Infection Control & Hospital Epidemiology (2018), 39, 1406–1411 doi:10.1017/ice.2018.255
Original Article
From ward to washer: The survival of Clostridium difficile spores on hospital bed sheets through a commercial UK NHS healthcare laundry process
Joanna Tarrant PhD, Richard O. Jenkins PhD and Katie T. Laird PhD Infectious Disease Research Group, School of Pharmacy, De Montfort University, Leicester, United Kingdom
Abstract
Objective: To quantify the survival of Clostridium difficile spores on hospital bed sheets through the United Kingdom National Health System (UK NHS) healthcare laundry process (Health Technical Memorandum (HTM) 01-04) in vitro and on bed sheets from patients with C. difficile through the commercial laundry. Methods: Clostridium difficile spores were inoculated onto cotton sheets and laundered through a simulated washer extractor cycle using an industrial bleach detergent with sodium hypochlorite 15% and peracetic acid sour 14% (acetic acid and hydrogen peroxide; pH, 2–4). Spore survival on hospital sheets naturally contaminated with C. difficile was also assessed using a washer extractor plus drying and finishing cycles at a commercial laundry. Patients: Naturally contaminated C. difficile bed sheets were taken from beds of patients that had previously been diagnosed with C. difficile infection (CDI) and had received care on an isolated C. difficile ward. Results: 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 25cm2) and ribotype 001/072 (0–9 cfu per 25cm2). Before laundering, naturally contaminated bed sheets had an average spore load of 51 cfu per 25cm2, and after washing, drying, and finishing, the spore load was 33 cfu per 25cm2. 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. Conclusions: 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.
(Received 1 July 2018; accepted 11 September 2018; electronically published October 16, 2018)
Clostridium difficile produces endospores, which are responsible for the transmission of the organism between patients, some- times causing a potentially life-threatening C. difficile infection (CDI) or asymptomatic carriage with some spore shedding.1,2 Evidence from genetic relatedness of CDI strains suggests that unknown sources of nonhypervirulent C. difficile spores persist, causing up to 82% of CDIs in vulnerable patients.3 Mitchell and Gardner4 reviewed global CDI mortality, including studies from 2005 to 2011, and estimated a 5.7%–6.9% CDI-attributable mortality rate. In North America, CDI-attributable mortality ranges from 5.7% to 16.7%, varying with endemic and epidemic periods.5 In 2015 and 2016, there were 14,192 and 14,139 cases of CDI in the UK, respectively.6 Contaminated linen as a potential source of CDI is understudied. The current UK healthcare laundry policy is the Health Technical Memorandum
Author for correspondence: Katie Laird, PhD, Infectious Disease Research Group,
School of Pharmacy, De Montfort University, Leicester, LE1 9BH, United Kingdom. E-mail:
klaird@dmu.ac.uk
Cite this article: Tarrant J, et al. (2018). From ward to washer: The survival of
Clostridium difficile spores on hospital bed sheets through a commercial UK NHS healthcare laundry process. Infection Control & Hospital Epidemiology 2018, 39, 1406–1411. doi: 10.1017/ice.2018.255
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
(HTM) 01-04 Decontamination of Linen for Health and Social Care (2016).7 In brief, all linen classified as ‘infected’ must be put in water-soluble bags (alginate bags) and then into nonperme- able bags. The linen must then be processed with a thermal disinfection cycle at either 65°C for ≥10 minutes or at 71°C for ≥3 minutes. Evidence of survival and cross contamination of C. difficile spores in simulations and related studies also suggest that these industrial wash parameters may be inadequate.8,9 Failed decontamination of laundry could contribute to surface C. difficile contamination within hospitals, and spread is likely exacerbated through the rented-linen business model in the United Kingdom, where regional commercial laundry facilities distribute linen to other hospitals or care facilities within the region. The potential contribution of textiles as an environ- mental factor to the complex transmission route of C. difficile may be of particular importance because 27% of new residents become asymptomatic carriers of C. difficile within the first 6 weeks of admittance to a care facility.10 The aim of the present investigation was to assess the survival of C. difficile spores through a washer extractor cycle, incorporating industrial laundry parameters, to determine whether linen could be a potential source of sporadic outbreaks of CDI.
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