Clostridium difficile infection perceptions and practices: a multicenter qualitative study in South Africa

BACKGROUND: Clostridium difficile infection (CDI) is understudied in limited resource settings. In addition, provider awareness of CDI as a prevalent threat is unknown. An assessment of current facilitators and barriers to CDI identification, management, and prevention is needed in limited resource settings to design and evaluate quality improvement strategies to effectively minimize the risk of CDI. METHODS: Our study aimed to identify CDI perceptions and practices among healthcare providers in South African secondary hospitals to identify facilitators and barriers to providing quality CDI care. Qualitative interviews (11 physicians, 11 nurses, 4 pharmacists,) and two focus groups (7 nurses, 3 pharmacists) were conducted at three district level hospitals in the Cape Town Metropole. Semi-structured interviews elicited provider perceived facilitators, barriers, and opportunities to improve clinical workflow from patient presentation through CDI (1) Identification, (2) Diagnosis, (3) Treatment, and (4) Prevention. In addition, a summary provider CDI knowledge score was calculated for each interviewee for seven components of CDI and management. RESULTS: Major barriers identified were knowledge gaps in characteristics of C. difficile identification, diagnosis, treatment, and prevention. The median overall CDI knowledge score (scale 0–7) from individual interviews was 3 [interquartile range 0.25, 4.75]. Delays in C. difficile testing workflow were identified. Participants perceived supplies for CDI management and prevention were usually available; however, hand hygiene and use of contact precautions was inconsistent. CONCLUSIONS: Our analysis provides a detailed description of the facilitators and barriers to CDI workflow and can be utilized to design quality improvement interventions among limited resource settings.