Various types (known as PCR ribotypes) of Clostridium difficile are now prevalent in hospitals across Europe. However the 027 type of the bacterium—which has become common in the USA and Canada—has so far not taken a firm hold in Europe, with only 5% of isolates tested being this type. These are the conclusions of an Article published Online First and in an upcoming Lancet, written by Dr Martijn P Bauer, Leiden University Medical Centre, and the National Centre for Infectious Disease Control, Netherlands, and colleagues.*
The attention given to this infection, diagnostic procedures in hospitals, presence and methodology of national surveillance, and availability of typing vary widely across Europe, which hampers comparisons between countries. The authors carried out this study to obtain a more complete overview of the situation in Europe and build capacity for diagnosis and surveillance of C difficile infection both nationally and Europe-wide.
For this study, a network of 106 laboratories in 34 European countries was set up with the aim of including one hospital for countries with fewer than two million inhabitants, three for those with between two and 20 million inhabitants, and five for those with more than 20 million inhabitants, with a balance between academic and non academic institutions.
Each hospital tested stool samples of patients with suspected C difficile infection or diarrhoea that developed 3 or more days after hospital admission. A case was defined when, subsequently, toxins were identified in stool samples. Detailed clinical data and stool isolates were collected for the first ten cases per hospital. After 3 months, clinical data were followed up.
The incidence of C difficile infection varied across hospitals (mean 4•1 per 10 000 patients per day per hospital, ranging from 0•0•3). Detailed information was obtained for 509 patients. For 389 of these patients, isolates were available for characterisation. 65 different types (PCR ribotypes) were identified, of which 014/020 (61 patients / 16%), 001 (37 /9% ) and 078 (31 / 8%) were the most prevalent. The prevalence of type 027 was 5%, with highest rates in UK and Ireland. Most infected patients had a previously identified risk profile of old age, comorbidity, and recent antibiotic use. At follow up, 101 (22%) of 455 patients had died, and C difficile infection played a role in 40 (40%) of deaths. After adjustment for potential confounders, an age of 65 years or older (3 × increased risk), and infection by PCR-ribotypes 018 (6 × increased risk) and 056 (13 × increased risk) were significantly associated with complicated disease outcome.
The authors say: "The incidence of C difficile infection and the distribution of causative PCR ribotypes differed greatly between hospitals in Europe; overall and attributable mortality were strikingly high...Although we emphasise that C difficile infection incidence rates of participating hospitals were not representative of national incidence rates, many hospitals with high rates of C difficile infection were from countries in northern and central Europe. Most of these countries are thought to have low antibiotic consumption per head, even during the winter respiratory infection season."
They conclude: "These findings underscore the importance of local surveillance to detect and control endemic and epidemic C difficile infection."
In an accompanying Comment, Dr Cirle A Warren and Dr Richard L Guerrant, Division of Infectious Diseases, University of Virginia, Charlottesville, VA, USA, say: " An important follow through would be the genotypic and phenotypic resistance patterns of these isolates. These are the isolates that will probably spill over into the community, the food supply, and animal husbandry—which can also be another source of antibiotic pressure and potential reservoirs for C difficile—and cause C difficile infection in those who otherwise have no risk factors."
They conclude: "To stay ahead of these costly and deadly outbreaks, we need to know what is out there and to identify and ameliorate what is driving their increasing frequency and severity. One thing is certain: antibiotic-resistant C difficile (and other resistant pathogens) is here to stay, as long as antibiotics are around."
Dr Martijn P Bauer, Leiden University Medical Centre, Netherlands. T) +31 715262613 E) m.p.bauer@lumc.nl
Dr. Ed J. Kuijper, Leiden University Medical Centre, T) +31 715263574. E) e.j.kuijper@lumc.nl
Dr Cirle A Warren, Division of Infectious Diseases, University of Virginia, Charlottesville, VA, USA. T) +1 434-924-5242 E) CA6T@hscmail.mcc.virginia.edu
For full Article and Comment, see: http://www.eurekalert.org/jrnls/lance/pdfs/cdiff.pdf
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Notes to editors: * The study was initiated and funded by the European Centre for Disease Prevention and Control (ECDC), which also coordinates the European Antibiotic Awareness Day, a European public health initiative to provide support for national campaigns on prudent use of antibiotics (http://antibiotic.ecdc.europa.eu). The focus of this year's European Antibiotic Awareness Day on 18 November is promoting prudent use of antibiotics in hospitals. "Decreasing antibiotic use in hospitals has been shown to result in decreasing incidence of Clostridium difficile infections." says Dr Dominique Monnet from ECDC.
Journal
The Lancet