractor. A busy infection prevention service may not have the bandwidth to survey off-site or contracted linen services more than once or twice a year. Trust and communication with those responsible for linen processing are critical to ensuring prompt notification and resolution if an issue is discovered.
Clean, processed linen should make it to the patient’s bedside clean. The quintessential infection prevention standard—separation of clean and dirty—must be baked into the management of clean linen. A unidirectional flow at the laundry processing facility will help prevent pathogens from soiled linen coming into contact with the clean linen, even indirectly from the hands or clothing of workers. Laundry surfaces should be routinely disinfected, and hand hygiene should be monitored for compliance. 12 Laundering requires both heat and water—prerequisites for the growth of pathogenic mold. Health care outbreaks of mucormycosis have been linked to linens. 13,14 In a vulnerable patient population, mold exposure is associated with severe or life-threatening infections. If linen must be transported from an off-site facility, it should be covered during transport to prevent contamination. Linens still warm from processing should be allowed to reach ambient temperature before covering, lest condensation and reduced airflow promote mold growth. Once linen arrives in the hospital, it should be unloaded promptly and stored in a manner that prevents contamination.
Storage
Within the clean linen supply, contamination may occur from hands of health care workers accessing clean linens without first performing hand hygiene. Clean storage rooms should be protected and monitored for excursions of temperature, humidity, and damage associated with floods. Costorage with soiled items or devices like refrigerators that include fans, condensation, or generate heat should also be avoided. Prevent contamination by ensuring covers or cabinets are kept closed. Methods of storing and using linens may vary. The astute infection preventionist may need to use shoe-leather epidemiology to identify how linens make it “the final mile” if there is a concern for potential transmission.
If there is a delay from when a bed is made to when a patient occupies the room, how long before linens would be replaced? Is there a mechanism to identify if a bed is used surreptitiously? This may not be a concern for busy facilities with high occupancy, rapid turnover, and adequate call room space, but with the change in elective procedures during the COVID-19 pandemic, there may have been changes to patient and employee flow. A process to ensure linens are freshly made immediately before patient arrival would reduce the risk of contamination.
There are many ways for pathogens to hitch a ride in the hospital environment. Linen is only one of many potential fomites that could be implicated in environmental transmission of hospital pathogens. Ensuring soiled linen is appropriately contained, transported, cleaned, and stored is essential to preventing transmission from this easy-to-overlook aspect of the health care environment.
References
1. Blaser MJ, Smith PF, Cody HJ, Wang WL, LaForce FM. Killing of fabric-associated bacteria in hospital laundry by low-temperature washing. J Infect Dis. 1984;149(1):48-57. doi:10.1093/infdis/149.1.48
2. Ellsbury E, Owosekun O, Mackey K, Ten Eyck D, Mahoney LE. Outbreak of viral hepatitis in the staff of a pediatric ward — California. MMWR. 1977;26(10):77.
3. Borg MA, Portelli A. Hospital laundry workers--an at-risk group for hepatitis A? Occup Med (Lond). 1999;49(7):448-450. doi:10.1093/occmed/49.7.448
4. Standaert SM, Hutcheson RH, Schaffner W. Nosocomial transmission of Salmonella gastroenteritis to laundry workers in a nursing home. Infect Control Hosp Epidemiol. 1994;15(1):22-26. doi:10.1086/646813
5. Fijan S, Steyer A, Poljsak-Prijatelj M, Cencic A, Ostar-Turk S, Koren S. Rotaviral RNA found on various surfaces in a hospital laundry. J Virol Methods. 2008;148(1-2):66-73. doi:10.1016/j.jviromet.2007.10.011
6. US Department of Health and Human Services, Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and the Health Care Infection Control Practices Advisory Committee (HICPAC) 2003. Published 2003. Updated July 2019. Accessed June 27, 2022. https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf
7. Pauli G, Blümel J, Burger R, et al. Orthopox viruses: infections in humans. Transfus Med Hemother. 2010;37(6):351-364. doi:10.1159/000322101
8. Maki DG, Alvarado C, Hassemer C. Double-bagging of items from isolation rooms is unnecessary as an infection control measure - a comparative-study of surface contamination with single-bagging and double-bagging. Infect Control. 1986;7(11):535-537. doi:10.1017/s0195941700065279
9. Infection prevention and control of monkeypox in health care settings. CDC. Updated May 22, 2022. Accessed June 29, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-health care.html
10. Orr KE, Holliday MG, Jones AL, Robson I, Perry JD. Survival of enterococci during hospital laundry processing. J Hosp Infect. 2002;50(2):133-139. doi:10.1053/jhin.2001.1137
11. Tarrant J, Jenkins RO, Laird KT. From ward to washer: the survival of Clostridium difficile spores on hospital bed sheets through a commercial UK NHS health care laundry process. Infect Control Hosp Epidemiol. 2018;39(12):1406-1411. doi:10.1017/ice.2018.255
12. Fijan S, Sostar-Turk S, Cencic A. Implementing hygiene monitoring systems in hospital laundries in order to reduce microbial contamination of hospital textiles. J Hosp Infect. 2005;61(1):30-38. doi:10.1016/j.jhin.2005.02.005
13. Cheng VCC, Chen JHK, Wong SCY, et al. Hospital outbreak of pulmonary and cutaneous zygomycosis due to contaminated linen items from substandard laundry. Clin Infect Dis. 2016;62(6):714-721. doi:10.1093/cid/civ1006
14. Sundermann AJ, Clancy CJ, Pasculle AW, et al. Remediation of mucorales-contaminated health care linens at a laundry facility following an investigation of a case cluster of hospital-acquired mucormycosis. Clin Infect Dis. 2022;74(8):1401-1407. doi:10.1093/cid/ciab638
