Unseen Threats: The Hospital Environment’s Role in C difficile Colonization

Pharmacy Times^® interviewed Bobby Warren, MPS, lab director, Duke Center for Antimicrobial Stewardship and Infection Prevention at the Duke University School of Medicine in Durham, North Carolina, on his presentation titled “The C diff Dilemma: How Hospital Policies and Environmental Contamination Keep Infections Alive” at the Peggy Lillis Foundation's 2025 C diff Summit in Washington, DC.

Warren discussed how hospital policies and environmental factors contribute to Clostridioides difficile (C difficile) colonization and infection. He emphasized the challenges of getting administrative buy-in for preventive measures, citing a lack of data, cost concerns, and a cycle of inaction.

Warren highlighted environmental contamination, ineffective cleaning practices, and the overlooked role of floors in transmission, along with inconsistent policies around isolating colonized patients. He noted that pharmacists, particularly through antimicrobial stewardship, can help advocate for change and strengthen the case for administrative engagement.

Patient bed in hospital room. Image Credit: © catinsyrup - stock.adobe.com

Pharmacy Times: What was the topic of your presentation at the Peggy Lillis Foundation's 2025 C diff Summit?

Bobby Warren, MPS: Broadly, my presentation was on how there's a lot of hospital policies and a lot of the hospital administration things that contribute to C difficile colonization acquisition, and a lot of that has to do with the health care environment.

[Pharmacists] are likely aware that spores can persist on surfaces for weeks to months and even longer, in some cases. On top of that, the transition from colonization to infection can take a really long time, so hospitals aren't really actively monitoring when folks become colonized, because there's no active symptoms immediately, it's therefore not necessarily their problem in the moment. When you ask for help on these policies, you're met with cyclical opposition where they ask how big the problem is, but you don't have the data, because it's not something you monitor. Then they ask for the data, and you tell them how much it costs, and they give you the argument of: Is that theoretical cost worth the potential harm reduction? Then you kind of go back to step 1, well, there's really no data, so we need to get the data to assess that. So that's generally the big picture problem.

C difficile spores are all over the health care environment. There's a bunch of studies that my team has done that show even in patient rooms where there isn't a [patient with C difficile] and they've been tested for C difficile and it's a [polymerase chain reaction (PCR)] negative test, meaning there's no evidence of C difficile in the patient's stool, we found [C difficile] in 15% of all samples we would take from those rooms, meaning that it's everywhere, and it's not necessarily coming from the patient that's in the room.

In addition to that 15% of samples, we did a retrospective analysis on the clinical data for that and looked at the bed flow data for those rooms and found that a [patient with C difficile] hadn't been in those rooms for over a year, so we're still finding it even in those rooms. So, the first issue is just administration willing to assess the issue to begin with.

The second issue comes down to bleach. Tons of disinfectants don't work on spores. The best one is bleach. However, bleach removes wax from floors, which costs a lot of money to replace. Then you ask, “Hey, can we bleach the floors? This is probably leading to acquisition [of C difficile].” You're met with the same cyclical pattern from before.

In addition to that, we've avoided the floor infection prevention for a fairly long time. It's just a can of worms that no one really wants to touch. And we met with opposition, such as, “How would things get from the floor to a clinically relevant area?” Or like, “Who, in their right mind, would put object x on the floor,” when, in reality, it's very common. The best example I can provide are the [Occupational Safety and Health Administration] approved non-slip socks that everybody in every hospital uses. Patients, whether they have C difficile or not, walk all over the floor, which we have demonstrated that [C difficile] is all over the floor, and then immediately get back in their bed. So, C difficile spores are probably coming in contact with the patient bed, as well as the footboard, where we hang tons of medical equipment.

The third issue is the stereotypical like bread and butter of infection prevention, which is the lack of actual cleaning and disinfection that's going on. We have a plan in place, [and environmental services (EVS)] workers and nurses either are or aren't doing it. A recent study we did showed that out of 300 samples, only 11% of them are actually disinfected by EVS staff, which is very low, but it's way too easy to blame EVS staff, when, in reality, tons of studies have shown that EVS staff feel like their work is important, but they feel like they're excluded, held at arm's length, not a part of the team, unimportant, and then definitely underpaid relative to everyone around them. So until we stop holding EVS employees as the trash folks, it's not going to get any better. We can't really expect them to do better.

Then the last problem that's relatively new is contact isolation. Now that we do 2-step testing with PCR and toxin as a reflex, we now identify indirectly colonized patients. What do we do with those? We know infected patients spread it around the room. Our previous study has shown that colonized patients that have diarrhea spread it around the room as well, similar to the infected patients. But when we took a survey of around 60 hospitals in the southeastern United States, we actually showed that 50% put them in contact isolation, and the other 50% don't. So, we're either wasting a lot of [personal protective equipment] and a lot of money or not preventing quite a lot of harm.

Each of these has their own potential solutions, but to me, it all comes back around to hospital administration, having buy in, and from there, I think a lot of things are possible.

Pharmacy Times: What can pharmacists do to support the issue of "buy-in" among health system administration?

Warren: When we go to hospital administration, as you could imagine, like they see our label as infection prevention, infectious disease, and, after a while, they know why we're there. They already have a plan as to how to potentially say no.

Having pharmacists on the team is a relatively new idea with antimicrobial stewardship. So I think the novelty there, and just having more people on one side of the fence as opposed to the other, is helpful. So, I mean, because it's farfetched, like the idea of the pharmacy being related to the health care environment, I think the idea that there they would still be concern, while it is kind of a long connection, would actually benefit us and improve that. There is something going on here.