, an assistant professor at the University of Pittsburgh’s Division of Infectious Diseases, Center for Genomic Epidemiology, is dedicated to advancing the field of outbreak detection and investigation in health care settings through his research and utilization of whole genome sequencing surveillance. He is also an 

Alexander Sundermann, DrPH, CIC, FAPIC

In 2023, several patients underwent routine knee surgeries at Parkwest Surgery Center in Knoxville, Tennessee. As we previously shared in 

, those procedures were followed by persistent infections caused by 

, a non-tuberculous mycobacterium (NTM) linked to the surgical environment.

 Now, that outbreak is the subject of active litigation. Lawsuits allege the center failed to follow infection control protocols and continued operating despite signs of ongoing transmission.

While the Parkwest case is still unfolding, it reflects a broader challenge: how can hospitals both detect and respond to outbreaks before they cause widespread harm—and legal exposure? Increasingly, health care systems are turning to more advanced tools to answer this question. Among them, pathogen genomics has emerged as a powerful way to detect transmission events early and accurately.

Yet, as more hospitals explore using genomic surveillance—sequencing infections regardless of the suspicion of an outbreak—a recurring concern surfaces: 

Will detecting more outbreaks expose us to more lawsuits?

Based on my work and discussions with hospitals across the country, the short answer is: not if you act. In fact, genomic surveillance may prove to be one of the strongest shields against litigation when used proactively and ethically.

Historically, proving a direct link between a hospital’s environmental conditions and a patient’s infection has been challenging in court. Outbreaks often unfold subtly and over long periods. But pathogen genomics changes that calculus. By comparing pathogen genomes from patients, equipment, or the environment, genomics can determine whether infections likely originated from a common source. This powerful evidence can support—

An example worth noting involves contaminated duodenoscopes, which were linked to superbug outbreaks in multiple U.S. hospitals during the 2010s. Though genomics wasn’t central to the lawsuits, outbreak investigations helped reveal that design flaws in the scopes—not hospital error—were likely responsible for the infections. Internal emails from the device manufacturer showed the company was aware of the contamination risks but delayed issuing warnings.

 In this case, strong investigative work and timely detection shifted liability from hospitals to the manufacturer, demonstrating how these tools can protect institutions when problems originate externally.

Genomic surveillance raises the evidentiary bar. It can help confirm that a hospital is not the source of an infection, or identify the route and stop transmission quickly, reducing harm and legal exposure.

Surveillance Is Not Negligence—Inaction Is

Detecting more outbreaks through genomic surveillance does not equate to more hospital negligence. Negligence stems from inaction, not detection. If your team identifies an outbreak through genomics and responds swiftly—enhancing cleaning, auditing practice, and notifying stakeholders—you are doing exactly what any reasonable infection preventionist is supposed to do.

In contrast, ignoring those signals—letting genetically linked infections spread without meaningful intervention—may increasingly be viewed as a breach of duty. As US courts grow more familiar with microbial forensics, failure to act on clear genomic and epidemiological evidence could be cited as a delayed or negligent response. Importantly, genomic data should never stand alone. Just as the FDA and CDC emphasize in outbreak investigations, sequencing results must be interpreted in the broader epidemiological context, considering time, place, and patient exposures to draw meaningful conclusions before action.

 This is why genomic surveillance should be viewed not as a risk but as a mitigation strategy. It provides earlier warning, more precise targets for intervention, and an evidence trail to demonstrate due diligence if a case ever arises.

Currently, genomic surveillance is not a defined standard of care in the US. But we are moving in that direction. Imagine 2 hospitals: Hospital A uses genomic surveillance, identifies an emerging outbreak at 2 cases, and contains it. Hospital B does not use surveillance and has 15 infections before realizing a problem. If the pathogens in Hospital B are genetically identical and traceable to a common environmental source, plaintiffs may argue those infections—and possibly deaths—could have been prevented if Hospital B had adopted available surveillance tools.

If we go back to the Parkwest Surgery Center case, multiple cases were reported until the outbreak was detected. But what if the center had been performing sequencing on these infections as they unfolded? They may have been able to detect, intervene, and stop the outbreak earlier. This is how standards evolve: not overnight, but incrementally, through cases, peer-reviewed evidence, and professional expectations.

So why the hesitation among hospitals? Often, it is rooted in a misconception: That finding more means you’re doing worse. In reality, the opposite may be true. Traditional infection prevention methods miss many outbreaks entirely. Genomics simply makes the invisible visible.

Studies from hospitals globally have shown that genomic surveillance detects many more outbreaks than traditional methods and that interventions stemming from these findings reduce infections and save costs.

 The hesitation should not be “What if we find more?” but rather, “What are we missing now—and what could it cost us later?”

What Does This Mean for Infection Preventionists?

As an infection preventionist, your role is to reduce harm, improve safety, and respond decisively to threats. Genomics gives you a sharper lens to do just that. It is not a liability. It amplifies your expertise.

Moreover, transparency and preparedness remain the best legal defense. If an outbreak occurs, being able to show that you had tools in place to detect and intervene—not just react—strengthens your position with regulators, patients, and even courts. Hospitals should not wait for genomics to be mandated before beginning to build capacity. Early adopters are already shaping the expectations of what responsible, modern infection prevention looks like.

We may not be able to prevent every infection. But we can prevent many from spreading undetected. Genomic surveillance is not a legal threat—it is a legal safeguard. When paired with strong infection control and prevention protocols, it becomes a vital part of the patient safety ecosystem. Genomic surveillance is not about creating new problems, but it’s about catching the ones we’ve been missing.

The views expressed here are my own and do not reflect those of any institution with which I am affiliated. This commentary is not intended as legal advice.

1.Sundermann A. Non-tuberculous Mycobacterium Outbreak at Surgery Center Highlights Infection Control Lapses. 

. May 13, 2025. Accessed May 15, 2025. https://www.infectioncontroltoday.com/view/non-tuberculous-mycobacterium-outbreak-surgery-center-highlights-infection-control-lapses

2.10Investigates: Surgery center faces lawsuits over infections following 2023 procedures. wbir.com. May 7, 2025. Accessed May 15, 2025. https://www.wbir.com/article/news/local/parkwest-surgery-center-faces-lawsuits-over-infections/51-7daf1a25-bcee-41b7-becd-fdb222ebccc9

3.Sundermann AJ, Rosa R, Harris PNA, et al. Pathogen genomics in healthcare: overcoming barriers to proactive surveillance. 

. 2024;69(1):e01479-24. doi:10.1128/aac.01479-24

4.Terhune C. Olympus Told U.S. Executives No Broad Scope Warning Needed Despite Superbug Outbreaks. KFF Health News. July 24, 2016. Accessed May 15, 2025. https://kffhealthnews.org/news/device-maker-told-its-u-s-operation-no-warning-needed-on-scope-contamination-risk/

5.Brown E, Dessai U, McGarry S, Gerner-Smidt P. Use of Whole-Genome Sequencing for Food Safety and Public Health in the United States. 

. 2019;16(7):441-450. doi:10.1089/fpd.2019.2662

Articles

A string of infections following routine knee surgeries in Tennessee has escalated into litigation, raising questions about how—and when—health care facilities should detect outbreaks. As genomic surveillance gains traction in infection prevention, some fear it could increase legal risk. In reality, it may offer hospitals their strongest legal defense.



Outbreak Detection, Patient Protection: The Legal Upside of Genomics in Infection Prevention

An oral abstract presented by Simone Godwin, DVM, MPH, CIC, at the SHEA Spring 2025, spotlighted a rare but revealing outbreak of 

 at an ambulatory surgical center (ASC) in Tennessee—an incident that exposed the vulnerability of outpatient surgery centers when infection prevention systems are overly complex or fragmented.

The conference was held from April 27 to 30, 2025, in ChampionsGate, Florida.

The outbreak first came to light in July 2023, when 5 patients developed 

 joint infections after procedures at the same ASC. Though the organism is an environmental pathogen, the fact that this center had so many in such a short time prompted a public health investigation.

That is when the real issues began to emerge. The ASC was part of a complex operational setup: a hospital-owned building, a privately run surgical group, and a separate management company overseeing operations. The facility was noted to lack a water management plan, had no certified sterile processing staff, and its infection preventionist (IP) juggled multiple unrelated roles. Notably, there is no law in Tennessee requiring ASCs to report surgical site infections, so there was no formal mechanism in place to detect an outbreak or issue.

 was not recovered from the ASC’s water or environment, investigators found multiple lapses in reprocessing and aseptic technique. A case-control study pointed to 1 unlicensed surgical technologist as being significantly associated with the infections. That technologist later began working at a second ASC where yet more cases emerged. Whole-genome sequencing confirmed the cases from both centers were genetically identical, linking them to a single source.

Infection Prevention Challenges in Outpatient Surgery

This outbreak reflects broader national concerns that all in infection prevention and control (IPC) are very familiar with for ASCs. These facilities have historically operated with less oversight than hospitals, despite now performing increasingly complex procedures such as joint replacements, advanced endoscopy, and pain management interventions. A 2010 study published in 

 found that 67% of Medicare-certified ASCs had at least 1 infection control lapse, with nearly 1 in 5 having violations in 3 or more key areas—including improper equipment reprocessing, unsafe injection practices, and lapses in environmental cleaning. Notably, 28% did not follow the recommended practices for reprocessing equipment.

While efforts have been made in the years since to raise the bar, the oversight gap has likely not fully closed. ASCs are still not held to the same mandatory surgical site infection surveillance or reporting standards as hospitals.

 Infection preventionists (IPs) working in ASCs may be part-time, cover multiple sites, or have limited authority, especially in privately owned or joint venture centers. In many cases, IPC programs exist on paper but lack the necessary staffing, resources, or influence to enforce best practices on a day-to-day basis. A 2024 review in the 

 further underscored this issue, noting that IPs are predominantly employed in hospitals, with relatively few working in ambulatory settings like ASCs—leaving significant gaps in infection prevention oversight across the outpatient care spectrum.

This patchwork of responsibility, especially when multiple entities (building owners, hospital systems, surgical groups, and ASC management firms) are involved, makes it easy for infection prevention efforts to fall through the cracks. The outbreak is a striking example of how systemic weaknesses—like unclear roles, untrained staff, and no surveillance mechanisms—can compound and allow preventable infections to spread undetected.

NTM Infections: Why Reporting Even One Case Matters

The Council for Outbreak Response: Healthcare-Associated Infections and Antimicrobial-Resistant Pathogens (CORHA)—a national collaborative that includes CDC, Council of State and Territorial Epidemiologists (CSTE), public health departments, and the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infeciton Control and Epidemiology (APIC) experts—has also issued guidance specific to nontuberculous mycobacteria.

According to CORHA, even a single case of extrapulmonary nontuberculous mycobacteria (NTM) infection (such as those involving surgical sites or joint infections) should prompt reporting to public health and investigation by the facility.

 CORHA’s recommendations emphasize that extrapulmonary NTM cases are often tied to environmental sources and may be early signs of a broader outbreak. CORHA encourages immediate notification of public health authorities and outlines steps for investigation, including environmental assessments, infection control reviews, and molecular testing of isolates when available. These tools help identify pseudo-outbreaks versus true health care-associated clusters and reinforce the importance of early detection, particularly in outpatient settings where routine surveillance may be limited.

The lesson is clear: outpatient surgical centers must treat infection prevention as foundational—not optional. Certification for sterile processing staff, structured onboarding and credentialing, and routine infection surveillance are critical safeguards. With groups like CORHA reinforcing that even a single extrapulmonary NTM case warrants public health reporting, the bar for vigilance is clear. As ASCs continue to expand their procedural scope, their infection control infrastructure must grow in parallel to prevent the kind of harm that is both devastating and, in many cases, preventable.

Godwin S. Lessons from an Outbreak of Mycobacterium fortuitum in an Ambulatory Surgery Center. Oral abstract presented at: SHEA Spring 2025 Conference; April 2025; Orlando, FL.

Schaefer MK, Jhung M, Dahl M, et al. Infection control assessment of ambulatory surgical centers. 

. 2010;303(22):2273–2279. doi:10.1001/jama.2010.744

National Healthcare Safety Network (NHSN) Surgical Site Infection Surveillance (SSI) for Ambulatory Surgery Centers. Alexandria, VA: ASCA; 2013. Accessed May 12, 2025. 

https://apic.org/Resource_/TinyMceFileManager/Academy/ASC_101_resources/Surveillance_NHSN/ASCA_NHSN_SSI_Surveillance_2013.pdf

Knighton SC, Engle J, Berkson J, Bartles R. A narrative review of how infection preventionist (IP) staffing and outcome metrics are assessed by health care organizations and factors to consider. 

. 2024;52(2):91–106. doi:10.1016/j.ajic.2023.06.017

Council for Outbreak Response: Healthcare-Associated Infections and Antimicrobial-Resistant Pathogens (CORHA). Nontuberculous Mycobacteria (NTM): Recommended Practices for Healthcare Outbreak Response. August 2022. Accessed May 12, 2025. 

https://corha.org/assets/documents/CORHA-Proposed-NTM-Thresholds-and-Definition-08-19.pdf

A rare Tennessee outbreak of Mycobacterium fortuitum revealed deep gaps in infection prevention at outpatient surgery centers—where oversight, staffing, and reporting often fall short.

Non-tuberculous Mycobacterium Outbreak at Surgery Center Highlights Infection Control Lapses

Endoscopy at the hospital. Doctor holding endoscope before gastroscopy

Issues with endoscopes and lumened surgical instruments are nothing new to infection prevention and control (IPC) professionals. For years, we’ve seen outbreaks, recalls, and redesigns, yet the risks never seem to disappear completely. Recently, 2 new studies published in 

 (AJIC) shine a light on some alarming findings, reminding us why vigilance in reprocessing these devices is still crucial.

, details an outbreak of OXA-181 carbapenemase-producing 

 at a hospital in Mecklenburg-Western Pomerania, Germany. In the initial phase of the outbreak, 19 patients were affected, and 16 had undergone endoscopic procedures. Investigators eventually traced the bacteria to a contaminated colonoscope. In response, the hospital took a drastic step—they replaced all old endoscopes (greater than 10 years old) with brand-new ones.

Problem solved, right? Not quite. Even with new scopes, contamination persisted. In follow-up testing, 4 out of 67 newly reprocessed endoscopes still harbored bacteria, including a gastroscope that tested positive for the outbreak strain. When researchers dismantled some of the scopes, they found cracks, wear, and biofilm formation, along with tolerance to peracetic acid (PAA)—the very disinfectant used for reprocessing.

This study drives home a key point: Replacing old scopes isn’t a magic fix if reprocessing issues and biofilm formation persist. Even brand-new equipment isn’t immune to contamination risks.

AJIC Study: Cleaning Challenges with Lumened Surgical Instruments

, led by Cori Ofstead, MSPH, a well-known expert in this field, takes a deep dive into lumened surgical instruments used in orthopedic; neurologic; and ear, nose, and throat procedures. The research team inspected 117 instruments across 40 different types using a borescope—an inspection tool that lets you see inside hard-to-reach places.

What they found was shocking but, sadly, not surprising. Every single instrument had visible debris, rust, or soil, even after cleaning. Brown and rust-colored patches were present in 95% of the instruments, and 73% contained lint or brush bristles. Many of the instruments had design features that physically blocked access for cleaning brushes, making proper decontamination nearly impossible. Even when technicians followed the manufacturer’s instructions for use (IFU) perfectly, contamination still remained.

That last point is especially frustrating. In IPC, we often assume that if we stick to the manufacturers’ instructions for use (IFUs), we’re doing everything “by the book.” But what happens when the book itself is flawed? The authors didn’t just identify problems—they also provided solutions. One key takeaway was that hospitals should send contaminated instruments back to manufacturers and push for real-world testing. IFUs should reflect the actual conditions of sterile processing departments, not just ideal lab settings.

The Takeaway: IFUs Aren’t Gospel—Stay Vigilant

Both studies reinforce a hard truth in infection prevention: just because you’re following the IFU doesn’t mean your instruments are actually clean. We need to stay skeptical, keep testing, and push for better design and oversight.

For infection preventionists, the message is clear: keep an eye on your scopes and lumened instruments. Question the status quo. If these studies show us anything, it’s that contamination can persist despite our best efforts—so we need to be relentless in the fight against it.

Two new studies reveal troubling contamination in both new endoscopes and cleaned lumened surgical instruments, challenging the reliability of current reprocessing practices and manufacturer guidelines.

Endoscopes and Lumened Instruments: New Studies Highlight Persistent Contamination Risks

Department of Health and Human Services (HHS)

When budgets are slashed, it’s easy to overlook what disappears until it’s too late. But this week’s sweeping layoffs across the Department of Health and Human Services (HHS)—meant to save a mere 0.1% of its overall budget—are anything but trivial. These cuts represent the unraveling of the very fabric that protects Americans from everyday health threats. From safeguarding newborns to managing pandemic supplies, ensuring prescription safety to preventing workplace injuries, entire public health programs were wiped out in one fell swoop.

Alexander Sundermann, DrPH, CIC, FAPIC, an infectious disease researcher and a member of the Infection Control Today

Editorial Advisory Board, has laid out in sobering detail just how deeply these decisions will affect communities—particularly the most vulnerable. 

These are not abstract policy changes—they’re personal, measurable losses in safety, services, and lives. Infection prevention personnel, already strained by understaffing and rising demands, now face a gutted infrastructure and disappearing federal support. The downstream effects will cascade into hospitals, nursing homes, dental clinics, community centers, and beyond.

These aren't bureaucratic trims. They are targeted dismantling of systems designed to keep people safe—systems built over decades. The damage is real, and the consequences will be felt across generations if swift action is not taken to reverse course.

Here’s how this week’s federal HHS layoffs—𝘄𝗵𝗶𝗰𝗵 𝘄𝗶𝗹𝗹 𝘀𝗮𝘃𝗲 𝗼𝗻𝗹𝘆 𝟬.𝟭% 𝗼𝗳 𝗶𝘁𝘀 𝗯𝘂𝗱𝗴𝗲𝘁—affect everyone. These are aggregated from various news articles I doom-scrolled on April 1, 2025:

▶️Are you a 𝗽𝗮𝗿𝗲𝗻𝘁?
CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) was eliminated. This team collected data from states to understand pregnancy complications and reduce infant deaths. If you’ve received prenatal health guidance—PRAMS probably informed it.

▶️Work in a job with possible 𝗲𝘅𝗽𝗼𝘀𝘂𝗿𝗲𝘀?
National Institute for Occupational Safety and Health (NIOSH) lost over 800 staff. Teams monitoring toxic exposures and other job-related illnesses and injuries were eliminated.

▶️Know someone affected by 𝗮𝗱𝗱𝗶𝗰𝘁𝗶𝗼𝗻/𝘀𝘂𝗶𝗰𝗶𝗱𝗲?
Substance Abuse and Mental Health Services Administration (SAMHSA) cut staff supporting state opioid overdose and suicide surveillance programs.

▶️Take prescription 𝗺𝗲𝗱𝗶𝗰𝗮𝘁𝗶𝗼𝗻?
FDA’s Center for Drug Evaluation and Research (CDER) lost over 800 staff—those who review new drugs, monitor side effects, and update safety labels.

▶️Worried about injuries, 𝗮𝘀𝘁𝗵𝗺𝗮, lead poisoning, or gun violence?
CDC cut teams working on injury prevention, environmental health, and national data systems like Web-based Injury Statistics Query and Reporting System (WISQARS).

▶️Had a 𝗱𝗲𝗻𝘁𝗶𝘀𝘁 appointment recently?
The National Institute of Dental and Craniofacial Research eliminated its education and outreach division, which promoted childhood oral health and prevention.

▶️Rely on rural or community 𝗵𝗲𝗮𝗹𝘁𝗵𝗰𝗲𝗻𝘁𝗲𝗿𝘀?
HRSA’s Bureau of Primary Health Care, which serves 31 million people, lost a third of its staff. This affects prenatal care, HIV programs, and access in underserved areas.

▶️Ever had an 𝗶𝗻𝗳𝗲𝗰𝘁𝗶𝗼𝘂𝘀 disease?
Entire teams working on HIV, tuberculosis, and global health preparedness were cut. Even the acting director of National Institute of Allergy and Infectious Diseases (NIAID) was placed on leave.

▶️Think emergency 𝘀𝘂𝗽𝗽𝗹𝗶𝗲𝘀 matter?
The Strategic National Stockpile team—responsible for pandemic PPE, vaccines, and critical medical equipment—was hit.

▶️Have a loved one in 𝗹𝗼𝗻𝗴-𝘁𝗲𝗿𝗺𝗰𝗮𝗿𝗲 or on Medicare?

Centers for Medicare & Medicaid Services (CMS) lost staff focused on nursing home oversight, home health inspections, fraud detection, and minority health rights.

▶️Support 𝗿𝗲𝗽𝗿𝗼𝗱𝘂𝗰𝘁𝗶𝘃𝗲 health abroad?
United States Agency for International Development (USAID) funding for global family planning was terminated, cutting off contraception access for nearly 50 million people.

▶️Need help with utility bills or emergency support?
The entire federal staff of the Low Income Home Energy Assistance Program (LIHEAP) was laid off. This program helped low-income families keep the lights and heat on.

▶️Care about tobacco prevention and cessation?
CDC’s Tobacco Control Program was gutted, pausing key efforts to reduce smoking-related deaths.

▶️Value government transparency?
CDC’s Freedom of Information Act (FOIA) office was eliminated, cutting off public access to health data and records.

These aren’t administrative trims. These are broad, systemic cuts targeting the very people and programs that keep the public healthy and safe.

𝗵𝗮𝗿𝗲. We all have something to lose.

These Department of Health and Human Services' layoffs save only 1% of the overall governmental budget. What are we losing when these are gone?

What Is Lost? Federal HHS Layoffs 

In health care settings, identifying commonly used surfaces that require frequent disinfection to reduce the risk of health care–associated infections (HAIs) is often straightforward. However, managing health care linens (HCLs) is less so. HCLs have been implicated in multiple hospital outbreaks, primarily associated with mold contamination, leading to serious and sometimes prolonged adverse patient outcomes.

 Despite their pervasive use—from outpatient settings and emergency departments to inpatient stays and operating rooms—HCLs are not directly regulated by any federal body, even though they come into contact with patients at every stage of care.

 If not properly cleaned, these linens could pose significant infection risks. What are the best management strategies to ensure HCLs are safe? Has your facility identified any potential issues? This article aims to prompt a closer examination of your processes and encourage proactive measures to safeguard patient health.

Prior studies and reviews have highlighted the association of HCLs with large outbreaks in health care facilities. Perhaps most notably, a mucormycosis outbreak occurred in a New Orleans, Louisiana, children’s hospital in 2008 and 2009; 5 children developed serious infections and died.

 Mucormycosis is a severe infection caused by fungi in the order Mucorales; it mainly affects immunocompromised patients and has a high mortality rate.7 The CDC investigation identified multiple pieces of linen contaminated with mold of the genus Rhizopus, which was implicated in the outbreak.

More recently, a CDC study documented a prolonged outbreak involving 16 patients with mucormycosis over 2 years at an Arkansas hospital.

 The investigation revealed significant issues at the offsite laundering facility, including dust accumulation and a lack of airflow controls, which exposed the clean HCLs to the outdoor environment.

HCL-related outbreaks are not restricted to molds. Lynne Sehulster, PhD, published a 2015 review of previously detected HCL outbreaks involving multiple pathogens.

 A more recent investigation into neonatal Bacillus infections further underscores the risks, revealing that despite meeting microbiological standards, laundered linens can still harbor harmful bacteria such as Bacillus cereus, where their presence on a piece of HCL allowed for bacterial growth and propagation under certain conditions.

At our hospital, UPMC Presbyterian Hospital in Pittsburgh, Pennsylvania, we conducted an investigation prompted by an outbreak of 4 mucormycosis cases over 11 months.

 Early in the investigation, environmental surveillance cultures and epidemiological data pointed to a possible HCL source at an offsite laundering facility. Stepwise cultures taken at various points in the HCL laundering process revealed a significant increase in fungal contamination after the drying step. A review of the offsite laundering facility’s roof, where intake air for the dryer was sourced, revealed unfiltered air being drawn in next to lint accumulation on the roof that tested positive for molds. We remediated the issue by enhancing lint management and cleaning procedures within the offsite laundering facility, which resulted in culture-negative HCLs arriving at our hospital.

The trend in HCL-related outbreaks challenges traditional infection prevention methods for detecting outbreaks. These outbreaks often involve only a few patients and are spread over months or even years.

 Typically, infection preventionists (IPs) are trained to suspect outbreaks when clusters of cases appear within a few weeks, often confined to specific units. However, because HCLs are used throughout an entire hospital, these outbreaks may present in patients across different units, making them harder to detect. An outbreak is defined as any increase in cases over an established baseline. In the case of mucormycosis, which is typically rare and occurs in immunocompromised patients, hospitals should expect no health care–acquired cases.

 Therefore, even a single case or 2 should raise suspicion and prompt an investigation, with HCLs being a key area to examine.

Infection Control Today's October Trending Topic: Environmental Hygiene

Recognizing the need to understand the scope of HCL contamination beyond our facility, we expanded our investigation with the Mucorales on Unclean Linen Discovery (MOULD) study.

 This study examined the mold contamination rate of HCLs at 15 large transplant and cancer hospitals across the US in 2017. By culturing HCLs as they arrived at these facilities, we aimed to measure how often “clean” HCLs were delivered to high-risk patient environments. We found that 7 of 15 (47%) facilities had Mucorales present on their HCLs, and 3 of 15 (20%) failed to meet our greater than 90% HCL Mucorales culture negativity threshold.

 These findings underscore the need for a closer examination of who oversees the management of HCLs.

The Association for the Advancement of Medical Instrumentation and the CDC provide HCL management guidelines.

 However, The Joint Commission does not oversee HCLs within health care facilities.13 Professional societies, such as the Association for Professionals in Infection Control and Epidemiology (APIC), have developed best practice recommendations for HCL management.

 Yet none of these guidelines come with direct regulatory oversight or the authority to enforce punitive measures if standards based on them are not met.

Some third-party organizations, such as the Textile Rental Services Association (TRSA) and the Healthcare Laundry Accreditation Council (HLAC), offer accreditation based on their developed standards.

 These certifications aim to produce “hygienically clean” linens, meaning they are free of pathogens in numbers sufficient to cause human illness. However, the exact threshold of pathogens needed to cause an infection is unknown, making it challenging to define specific pathogen limits. Moreover, during our MOULD study in 2017, an HLAC or TRSA certification at the offsite laundering facility was not associated with meeting our threshold for Mucorales-free HCLs.

 However, since our publication, both TRSA and HLAC have updated and enhanced their guidelines.

The journey of a piece of HCL may seem straightforward but is fraught with numerous opportunities for contamination. Take a washcloth, for example. The washcloth is considered contaminated after being used on a patient and should be placed in a laundry bag (ideally not a biohazard bag). Once collected, these laundry bags are typically stored temporarily before being transported via truck to a third-party laundering facility. The bags are opened there, and the linens are sorted by type. The sorted items then pass through industrial washers, followed by drying, and are subsequently moved to a folding or packaging area. Once cleaned and packaged, the linens are shipped back to the health care facility, where they are often stored in a centralized area before being distributed to individual patient units and care areas. Each step in this process presents potential risks for contamination, emphasizing the need for stringent controls and monitoring.

What can an infection prevention and control department do to ensure that its health care facility’s HCLs will not cause illness? In 2022, a study led by Janet Glowicz, PhD, and colleagues at the CDC provided a comprehensive review that compiled various guidelines and case studies, resulting in practical checklists for IPs.

 This report identifies potential failure points of the HCL process that could lead to the contamination of HCLs, making it a valuable addition to the IP toolbox. In our experience, establishing a close partnership with your laundry facility is essential for successfully implementing any auditing process or changes. The first step in this process should be reaching out to your laundry or supply chain partners—if you have not already done so—to arrange a tour of your laundry facility. Bring along the checklist by Glowicz et al (see Supplementary Materials in the study) and walk through the entire process, identifying any areas of concern.

Additionally, consider what contamination levels would be deemed elevated in the event of an outbreak. If you have not already, taking baseline cultures and samples will allow your facility to compare them to retrospective samples when no outbreaks or HCL-related infections are suspected, providing a valuable reference point for future investigations. It is important to ensure that these samples’ locations are strategically chosen to provide meaningful data. It would be best to decide whether your facility or the laundry facility should be responsible for taking these samples. Consider the types of linens (eg, pillowcases, blankets) and the number and frequency of samples to be taken. These decisions, particularly regarding sample collection, should be made collaboratively with your health care facility team and the laundry facility to ensure a comprehensive approach to preventing contamination and safeguarding patient health.

In the future, many aspects of laundering HCLs can be addressed in infection prevention and control. First, scientific studies that associate the level of contamination in HCLs with the development of patient infections are crucial for establishing a more definitive threshold for what constitutes hygienically clean linen. Such studies would need to involve multiple facilities across various patient populations and regions. Second, stronger partnerships should exist between health care facilities, health agencies, laundering facilities, and third-party certification groups. Multidisciplinary collaborations could help develop best practices and standardize guidelines across cleaning,
storing, and using HCLs for patients. Third, some level of enforcement is necessary to ensure health care and laundering facilities adhere to these guidelines. The Centers for Medicare & Medicaid Services could drive this enforcement through reimbursement metrics like those used for reporting HAIs and antimicrobial use and resistance reporting. Lastly, health care facilities that suspect or investigate HCL-related outbreaks or infections should be encouraged to share their findings rather than discouraged from publishing them. Increased transparency and the sharing of experiences will allow other health care facilities to benefit from the aggregated findings of outbreaks, helping the field of infection prevention and control to more accurately measure the burden of HCL-related issues and improve practices across the board.

At the APIC 2023 Annual Conference & Exposition, Glowicz and I copresented on her report and our experiences at the University of Pittsburgh in investigating HCL outbreaks, identifying the causes of contamination, and ensuring an enhanced level of safety. Through sharing our work and the contributions of many others in this critical area, we aim to inspire and empower IPs to take proactive measures in their facilities to safeguard their patients. By fostering a culture of vigilance and collaboration, we can collectively advance the standards of HCL management and enhance patient safety across all health care settings.

1. Sehulster LM. Healthcare laundry and textiles in the United States: review and commentary on contemporary infection prevention issues. 

. 2015;36(9):1073-1088. doi:10.1017/ice.2015.135

2. Cheng VCC, Chen JHK, Wong SCY, et al. Hospital outbreak of pulmonary and cutaneous zygomycosis due to contaminated linen items from substandard laundry. 

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Health care linens are critical yet overlooked infection risks. Ensure proactive management by auditing laundering processes to prevent contamination and safeguard patient health across care settings. Read this article by Alexander Sundermann, DrPH, CIC, FAPIC.