Assessment of Knowledge and Practice of Healthcare Providers in Saudi Arabia Regarding Clostridioides difficile Infection Diagnosis and Management: A Cross-Sectional Questionnaire-Based Study

Figures & data

Table 1 Survey Demographics

Characteristics	N (%)
Specialty
Internal medicine	69 (37.7)
Family medicine	14 (7.7)
Infectious disease	27 (14.8)
Emergency medicine	8 (4.4)
Intensive care	11 (6.0)
Other medical specialties	31 (16.9)
Clinical pharmacist	23 (12.6)
Level of training
Resident	57 (31.1)
General physician/practitioner	52 (28.4)
Consultant	74 (40.4)
Years of experience
<10	92 (50.3)
10–20	62 (33.9)
>20	29 (15.8)
Age (years)
25–34	78 (42.6)
35–44	59 (32.2)
45–54	31 (16.9)
55–64	7 (3.8)
≥ 65	8 (4.4)
Hospital region
Central	85 (46.4)
Western	29 (15.8)
Eastern	5 (2.7)
Southern	55 (30.1)
Northern	9 (4.9)
Hospital size (beds)
< 100	28 (15.3)
101–200	47 (25.7)
201–500	66 (36.1)
> 500	42 (23.0)
Type of practice site
Governmental or Semi-governmental hospital	148 (80.9)
Private hospital	27 (14.8)
Private lab	8 (4.4)
Hospital/lab is accredited	158 (86.3)
Existence of hospital policy for CDI testing^a	25 (13.7)

Notes:^aThis is based on a question asked to participants if there is any specific policy in their institutions for CDI testing for diagnosis of possible CDI cases, not on data from their hospitals.

Abbreviation: CDI: Clostridioides difficile infection.

Table 2 Participants Responses to the Practice Items

Items	N (%)
Do you check on use of laxatives before ordering test for C. difficile?
Yes	158 (86.3)
No	25 (13.7)
What are the factors that trigger you to request stool testing for CDI?^a
One factor	92 (50.3)
Two factors	32 (17.5)
Three factors	36 (19.7)
Four factors	23 (12.6)
What test(s) is/are used to diagnose CDI at your hospital?
(Multi-step) Combined GDH/toxin EIA, followed by NAAT for discrepant results	2 (1.1)
(Multi-step) GDH EIA followed by cell cytotoxicity neutralization assay or toxin EIA (if GDH positive)	5 (2.7)
(Multi-step) NAAT followed by EIA for toxin (if NAAT positive)	3 (1.6)
(Single test) C. difficile included in a GI panel of multiple pathogens (eg Biofire)	11 (6.0)
(Single test) Combined EIA for glutamate dehydrogenase (GDH) assay and toxin	12 (6.6)
(Single test) Enzyme immunoassay (EIA) for toxin only	19 (10.4)
(Single test) Nucleic acid amplification test (NAAT) only, eg PCR or LAMP	20 (10.9)
(Single test) Toxigenic culture (C. difficile culture followed by detection of toxins)	11 (6.0)
(Multi-step) GDH EIA followed by cell cytotoxicity neutralization assay or toxin EIA (if GDH positive)	1 (0.5)
Not sure	64 (35.0)
We send stool samples to an external lab	10 (5.5)
We send stool samples to an external lab, OR Not sure	1 (0.5)
Several selections^b	8 (4.4)
(Single test) NAAT, OR (Single test) EIA for toxin only	6 (3.3)
(Multi-step) GDH EIA followed by NAAT (if GDH positive)	5 (2.7)
(Single test) NAAT, OR (Single test) Toxigenic culture	3 (1.6)
(Single test) NAAT) only OR Not sure	2 (1.1)
Do you have to report positive C. difficile specimens to someone at your hospital?
Yes	123 (67.2)
No	60 (32.8)
Do you activate any precaution for patients with CDI?
Yes	145 (79.2)
No	38 (20.8)
If you activate any precaution, choose the applicable precaution(s)
Contact precautions	95 (65.5)
Enteric precaution	15 (10.3)
Airborne precaution	26 (17.9)
Droplet precaution	2 (1.4)
Contact precautions, enteric precaution	2 (1.4)
Contact precautions, enteric precaution, droplet precaution, airborne precaution	1 (0.7)
Contact precautions, droplet precaution, airborne precaution	4 (2.8)
It would be appropriate to treat patients empirically with antibiotics for CDI, if he/she develop diarrhea while on antibiotics and has a negative toxin assay
Yes	76 (41.5)
No	107 (58.5)
Frequency of CDI testing in your practice
Never	25 (13.7)
Daily	13 (7.1)
Weekly	57 (31.1)
Monthly	59 (32.2)
Every six months	20 (10.9)
Yearly	9 (4.9)

Notes: ^aPresence of loose or watery stools; nosocomial diarrhea; onset of diarrhea after antibiotic use; advanced age with diarrhea. ^b(Single test) NAAT only, (Multi-step) Combined GDH/toxin EIA, (Single test) C. difficile included in a GI panel (eg Biofire), (Single test) Toxigenic culture, We send stool samples to an external lab; Not sure; (Single test) Combined EIA for glutamate dehydrogenase (GDH) assay and toxin, (Multi-step) GDH EIA followed by cell cytotoxicity neutralization assay or toxin EIA (if GDH positive).

Abbreviations, CDI, Clostridioides difficile infection; EIA, enzyme immunoassay; GI, gastrointestinal; GDH, glutamate dehydrogenase; LAMP, loop-mediated isothermal amplification; NAAT, nucleic acid amplification testing; PCR, Polymerase chain reaction.

Table 3 Participants’ Responses to the Knowledge Items

Items	N (%)
In a patient with CDI, it is necessary to retest at the end of therapy to assure eradication of the organism.
Yes	78 (42.6)
No	105 (57.4)
How likely is a patient to have CDI if the PCR test is positive?
Not at all	24 (13.1)
Somewhat or moderately	97 (53.0)
Very or highly	62 (33.9)
Based on the available literature, CDI treatment options are the same regardless of the severity of the infection
Yes	64 (35.0)
No	119 (65.0)
Based on the IDSA guidelines, which of the following factors are considered to classify CDI severity?^a
Wrong factors^b	22 (12.0)
One factor	48 (26.2)
Two factors	55 (30.1)
Three factors	41 (22.4)
Four factors	17 (9.3)
Based on IDSA guideline, the optimal 1st line treatment for non-severe initial episode CDI:
Wrong choice^b	98 (53.6)
One right choice^c	65 (35.5)
Vancomycin or fidaxomicin (orally)	20 (10.9)
Based on IDSA guideline, the optimal 1st line treatment for severe initial episode CDI:
Wrong choice^b	13 (7.1)
One right choice	140 (76.5)
Two right choices	25 (13.7)
Vancomycin orally, fidaxomicin orally, or metronidazole IV plus vancomycin orally	5 (2.7)
Based on IDSA guideline, the optimal treatment for recurrent CDI includes
Wrong choice^b	62 (33.9)
One right choice^d	89 (48.6)
Vancomycin or fidaxomicin (orally)	32 (17.5)
Risk factors for developing CDI include the following:^e
One right choice	27 (14.8)
Two right choices	18 (9.8)
Three right choices	38 (20.8)
Four right choices	35 (19.1)
Five right choices	44 (24.0)
Six right choices	12 (6.6)
Advanced age, duration of hospitalization, exposure to antibiotics, exposure to chemotherapy, gastrointestinal surgery or tube feeding, renal failure, and usage of PPIs	9 (4.9)
The following antibiotics should be discouraged for patients with CDI risk factors:^f
Wrong choice^b	14 (7.7)
One right choice	52 (28.4)
Two right choices	50 (27.3)
Three right choices	39 (21.3)
Third-generation cephalosporins, fluoroquinolones, clindamycin, penicillins including β-lactamase inhibitors	28 (15.3)
Based on the available literature, the appropriate antibiotic duration for CDI treatment is:
5 days	18 (9.8)
10 days	84 (45.9)
14 days	77 (42.1)
21 days	4 (2.2)
What triggers you to order C. difficile test for a patient?
Abdominal pain	1 (0.5)
Diarrhea, 1–2 episodes in 24 hours	17 (9.3)
Diarrhea, 3 or more episodes in 24 hours	165 (90.2)

Notes: Underlined category represents the complete correct answer. ^aScr, WBCs, hypotension, albumin. ^bThe respondent selected wrong answer. ^cVancomycin PO or fidaxomicin PO. ^dVancomycin PO or fidaxomicin PO. ^eAdvanced age, duration of hospitalization, exposure to antibiotics, exposure to chemotherapy, gastrointestinal surgery or tube feeding, renal failure, and usage of PPIs. ^fThird-generation cephalosporins, fluoroquinolones, Clindamycin, penicillins including β-lactamase inhibitors.

Abbreviations: CDI, Clostridioides difficile infection; IDSA, Infectious Diseases Society of America; PPIs, proton pump inhibitors.

Table 4 Distribution and Comparison of Participants Based on the Level of Knowledge

Characteristics	Level of knowledge
	Adequate n (%)	Insufficient n (%)	Inadequate n (%)	p-value^a
Overall (n=183)	51 (27.9)	65 (35.5)	67 (36.6)
Specialty				<0.0001
Internal medicine	18 (26.1)	30 (43.5)	21 (30.4)
Family medicine	2 (14.3)	7 (50.0)	5 (35.7)
Infectious disease	25 (92.6)	0 (0.0)	2 (7.4)
Emergency medicine	0 (0.0)	4 (50.0)	4 (50.0)
Intensive care	2 (18.2)	4 (36.4)	5 (45.5)
Other medical specialties	1 (3.2)	18 (58.1)	12 (38.7)
Clinical pharmacist	3 (13.0)	4 (17.4)	16 (69.6)
Level of training				<0.0001
General physician/practitioner	5 (9.6)	30 (57.7)	17 (32.7)
Resident	8 (14.0)	22 (38.6)	27 (47.4)
Consultant	38 (51.4)	15 (20.3)	21 (28.4)
Years of experience				0.0946
<10	20 (21.7)	35 (38.0)	37 (40.2)
10–20	25 (40.3)	21 (33.9)	16 (25.8)
>20	6 (20.7)	11 (37.9)	12 (41.4)
Age (years)				0.2446
25–34	16 (20.5)	33 (42.3)	29 (37.2)
35–44	23 (39.0)	18 (30.5)	18 (30.5)
45–54	10 (32.3)	9 (29.0)	12 (38.7)
55–64	0 (0.0)	3 (42.9)	4 (57.1)
≥ 65	2 (25.0)	4 (50.0)	2 (25.0)
Hospital region				0.4816
Central	20 (23.5)	38 (44.7)	27 (31.8)
Western	11 (37.9)	8 (27.6)	10 (34.5)
Eastern	1 (20.0)	1 (20.0)	3 (60.0)
Southern	17 (30.9)	18 (32.7)	20 (36.4)
Northern	2 (22.2)	2 (22.2)	5 (55.6)
Hospital size (beds)				<0.0001
< 100	1 (3.6)	18 (64.3)	9 (32.1)
101–200	7 (14.9)	25 (53.2)	15 (31.9)
201–500	24 (36.4)	11 (16.7)	31 (47.0)
> 500	19 (45.2)	13 (31.0)	10 (23.8)
Type of practice site				0.0004
Governmental or Semi-governmental hospital	49 (33.1)	44 (29.7)	55 (37.2)
Private hospital	2 (7.4)	19 (70.4)	6 (22.2)
Private lab	0 (0.0)	4 (50.0)	4 (50.0)
Accreditation status				0.0053
Yes	49 (31.0)	51 (32.3)	58 (36.7)
No	2 (8.0)	16 (64.0)	7 (28.0)
Existence of hospital policy for CDI testing				0.0517
Yes	32 (35.2)	33 (36.3)	26 (28.6)
No	19 (20.7)	34 (37.0)	39 (42.4)
Number of CDI testing				0.2833
Never	6 (24.0)	9 (36.0)	10 (40.0)
Daily	1 (7.7)	8 (61.5)	4 (30.8)
Weekly	21 (36.8)	15 (26.3)	21 (36.8)
Monthly	17 (28.8)	23 (39.0)	19 (32.2)
Every six months	6 (30.0)	8 (40.0)	6 (30.0)
Yearly	0 (0.0)	4 (44.4)	5 (55.6)

Notes: ^ap-values in bold signify statistical significance at p<0.05, indicating evidence that differences in knowledge levels between the compared groups are not due to random variations.

Abbreviation: CDI, Clostridioides difficile infection.