infection control & hospital epidemiology september 2015, vol. 36, no.

review article

Healthcare Laundry and Textiles in the United States: Review and

Commentary on Contemporary Infection Prevention Issues

Lynne M. Sehulster, PhD, M(ASCP)

Healthcare professionals have questions about the infection prevention effectiveness of contemporary laundry processes for healthcare textiles
(HCTs). Current industrial laundry processes achieve microbial reductions via physical, chemical, and thermal actions, all of which result in
producing hygienically clean HCTs. European researchers have demonstrated that oxidative laundry additives have sufficient potency to meet
US Environmental Protection Agency benchmarks for sanitizers and disinfectants. Outbreaks of infectious diseases associated with laundered
HCTs are extremely rare; only 12 such outbreaks have been reported worldwide in the past 43 years. Root cause analyses have identified
inadvertent exposure of clean HCTs to environmental contamination (including but not limited to exposure to dust in storage areas) or a
process failure during laundering. To date, patient-to-patient transmission of infection has not been associated with hygienically clean HCTs
laundered in accordance with industry process standards. Occupationally acquired infection involved mishandling of soiled HCTs and failure to
use personal protective equipment properly. Laboratory studies of antimicrobial treatments for HCTs demonstrate a wide range of activity from
1 to 7 log10 reduction of pathogens under various experimental conditions. Clinical studies are needed to evaluate potential use of these
treatments for infection prevention. Microbiological testing of clean HCTs for certification purposes is now available in the United States. Key
features (eg, microbial sampling strategy, numbers of textiles sampled) and justification of the testing are discussed.
Infect. Control Hosp. Epidemiol. 20 1 5; 3 6( 9) :1 07 3 – 10 88

introduction of patient contact, the processing of reusable surgical textiles is

not discussed here. This topic is thoroughly addressed in a
Recent innovations in the laundry industry have led to major
standard published by the Association for the Advancement
advances in laundry equipment, laundry chemicals, fiber and
of Medical Instrumentation.4 Recent industry developments
fabric technology, and laundry facility design and engineering.
(ie, antimicrobial treatments of HCTs and microbiologic
Collectively, these have enabled healthcare facilities and their
testing of laundered HCTs) are reviewed in an effort to give
contract laundry operators to provide a quality product for a
infection preventionists some insight on these topics that may
diverse textile inventory of bed linens, towels, washcloths,
be helpful in future purchase/procurement decisions. The
patient gowns, uniforms, scrub suits, and drapes or other
resources for this narrative review include peer-reviewed
surgical textiles.1,2 Residential care facilities (eg, assisted living
medical literature using PubMed (search terms including but
facilities, long-term care facilities) often will provide laundry
not limited to “textiles,” “laundry,” “infection,” “sanitization”),
services for residents’ personal clothing in addition to typical
standards and guidelines, and textile information from industry
healthcare textiles (HCTs), if laundry equipment appropriate
publications and websites.
for these garments is available.3
Healthcare professionals have questions about the infection
prevention effectiveness of these modern healthcare laundry
developments. The epidemiology of microbial contamination
o v e r v i e w o f t h e la u n d r y p r o c e s s
of HCTs and the potential for infection transmission identifies When textiles are heavily contaminated with potentially
2 distinct situations: (1) freshly laundered HCTs, and (2) HCTs infective body substances (eg, blood, stool, urine), they can
in use. This review addresses evidence that current industrial contain 1 × 104 to 1 × 106 colony-forming units of bacteria per
laundry processes are sufficient to interrupt patient-to-patient square centimeter of fabric.5 However, through a combination
transmission of infection, focusing on those laundered HCTs of soil removal, pathogen removal, and pathogen inactivation,
having the greatest degree of contact with patients and contaminated laundry can be rendered hygienically clean.
healthcare professionals. Although surgical textiles and drapes Hygienically clean laundry carries negligible risk to healthcare
would normally be included among HCTs with a high degree personnel and patients, provided that the clean textiles are not

Affiliations: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
Received July 7, 2014; accepted April 9, 2015; electronically published June 18, 2015
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2015/3609-0012. DOI: 10.1017/ice.2015.135
1074 infection control & hospital epidemiology september 2015, vol. 36, no. 9

inadvertently contaminated before use.2,6 The Association room should also be maintained at ambient temperature and
for the Advancement of Medical Instrumentation defines relative humidity ranges to help prevent the proliferation of
hygienically clean for clean, nonsurgical, reusable textiles as any residual microbial contamination in the textiles.4
being “free of pathogens in sufficient numbers to cause human
illness.”4
The laundry process starts with collection of soiled and m i c r o b i a l i n a c t i v a t i o n as s o c i a t e d
contaminated textiles at point of use. Handling contaminated w it h t h e l a u n d ry p r o c e s s
laundry with minimal agitation can help prevent the genera- Microbial Reductions Associated With Washing and Drying
tion of potentially contaminated lint aerosols in patient-care
areas.7–9 Previously, contaminated laundry originating in The antimicrobial action of the laundering process results
hospital isolation rooms (eg, patient rooms under contact from a combination of mechanical, thermal, and chemical
precautions) was segregated and handled with special factors all in action over a period of time.6,13,16,17 Studies
practices. However, few, if any, cases of healthcare-associated demonstrate that cool water wash cycles at temperatures
infections (HAIs) have been linked to this source.10 Single- of 71°F–77°F (22°C–25°C) can reduce microbial contamina-
blinded studies have demonstrated that laundry from isolation tion when the wash cycle duration, the wash detergent, and the
rooms is no more heavily contaminated with microorganisms amount of laundry additive are all carefully monitored and
than laundry from elsewhere in the hospital.11 Adherence to controlled.5,18–23 Wash cycles with detergent and 71.6°F
standard precautions and minimal textile agitation when (22°C) water removed easily dislodged soils and achieved a
handling contaminated laundry in isolation rooms are 3 log10/cm2 reduction in microorganisms with the help of the
considered sufficient to prevent the dispersal of potentially washer’s agitation, rinsing, and drainage.5 Surfactants and
infectious aerosols.12 The Occupational Safety and Health detergents function to suspend more tightly bound soils. Use
Administration prohibits the sorting or rinsing of con- of low-temperature wash cycles has demonstrated effectiveness
taminated laundry at the location where contamination in either inactivation or removal of healthcare-associated
occurred (eg, in the patient’s room). These tasks should be pathogens such as Klebsiella pneumoniae, total coliforms,
accomplished in the facility at a hopper sink in a soiled linen Staphylococcus aureus, enterococci, poliovirus, adenovirus, and
room.7 If a contract laundry service is used, sorting takes place pollen allergens.5,21–25 Use of hot water provides a sanitizing
at that off-site facility. effect capable of producing microbial reduction of at least
Laundering cycles consist of an initial flush with water, the 5 log10 per square centimeter.18 A temperature of at least 160°F
main wash with cleaning agents and other laundry additives, (71°C) for a minimum of 25 minutes is recommended
followed by rinsing with clean water.2,13 The number of rinses frequently for traditional hot-water washing.2 Regardless of
is determined by water quality, the size of the load, fabric type, whether hot or cold water is used for washing, the tempera-
and the laundry chemicals used, all of which are taken into tures reached in drying and especially during ironing provide
account when selecting the appropriate wash/rinse cycle additional microbicidal action, resulting in a reduction in the
parameters. The last rinse for each load of laundry includes the range of 0.5 to 2.0 log10 per square centimeter.5,22
addition of an acid (ie, a souring agent) that causes a pH shift
from approximately pH 12 to pH 5. This action neutralizes
Microbial Inactivation via Laundry Additives
residual alkalinity in the water from the soap or detergent used
in the wash. Eliminating residual alkali from textiles is an Laundry Chemicals: Modes of Action. Contemporary
important measure in reducing the risk for skin irritation.2,13 laundry chemicals are divided into 5 major groups: (1) detergents
Dryer temperatures and cycle times are dictated by fabric and surfactants, (2) chlorine chemicals and chlorine bleach
and fiber characteristics. Manmade fibers (ie, polyester and (ie, sodium hypochlorite), (3) quaternary ammonium
nylon) require shorter dry times and lower dryer temperatures compounds, (4) hydrogen peroxide and hydrogen peroxide/
compared with those used for cotton. Sorting the textiles by peracetic acid/acetic acid, and (5) ozone. General properties
fiber/fabric type before laundering can help maximize the and modes of action for these chemicals are summarized in
effectiveness of the drying phase. Cleaned and dried textiles are Table 1. A recent major trend to move away from an almost
pressed if needed, folded, and packaged for transport, dis- universal reliance on chlorine-based laundry additives in favor
tribution, and storage. Off-site laundries should package of using oxidative chemistries encountered some pushback
or cover clean textile bundles before transport to prevent from infection preventionists.46 However, knowing the
inadvertent contamination from dust and dirt during loading, advantages, disadvantages, and function of these chemicals
delivery, and unloading. State regulations and/or accrediting can be helpful when discussing laundering options with
standards may dictate the procedures for this activity.14,15 laundry contractors. Modern laundry chemistries are less
Laundered HCTs must be stored in a manner to keep them destructive to modern fabrics, thereby expanding the textile
dry and free from soil and contamination. In the healthcare options available to healthcare facilities.
facility, the clean textile storage room/area should be designed Laundry Chemicals: Antimicrobial Potency. There are
to minimize dust contamination of the textiles. The storage circumstances when adding a disinfectant or adding a detergent
table 1. Major Categories of Laundry Chemicals for Soil/Microbe Removal and/or Inactivation
Chemical group General mode of action Important use conditions Log10 reductionsa Applications Comments References
Detergents and ∙ Reduces water ∙ Product selection and ∙ 3 log10 in water with ∙ All wash cycles ∙ Detergents contain 5,13,18–26
surfactants tension amounts for use agitation more than one
∙ Lifts soil, oils, and determined by: ∙ Use of hot water surfactant
contamination ○ Product (160°F [71°C]) can ∙ Pre-sorting by
away from fabrics chemistry boost this up to fabric is helpful
and keeps them in ○ Water quality 5 log10 when selecting a
suspension for ○ Water detergent product
removal temperature for use
during rinse ○ Type of fabric ∙ Use of a souring
○ Weight of agent reduces pH
the load during rinsing to
remove alkaline
residues
Chlorine chemicals/ ∙ Strong ∙ Typical wash ∙ ≥3 log10 when used ∙ Use for fabrics that ∙ Injected during 1,13,27–33
chlorine bleach oxidizing agents conditions: to sanitize fabric tolerate repeated specific bleach cycle
∙ Stain removal ○ 75-200 ppmb ∙ ≥4 log10 when used bleach use ∙ Can damage some
∙ Antimicrobial ○ 140°F-150°F to disinfect fabric ∙ Stain removal for fabrics with
action of free (60°C-65.6°C) heavily soiled textiles repeated use
chlorine likely due ○ pH 10.2-10.8 ∙ Whitening ∙ Chlorine interacts
to chemical ∙ Requires an extra rinse ∙ Antimicrobial with chlorhexidine
interactions with and use of an anti- action gluconate residues
proteins, nucleic chlor additive to to produce orange/
acids, and critical remove chlorine brown stains on
structural sites residue the fabric
∙ Do not mix with
ammonia
∙ May produce rust
on steel equipment
∙ Use concentrations
may be higher
in Europe

healthcare laundry and textiles

Quaternary ∙ Positive-charged ∙ Use concentration ∙ ≥3 log10 when used ∙ Use for fabrics that are ∙ Generally 32–37,
ammonium portion of the ranges 150-780 ppmb to sanitize fabric not heavily stained introduced into the N. Gaubert, personal
compounds chemical covalently ∙ Use temperature ∙ ≥3 log10 when used ∙ Antimicrobial action: final rinse communication,
binds to fabrics with ranges ~60°F-95°F as a residual sanitizer ○ Deodorizer ∙ Use concentration September 2014
negative charge (~15.5°C-35°C)b ∙ ≥4 log10 when used to ○ Sanitizer varies depending on
∙ Antimicrobial disinfect fabric ○ Disinfectant the antimicrobial
action due to but ○ Residual self- action needed and
not limited to sanitizer the water level in
damaging cell struc- ○ Mildew the rinse cycle
tures and proteins, inhibitor
and inactivating key
metabolic enzyme
function

1075
 1076
Table 1. Continued

infection control & hospital epidemiology

Chemical group General mode of action Important use conditions Log10 reductionsa Applications Comments References
Hydrogen peroxide ∙ Oxidative ∙ H2O2 products used ∙ 3 log10 when used to ∙ Use for fabrics that ∙ No interaction 38,39,
(H2O2), hydrogen bleaching agents at higher wash sanitize fabric cannot tolerate with chlorhexidine N. Gaubert, personal
peroxide/ peracetic ∙ Antimicrobial temperatures ∙ ≥4 log10 when used to chlorine bleach gluconate residues communication,
acid/acetic acid action due to compared with those disinfect fabric ∙ Stain removal ∙ Injected during September 2014
oxidative action on for chlorine products ∙ Whitening specific bleach cycle
microbial enzymes, ∙ H2O2 use ∙ Antimicrobial ∙ Often used as part
denatures proteins concentration: ≥250 to action of green/sustainable
∙ H2O2 produces 300 ppmb programs
destructive ∙ H2O2/peracetic ∙ Produces benign
hydroxyl free acid/acetic acid use by-products (water,
radicals concentration: oxygen, acetic acid)
∙ Antimicrobial ≥100 ppmb ∙ Less damage to
action of the fabrics compared
combination with chlorine
product is bleach
synergistic

september 2015, vol. 36, no. 9

Ozone (O3) ∙ Oxidizing agent ∙ Use cold water ∙ ≥4 log10 ∙ Use for fabrics that ∙ Marketed as a 40–45
∙ Antimicrobial temperature cannot tolerate “system,” generated
action due to (~50°F-60°F chlorine bleach on demand
denaturation of [9°C-15.5°C]) ∙ Antimicrobial ∙ Use in cold water
proteins, destroys ∙ Use concentration action minimizes ozone
bacterial cell walls ranges 0.5-3 ppmb dissipation
∙ Raise water
temperature in final
rinse for best wash
performance
∙ Requires higher
concentrations for
cleaning healthcare
textiles due to heavy
soil/bioburden
levels
∙ Savings on utility
expenses (eg, water,
natural gas)

NOTE. anti-chlor, an anti-chlorine compound or chlorine neutralizer; ppm, parts per million.
a
Log10 reductions achieved via removal of microorganisms or microbial inactivation.
b
Recommended ppm or use temperature may vary by product.
 healthcare laundry and textiles 1077

table 2. Log10 Reductions Associated With Wash Cycles: Impact of Contemporary Laundry Additive Chemistries and Water Temperature
Log10 reductions

Process Gram-positive Gram-negative

Pre-wash at 95°F (35°C) (single step, 10.5 min with detergent) 0.73 to 2.47 0.70 to 1.16
Main wash at 113°F (45°C) without pre-wash (single step, 19.5 min with detergent + bleaching agent) 0.97 to 2.58 1.11 to 2.66
Main wash at 140°F (60°C) without pre-wash (single step, 19.5 min with detergent + bleaching agent) 1.34 to >5.56 3.71 to >5.6
E60 + 35: pre-wash at 95°F (35°C) (10.5 min with detergent), main wash at 140°F (60°C) (19.5 min with 1.91 to >7.68 > 5.6 to >7.76
detergent + bleaching agent)
Completed main wash at 167°F (75°C) (pre-wash and main wash) >5.56 to >7.88 >5.6 to >7.76
Disinfecting only at 167°F (75°C) (no pre-wash or main wash) >5.56 to >7.88 >5.6 to >7.76
Complete 3-step cycle (prewash 10.5 min with detergent, main wash 19.5 min with detergent + bleaching >5.56 to >7.88 >5.6 to >7.76
agent, and disinfection at 176°F [80°C])
NOTE. Adapted and compiled from reference 49.
Detergent: anionic and nonionic surfactants (5%), phosphates (25%), silicates, sodium carbonate, optical whitener; use concentration in
pre-wash: 6.2 g detergent/kg textiles; main wash: 5.0 g detergent/kg textiles.
Bleaching agent: hydrogen peroxide (35%); use concentration in main wash: 4.4 mL/kg textiles.
Disinfecting agent: hydrogen peroxide (20%), peroxyacetic acid (7.5%), acetic acid (7.5%); use concentration in main wash: 3.0 mL/kg textiles.
Equipment: laboratory washing machine: 7.5 kg capacity, 75 L volume.
Challenge organisms: Enterococcus faecium, Staphylococcus aureus, Mycobacterium terrae, Candida albicans, Enterobacter aerogenes, Pseudomonas
aeruginosa. Starting inoculum for each organism (allowed to dry onto fabric): ~1 × 106 to 1 × 107 colony-forming units/cm2.
Organic matter challenge: swine blood, swine fat, artificial sweat.
Fabric used: cotton, previously sterilized; cut into square centimeters.
Assay method: recovery of the laundered cotton squares, each immersed in 20 mL normal saline + Tween 80 and vortexed, and serial dilutions
plated on appropriate selective media.
E60 + 35 is the designation in this study for the laundry process using a pre-wash and a main wash.
The disinfecting step by itself could not remove stains.

whose formula contains a disinfectant at some point into the achieved under varying wash cycle parameters and use of
wash/rinse cycle can enhance the overall disinfection of the oxygenated laundry additives. Experimental design details
laundering process. Examples of these decisions include (1) when and results of this work are summarized in Table 2. The use
textile properties indicate use of cooler water temperatures of a hydrogen peroxide bleaching agent and a disinfectant
(eg, 104°F [40°C]), (2) if a high proportion of the textile load is (containing hydrogen peroxide + peracetic acid + acetic acid)
very heavily soiled, or (3) if there is concern about suspended in 140°F (60°C) water produced greater than 7 log10 reduction
microbes in wash or rinse water settling back onto the textiles in for selected bacterial and yeast challenge microorganisms
the load.13,27 Altenbaher et al47 noted that when any of the (ie, Enterococcus faecium, S. aureus, Pseudomonas aeruginosa,
4 factors needed to produce hygienically clean textiles (ie, water Enterobacter aerogenes, Candida albicans).47,49 They also eval-
temperature, agitation, chemical type and concentration, and uated the potency of 3 disinfecting bleaches in the wash cycle
duration of the wash cycle) is altered (eg, lowering the wash/rinse under various cycle parameters.50 The experimental details of
water temperature), the addition of a disinfecting laundry this work are summarized in Table 3. Longer wash cycle times
chemical can compensate for the anticipated loss of anti- were necessary to achieve greater than or equal to 7 log10
microbial activity of the overall process. For lightly soiled reduction of E. faecium regardless of the type of laundry
textiles, however (eg, healthcare residents’ clothing), the use of a additive compared with the wash cycle times needed for
disinfectant may not offer any advantage over the use of detergent. E. aerogenes. Of the 3 chemicals, only the peracetic acid–
Traditionally, the use of chlorine bleach ensured an extra containing product achieved higher reduction levels (>4.0 log10)
margin of safety.1,27,46,48 For example, the addition of bleach to for E. faecium during shorter wash cycle times (10–20 minutes).
a low-temperature wash cycle increased the microbial log These results suggest that for institutional laundries, peroxy-
reduction by an additional 3 log10 per square centimeter.5,22 acetic acid in hydrogen peroxide products would meet or
A total available chlorine residual of 50–150 parts per million is exceed the US Environmental Protection Agency log reduction
usually achieved during the bleach cycle.18 Chlorine bleach in benchmark (≥4.0 log10) for adequate textile disinfection
commercial laundry applications is most effective at water for short wash cycles at warm temperatures for healthcare
temperatures of 140°F–150°F (60°C–65.6°C).31 purposes.32 All 3 products achieved greater than 7 log10
Potency evidence for contemporary oxidative laundry reductions for both E. faecium and E. aerogenes at 86°F (30°C)
additives is now available. Fijan et al49 conducted laboratory when the full wash and rinse cycles were completed in
evaluations to determine the log reductions of bacteria 81 minutes.50
1078 infection control & hospital epidemiology september 2015, vol. 36, no. 9

table 3. Log10 Reduction Activity of Selected Oxidative Disinfecting Bleaches in Low-Temperature Wash Cycles
Log10 reductions

Enterococcus faecium Enterobacter aerogenes

Wash cycle parametersa D1b D2c D3d D1 D2 D3

Main wash cycle for 43 min +3 rinses with clean water; total time 81 min >7.28 >7.28 >7.28 >7.66 >7.66 >7.66
Main wash cycle for 43 min, no rinses 3.85 >7.28 5.28 >7.66 >7.66 >7.66
Main wash cycle for 20 min, no rinses 2.13 5.36 2.63 6.09 >7.66 6.30
Main wash cycle for 10 min, no rinses 1.33 4.88 1.93 4.33 4.98 3.17

Main wash cycle for 43 min, detergent only (no disinfecting bleach), no rinses 3.80 >7.66
NOTE. Compiled and adapted from reference 50.
a
Water specifications: all experiments run at 86°F (30°C). Wash water volume = 8 L, bath ratio = 1:8, each rinse water volume = 9 L.
Detergent used in all experiments contained 12% sodium alkylbenzene sulphonate, 2% sodium lauryl ether sulphate, 2.5% isopropanol, 3%
fatty alcohol etoxylate, 1.5% sodium hydroxide. Amount used was 10 g/2.5 kg of dry textiles.
Separate cotton test swatches were inoculated with E. faecium and E. aerogenes and allowed to dry. Starting concentrations after drying were
1.9 × 107 colony-forming units (cfu)/swatch for E. faecium and 4.6 × 107 cfu/swatch for E. aerogenes. Swatches were laundered along with 2.5 kg
of previously disinfected ballast cotton/polyester (50/50) fabric.
Washing machine was a small-scale laboratory industrial drum washing machine.
b
D1 = sodium chlorate (10%). Amount used = 10 mL per 2.5 kg dry textiles.
c
D2 = peroxyacetic acid in hydrogen peroxide (2.5% peroxyacetic acid, 10% hydrogen peroxide, 2.5% acetic acid). Amount used = 12.5 mL/
2.5 kg dry textiles.
d
D3 = hydrogen peroxide (35%). Amount used = 7.5 mL/2.5 kg dry textiles.

Questions have been asked about home laundering of P. aeruginosa to support claims for disinfection.32 Laboratory
hospital scrubs and uniforms. There have been concerns that data for inactivation of S. aureus and K. pneumonia are
home laundering of healthcare attire may expose family required to support claims for sanitization.32 Additional label
members to healthcare-associated pathogens.51 However, claims for inactivation of other healthcare-associated patho-
infections in families attributed to home laundering of gens must similarly be supported by laboratory data. The
healthcare attire have not been demonstrated conclusively. As microbial log reduction benchmark for laundry disinfectants is
an example, studies have documented that the loss of anti- greater than or equal to 4 log10, whereas the benchmark for
microbial activity by using wash water temperature of 140°F laundry sanitizers is greater than or equal to 3 log10.
(60°C) can be compensated with longer wash cycle time, hot
air drying, and ironing.52–54 Industrial laundering offers many
process advantages over home laundering, such as (1) more
epidemiology of hais attributed to
exact control over all aspects of the process, (2) the ability to
laundered hcts
tailor wash parameters more accurately to match the soil level HCTs will become populated with microorganisms while these
of the load, and (3) more choices in detergent and laundry textiles are in use. Several research teams evaluating microbial
additives (eg, sours). The current stance is hospital-directed ecology in healthcare settings have demonstrated that patients
laundering of employee scrubs and uniforms, although home and their hospital beds are at the center as a source of room
laundering continues to be debated.55 The Occupational Safety contamination, with pathogen levels dropping in concentra-
and Health Administration regulations require employers to tion per area as the distance from the patient increases.56–58
provide laundry processes for reusable personal protective This suggests that hospital bed textiles become contaminated
equipment textiles and healthcare attire or uniforms with primarily with the patient’s flora and to a lesser degree
visible blood or other potentially infectious material with those microorganisms already present in the healthcare
contamination.7 environment, including pathogens that are particularly adept
Laundry sanitizers and disinfectants marketed in the United at long-term survival.56–61 However, the epidemiology of
States must be registered by the Environmental Protection outbreaks associated with laundered, reusable HCTs strongly
Agency. Registered laundry product labels must have the supports the notion that current industrial laundry processes
following information at a minimum: (1) the intended use of are effective in interrupting patient-to-patient transmission.
the product (eg, a presoaking additive, an additive for the wash
cycle), (2) the appropriate use conditions, and (3) the
Outbreaks of Infection Attributed to Laundered HCTs
product’s compatibility with fabrics and other laundry chemicals.
Those products intended for HCT laundering should be The volume of HCTs processed annually in the United States is
tested at a minimum against S. aureus, K. pneumoniae, and difficult to determine, but this figure provides context when
 healthcare laundry and textiles 1079

discussing the epidemiology of HAIs attributed to HCTs. These observations about outbreaks involving environ-
A current estimate for the annual volume of US hospital mental pathogens strongly suggest that transport and storage
laundry is approximately 4.34 billion pounds as derived from of cleaned HCTs can present opportunities for postlaundering
Government Accounting Office62 and American Hospital contamination of textiles. Storage or holding areas for cleaned
Association data sources.63 However, when the laundry needs textiles should be designed and engineered to protect textiles
for nonhospital healthcare settings are included, a conservative from dust and soil.4,13,82 The importance of temperature,
estimate of the total volume of HCTs processed annually in the relative humidity, and moisture control in storage areas is
United States today for all healthcare venues would be several central to preventing microbial proliferation in and on materials
billion pounds higher. that have some organic components. Given that some HCTs
Outbreaks involving laundered HCTs from the 1970s to the may consist of fibers with high organic content (eg, cotton) and
present are summarized in Table 4, along with occupational some textiles absorb moisture by design (eg, towels), textiles
exposures to pathogens on soiled HCTs. The occupational with high moisture content (eg, textiles packaged in plastic
infection clusters involved exposure to infectious aerosols before they are completely dry) might provide a favorable
from mishandling of the textiles or failure to use personal environment for microbial proliferation, especially if the
protective equipment.2 The outbreaks of clinically sympto- ambient temperature in the textile package storage area is warm.
matic infection among patients are associated mostly with Environmental pathogen contamination of HCTs also
textiles contaminated with environmental pathogens after draws attention to the necessity of proper water and equipment
laundering or contaminated owing to a deficiency in the management in the laundry. Bacillus spores can be present in
laundering process.2 At least 350 patients worldwide have been water, and water recycling can potentially build up the spore
infected in 12 outbreaks over the past 43 years. Despite the concentrations in the wash and rinse cycles. Additionally,
presence of microorganisms on clothing and HCTs, there laundry additives may lack sufficient sporicidal potency to
appears to be little to no evidence of patient-to-patient trans- inactive large numbers of these spores during laundering.
mission of infection attributed to laundered textiles, even for Prompt removal of wet textiles from the machines and proper
Clostridium difficile infection.81 We have not found reports of washer maintenance should help to minimize equipment
C. difficile spore persistence on patient-care HCTs, nor have we contamination and biofilm development.67
found reports of patient-to-patient transmission of C. difficile
infection associated with HCTs not mixed with cleaning
cloths, etc, during laundering.
a n t i m ic r o b i a l t r e a t m e n t s a n d
Of the 12 outbreaks, 7 (58%) were due to contamination
residues for hcts
from Bacillus cereus (a common environmental, spore-forming Early uses of antimicrobial treatments of textiles and garments
microorganism) occurring in the late spring or the summer prevented fabric from rotting in adverse environmental
months. Towels were noted as being contaminated with conditions.83 Treated textiles have been evaluated in clinical
B. cereus in 4 (57%) of these 7 events. Higher ambient studies as part of a treatment strategy for atopic dermatitis for
temperatures (which favor spore-forming microorganisms), several years.84–86 More recent research is targeting the general
coupled with normally moisture-absorbent textiles, result in infection prevention market. Antimicrobial agents for textiles
conditions that favor environmental pathogen proliferation. represent a diverse array of chemicals and metals including but
Root problems associated with the B. cereus outbreaks included not limited to gold, silver, copper, chitosan, chitooligosaccharides,
(1) dust contamination of the clean textiles, (2) inappropriate quaternary ammonium compounds, and zeolite-containing
wash/rinse water temperatures, and (3) storage conditions compounds. These agents can be added to textiles either as a
that promoted microbial growth. Two of these root problems chemical treatment of woven fabric or finished textile item, or
were also identified in a recent Rhizopus outbreak in as an impregnated fiber that is incorporated into fabric during
Louisiana, where storage conditions may have encouraged weaving.87 Despite the differences in experimental design,
fungal growth on the HCTs.73 This outbreak was limited to a laboratory studies in general have confirmed the potency
very small group of severely immunocompromised patients, of these active agents in reducing microbial populations on
even though contaminated HCTs presumably were used fabrics during contact periods ranging from days to weeks.88–90
elsewhere in the hospital. Of the 12 outbreaks, 4 (33%) The log10 reduction observed in these studies can range from
reported problems with laundered textile storage in the 1 to 7 log10, but most microbial inactivation potencies observed
hospital; 7 (58%) reported contaminated washing equipment, cluster between 3 and 5 log10 (Table 5). Antimicrobial activity
inappropriate wash cycle or water temperature settings, or is affected by many factors, such as (1) properties of the chal-
recycled water issues; and 1 (8%) attributed the outbreak to lenge microorganism(s), (2) intrinsic moisture content of the
inadvertent contamination occurring during transit from the fabric, (3) length of the contact time, (4) method of treatment
laundry to the hospital. Reports of HCTs becoming con- application, (5) type of fabric, and (6) number of wash cycles
taminated during use and reports of infection attributed to after treatment. 87
HCTs used for multiple patients with no laundering are not Antimicrobial treatment may be useful in inactivating
included here. microbes transferred onto fabrics touched frequently by hand,
 1080
infection control & hospital epidemiology
table 4. Outbreaks of Healthcare-Associated Infections Attributed to Laundered Healthcare Textiles (HCTs) and Occupational Exposures Involving Soiled HCTs: 1970 to 2015
A. Healthcare-associated infections among patients

No. of
patients
Location & year Organism affected Textile(s) implicated Root problem(s) Corrective measures References
Minneapolis, MN; Aspergillus flavus NS ∙ Hospital linens ∙ Inadvertent environmental contamination ∙ Repair truck cargo bay door 64
late 1970s while in transit due to malfunction of truck ∙ Improve textile packaging to better prevent
cargo bay door dust contamination
UK; 1980 Bacillus cereus 28 ∙ Infant diapers ∙ Contaminated washing machine ∙ Disinfect contaminated washer with boiled 65
water ×3 days
∙ Discontinued overnight soaking of diapers
in water
UK; 1990 B. cereus 2 ∙ Hospital linens ∙ Storage of soiled textiles at elevated ∙ Increase water flow during wash and rinse 66, 67
temperatures prior to laundering ∙ Increase amount of H2O2 added to wash
∙ Avoid leaving damp textiles in washers

september 2015, vol. 36, no. 9

overnight

UK; early 1990s Streptococcus NS ∙ Vests for newborns ∙ Washing not consistent with recommended ∙ Resume recommended laundering processes 68
pyogenes laundry cycle parameters with main hospital laundry contractor
∙ Hot air dryer contaminated
The Netherlands; Acinetobacter spp. 107 ∙ Feather/down pillows ∙ Pillows were naturally contaminated (feathers a ∙ Switched to synthetic fluff pillows that could 60
1990-1992 niche for Acinetobacter spp.) tolerate laundering at 185°F (85°C)
∙ Pillows could not tolerate standard wash water
temperature of 185°F (85°C); used 140°F
(60°C) water temperature
∙ Fluffing pillows caused release of contaminated
aerosols
Japan; 2004-2005 B. cereus 3 ∙ Towels ∙ Dust intrusion and textiles contamination ∙ Minimize dust intrusion 69, 70
∙ Patient gowns from outside construction ∙ Add chlorine bleach to wash cycle
∙ Add 392°F (200°C) steam press
Japan; 2004-2005 B. cereus 5 ∙ Towels ∙ Contaminated washing machine ∙ Switched laundry service provider 71
∙ Recycled water ∙ Chorine bleach added to wash cycle
∙ Moist towels stored for use in steam boxes
Japan; 2006 B. cereus 11 ∙ Towels ∙ Washing machine heavily contaminated ∙ Cease using recycled water 72
∙ Bed sheets ∙ Recycled water for washing and rinsing ∙ Decontaminate and clean implicated washer
∙ Autoclave contaminated linens
∙ Handwashing, hand hygiene
New Orleans, LA; Rhizopus sp. 5 ∙ Bed linens ∙ Dust intrusion ∙ Replaced healthcare textiles 73
2009 ∙ Patient gowns ∙ Inadvertent environmental contamination ∙ Switched laundry service providers
∙ Storage area contamination ∙ Cleaned, disinfected linen storage area
∙ Minimize construction dust intrusion
UK; 2009 B. cereus 7 ∙ Hospital linens ∙ Lack of adequate dust control ∙ Implement effective dust control 74
∙ Cot blankets, sheets, ∙ Dust contamination of stored linens in main ∙ Increase amount of fresh water during
pillow cases hospital linen storage wash cycle
∙ Use a washer-extractor for selected
linen items
Singapore; 2010 B. cereus 171 ∙ Hospital textiles ∙ Dust intrusion from outside construction ∙ Minimize dust intrusion 75
∙ Towels ∙ Textile contamination in storage ∙ Revise textile storage infection prevention
strategy
∙ Reassess laundry process parameters for
infection prevention
Easton, PA; 2013 Clostridium difficile 11 ∙ Mop pads used for ∙ Mop pads washed without bleach ∙ Washing machine serviced, microfiber setting 76
cleaning ∙ Wash cycle erroneously set to “Microfiber” inactivated
setting ∙ Mop pads and rags double-washed
∙ Infection prevention inservice for staff

B. Occupational exposures to soiled HCTs

No. of
workers
Location & year Organism affected Textile(s) implicated Root problem(s) Corrective measures References

Kansas City, MO; 1985 Scabies 5 ∙ Soiled textiles ∙ Failure to wear PPE (gloves) while sorting NS 77
∙ Soiled bed linens soiled textiles
∙ PPE left on soiled textiles as employees went
on break
∙ Possible nonlaundry exposures?
Rural Ontario, Microsporis canis 13 workers ∙ Soiled hospital textiles ∙ Handling soiled bed linens used by infected ∙ Use PPE to cover arms, gloves for hands when 8
Canada; late 1980s 11 patients ∙ Soiled bed linens patient collecting and sorting soiled textiles
Rural TN; 1992 Salmonella hadar 8 ∙ Soiled bed linens ∙ Failure to wear PPE consistently ∙ Handle soiled linens with minimal agitation 78
(3 laundry ∙ Soiled drawsheets ∙ No use of protective outerwear ∙ Wear PPE garments and gloves
workers)
Malta; late 1990s Hepatitis A virus 22 ∙ Soiled hospital textiles ∙ Improper handling of fecally soiled textiles ∙ Assess soiled textile collection and sorting 79a
processes

healthcare laundry and textiles

∙ Suggest hepatitis A vaccination
The Netherlands; Antineoplastic 100–200 ∙ Chemically soiled ∙ Gloves not worn by healthcare workers ∙ Minimize agitation to prevent aerosols when 80
mid-2000s drugs hospital ∙ Poor aerosol control when handling and handling contaminated linens
textiles, gowns collecting contaminated sheets ∙ Comply with glove PPE recommendations

NOTE. NS, not specified in the report; PPE, personal protective equipment.
a
Report is primarily a serosurvey of workers presumed at risk for hepatitis A.

1081
 1082
infection control & hospital epidemiology
table 5. Antimicrobial Treatments of Textiles: Reported Log10 Reductions of Challenge Microorganisms for Selected Treatment Agents
Log10 reductionsa

Gram-positive Gram-negative Fungi and

Antimicrobial treatment agent bacteriab bacteriac yeastsd Virusese Application method Concentration Fabric type References
Chitosan 3, 5 1, 3 >4 Impregnation 0.5% (w/v) Cotton 91
(Candida)
>4, >3 >4 Manufacturer treated NS 100% cotton 92
>3 to 5 Dipped into treatment 0.1% and 1% Cotton 93
agent solution
Chitooligosaccharide >2, >3 >1, >3, >3 >2 Impregnation 0.5% (w/v) Cotton 91
Citric acid + sodium >4 to >7 >1 to >4 Impregnation 7% citric acid +6.5% Cotton 94
hydrophosphate SHP
monohydrate (SHP)
Copper >1 Copper oxide fiber woven NS Cotton 95
(Candida) into fabric

september 2015, vol. 36, no. 9

Copper zeolitef >3 to >6 Manufacturer treated NS 100% cotton 96
Quaternary ammonium >1 >2 Manufacturer treated NS NS 92
compound
Quaternary ammonium >4 Manufacturer treated 1.05 mg/g textile Cotton 95
chloride compound (DDAC)
Quaternary ammonium 7 5, 7 Added during wash cycle 1% in 10% nonionic 50%/50% C/P 97
compound + organosilane detergent, 5% in
10% nonionic
detergent
Silver (Ag) >4 to 5 >5 Manufacturer treated 180 ppm 20%/80% C/P 90
Ag/TiO2 ceramic >2 2 to 3 Dipped into treatment 4.5 g/m2 to 6.0 g/m2 100% cotton 98
nanocomposite, 3 >2 to 3 agent solution Polypropylene
hydroxyapatite binder
Silver/zinc ammonium zeolite >4 >5 Manufacturer treated NS 40%/60% C/P 92
Silver/zinc copper zeolite >2 >1 Manufacturer treated NS 35%/65% C/P 92
NOTE. Ag/TiO2, silver/titanium dioxide; C/P, cotton/polyester; DDAC, didecyldimethyl ammonium chloride; NS, not specified; ppm, parts per million; w/v, weight/volume.
a
Results expressed as whole integers to depict the general magnitude of microbial inactivation. The range indicates maximum reductions when multiple challenge microorganisms were
evaluated. Check references for complete listing of challenge microorganisms. A result preceded by the > symbol indicates the log reduction is greater than the number listed but less than
the next higher integer.
b
Strains of Staphylococcus aureus (eg, methicillin-susceptible S. aureus, methicillin-resistant S. aureus) used most frequently.
c
Escherichia coli and Pseudomonas aeruginosa used most frequently.
d
Trichophyton spp. and Candida spp.
e
Avian influenza viruses H5N1, H5N3.
f
Zeolite is a mineral, typically a hydrated aluminosilicate of sodium, potassium, calcium, or barium. Zeolite acts as an absorbent and/or catalyst.
 healthcare laundry and textiles 1083

such as privacy curtains,99 or in reducing the microbial burden by incubation for growth) or immersing fabric into broth and
on hospital outerwear (eg, scrubs).100 Patients will have the enumerating growth in the broth after incubation. Recently,
greatest degree of direct contact with their gowns, the bed microbiological testing of clean HCTs for “hygienically clean
linens and blankets, towels and wash cloths. Adverse effects on certification” purposes has been introduced to the United
skin and cytotoxicity may be issues if the antimicrobial treat- States.111 The basic testing program consists of 4 phases:
ment chemical degrades such that bioactive compounds are (1) initial qualification (2 garments tested), (2) probationary
released (ie, leached) from the material during wear.101 In one period (6 different textiles tested in 3 months), (3) quarterly
study, silver-treated fabrics were found to leach silver in the quality control testing (testing 28 textiles over 3 years), and
presence of artificial sweat.102 Dermal adsorption is known to (4) onsite sampling (2 textiles tested in each of 3 years). This
occur with Triclosan and quaternary ammonium compounds.83 program adopts the pass/fail benchmark of less than or equal
Treatment chemicals could also cause skin irritation, which to 20 colony-forming units/100 cm2 total aerobic microbial
can lead to localized skin infections, which in turn may create count on fabric (similar to the German test benchmark) using
portals of entry for pathogens. Sensitization and allergic quarterly RODAC testing. Additional textile samples are
reactions are also possible. Risk-benefit analyses for patient- required to be tested if a laundry’s test results exceed the
safety purposes should be performed as part of treated textile benchmark or if there are changes in the parameters of
research to evaluate potential skin reactions to continual contact the laundry processes. Target microorganism testing using the
with antimicrobial chemical residues.83,103 US Pharmacopeia USP <62> Microbiological Examination of
Once a textile treatment is deemed safe for skin contact, the Nonsterile Products: Tests for Specific Microorganisms is
antimicrobial performance of the textile should be evaluated in conducted semiannually to detect S. aureus, P. aeruginosa, and
a clinical setting.104 Lazary et al105 recently studied the impact E. coli.112
on HAI incidence when copper oxide–impregnated (biocidal) The Centers for Disease Control and Prevention has not
HCTs and patient garments were used in a long-term brain recommended routine microbiological testing of nonporous
injury ward. Although the report’s “before/after” design for an environmental surfaces or of HCTs for infection control
intervention study may not be the most rigorous approach purposes.2,113 Currently, there is no public health consensus
from an epidemiologic perspective, the reported reduction in regarding a microbial benchmark to define hygienically clean
HAI incidence (24%) when the biocidal textiles were used for textiles. Most importantly, given the historical record for
suggests that the use of antimicrobial-treated HCTs may patient safety and extremely infrequent episodes of infection
provide some benefits for infection prevention. This report may attributed to clean HCTs, the need to establish a certification
be the first to examine the public health impact of biocidal program based on microbiological testing does not appear to
HCTs, and clearly much more research is needed employing be supported by epidemiologic data. The testing of clean HCTs
rigorous epidemiologic methods to determine whether appears to be a test of a “finished” product. Currently in US
reductions in HAI incidence occur with biocidal HCT use. Such health care, the only finished product testing that is recom-
research could help to determine whether use of these textiles mended by the Centers for Disease Control and Prevention is
provides greater infection prevention benefits during long-term the routine testing of water and dialysate in dialysis settings.
hospitalizations versus those achieved during short-term care. The key rationale for testing performed in dialysis settings is
Antimicrobial treatments of textiles in the United States the fact that levels of microbial contamination have been
may be subject to review by the Environmental Protection associated with adverse outcomes in dialysis patients. Based on
Agency to determine whether the pesticide registration provi- those data, there are action level benchmarks for heterotrophic
sions of the Federal Insecticide, Fungicide, and Rodenticide plate counts in water and dialysate that, if exceeded, require
Act apply in full (ie, to both the treatment chemical and the immediate action to restore water quality for patient safety.114
treated item) or whether the “Treated Articles Exemption” in The benchmark set for clean HCTs testing does not appear to
this act (40 CFR §152.25(a)) is applicable.106,107 Note that the be linked to patient outcomes, nor is there any indication from
Treated Articles Exemption does not apply to items used in the certification program literature that the benchmark is
direct patient care (eg, antiseptic wound dressings, certain statistically valid (ie, within 90%–99% confidence intervals).
textiles intended for atopic dermatitis therapy). Such items Microbiological testing conducted in other hospital services,
would be cleared by the US Food and Drug Administration.108 such as central sterilization for instruments, is basically process
monitoring of industry-established standards and equipment
manufacturer specifications.
m i c r o b i o l o g i c te s t i n g o f l a u n d e r e d When considering adopting a microbiological testing
t e x t il e s program for textiles, there are several important factors to
Microbiological testing of clean HCTs is conducted in Europe evaluate. The method must be scientifically rigorous and
and Australia as part of their regulatory programs established validated. If a method needs to be developed, it should
for the healthcare sector.109,110 Sampling methods for this test undergo both intra-laboratory and inter-laboratory testing to
include the use of RODAC (Replicate Organism Detection define all aspects of the method, including aseptic technique,
And Counting) plates pressed onto a fabric’s surface (followed and ideally the validation results should be subject to scientific
1084 infection control & hospital epidemiology september 2015, vol. 36, no. 9

scrutiny.115,116 The method selected for use in the US HCT contamination due to a malfunction of the laundry process or
certification program (USP <62>) was originally developed poor storage conditions of HCTs after laundering. A Hazard
for testing pharmaceutical and cosmetic substances. Currently Analysis and Critical Control Point assessment of all post-
there are no microbiological test methods for textiles that laundering tasks should be included in any outbreak investi-
are part of either the AOAC International117 or the ASTM gation of laundered HCTs.14,121,122
collections of validated methods.118 RODAC plate sampling Studies to evaluate new developments in laundry processing
and other sampling techniques cover very small areas, and in addition to current operations are encouraged. Survey
microbial bioburden may not be spread evenly over the entire entities such as the US Centers for Medicare & Medicaid Ser-
item. The method should be statistically valid, providing a vices are now acknowledging use of laundry additives other
meaningful representative sampling of the HCT product out- than chlorine bleach for HCT sanitization in healthcare facil-
put during the sampling period. Given that most healthcare ities.123 Following manufacturer instructions for laundry
laundry facilities will process thousands, if not millions, of equipment, laundry chemicals, and fabrics is crucial to the
pounds of laundry in the 3-year certification period (the period provision of quality service to healthcare facility patients.123
established in the testing program in the United States), testing The provision of hygienically clean HCTs is an important
a very small number of textiles would not meet this criterion. service. Healthcare facilities are responsible for ensuring that
The testing strategy should target the true end of the laun- laundry contractors provide their service in a safe and effective
dering process—when the textile goes to storage. Given the manner.124 At least one on-site inspection of the laundry
nature of the problems leading to some of the outbreaks facility by hospital staff on an annual basis is needed to make
summarized in Table 4 (poor storage conditions supporting this determination. In order to help infection preventionists or
microbial proliferation), spore-forming bacteria and fungi were environmental service directors with this inspection, the
identified, whereas S. aureus, P. aeruginosa, and E. coli were not. Association for Linen Management is now making a laundry
Microbiological testing will not detect contamination where we facility checklist available on its website.125
have seen it occur most often—in transit, in storage. Most
importantly, there would need to be a plan of action for the
infection preventionist at the hospital and the laundry managers acknowledgments
when test results exceed the benchmark. Would a recall of HCTs The author acknowledges prepublication review of the manuscript by Nancy
be warranted under these circumstances, and if so, how far back Bjerke, RN, BSN, MPH, CIC, cochair, Standards Committee, Healthcare
from the current load? If the HCT testing benchmark is not Laundry Accreditation Council; Patti Costello, executive director, Association
for the Healthcare Environment; and Linda Fairbanks, executive director,
linked to patient outcomes and no infection prevention inter-
Association for Linen Management. The author also acknowledges conversa-
vention is developed to address high heterotrophic plate counts, tions with Walter W. Bond, MS, environmental microbiology consultant,
there may be no justification for testing. RCSA, on the microbial topics addressed in this manuscript.
Financial support. None reported.
Potential conflicts of interest. The author reports that she was a member of the
concluding remarks Healthcare Laundry Accreditation Council from 2005 to 2012. No compensation
from HLAC was received during or after this tenure.
Current infection prevention strategies and textile manage-
Disclaimer: The findings and conclusions in this report are those of the
ment during patient use appear to be adequate in preventing author and do not necessarily represent the official position of the Centers for
HAIs, provided that every step is taken to maintain the Disease Control and Prevention.
hygienic quality of HCTs before use. Patient-to-patient trans-
mission of microorganisms involving clean textiles has not Address correspondence to Lynne M. Sehulster, PhD, M(ASCP), Prevention
been demonstrated to date, despite the fact that pathogenic and Response Branch, Division of Healthcare Quality Promotion, Centers for
microorganisms can survive on textiles.57,81,119 Well-designed Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop A-35, Atlanta,
studies are needed to determine whether and to what extent GA 30329-4027 ([email protected]).
HCTs may be a factor in patient colonization.57,58 Clinical
studies are needed for risk/benefit evaluation of antimicrobial- ref e ren ces
treated or -impregnated HCTs.
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