5 deaths linked to infections tied to hospital linens

The five children ranged in age from 35 days to 13 years. They arrived at Children’s Hospital from different homes, had severe illnesses of various types and were admitted to assorted hospital wards in 2008 and 2009.

The one thing the three boys and two girls had in common, before they all died, was the hospital linens, and that’s how they were infected by a nasty fungus that ate them away, according to a soon-to-be-published research study.

News of the outbreak, five years after investigators with the U.S. Centers for Disease Control and Prevention sleuthed out its likely source, prompted a former New Orleans city health director to slam the hospital and state on Tuesday for failing to sound the alarm to the public when it happened.

While hospital officials and a CDC doctor defended the response to the flesh-eating fungus infection, at least one family of a child who died after contracting mucormycosis in the outbreak blames the hospital, the state, doctors and a linen company for the ravages their son endured before dying.

Among other claims, Stephen Tyler and Dorothy Malik allege that doctors failed to promptly order a biopsy of a black spot the size of a quarter that appeared on 13-year-old Zachary Tyler’s armpit in March 2009.

The spot would soon grow to the size of a baseball, and then another appeared at the base of his spine. The malpractice suit, filed four years ago in Orleans Parish Civil District Court, describes a horrifying ordeal as doctors cut away tissue and major muscle and performed a colonostomy over more than 20 procedures to stave off further spread of the fungal infection.

Zachary, who came to Children’s Hospital with a rare blood disease, ultimately succumbed to a herpes infection on May 17, 2009, while on a ventilator, the lawsuit states.

Only a year later did the family learn “from a confidential source that in 2009 there was an outbreak of mucormycosis at Children’s Hospital as a result of contaminated linens supplied by TLC Services, Inc. and that as a consequence of this outbreak five patients died, including Zachary Tyler,” the lawsuit states.

The 14-page article about the outbreak, to be published in the Pediatric Infectious Disease Journal next week, did not name the three companies that Children’s Hospital had employed to clean and provide bedding, gowns and other linens.

A call for a response from TLC Services went unreturned.

CDC investigators weeded out other possible sources for the deaths, including lotions, soaps, medication, tongue depressors and medical equipment. According to the report, “the only such exposure all the case-patients had in common was hospital linens.”

Sophisticated testing linked fungi in the linen with the same “isolates” in the infected young patients.

“The organism is very invasive. It can invade through tissue planes, and it likes iron, so it invades blood vessels. You can also inhale it. It can cause very severe pulmonary disease, and it sort of just chews through you,” said Dr. Tom Chiller, a CDC medical epidemiologist who specializes in fungi.

“These are incredibly — thankfully — rare infections, and they’re very severe.”

According to the article, once the source of the outbreak was known, the hospital changed its linen supply company and where it offloaded the trucks, removed all the old linen, disinfected storage areas and began sterilizing linens for high-risk patients with compromised immune systems.

Dr. John Heaton, associate medical director for patient quality and safety at Children’s Hospital, said the hospital acted quickly, recognizing a commonality in skin lesions on two patients in a special care unit in 2009. The hospital immediately called in state health officials and the CDC, he said.

“That set off the alarm,” Heaton said. “As soon as we noticed, as is our policy anytime there’s an outbreak, we jump on it with both feet.”

Heaton also said all five patients who died from mucormycosis already suffered from other serious medical conditions and had severely compromised immune systems.

“It only occurs in patients who are deathly ill. In fact, the fungus was not the primary cause of death in any of these patients. They had numerous other reasons to succumb,” he said.

The article does not name the five patients, who were admitted from July 2008 to May 2009. Two had heart conditions, two had blood diseases and one was a pre-term birth.

All five were first infected on their skin, a signal that helped steer the hospital and researchers toward linens. One girl died within a day of her diagnosis with the fungal infection. Tyler lived for 54 days after doctors figured it out.

Harry Widmann, an attorney for Tyler’s parents, said the parents did not want to comment on the case.

“This is an ongoing matter. We are working to make sure everyone responsible is held accountable,” Widmann said in a statement.

Dr. Brobson Lutz, the former city health director, said the hospital should have let the world know.

“I’m not sure that Children’s would have suffered all that much criticism had they said, ‘Look, we found a problem we didn’t know exists.’ Whenever one place finds a problem like this, it’s usually a system problem. It’s usually other places. The fact they kept this under wraps to me is just near-criminal,” Lutz said.

“I don’t think the normal citizen needs to take any more protection, but if I had a child who had an immunological disorder, had a cancer, I would want that information. I’d be more concerned about the bed linens my child had and such.”

While the research is only coming out now, epidemiologists presented their early findings on the outbreak to their colleagues at a conference four years ago in Atlanta.

Heaton said the hospital spread the word aggressively to doctors throughout the hospital, and the findings appeared in “hospital laundry publications.”

He called Lutz’s criticism “decidedly unfair.”

“We were very proactive about getting the word out about this. Any assertion we tried to keep this from anybody is flat wrong,” Heaton said.

He said the hospital also gave the CDC consent to report its findings in 2009. Heaton said the hospital alerted patients who were infected, but did not tell patients and their family members throughout the hospital about the outbreak.

“I don’t know that we typically would do that, and I don’t believe we did it at the time,” he said. “It’s impossible to predict who might be vulnerable with immuno-suppression. Our efforts were toward eradication of the infections and protecting patients.

“We felt spreading the word through the proper industry to the people actually taking care of these patients would be more effective than putting it on the general media. There’s certainly a lot of potential for misunderstanding.”

A CDC spokeswoman said the agency had no available figures for mucormycosis deaths nationwide, but the report said they appear to be rising, particularly in bone marrow and organ transplant patients. The article theorizes that the increase may be due to more susceptible patients surviving longer and the use of antifungal drugs that are ineffective against the opportunistic fungus.

The investigators didn’t stop at the hospital, heading also to the linen companies’ plants to test for the fungus.

“In this outbreak, we suspect the contamination of clean linen occurred at the laundry facility or during delivery, after the linen had been washed and dried,” the article said.

The Louisiana Department of Health and Hospitals issued a statement on the outbreak and the lack of a public announcement.

“Investigations regarding infectious disease are a serious matter. In conducting these investigations, the Department must weigh the risks to the general public while protecting the privacy of families and patients,” the statement read.

“As those most at risk for mucormycosis are patients with significantly suppressed immune systems, the risk to the general population was very low in this situation. However, DHH did contact other hospitals to determine if similar problems were occurring.”

The DHH statement said the hospital went beyond state law to report the situation. Chiller, the CDC doctor, said the hospital did “a fantastic job.”

The article said the last case of the fungal infection attributable to the hospital before the outbreak came 15 years earlier. Heaton said the hospital occasionally sees patients who come in with signs of the infection, perhaps once or twice a year.

The article says the hospital’s actions shortly after the outbreak seemed to prove effective, with later samples turning up none of the fungus.