Background: Clostridiodes difficile infection (CDI) is a prevalent healthcare-associated infection that also occurs in community settings. Household hygiene may be an underutilized strategy for controlling environmental spore contamination. Currently, no standardized protocol exists for cleaning the homes of individuals with CDI, and patients often lack guidance on effective hygiene practices.
Catherine D. Egan, MBA, CPHI(C), CIC1*, Scott J. Weese, DVSc, DVM, Dipl. ACVIM2, Andria Jones, DVM, PhD3, Kelsey Spence, PhD3, William Ciccotelli, MD4
1 Environmental Public Health, Conestoga College, 299 Doon Valley Drive, Kitchener, Ontario, Canada
2 Department of Pathobiology, OVC and Centre for Public Health and Zoonoses, University of Guelph, Ontario, Canada
3 Department of Population Medicine, OVC and Centre for Public Health and Zoonoses, University of Guelph, Ontario, Canada
4 Department of Infectious Diseases and Medical Microbiology, Grand River Hospital, Kitchener, Ontario, Canada
*Corresponding Author:
Catherine D. Egan
Environmental Public Health
Conestoga College
299 Doon Valley Dr
Kitchener, Ontario, N2G 4M4, Canada
Email: cegan01@uoguelph.ca
ABSTRACT
Background: Clostridiodes difficile infection (CDI) is a prevalent healthcare-associated infection that also occurs in community settings. Household hygiene may be an underutilized strategy for controlling environmental spore contamination. Currently, no standardized protocol exists for cleaning the homes of individuals with CDI, and patients often lack guidance on effective hygiene practices.
Objective: This study aimed to explore the household hygiene experiences and practices of patients discharged from hospital following a CDI diagnosis.
Methods: Semi-structured interviews were conducted with individuals diagnosed with CDI within one year of hospital discharge. Seven interviews were completed – four in person and three by telephone. An inductive content analysis approach was used to code and analyze the transcripts.
Results: Participants generally lacked awareness of CDI transmission pathways. Cleaning routines were based on habit (e.g., weekly schedules) or visible dust accumulation, rather than the potential for contamination or transmission risk. Most cleaning products used were not effective against spores.
Conclusion: The hygiene practices reported by participants were unlikely to adequately decontaminate their home environments. Developing and providing a targeted hygiene protocol at discharge may help reduce the risk of reinfection or transmission to household members.
INTRODUCTION
Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated diarrhea in industrialized countries (Normington et al., 2021). Clostridioides difficile (C. difficile) produces spores that are shed in the faeces of infected individuals during and after illness, contaminating the healthcare environment – particularly patient rooms (Otter et al., 2011; Weber et al., 2013). These spores are highly resilient, capable of surviving in the environment for five months or more (Jinno et al., 2012; Kim et al., 1981; Porter et al., 2024) and are resistant to many commonly used disinfectants, including quaternary ammonium compounds (Davies et al., 2020).
While the transmission of Clostridioides difficile infection (CDI) in healthcare settings has been extensively studied – leading to well-established environmental decontamination protocols – evidence on the role of the household environment in CDI transmission remains limited. A scoping review conducted by our team confirmed this gap in the literature (Egan et al., 2023). Only two studies were identified, both with very small sample sizes. These studies concluded that household transmission may contribute to cases of community-associated CDI (CA-CDI) and recurrent CDI, respectively (Loo et al., 2016; Shaughnessy et al., 2016).
CA-CDI, defined as CDI occurring without prior exposure to healthcare interventions, has remained relatively stable in Canada, with rates of 1.40 per 1,000 patient admissions in 2018 and 1.38 per 1,000 in 2022 – equating to approximately 1,400 cases annually (CNISP, 2024). Recurrent CDI (RCDI), characterized by the return of symptoms within eight weeks following successful treatment, affects approximately 20% of individuals with CDI (Larrainzar-Coghen et al., 2016). RCDI may be caused by reinfection with the same strain present in the environment (Oka et al., 2012).
Patients may be discharged from hospital while still shedding C. difficile spores. These spores can persist on household surfaces, where they may be transferred to hands and subsequently ingested, potentially leading to intestinal colonization or infection (Otter et al., 2011; Rusin et al., 2002). The infectious dose for C. difficile is very low (Otter et al., 2011); even minimal exposure to spores poses a risk of colonization or infection for household members (Miller et al., 2022). However, ingestion of spores alone is typically insufficient to cause CDI; disruption of the gut microbiota – most often due to antibiotic use – is usually a prerequisite for the development of symptoms (Bagdasarian, et al., 2015).
Effective cleaning and disinfection in healthcare settings require appropriate selection, proper dilution, correct application, and sufficient contact time – the duration a chemical agent must remain wet on a surface to be effective (Otter et al., 2013). Similar evidence-based guidance is needed for household decontamination to reduce the risk of C. difficile transmission, colonization, or reinfection (Bloomfield et al., 2017) to prevent the risk of transmission that can result in colonization or re-infection.
Previous research by our group found that Ontario hospitals did provide household hygiene advice to patients with CDI based on provincial guidelines; however, this information often downplayed the risk of transmission and lacked specific instructions on how to effectively reduce C. difficile spores in the home environment (Egan et al., 2019).
The purpose of the current study is to describe the lived experiences of individuals discharged from hospital with CDI, with a focus on their knowledge, perceptions, and household hygiene practices. The insights gained from this research may inform the development of evidence-based household hygiene guidelines to help reduce the risk of CDI transmission and reinfection.
METHODS
Research ethics approval was obtained from the University of Guelph Research Ethics Board (REB# 23-04-007) and the Waterloo-Wellington Research Ethics Board (WWREB# 2023-0758). This study forms part of the primary author’s PhD research project.
Participants
Table 1 summarizes the characteristics of the participants by age, gender, details of CDI, type of interview, and information received about household hygiene.
Participant recruitment was conducted with the support of the infection prevention and control (IPAC) team at the participating hospital. In September 2023, the IPAC team identified 49 patients who had laboratory-confirmed CDI and had been discharged to their homes (excluding long-term care and retirement homes) since September 2022. Letters of invitation were sent to these individuals, but the response rate was low, with only three agreeing to participate. In October 2024, ethical approval was obtained to extend recruitment by sending letters to an additional 55 individuals who had been diagnosed with laboratory-confirmed CDI and discharged since the initial round. This second round of recruitment resulted in four additional participants agreeing to take part in the study. The overall response rate was 7/104 (6.7%).
Interviews and data analysis
Semi-structured interviews were conducted by the primary author, either by telephone or in person, according to participant preference, using a pilot-tested interview guide. Verbatim transcripts were created from the audio recordings and served as the basis for content analysis following the methodology outlined by Erlingsson and Brysiewicz (2017). Transcription, inductive coding, and analysis were carried out manually by the primary author through an iterative process, resulting in the identification of four themes. All data were stored securely on a password-protected computer and OneDrive account accessible only to the primary author.
Text presented in quotations reflects the direct words of participants.
RESULTS
Four themes emerged during the content analysis: 1) knowledge gaps regarding the cause, risk, and transmission of CDI; 2) the perception that visibly clean is hygienically clean; 3) the emotional charge associated with household hygiene and faeces; and, 4) ineffective household hygiene practices to reduce C. difficile. Selected participant quotations are provided by theme in Table 2.
Theme one: knowledge gap related to cause, risk and transmission of CDI
Participants demonstrated a knowledge gap regarding how they acquired CDI and the mechanisms by which it could be transmitted to others. One participant mentioned using masks as a preventive measure, though this is not an effective method for preventing CDI transmission. After the interviewer explained the transmission pathway, the participant responded, “Well, I’ll tell you, probably about 95% of the population has no idea what you just said.”
Participants’ knowledge of household hygiene varied based on their life experiences. Two participants perceived themselves as having a higher level of understanding regarding infection transmission, which they attributed to their work experience: one was a former chef, and the other was a former dental hygienist with a degree in science. Two additional participants reported that their hygiene practices were based on their family’s approach, which may have been insufficient.
Two participants reported independently seeking information online. One referred to the Mayo Clinic website, while the other consulted the “Governments of Canada and Ontario” websites. They searched for general information about CDI as well as specific prevention measures, such as how to clean their homes.
Most participants (6/7; 85.7%) reported not recalling receiving formal information from the discharging hospital. One participant mentioned, “The doctor who discharged me at the hospital did say something about recent studies saying you should use your own washroom… you don’t want your family to get this.” Another participant shared that she received informal information from the cleaner who cleaned her isolation room twice daily. The cleaner told her that Clorox was the only disinfectant capable of killing C. difficile. The participant relayed this information to her sister, who then purchased a pre-mixed Clorox spray product to clean the house. However, during the in-person interview, the primary author noted that the product was not sporicidal, as it contained quaternary ammonium rather than chlorine.
Theme two: perception that visibly clean is hygienically clean
Participants were asked to identify the most contaminated areas in their homes as an indication of where they would focus their cleaning efforts. The kitchen, floors, and toilets were the most frequently mentioned, with four out of seven participants citing these areas. Definitions of “clean” provided by participants primarily centered around visual cues, such as dusting and tidiness. However, there were also comments about the importance of keeping bathrooms (especially toilets) clean. One participant, unprompted by the interviewer, mentioned cleaning in relation to “food and bowel movements” and emphasized the need for “disinfection” where possible in the home, while also acknowledging that many surfaces in the living room could not be disinfected.
Less than half (3/7; 42.8%) of the participants reported implementing specific practices to prevent transmission once the person with CDI was discharged home. One participant mentioned using a separate bathroom and changing bed sheets more frequently, another reported wiping down surfaces more often, and the third participant said they placed sheets on the couch to prevent contamination.
Theme three: perception of household hygiene and faeces as emotionally charged
Participants spoke about the emotional toll the illness took on them and their spouses: fear of accidents if they couldn’t reach the toilet in time, the “depression” associated with being “infected”, and fear that hospital staff lacked knowledge about C. difficile. Words such as “paranoid”, “fanatic”, “guilt”, and “shame” were used to describe their feelings.
In addition to the fear and uncertainty surrounding CDI, participants also discussed the discomfort associated with talking about household hygiene and faeces. One participant remarked, “I’ve thought about this quite a bit and this is a very, very difficult subject for people to address because the way they clean their house is sacrosanct. And people don’t like talking about faeces.” Another echoed this sentiment, saying, “It’s a taboo discussion. Whether it’s culture or your beliefs, you don’t talk about it, about poo.”
Theme four: Ineffective household hygiene practices against C. difficile
Participants who lived with others reported sharing cleaning duties where physically able. Cleaning floors and dusting were the most frequently mentioned tasks. Several participants expressed a desire to clean “everything”, with particular attention to “anything that people touch a lot” such as “taps, you know, your counters, the knobs”.
Most participants (6/7; 85.7%) reported conducting weekly cleaning of the home. One participant described cleaning the bathrooms and kitchen once a day, while the spouse of another participant reported cleaning the bathroom after each use by the person with CDI.
Participants described their processes for cleaning in general terms. “Top-down”, “wipe and go” and “spray and let sit” were common descriptions. When asked about contact time between the cleaning product and the surface, no participant considered how long the product should stay wet on the surface to be effective.
Six participants reported using wipes (e.g., Lysol wipes) on the high touch surfaces in their homes such as door handles, light fixtures, and using them until “it gets dirty”, or after doing “several rooms”. One participant reported using surface wipes on themselves which is not recommended as the active ingredients are not meant for skin contact. Three participants described using non-commercial cleaning cloths. One described using a cloth once on a contaminated item (toilet seat) and then changing it, and two described using cloths multiple times before laundering.
Participants were asked if they thought their household hygiene practices were effective against C. difficile. Three participants thought that they were “diligent” and “thorough”, and one said since their spouse didn’t catch it, they believed they were effective in preventing the transmission.
Several barriers to cleaning in general emerged from the interviews. Age, arthritis, chemotherapy and time required to clean were barriers identified by participants. These barriers impacted when and how cleaning could be conducted. CDI symptoms and consequences such as fatigue and weight loss were reported as barriers to performing household cleaning. Two participants described the need to spread the cleaning over several days while they were recovering.
Participants described selection of products based on brand name recognition, ease of use, perceived effectiveness as a cleaner, or lack of strong smell. Some non-commercial substances were also identified such as soap, hot water and vinegar. None of the reported cleaners were sporicidal with the potential exception of one respondent who reported using “Javex” (a sodium hypochlorite product) and water but without a specific concentration it was not possible to determine if the concentration was sufficient to be sporicidal.
DISCUSSION
Knowledge gaps
Participants in the current study expressed concern about transmission of CDI to and from others, and the desire to avoid “getting it again”, but there was a lack of understanding of the mode of transmission of C. difficile. Serious gaps in knowledge were also noted in terms of what to clean and most placed emphasis on dusting and cleaning floors and a secondary focus on high-touch surfaces. Surfaces in a home that are likely to pose a low risk of transmission of infection are floors and furniture and higher risk surfaces are hand contact surfaces and the equipment (cloths, etc.) used to conduct cleaning, and hands (Maillard et al., 2020). A European survey conducted in February 2020 demonstrated poor understanding of the household situations that posed a risk of transmission and that required hygiene practices to be conducted (International Association for Soaps & Hygiene, 2021). In fact, participants demonstrated a lack of clarity about what “hygiene” actually means (International Association for Soaps & Hygiene, 2021).
Household hygiene advice may be provided to a person with CDI while hospitalized or upon discharge as noted in a previous study by the authors (Egan et al., 2019). However, the participants in this study did not seem to recall receiving this information. This indicates a need for additional mechanisms such as a central web-based resource or support from public health agencies for people with CDI in the community.
Perceptions
Participants described having a “clean home” to mean the absence of visible dirt, which is in line with previous studies (Bloomfield et al., 2017; Maillard et al., 2020). This is problematic in that pathogens like C. difficile can survive on surfaces that appear to be clean (Porter et al., 2024).
The emotions and embarrassment that participants reported may have prevented them from discussing the mechanisms of transmission with healthcare providers which may have contributed to their lack of knowledge. This finding supports earlier findings where participants reported embarrassment and humiliation (Guillemin et al., 2014).
Household hygiene practices
Participants' description of when they cleaned were aligned with results from a multi-country study on household hygiene behaviour that showed that cleaning tends to be done on a daily or weekly schedule rather than as contamination occurs (e.g., immediately after a person with CDI defecates) (Aunger et al., 2016).
Household hygiene practices of the participants in this study did not consider important elements such as the essential moments to clean, contact time, management of cleaning equipment, and use of sporicidal agents. This is likely because they did not recall receiving this information.
Products available in ready-to-use formulation at retail in Canada are not sporicidal. Chlorine bleach mixed with water to achieve a hypochlorite concentration of at least 1,000 ppm with an appropriate contact time is the only feasible sporicidal option for household use. Recognition that a bleach product should be used is not sufficient – the effective concentration and contact time must also be understood. However, even with knowledge of effective concentration levels, application of a chlorine solution is not practical for all surfaces that may be contaminated in a home (e.g., soft furnishings).
Overall, the cleaning procedures described by participants in this study were insufficient to mitigate risk of C. difficile transmission, from knowing when to clean, cleaning frequency and choice of cleaning products. There is a demonstrated need for healthcare providers to provide information on appropriate household hygiene measures that can prevent colonization or re-infection of CDI (Weaver et al., 2017).
Strengths and limitations
The main limitation of this research is the small sample size and the resulting lack of diversity in the participants. However, there was a small source population to begin with and the difficulty of discussing this topic may have deterred people from responding. Despite the small sample size, the comments made by participants were consistent and, therefore, we think that data saturation (when no new themes emerge from responses) was attained, a key measure of adequacy in qualitative research (Hennink & Kaiser, 2022). The study was not intended to provide representation of all CDI patients but rather to gain perspective of some patients to inform future educational efforts. Multiple attempts were made to recruit participants and all participants who agreed to participate were included in the analysis. Further study to obtain a more diverse sample, to ask about hand hygiene, personal protective equipment and laundry practices and a review of specific hospital discharge procedures would be helpful.
In-person interviews allowed for deep discussion and the ability to see the household environment and the cleaning products. As might be expected, more detailed information came from in-person interviews than the telephone interviews as the participants seemed more motivated to provide information. This could be because people who are more likely to enjoy talking selected the in-person option, or that face-to-face communication helped to build trust and open dialogue.
Participant recall about receiving information from the hospital may also be poor given that the time between discharge and the interview could be up to one year. However, the time from discharge to interview was not measured, so the impact of recall bias is unknown.
CONCLUSION
This study explored participants’ lived experience with household hygiene post-CDI and, similar to existing research, highlights knowledge gaps in the understanding of CDI and the cleaning procedures required to mitigate transmission. All household hygiene practices and products described by participants would be ineffective to reduce the risk of household transmission. Household hygiene and faeces were considered emotionally charged, embarrassing and difficult to discuss.
Hence, there is a need for patient education specific to measures to take to reduce the risk of transmission and reinfection (Donskey, 2023). A targeted hygiene approach is important in all households but is even more pressing in households where one of the members is excreting a pathogen that can survive in the environment and cause colonization and infection in others, such as C. difficile. A protocol for household cleaning/decontamination for people with C. difficile should be developed that would give guidance on what, when, where, and how to clean surfaces in the home based on the potential reservoirs, the probability of contamination of surfaces, the potential for exposure, etc. The guidance should also include advice on how and when to conduct a “terminal” cleaning based on the estimated length of time that the shedding of spores will occur (Bloomfield et al., 2016).
REFERENCES
Aunger, R., Greenland, K., Ploubidis, G., Schmidt, W., Oxford, J., & Curtis, V. (2016). The determinants of reported personal and household hygiene behaviour: A multi-country study. PLOS ONE, 11(8), e0159551. https://doi.org/10.1371/journal.pone.0159551
Bagdasarian, N., Rao, K., & Malani, P. N. (2015). Diagnosis and treatment of Clostridium difficile in adults: a systematic review. Journal of American Medical Association, 313(4), 398-408. https://doi.org/10.1001/jama.2014.17103
Bloomfield, S. F., Carling, P. C., & Exner, M. (2017). A unified framework for developing effective hygiene procedures for hands, environmental surfaces, and laundry in healthcare, domestic, food handling, and other settings. GMS Hygiene and Infection Control, 12.
Bloomfield, S. F., Rook, G. A., Scott, E. A., Shanahan, F., Stanwell-Smith, R., & Turner, P. (2016). Time to abandon the hygiene hypothesis: New perspectives on allergic disease, the human microbiome, infectious disease prevention, and the role of targeted hygiene. Perspectives in Public Health, 136(4), 213–224. https://doi.org/10.1177/1757913916650225
Canadian Nosocomial Infection Surveillance Program (CNISP). (2024). Healthcare-associated infection (HAI) and antimicrobial resistance in Canadian acute care hospitals, 2018–2022. Canadian Communicable Disease Report, 50(6), 179–196. https://doi.org/10.14745/ccdr.v50i06a02
Davies, K., Mawer, D., Walker, A. S., Berry, C., Planche, T., Stanley, P., Goldenberg, S., Sandoe, J., & Wilcox, M. H. (2020). An analysis of Clostridium difficile environmental contamination during and after treatment for C. difficile infection. Open Forum Infectious Diseases, 7(11), ofaa362. https://doi.org/10.1093/ofid/ofaa362
Donskey, C. J. (2023). Empowering patients to prevent healthcare-associated infections. American Journal of Infection Control, 51(11S), A107–A113.
https://doi.org/10.1016/j.ajic.2023.03.008
Egan, C. D., Jones-Bitton, A., Sargeant, J. M., & Weese, J. S. (2019). Household hygiene advice for patients with Clostridium difficile: Summary of hospital practice in Ontario, Canada. Canadian Journal of Infection Control, 34(2), 85–92.
Egan, C. D., Sargeant, J. M., Jones-Bitton, A., Zentner, S. E., & Weese, J. S. (2023). Role of the household environment in transmission of Clostridioides difficile infection: A scoping review. Journal of Environmental Health. ScopeRevProtocol_CDIHouseholdEnv_EGANv4.pdf (315.06 KB).
Erlingsson, C., & Brysiewicz, P. (2017). A hands-on guide to doing content analysis. African Journal of Emergency Medicine, 7(3), 93–99. https://doi.org/10.1016/j.afjem.2017.08.001
Guillemin, I., Marrel, A., Lambert, J., Beriot-Mathiot, A., Doucet, C., Kazoglou, O., Luxemburger, C., Reygrobellet, C., & Arnould, B. (2014). Patients’ experience and perception of hospital-treated Clostridium difficile infections: A qualitative study. Patient, 7, 97–105.
Hennink, M., & Kaiser, B. (2022). Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Social Science & Medicine, 292, 114523.
https://doi.org/10.1016/j.socscimed.2021.114523
International Association for Soaps, Detergents and Maintenance Products (A.I.S.E.), & International Society for Hygiene (I.S.F.H.). (2021). Developing household hygiene to meet 21st century needs.
Jinno, S., Kundrapu, S., Guerrero, D. M., Jury, L. A., Nerandzic, M. M., & Donskey, C. J. (2012). Potential for transmission of Clostridium difficile by asymptomatic acute care patients and long-term care facility residents with prior C. difficile infection. Infection Control & Hospital Epidemiology, 33(6), 638–639.
https://doi.org/10.1086/665712
Kim, K. H., Fekety, R., Batts, D. H., Brown, D., Cudmore, M., Silva, J., Jr., & Waters, D. (1981). Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis. The Journal of Infectious Diseases, 143(1), 42–50.
https://doi.org/10.1093/infdis/143.1.42
Larrainzar-Coghen, T., Rodriguez-Pardo, D., Puig-Asensio, M., Rodriguez, V., Ferrer, C., Bartolome, R., Pigrau, C., Fernandez-Hidalgo, N., Pumarola, T., & Almirante, B. (2016). First recurrence of Clostridium difficile infection: Clinical relevance, risk factors, and prognosis. European Journal of Clinical Microbiology & Infectious Diseases, 35(3), 371–378.
https://doi.org/10.1007/s10096-015-2549-9
Loo, V. G., Brassard, P., & Miller, M. A. (2016). Household transmission of Clostridium difficile to family members and domestic pets. Infection Control & Hospital Epidemiology, 37(11), 1342–1348. https://doi.org/10.1017/ice.2016.178
Maillard, J. Y., Bloomfield, S. F., Essack, S. Y., Gandra, S., Gerba, C. P., Rubino, J. R., & Scott, E. A. (2020). Reducing antibiotic prescribing and addressing the global problem of antibiotic resistance by targeted hygiene in the home and everyday life settings: A position paper. American Journal of Infection Control, 48, 1090–1099.
https://doi.org/10.1016/j.ajic.2020.03.017
Miller, A. C., Arakkal, A. T., Sewell, D. K., Segre, A. M., Pemmaraju, S. V., Polgreen, P. M., & Group, C. D. C. M.-H. (2022). Risk for asymptomatic household transmission of Clostridioides difficile infection associated with recently hospitalized family members. Emerging Infectious
Diseases, 28(5), 932–939.
https://doi.org/10.3201/eid2805.212023
Normington, C., Moura, I. B., Bryant, J. A., Ewin, D. J., Clark, E. V., Kettle, M. J., Harris, H. C., Spittal, W., Davis, G., Henn, M. R., Ford, C. B., Wilcox, M. H., & Buckley, A. M. (2021). Biofilms harbour Clostridioides difficile, serving as a reservoir for recurrent infection. NPJ Biofilms and Microbiomes, 7(1), 16.
https://doi.org/10.1038/s41522-021-00184-w
Oka, K., Osaki, T., Hanawa, T., Kurata, S., Okazaki, M., Manzoku, T., Takahashi, M., Tanaka, M., Taguchi, H., Watanabe, T., Inamatsu, T., & Kamiya, S. (2012). Molecular and microbiological characterization of Clostridium difficile isolates from single, relapse, and reinfection cases. Journal of Clinical Microbiology, 50(3), 915–921.
https://doi.org/10.1128/JCM.05588-11
Otter, J. A., Yezli, S., & French, G. L. (2011). The role played by contaminated surfaces in the transmission of nosocomial pathogens. Infection Control and Hospital Epidemiology, 32(7), 687–699. https://doi.org/10.1086/660363
Otter, J. A., Yezli, S., Salkeld, J. A. G., & French, G. L. (2013). Evidence that contaminated surfaces contribute to the transmission of hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. American Journal of Infection Control, 41(5), S6–S11. https://doi.org/10.1016/j.ajic.2012.12.004
Porter, L., Sultan, O., Mitchell, B. G., Jenney, A., Kiernan, M., Brewster, D. J., & Russo, P. L. (2024). How long do nosocomial pathogens persist on inanimate surfaces? A scoping review. Journal of Hospital Infection, 147, 25–31. https://doi.org/10.1016/j.jhin.2024.01.023
Rusin, P., Maxwell, S., & Gerba, C. (2002). Comparative surface-to-hand and fingertip-to-mouth transfer efficiency of gram-positive bacteria, gram-negative bacteria, and phage. Journal of Applied Microbiology, 93, 585–592.
https://doi.org/10.1046/j.1365-2672.2002.01681.x
Shaughnessy, M. K., Bobr, A., Kuskowski, M. A., Johnston, B. D., Sadowsky, M. J., Khoruts, A., & Johnson, J. R. (2016). Environmental contamination in households of patients with recurrent Clostridium difficile infection. Applied and Environmental Microbiology, 82(9), 2686–2692.
https://doi.org/10.1128/AEM.03888-15
Weaver, F. M., Trick, W. E., Evans, C. T., Lin, M. Y., Adams, W., Pho, M. T., Bleasdale, S. C., Mullane, K. M., Johnson, S., Sikka, M. K., Peterson, L. R., Solomonides, A. E., & Gerding, D. N. (2017). The impact of recurrent Clostridium difficile infection on patients’ prevention behaviors. Infection Control & Hospital Epidemiology, 38(11), 1351–1357.
https://doi.org/10.1017/ice.2017.208
Weber, D. J., Anderson, D. J., Sexton, D. J., & Rutala, W. A. (2013). Role of the environment in the transmission of Clostridium difficile in health care facilities. American Journal of Infection Control, 41(5 Suppl), S105–S110.
https://doi.org/10.1016/j.ajic.2012.12.009