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Bioaerosols generated from toilet flushing in rooms of patients with Clostridioides difficile infection

  • Geneva M. Wilson (a1) (a2), Virgil B. Jackson (a1), Linda D. Boyken (a3) (a4), Marin L. Schweizer (a1) (a3) (a5), Daniel J. Diekema (a3) (a4), Christine A. Petersen (a1) (a2), Patrick J. Breheny (a6), Matthew W. Nonnenmann (a7), Eli N. Perencevich (a1) (a3) (a4) (a5) and for the CDC Prevention Epicenter Program...



Clostridioides difficile infection (CDI) is the most frequently reported hospital-acquired infection in the United States. Bioaerosols generated during toilet flushing are a possible mechanism for the spread of this pathogen in clinical settings.


To measure the bioaerosol concentration from toilets of patients with CDI before and after flushing.


In this pilot study, bioaerosols were collected 0.15 m, 0.5 m, and 1.0 m from the rims of the toilets in the bathrooms of hospitalized patients with CDI. Inhibitory, selective media were used to detect C. difficile and other facultative anaerobes. Room air was collected continuously for 20 minutes with a bioaerosol sampler before and after toilet flushing. Wilcoxon rank-sum tests were used to assess the difference in bioaerosol production before and after flushing.


Rooms of patients with CDI at University of Iowa Hospitals and Clinics.


Bacteria were positively cultured from 8 of 24 rooms (33%). In total, 72 preflush and 72 postflush samples were collected; 9 of the preflush samples (13%) and 19 of the postflush samples (26%) were culture positive for healthcare-associated bacteria. The predominant species cultured were Enterococcus faecalis, E. faecium, and C. difficile. Compared to the preflush samples, the postflush samples showed significant increases in the concentrations of the 2 large particle-size categories: 5.0 µm (P = .0095) and 10.0 µm (P = .0082).


Bioaerosols produced by toilet flushing potentially contribute to hospital environmental contamination. Prevention measures (eg, toilet lids) should be evaluated as interventions to prevent toilet-associated environmental contamination in clinical settings.


Corresponding author

Author for correspondence: Geneva M. Wilson, E-mail:


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Bioaerosols generated from toilet flushing in rooms of patients with Clostridioides difficile infection

  • Geneva M. Wilson (a1) (a2), Virgil B. Jackson (a1), Linda D. Boyken (a3) (a4), Marin L. Schweizer (a1) (a3) (a5), Daniel J. Diekema (a3) (a4), Christine A. Petersen (a1) (a2), Patrick J. Breheny (a6), Matthew W. Nonnenmann (a7), Eli N. Perencevich (a1) (a3) (a4) (a5) and for the CDC Prevention Epicenter Program...


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