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Understanding of Clostridium difficile Infection Among Health Care Providers at Long-Term Care Facilities


Annals of Long-Term Care: Clinical Care and Aging. 2016;24(2):16-24.
Received March 26, 2015; accepted September 14, 2015. 


Pragnesh Patel, MD
Division of Infectious Diseases
Harper University Hospital 5 Hudson
3990 John R
Detroit, MI 48201
Phone: (313) 993-6134
Fax: (313) 966-9898


Pragnesh Patel, MD1; Reda A Awali, MD, MPH2; Sudha M Sadasivan, PhD, MPH2; Caitlin Biedron, MD2 Julie A Trzeciak, MPH2; Bharat Marwaha, MD2; Preethy Samuel, PhD3; Teena Chopra, MD, MPH2


The authors report no relevant financial relationships.



1Department of Geriatrics, Wayne State University, Detroit, MI 
2Division of Infectious Diseases, Detroit Medical Center-Wayne State University, Detroit, MI
3Department of Health Care Sciences, Wayne State University, Detroit, MI 


Health care providers (HCPs) at long-term care facilities (LTCFs) are faced with unique challenges while caring for patients with Clostridium difficile infection (CDI). A 27-item self-administered questionnaire was conducted at five LTCFs located in Southeastern Michigan and South Wisconsin between November 2012 and March 2013. The survey was designed to assess HCP knowledge about CDI and their compliance with the 2010 SHEA/IDSA guidelines for CDI prevention as well as their facility’s standard infection control practices. HCPs with more direct contact with patients were more knowledgeable about the epidemiology of CDI and were more likely to comply with the 2010 SHEA/IDSA guidelines than HCPs with less direct contact with patients. Overall, HCPs exhibited significant gaps of knowledge pertaining to diagnosis, management, and prevention of CDI. Compliance with national and facility-specific infection control guidelines was limited, with more than 50% of respondents practicing isolation measures that were different from the standard practices of their facilities. The findings underscore the importance of developing robust educational programs for HCPs at LTCFs about CDI and its prevention and improving communication between infection control teams and HCPs. 

Key words: Clostridium difficile infection, infection control practices, long-term care facilities, staff education

Clostridium difficile is a spore-forming, anaerobic, gram-positive bacillus that can cause broad-spectrum clinical disease, ranging from mild diarrhea to potentially fatal colitis.1-3 Over the last decade, the incidence of healthcare-associated infections (HAIs) due to C difficile has surpassed the incidence of HAIs due to methicillin-resistant Staphylococcus aureus (MRSA) in community hospitals.4 In 2011, C difficile resulted in .5 million infections, contributing to approximately 29,000 deaths in the United States.5 The dramatic increase in incidence and severity of C difficile infection (CDI) was prominent among older adults (over 60 years of age).6

Over the past 30 years in the United States, the number of long-term care facilities (LTCFs), including nursing homes and long-term acute care hospitals (LTACHs), has increased tremendously with very high rates of transfers between acute-care hospitals and LTCFs.7,8 The 2004 National Nursing Home Survey showed that 36% of LTCF residents were originally transferred from acute health care facilities.7 More importantly, patients diagnosed with CDI in acute-care hospitals were more likely to be discharged directly to LTCFs; 2% of all patients transferred had active CDI.7,9,10 These statistics emphasize the importance of addressing and preventing CDI transmission across the continuum of care, including in LTCFs.

Residents of LTCFs are at greater risk for CDI because, in addition to being older, they have multiple comorbidities and are frequently exposed to health care settings and antimicrobial agents.11 In particular, the LTCF population has a higher risk for CDI because of the limited infection control resources and limited ability to isolate and/or cohort CDI patients at LTCFs.11 Moreover, health care providers (HCPs) at these facilities were found to have different risk perceptions and lack of knowledge regarding CDI and its transmission among LTCF residents.12 The aim of this study was to identify the gaps in knowledge among LTCF HCPs regarding CDI and assess HCP compliance with the 2010 SHAE/IDSA guidelines as well as their own facilities’ policies for CDI prevention and control.


Study Design

A survey was conducted at five LTCFs located in Southeastern Michigan and South Wisconsin between November 2012 and March 2013. The survey and the study protocol were approved by Wayne State University Institutional Review Board. All five LTCFs participating in the survey study were skilled nursing homes (SNHs); some of them provided assisted living services as well. A data-sharing agreement was obtained from each participating SNH.

The infection control practitioner (ICP) at each facility was contacted by our research team to discuss the terms of study participation. ICPs at each facility were asked to complete a 12-item form to report information about their LTCF (such as number of beds), rates of CDI at their LTCF, and infection control practices for CDI used at their LTCF.

Survey participants included HCPs at each participating LTCF. HCPs were divided into two tiers according to the extent of direct contact with patients. HCPs who were frequently exposed to and in direct contact with CDI patients were considered first tier and included physicians, nurses, nurse practitioners, infection control personnel, and physician assistants. HCPs less frequently exposed to CDI patients were considered second tier and included dieticians; pharmacists; respiratory, physical, and occupational therapists; technicians; and administrative and management personnel.

A questionnaire-based paper survey (Figure 1) was developed using the 2010 Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) practice guidelines for CDI prevention and control (Table 1).10 It was composed of 27 multiple-choice questions: five questions to collect information about demographics; seven questions to assess general knowledge related to CDI; seven questions to address the surveillance and diagnostic testing of CDI at the respondent’s facility; and eight questions to assess knowledge about and compliance with the national and facility infection control practices for CDI. Compliance with CDI control practices was self-reported. If the respondent did not know the answer to the survey question, they could answer, “Don’t know,” or leave the question unanswered.

figure 1figure 1 continuedtable 1

Each facility’s ICP distributed the surveys to all HCPs working at their facilities. The questionnaire was voluntary and took about 15 minutes to complete. The HCPs were given 4 weeks to answer the survey. To ensure the anonymity of participants, the questionnaires were delivered to HCPs and then returned to our research team by ICPs at the corresponding facilities.

Statistical Analysis

Analyses were performed using IBM SPSS Statistics 22 (SPSS Inc., Chicago, IL, USA). Responses of participants from all five LTCFs were pooled and coded appropriately for missing data. Descriptive statistics were used for demographics and assessing HCP compliance with 2010 SHEA/IDSA CDI control guidelines in general, and the facility-specific practices in particular. Fisher’s exact tests were employed to compare the rates of correct answers between first-tier and second-tier contacts. A P-value <0.05 was considered statistically significant.


One hundred fifty-eight HCPs completed the survey. Of the participants, 132 (89%) were older than 35 years; 104 (67%) were first-tier HCPs; 139 (91%) were female; and 87 (57.5%) worked at their facilities for at least 6 years. Of first-tier HCPs, 66% were exposed to at least one CDI patient in the previous 3 months (prior to completion of the survey), compared with 72% of second-tier HCPs (P=.45).

HCP Knowledge about CDI

The majority of respondents were able to identify the risk factors of CDI (n=129; 82%) and were aware of the medical conditions and complications caused by CDI (n=105; 67%; Table 2). First-tier HCPs were more likely than second-tier HCPs to identify the risk factors for CDI (86% vs 71%; P=.02) and complications of CDI (75% vs 49%; P=.001). Among all HCPs, only 81 respondents (52%) were knowledgeable about the antibiotics predisposing for CDI; the proportion of first-tier HCPs that correctly identified these antibiotics was significantly higher than that of second-tier HCPs (57% vs 38%; P=.03). Polymerase chain reaction (PCR) was correctly identified as the gold-standard test for diagnosing CDI by 11 respondents (7%), with no significant difference between the numbers of correct responses among first-tier and second-tier HCPs. A total of 53 HCPs (34%) were aware of oral metronidazole or oral vancomycin being the first-line antibiotic treatment for CDI; first-tier HCPs were more likely to be aware of these treatments as first-line antibiotics for CDI than second-tier HCPs (42% vs 16%, P=.001). Only 28 respondents (18%) were aware of the most effective measures to reduce the incidence of CDI. First-tier HCPs were more likely to adopt these measures than second-tier HCPs (23% vs 10%, P=.05). The majority of HCPs (87%) were aware of the most effective measures for preventing transmission of CDI; first-tier and second-tier HCPs were equally knowledgeable about these measures (89% vs 82%, P=.22).

Compliance with 2010 SHEA/IDSA Guidelines for CDI Prevention

About 90% of first-tier HCPs reported using gloves and gowns for CDI contact precautions, compared with 75% of second-tier HCPs (P=.01; Table 2). First-tier HCPs were significantly more likely than second-tier HCPs to recognize complete isolation and cohorting as the best measures for containing CDI patients (90% vs 62%; P<.001). The proportion of first-tier HCPs who reported washing and rubbing hands with soap and water after caring for CDI patients was significantly higher than that of second-tier HCPs (98% vs 90%; P=.04). Forty-two percent of first-tier HCPs would typically initiate precautions as soon as CDI is suspected, compared with 33% of second-tier HCPs (P=.31). Although not statistically significant, first-tier HCPs were more likely to keep isolation and contact precautions until after cessation of diarrhea for at least 24–48 hours compared with second-tier HCPs (19% vs 17%; P=.79).

table 2

Facility-Specific CDI Testing and Surveillance

The infection control practices used when caring for patients with suspected or confirmed CDI at each of the five LTCFs, as reported by each facility’s ICP, are presented in Table 3. All five facilities accepted CDI patients and conducted regular in-service trainings for their HCPs regarding CDI prevention and contact precautions. However, one of the five facilities lacked an infection control manual with CDI specific guidelines as well as necessary medical equipment dedicated specifically to caring for CDI patients. All five facilities claimed to adopt the 2010 SHEA/IDSA contact precaution guidelines for CDI including complete isolation or cohorting of patients with CDI, using gloves and gowns while caring for patients with suspected or confirmed CDI, and using bleach or other chlorine-based products to clean rooms contaminated with C difficile.10 One LTCF reported initiating contact and isolation precautions as soon as the patient starts having diarrhea and/or CDI is suspected; however, three LTCFs have these measures initiated after 24 hours of diarrhea or after CDI is confirmed by laboratory testing. Moreover, four facilities claimed to discontinue contact and isolation measures after 24–48 hours of cessation of diarrhea, with one facility terminating these measures after completion of CDI treatment (Table 3).

table 3

HCP Knowledge About and Compliance With Facility-Specific CDI Practices

Figure 2 summarizes HCP knowledge about their facilities surveillance and antimicrobial control programs. The majority of the respondents claimed that their facilities conducted the diagnostic stool testing for CDI (60%) and that C difficile culture or toxigenic culture was the test routinely performed (62%). Of the participants, 34% didn’t know what type of test was performed at their facilities. The top three measures to control antibiotic use reported by HCP included educating healthcare providers about the proper use of antibiotics (27%), accessible advice from an infectious disease physician or pharmacist (22%), and using an antibiotic order form (16%).

figure 2

Compliance of HCPs with their facility’s CDI control practices is summarized in Figure 3.

figure 3


The majority of survey studies assessing HCP’s knowledge about CDI have been conducted in acute-care settings.13-19 One survey study was conducted at six LTCFs in Virginia to assess HCP knowledge and attitudes regarding CDI; however, this study was limited by the narrow geographical area of participating LTCFs and the small number of survey participants (6 ICPs and 21 licensed practical nurses).12 Our study involved a large number of HCPs with a wide range of professions who worked at five LTCFs distributed over a 2-US-state area. This study assessed the compliance of HCPs in LTCF with national and facility-specific guidelines for CDI prevention.

Overall, HCPs in our study exhibited significant gaps of knowledge about CDI, especially pertaining to diagnosis, management, and prevention of the disease. More than 90% of respondents failed to identify PCR as the gold standard test for diagnosing CDI; about two-thirds didn’t recognize the first-line antibiotic treatment for CDI; and more than 80% were unaware of the most effective measures to reduce the incidence of CDI. Five LTCFs implemented routine in-service trainings for CDI prevention; however, less than 40% of HCP reported initiating contact precautions as soon as CDI is suspected. Also, less than 20% of respondents attempted to maintain these precautions for at least 24–48 hours after cessation of diarrhea.

Our findings are consistent with several studies conducted in acute-care settings emphasizing major gaps in knowledge and practice related to CDI diagnosis and management among health care staff.13-16 Archbald-Pannone reported that lack of knowledge about CDI among LTCF staff was an important barrier for caring for CDI patients.12 We believe that this could be due to underestimation of the magnitude and clinical importance of CDI in these facilities, causing education about CDI to be de-prioritized by HCPs and facility directors alike. 

Our findings showed that first-tier HCPs were more knowledgeable than second-tier HCPs about the risk factors and initial treatment of CDI as well as the effective ways to decrease the incidence of CDI. Despite the fact that HCPs in both tiers were equally exposed to CDI patients within the 3 months prior to the survey, first-tier HCPs were more likely to adopt the 2010 SHEA/IDSA guidelines for contact precautions and hand hygiene when caring for CDI patients. The Health Belief Model, one of the famous behavioral change theories, suggests that individuals’ beliefs about health risks and their perception of disease threat will help trigger health-promoting behavior.20 Accordingly, one can reasonably posit that HCP who are in direct contact with CDI patients would be more motivated to seek knowledge about the disease and to comply with the CDI prevention guidelines than their second-tier counterparts. Risk perceptions have been found to play an important role in enhancing HCP compliance with infection control practices, especially in the context of C difficile and MRSA infections.21 Future prospective studies should focus on investigating the attitudinal barriers and motives for HCPs at LTCFs while caring for residents with CDI.

Our results showed that none of the participating facilities had CDI-specific policies that completely complied with the 2010 SHEA/IDSA guidelines for CDI prevention. Only one LTCF reported initiating contact and isolation precautions as soon as CDI is suspected, and one of the facilities was not medically equipped to take care of CDI patients. In addition, the top three reported measures to control antibiotic use in the LTCFs we studied included education about the proper use of antibiotics, seeking advice from an infectious disease expert, and using antibiotic order forms. Thus, none of the five facilities had an actual antibiotic stewardship program to inform the proper use of antibiotics. These findings were not surprising, given the limited resources and lack of regulatory guidelines for prevention and management of CDI at LTCFs in the US.12

All five LTCFs in our study accepted CDI patients; however, more than one-fourth of the respondents were not sure or did not know whether their facilities accept patients with CDI diagnoses. More alarmingly, about 14% of HCP failed to comply with their facility-specific contact precautions for CDI, and more than half of respondents reported practicing isolation measures that are different from those adopted by their facilities. These findings reflect a major lack of communication and coordination between the health care administration, the infection control team, and the health care staff at LTCFs.

The findings of the current study should be interpreted within the context of some limitations. First, the survey was administered to a convenience sample of HCP at each LTCF, which prevented us from being able to calculate a response rate. This fact may also limit the applicability of the questionnaire to the general LTCF HCP population. However, the large sample size and inclusion of five LTCFs from two different states may have enhanced the generalizability of the results. Second, the study used a non-validated questionnaire and did not address the respondents’ perceptions of CDI and its preventive measures. Nevertheless, the survey questionnaire was comprehensive and was based on the 2010 SHEA/IDSA guidelines for CDI prevention, which enhanced the validity of our survey.

The findings of our study suggest significant gaps in knowledge among HCPs regarding the clinical importance and burden of CDI in LTCFs. The development and implementation of educational programs targeted at HCP in LTCFs are crucial to increase the awareness about the epidemiology, transmission, and prevention of CDI. Moreover, infection control policies with CDI-specific guidelines particularly suited to LTCFs, as well as mandatory antimicrobial stewardship programs, will help reduce the incidence of CDI in these facilities. More importantly, effective communication strategies between infection control teams and HCPs at LTCFs are critical to provide timely feedback and updates about CDI and improve compliance with CDI preventive measures.


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