ArticlesClostridium difficile infection in Europe: a hospital-based survey
Introduction
Clostridium difficile infection is prevalent in health-care facilities throughout the developed world, but also presents as large outbreaks. Less often, it is acquired in the community from an unknown source. It characteristically occurs in elderly patients with comorbidity in whom the intestinal flora has been disrupted by previous use of antibiotics.1, 2 Since early 2003, increasing rates of C difficile infection have been reported in Canada and the USA, with a larger proportion of severe and recurrent cases occuring in these countries than previously reported. The raised incidence and virulence of such infection have partly been explained by the spread of fluoroquinolone-resistant strains belonging to the PCR-ribotype 027.3, 4, 5 In addition to the usual toxins A and B, these fluoroquinolone-resistant strains produce a binary toxin, with a hitherto uncertain pathogenic significance.1, 2, 3, 4, 5, 6 In Europe, PCR-ribotype 027 was first reported in 2005 in England and shortly thereafter in the Netherlands.7, 8 Subsequently, epidemics of C difficile infection caused by PCR-ribotype 027 have been recognised in hospitals in many European countries.9
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.9, 10 We did 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.
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Study design and patients
With support from the European Centre for Disease Prevention and Control, we appointed national coordinators for 34 European countries (including 27 member states, three candidate states, and four European-Free-Trade-Association countries) who selected hospitals in each country, relative to the country's population size. No randomisation was used for this selection. The aim was to include one hospital for countries with fewer than two million inhabitants, three for those with between two and 20
Results
In total, 97 hospitals provided patients or epidemiological data, or both. Because some hospitals were unable to supply denominator data, we could not calculate incidences for all hospitals (table 1). Most hospitals were large, as judged by the number of patient-days and admissions (median number of admissions per month 2645; IQR 1808–4257); 62 hospitals (67%) were academic hospitals. The estimated incidence of health-care-associated infection varied widely between hospitals. We calculated the
Discussion
We have shown that 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. The strengths of this pan-European study are the large number of participating countries and hospitals, and a study design with a fixed 3-month follow-up. The high follow-up rate and the fact that patients with missing follow-up were younger, were more likely to be outpatients, and had
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