Diversity of Clostridium difficile PCR ribotypes in Europe: results from the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID), 2012 and 2013

Abstract

Clostridium difficile infection (CDI) is the major cause of infective diarrhoea in healthcare environments. As part of the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID), the largest C. difficile epidemiological study of its type, PCR ribotype distribution of C. difficile isolates in Europe was investigated. PCR ribotyping was performed on 1,196 C. difficile isolates from diarrhoeal samples sent to the European coordinating laboratory in 2012-13 and 2013 (from two sampling days) by 482 participating hospitals from 19 European countries. A total of 125 ribotypes were identified, of which ribotypes 027 (19%, n =222), 001/072 (11%, n = 134) and 014/020 (10%, n = 119) were the most prevalent. Distinct regional patterns of ribotype distribution were noted. Of 596 isolates from patients with toxin-positive stools (CDI cases), ribotype 027 accounted for 22% (32/144) of infections in cases aged from 18 to less than 65 years, but the prevalence decreased in those aged ≥ 65 years (14% (59/412)) and further decreased in those aged ≥ 81 years (9% (18/195)). The prevalence of ribotype 027 and 176, but not other epidemic strains, was inversely proportional to overall ribotype diversity (R(2) = 0.717). This study highlights an increased diversity of C. difficile ribotypes across Europe compared with previous studies, with considerable intercountry variation in ribotype distribution. Continuous surveillance programmes are necessary to monitor the changing epidemiology of C. difficile.

National Surveillance forClostridioides difficileInfection, Sweden, 2009–2016

“…The distribution of the most common PCR ribotypes in Sweden has, with a few exceptions, been relatively constant since 2009 (Technical Appendix Table) and is comparable to that observed in other countries of Northern Europe ( 4 ). RT014 was the most common type throughout the whole period, except in 2011, when it was the second most common after RT020.…”

“…Although decreased antimicrobial drug consumption or prudent use might be part of the explanation, we suggest that the major impact is attributable to improved hygiene measures in healthcare settings. This hypothesis is supported by 1) the fact that the volume of antimicrobial drugs typically associated with increased risk for acquiring CDI sold to hospitals, where CDI is predominant ( 4 ), was virtually unchanged during the study period ( 22 ); 2) a substantial reduction in CDI cases that occurred among elderly patients, who are known to be hospitalized to a greater extent; and 3) the apparent disappearance of geographic clusters of specific C. difficile PCR ribotypes, indicative of reduced nosocomial spread. However, because CDI cases are not classified into community- and healthcare-associated CDI, we cannot entirely rule out the possibility that the observed incidence reduction occurred mainly in the community, where antimicrobial drug sales have decreased more compared with sales to inpatient facilities ( 22 ).…”

“…In conjunction with the 7% reduction of incidence rate during 2014–2015, with the exception of RT078, all of the previously common multidrug-resistant (MDR) types were no longer among the 10 most common ribotypes. RT078 prevalence was ≈3% in Europe during 2012–2013; this ribotype is also common in pigs and calves ( 4 , 10 ). RT046 is predominant in scouring piglets in central parts of Sweden ( 11 ).…”

“…Because only a few outbreaks have been reported and diversity of types is high in northern Europe, including Sweden ( 4 ), the high incidence is probably not explained by nationwide outbreaks but is more likely attributable to increased clinical awareness, contributing to correct diagnoses and treatment. Sampling rates for CDI in Sweden are also high ( 17 ), an average of 116 samples/10,000 patient-days in 2016, a factor that is correlated with higher incidence ( 19 – 21 ).…”

“…Countries in Europe have large variations in CDI incidence rates and distribution of prevalent PCR ribotypes, and the highest incidence rates occur in the northern countries, even though these countries have a low prevalence of RT027 ( 4 , 5 ). In addition, across Europe, a weak negative correlation has been observed between CDI incidence rates and cephalosporin use ( 5 ).…”