Knowledge, attitudes, and practice regarding Clostridium difficile infection (CDI) among faculty and residents in an academic medical center

Background:  C. difficile is a significant healthcare-associated and community-acquired pathogen. New treatment, diagnosis and prevention guidelines were recently published, and highly sensitive tests are now available. We wished to determine the educational needs of physicians in an academic medical center prior to the introduction of a new assay incorporating antigen, toxin and polymerase chain reaction testing.   

 

Objective:  We administered a survey to determine physician knowledge, attitude and practice regarding CDI. The study was approved by the Institutional Review Board of the University of New Mexico.

Methods:  The UNM School of Medicine has approximately 1300 faculty and 700 residents. Infection Control reports around 200 cases of healthcare- and community-associated CDI yearly. Our guidelines require contact precautions for CDI and hand hygiene with soap and water after patient contact.  Testing is performed with  an enzyme immunoassay for Toxins A and B. Using the current IDSA/SHEA guidelines as the standard for clinical practice, we developed  21 questions on testing, best practice in infection control and treatment, and attitudes  regarding patient education and the risk of CDI with various antimicrobials. The anonymous survey was distributed via a web link in electronic mail. Responses were tabulated by department and faculty and resident status. Where responses differed between groups, odds ratios were calculated and confidence intervals generated using the chi-square statistic.

Results:  124 faculty and 92 residents responded to the survey (overall response rate 11%), mostly from the departments of Internal Medicine, Pediatrics and Family Medicine. Table 1 indicates the percentage of respondents giving the correct answer per national or local guidelines in knowledge or practice questions. While 54% indicated that our laboratory performed a toxin assay, 32% thought a culture was performed. For infection control, 26% would not use contact precautions, but would use hand hygiene with soap and water after patient contact. 51% of respondents rated our current lab test as “very reliable”, and 84% would rarely or never treat a patient if the test were negative. When asked about a patient with a suggestive scenario for CDI and negative PCR test, 32% of respondents indicated that the patient was moderately to highly likely to have CDI.  53% responded that they “almost never” or “never” counsel patients about the risk of CDI when prescribing antibiotics. Faculty were significantly more likely than residents to report using alcohol hand gel after examining a patient with CDI (OR 19.9, 95% CI 2.6-152).  

Conclusions: The survey identified gaps in knowledge and practice across all groups.  The voluntary design of the survey may have deterred those less knowledgeable about CDI. The introduction of a new test is an opportune time to educate medical staff on all aspects of CDI.