Clostridium difficile Ribotypes Are Prevalent in European Hospitals

Diverse types of the bacteria Clostridium difficile are more widespread in European hospitals than was originally postulated.

Stool samples from patients with suspected C. difficile infection and diarrhea were tested by enzyme immunoassays (EIA), cytotoxicity test, or polymerase chain reaction (PCR) assays.

A multihospital study carried out at Leiden University Medical Center (Leiden, Netherlands; www.lumc.nl) included a network of 106 laboratories in 34 European countries. The network 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.

Patients were included in the study whose stools were positive for toxin A, B, or both or revealed the presence of toxin-producing C. difficile were defined as having C. difficile infection. Detailed information was obtained for 509 patients, and for 389 of these patients, isolates were available for characterization. Identification of C. difficile was confirmed by an in-house PCR test for the glutamate dehydrogenase gene specific to C. difficile. Isolates were further characterized by PCR ribotyping. Since PCR-ribotypes 014 and 020 are nearly identical and differ only by one band on a specific agarose-gel electrophoresis, the types were reported together as ribotype 014/020.

Sixty five different PCR ribotypes were identified, and the most prevalent types were: 014/020 from 61 patients (16%); 001 from 37 stools (9%), and 078 from 31 samples (8%) The prevalence of type 027 was 5%, with highest rates in UK and Ireland. The 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.

The authors concluded that the incidence of C. difficile infection and the distribution of causative PCR ribotypes differed greatly between hospitals in Europe and overall attributable mortality were strikingly high. They emphasized 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. The study was published online on the 15 November, 2010, in the Lancet.

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