C diff Spores on Bedsheets Survive Hospital Laundering

Hospital Bed Sheets Still Germy Despite Washing

Troy Brown, RN

Conventional laundering methods for hospital bedsheets left 60% of Clostridium difficile spores behind, increasing the risk of contaminating other bed linens and patients, new data show.

"The findings of this study may explain some sporadic outbreaks of C difficileinfections in hospitals from unknown sources, however, further research is required in order to establish the true burden of hospital bedsheets in such outbreaks," senior author Katie Laird, PhD, head of the Infectious Disease Research Group, School of Pharmacy, De Montfort University, Leicester, United Kingdom, said in a news release.

Joanna Tarrant, PhD, from the Infectious Disease Research Group, School of Pharmacy, De Montfort University, and colleagues report their findings in an article published online October 16 in Infection Control and Hospital Epidemiology.

To test the effect of laundering on C difficile spores, the investigators used both naturally contaminated bedsheets from patients infected with C difficileand experimentally inoculated sheets. The sheets were washed according to the current UK National Health Service (NHS) laundry policy, as specified in Health Technical Memorandum (HTM) 01-04.

With the experimentally inoculated sheets, the authors initially tested the effects of washing without detergent (a control cycle), exposing the spores to the heat and agitation specified in the NHS protocol, and found that the sheets remained heavily contaminated.

After washing with detergent, the experimentally inoculated sheets still contained 0 to 9 colony-forming units (cfu) per 25 cm2 swatch. Moreover, previously sterile swatches washed in the load with the experimentally inoculated sheets held 0 to 14 cfu/25 cm2. Thus, the washing not only did not sterilize the original bedsheets but also spread the contamination to other items in the laundry load.

When the team repeated the analysis with naturally contaminated sheets laundered at a commercial laundry in accordance with the NHS protocol, the results were similar. Prior to washing, the sheets were contaminated with an average of 51 cfu/cm2. After laundering, the spore count was 33 cfu/cm2.

"The thermal disinfection conditions, described in HTM 01-04, were inadequate to fully decontaminate linen that had been naturally contaminated with C. difficile spores," the authors write.

The residual contamination could be contributing to sporadic outbreaks, the authors note, especially if facilities rent linens from companies that distribute bedding to multiple hospitals or healthcare facilities.

The study received no financial support. The authors have disclosed no relevant financial relationships.

Infect Control Hosp Epidemiol. Published online October 16, 2018. Abstract



Nancy Allen|  Other Healthcare Provider
I worked in a large teaching hospital in the 1970s. C. difficile just was not a problem. No one even mentioned this at the hospital acquired infection meetings. So what has happened in the past 40 years ?? Has there been research on C. difficile for a potential bioweapon ? Has there been genetic manipulation ? Why is this organism so hardy, and so resistant to control ? 

barbara zaremski|  Psychologist
@Nancy Allen     other health care provider  - mandatory change in the laundry detergents

Cat B|  Registered Nurse (RN)
I've often wondered about the true 'cleanliness' of hospital linens, especially when I'd occasionally open up a 'clean' flat sheet only to discover left over stains or tangible material still inside. It was rare to find, but after reading this, I now question ALL sheets, even if they appear to be clean and white. Worse still, is the thought of all these patients (unknowingly) laying in invisible filth. Besides C-diff, what ELSE is present in these seemingly clean and freshly laundered linens? This article has raised enough concerns to launch a full investigation of laundering practices in every institution and the requirement that there be ongoing quality control by an independent entity. We talk about 'washing our hands' and using precautions, but another elephant is in the patient's room....BIG time.


nwakaku bibian Kuforiji| Clinical Nurse Specialist
. Registered Nurse .

The outcome of the research should direct attentions to the concentration and constitution of the active ingredients found in the reagents in the washing formula. The time for the heating temperature, ironing heat and the sorting system should be reconsidered. The washing machine also should be upgraded and not overloaded for efficiency and effectiveness. The water supply to the machine must be adequate. The human error and system failure should be ruled out before concluding

Toshie Dempsey|  Registered Nurse (RN)
I can't believe that some of healthcare workers in the United States are wearing in their scrub in the outside of the facility, such as grocery stores.

Cat B| Registered Nurse (RN)
@Toshie Dempsey They shouldn't be and many institutions have banned this practice. How about this question, what's still in those scrubs the moment they pull them off the linen cart and put it on?

JUDITH BALDINI|  Registered Nurse (RN)
@Toshie Dempsey yeah, i'm not going to go home change and then go back to get items needed at store when i can pick them up on way home.  most of us wear isolation gowns in all rooms anymore. 

Laura Grant|  Registered Nurse (RN)
Yeah, why should you be inconvenienced in order not to contaminate the rest of us? Considering how often isolation gowns are not donned/doffed correctly, that isn’t an excuse for you. How about you change your scrubs before you leave? But hey take all those spores to your home and enjoy them. If we want to be treated as professionals we need to be responsible for our actions.

Maree Ryan|  Registered Nurse (RN)
Once again give me the old days. White cotton uniforms and sheets etc boiled and pressed in hospital. Never left the Hosp

Washed hands. Charts on ends of beds quicker and more efficient than computers( ive timed this)

Why change things unless its  better!!!!!!!!


Susan Ross|  Registered Nurse (RN)
@Maree Ryan seriously? Do you drive a car? You obviously have a computer, a phone?, refrigerator etc.? I appreciate the thought but the old white cotton uniforms were horrible. They wrinkled, abosorbed every drop of yuck that they were exposed too, you had to iron them and they still looked like they were slept in. I worked the GI/GU and post open heart floor - my uniforms were disgusting after 1 day and scrubs were only used in the ER. No nurse should have gone home to wash contaiminated uniforms in the family washer and dryer. Talk about contaiminating others!

And the material shrunk every time. How about the nursing caps and orthopedic shoes? I can't count the number of times the cap fell off my head into a bedpan or other disgusting body fluid. There were not enough hairpins to keep it in place given the acitivites we were expected to perform.You're assuming pressing the sheets and 'boiling' them killed bugs? Is there a study proving that? Unlikely.

Paper charts  - ink smeared and was unreadable or so abbreviated (because charting took SO long - hours after a shift ended and nurses did NOT get paid for those hours)  people didn't always document correctly (E.H.R's force them too) etc.

I'm not a big fan of so many aspects of what we consider 'advancements in medicine' but please, cleaning, uniforms and documentation are clearly advanced compared to 50 years ago.

Dr. Conrad Miller|  General Practice
@Susan Ross @Maree Ryan We use to drop our uniforms in a basket provided by the hospital.

Donna Gerber|  Licensed Practical Nurse (LPN/LVN)
dr conrad - You're the only other person I know who uses  the word use correctly!


MaryAnn Kirby|  Registered Nurse (RN)
RN of 55 plus years.

I have visited laundry rooms where I worked. The washing machines were so stuffed that there was barely room for water!!!!!!!


Lawrence D. Loveless|  Registered Nurse (RN)
C dif is normal gut flora, that causes problems after antibiotics destroy the sensitive organisms causing an imbalance in the gut flora. One practitioner relates she had diarrhea for 3 months. She should have been treated with probiotics etc. Nurses and Doctors romance the computer, and NOT THE PATIENT! My Doctor or NP rarely look at me during our visit, while constantly “working on the computer”! Where is the bleach! How about using an high temp dryer for those sheets?

Narelle Brown|  Clinical Nurse Specialist
Thanks for the article. It's a neat method, and it shows a huge need for further research and for updates to protocols. My comments below pertain to the Australian context:

-Public hospitals here have moved away from using isopropyl alcohol for cleaning, after much lobbying by Nurses. We have buckets of soapy wipes which we use for bedside cleaning.

-I teach, as I have been taught by the warrior Nurses in Infection Control, my medical Students to ensure they use soap, water and DRY their hands well at least each hour, whilst performing hand hygiene with the alcohol based handrubs per the WHO Five Moments of Hand Hygiene standards in between times.

C Diff gives me the shudders.

M Schmidt|  Registered Nurse (RN) 1
@Narelle Brown

C-diff is not removed by alcohol based hand-rubs.  I would suggest soap and water always.


Fay Nilsen|  Nurse Midwife
@M Schmidt @Narelle Brown  . Unfortunately you can't always use soap and water. If you're a community based nurse like I am, you use hand rub when you're 'on the road'.

amanda burns|  Clinical Nurse Specialist
Also. If this was a legitimate finding wouldn’t we have far more cases of unexplained Cdif????

If we have clusters we call it a period of increased incidence and will decontaminate a whole ward by doing a ifher level of cleaning followed by hydrogen peroxide vapour . Incidently we have had just one lapse in care this year due to a abx prescribing. ? We do RCAs for our HCAI CDdif cases, we monitor rybotypes, yes there are many cases which have no lapses in care : but would never look to blame sheets.


carol base|  Clinical Nurse Specialist
No choline bleach? Shame.

Sandi Brown|  Nursing Student
So what do I wash my dark colored scrubs in? Can't use bleach any recommendations?

carol base|  Clinical Nurse Specialist
Lysol has a product for the wash. Clorine bleach is why we have white sheets, towels, washcloths and most cotton underwear!

Holly Carlson|  Registered Nurse (RN)
@Sandi Brown Go back to white uniforms! LOL. Actually, not laughing at the situation at all.  But every time I wore my whites, I got lots of compliments form my patients at how professional I appeared.... They seemed to feel more cared for too.


J L|  Registered Nurse (RN)
@Holly Carlson @Sandi Brown Yes, they do look so nice and bright, but it doesn't last. They quickly turn yellow and no amount of bleach or laundry bluing makes any difference!

M Schmidt|  Registered Nurse (RN)
@Sandi Brown

Use the hottest water that you can, and iron (yes heat) them. That will kill c-diff. 

Debbie Miniex|  Other Healthcare Provider
I'm a Supervisor in Housekeeping at a hospital. We have protocol of cleaning discharges.We have to clean the rooms twice, once with a heavy duty detergent, let it set for 5-10 minutes before washing, this allows for the germ to break up and also in the deep surfaces. then the second cleaning is a bleach cleaning that has to be approve by our Infection Control. That includes washing from top to bottom, side to side, taking curtains downs. The floors also have to be washed with the bleach solution. We also have to wash our hands with warm water and soap afterwards. We have our linens washed by a linen service.. I wonder washing linens in cold water instead of hot water would be better. Warm or hot water causes the germ to grow where cold water would kill the germ.


Ann Garland|  Registered Nurse (RN)
@Debbie Miniex

How are the mops used to clean a patient's room sanitized. Does your staff change mop head between rooms? Are contact isolation room cleaned last?

Ann Marie -Director of Quality

JOY WAWRZYNIAK|  Registered Nurse (RN)
So, what is answer? Does hot water at a certain temp or bleach kill the C diff? Where is the rest of the article?

virginia samhouri|  Nurse Practitioner (NP)
I am a CRNP adult and Gero and a CNS in Primary Care. I have also been a patient in the hospital both immunosuppressed and not. I have contracted C diff both times in the hospital.

In one hospitalization I kept telling them there were feces on the wall of the extremely tiny bathroom where both hands barely fit over the tiny sink. The 15 days I was there the feces remained on the wall. No one followed through and cleaners did toilet, sink and floor. Period.

The second time I was six months in three hospitals. In the first my PCP kept telling Infectious Disease I was the perfect storm for C Diff and with my diarrhea so bad they should keep me on the CDiff treatment. But ID discontinued treatment and I continued to suffer agonizing abdominal pain and horrible diarrhea for the three months in that hospital. The day I was transferred to the University hospital the first hospital did a C Diff test which was negative. The University hospital did their more expensive CDiff test on admission and it was positive and they treated me and the c diff was cured. Understand I was trying to not mess the bed and climb out to the commode after six major pelvic surgeries for undiagnosed osteomyelitis. Really the suffering that I had because the hospital did not want to spend the money on the more expensive c diff test was not right. The chief of ID at this first hospital told me himself that because of my experience he got the hospital to use the more expensive test. I think they did it because they are afraid of being sued. The other point in these spores living on is the hospital employees depend on cleaning their hands with alcohol and this does NOT kills the spores. Many sinks have been removed so only alcohol is available. What is wrong with this picture?

And, I maintain that pushing the cart with a computer into every patients’ room even on infection precautions is not safe and spreads disease. The cart touches each curtain as it goes through the entrance of each room.

And, does anyone besides me clean his or her own stethoscope? But I use what is available which is alcohol and we know c diff spores are not killed by alcohol. The knowledge and technology and common sense is available to do things better than we currently are. The cost to the patient (I could have died) and the hospital is so much more and so short sighted. Everyone is so busy charting and documenting that they do not pause to THINK.

Kathy Robinson|  Licensed Practical Nurse (LPN/LVN)
All very good points. Any isolation patient should have disposable equipment; no nurse should be using his or her own stethoscope but I’ve seen it done. My stepmom is an ‘old’ retired nurse. She said they used to have to scrub the walls and take down all the curtains in isolation rooms and they had to sit for 24 hours. There is no way that we are cleaning well today.

Ann Garland|  Registered Nurse (RN)
@Kathy Robinson

Indeed... Who is monitoring our physician, ancillary services, lab techs etc who are also guilty of not washing their hands and cross contaminating the patients? So much opportunity for improvement.

Ann Marie  Director of Quality


Darcy Tietjen|  Registered Nurse (RN)
@Ann Garland @Kathy Robinson Where I work the worst "no hand washing" room to room are the physicians.  We report them and nothing happens.  Slimy Dr's. Shame on them.

Cat B|  Registered Nurse (RN)
@virginia samhouri  It is so unfortunate that anyone has to suffer because of this, ESPECIALLY our own! I always cleaned my entire stethoscope after each use (yes, every time I used it),  first with alcohol and then with a hospital grade anti-bacterial wipe. I always believed that stethoscopes were (and still are) a lethal tool of contamination and spread.


Victoria Howerton|  Registered Nurse (RN)
Throw away the bedsheets used by patients with C. Dif. It's not like it's Egyptian cotton.  And use bleach on the other linens. Good grief.


sandy oestreich|  Nurse Practitioner (NP)
@Victoria Howerton On-target thinking!  Why not just use bleach on all sheets?  Just watch that you are not using cheaper bleach now on shelves pretending to be full strength. (I have contacted grocery chains and they are totally disinterested that customers mostly have no idea that they are getting half-strength bleach!!  "What they don't know won't hurt them?"

As Nurse Practitioner, wife and Mom, I have remonstrated with major grocery chains that their bleach may not be sterilizing for those families with CDiff or other resistant organisms..All to no avail. They do not care.

Some bleaches on major stores' shelves ARE A SCAM. Read the labels carefully. Some don't even include on bleach labels the bleach strength as Clorox, for example, does.  Check it out..

JENNIFER PRUITT|  Registered Nurse (RN)
@sandy oestreich @Victoria Howerton The no splash bleach will not kill any germs!

Ann Garland|  Registered Nurse (RN)
I like dispatch as cleaning agent

Cynthia Jones|  Nursing Student
I worked at the top hospital in Illinois and took a sheet from the cart to make a patient's bed and there was dried fecal matter down the length of the folded and pressed sheet. To save money, the linens are laundered with too many items in the wash at a time, which does not allow for free flow of water and cleaner. Anything to save money! This is likely the reason that bleaches not a standard part of the laundering process, as the cost of the bleach and the decreased life of the linens will increase overall cost. Yikes... As I tell everyone I know, don't get sick!!!


Michael Hart|  Registered Nurse (RN)
Repeat the trials using a 5% solution of sodium hypochlorite along with the surfactant of choice.

sandy oestreich|  Nurse Practitioner (NP)
@Michael Hart Better, 6% ?

Mylene Apigo|  Registered Nurse (RN)
Hospital may need to invest on chlorox

Paul Allen|  Registered Nurse (RN)
What I would like to know, in light of this, is would it be less expensive for hospitals to return to doing their own laundry?  Do we lose ouitcomes when we lose control of the processes?

Cathy Kinnaman|  Licensed Practical Nurse (LPN/LVN)

Annette Rovito|  Registered Nurse (RN)
Where did you find the sporicidal cleaner?


Ann Garland|  Registered Nurse (RN)
@Annette Rovito Agreed!!!

Janice Burns|  Registered Nurse (RN)
This was useless. It failed to specify what works, only what did not work. We tell our patients to wash them with a cup of bleach.


Betty Garber|  Licensed Practical Nurse (LPN/LVN)
Perhaps all bed linen should be soaked in bleach for 10 minutes before laundering?


J L|  Registered Nurse (RN)
@Betty Garber  The fabric would quickly fray and fall apart.


amanda burns|  Clinical Nurse Specialist
Hi there, interesting article . What level of contamination did you do to the sheets..( since in high levels that staff would bin the sheet )Also, since some strains are more virulent than others, what strain did you use to contaminate. Eg 078 and 027 notorious for potency. Best wishes, Amanda. Infection prevention control specialist.


Carina Messina|  Registered Nurse (RN)
@amanda burns

Copying from the Abstract of the article. I am not sure it'll help you shine some light on the process. We knew the spores can live on surfaces for 6 months, and I never suspected that the spore could survive the laundry process.

Wow. It is worse than I thought. Grateful for this interesting article. I will also see what the CDC says about this same process. Very interesting, not surprising though.

The simulated washer extractor cycle, with an industrial detergent, demonstrated survival of 2 strains of C. difficile NCTC 11209 (0–4 colony-forming units [cfu] per 25 cm2) and ribotype 001/072 (0–9 cfu per 25 cm2). Before laundering, naturally contaminated bed sheets had an average spore load of 51 cfu per 25 cm2, and after washing, drying, and finishing, the spore load was 33 cfu per 25 cm2. Before and after washing, the C. difficile strain was identified as ribotype 001/072. Both the simulated and in-situ laundering processes failed the microbiological standards of no pathogenic bacteria remaining.

Clostridium difficile spores are able to survive laundering through a commercial washer extractor and may be contributing to sporadic outbreaks of CDI. Further research to establish exposure of laundry workers, patients, and the hospital environment to C. difficile spores from bed sheets is needed.

1st - Time to mandate antimicrobial linens as suggested by the CDC in 2011 2nd - Time to disinfect with HOCl as it SAFELY kills all bacteria, viruses, fungi and "Superbugs" known to man as it destroys the protein of the microorganisms which renders them GONE!!!! Someone has to change this culture as money controls it all. PREVENTION CAN BE ACHEIVED BUT IT HAS TO BE A PRIORITY AND HOCl must be used! HOCl is EPA certifies for hospital disinfection but Big Pharma makes billions selling us their toxics. HOCl is 80 to 100X's stronger than bleach and safe on humans and pets!

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