dc.description.abstract
Introduction Since 2000, a considerable increase in the number of Clostridium
difficile infections (CDIs) leading to substantial morbidity, mortality and
attributable costs has been observed, at least in North America and Europe
[1]. Changes in the epidemiology of CDI have been mainly attributed to the
emergence of a new hypervirulent strain called PCR ribotype 027, causing
numerous outbreaks in North America and Europe [2,3] and, to a lesser extent,
PCR ribotype 078 [1,4,5]. In addition, patients not previously considered to
be at risk for the disease (e.g., without recent antibiotic therapy or
hospitalisation) have also been described [1,6-8]. The European CDI study
(ECDIS), initiated and funded by the European Centre for Disease Prevention
and Control (ECDC), showed that the incidence of CDI varied from hospital to
hospital [9]. In 2008, a weighted mean incidence of 4.1 cases (range:
0.0–36.3) per 10,000 patient-days per hospital reported by the ECDIS study was
almost 70% higher than that reported in a previous European surveillance study
in 2005 (2.45 cases per 10,000 patient-days per hospital, range: 0.13–7.1)
[9,10]. ECDIS also revealed the contribution of strains other than PCR
ribotype 027 and that some of these strains, notably PCR ribotypes 015, 018
and 056, could cause severe CDI. In response to the emerging problems
associated with C. difficile, an ECDC working group published background
information about the changing epidemiology of CDI, CDI case definitions and
surveillance recommendations [2]. To support European Union (EU)/European
Economic Area (EEA) Member States in increasing their capacity for CDI
surveillance, ECDC also initiated and funded a new project – ECDIS-Net – to
develop a European surveillance protocol and enhance laboratory capacity for
diagnosis and typing of C. difficile in EU/EEA Member States. In 2011, a
survey of existing CDI surveillance systems in European countries was
performed as part of the ECDIS-Net project. The results of this survey,
presented here, were later used to develop a standardised pan-European CDI
surveillance protocol, which was tested in a three-month pilot study in 2013
[11]. Data collection in the ECDC-coordinated Europe-wide hospital-based CDI
surveillance, using a finalised version of this piloted protocol, began on 1
January 2016 [12]. Methods National coordinators for this study were
identified through the members of ECDC’s Healthcare-Associated Infections
surveillance Network (HAI-Net) and via representatives for the ECDIS study
[9]. A link to a web-based questionnaire was sent to these national
coordinators to assess the characteristics of existing CDI surveillance
systems in European countries. If the national coordinators indicated that CDI
was under surveillance in their country, the surveillance protocols were
requested and used to augment the information obtained via the questionnaire.
Information on the national CDI surveillance systems was entered using a web-
based electronic form designed for the purpose of this study. Results Between
6 June and 15 July 2011, 33 of the 35 national coordinators approached from 31
European countries responded to the web-based questionnaire (Iceland and Wales
did not respond). Four surveillance systems were excluded from further
analysis, as they were not ongoing, comprehensive nationwide surveillance
systems, i.e. they were completed one-off studies (two studies from Spain),
only regional (Switzerland) or focused only on outbreaks (one system of the
Netherlands). In 14 countries, the national coordinators indicated that
surveillance of CDI was in place. Of these, surveillance protocols were
available from 10 surveillance systems. Thus, 18 CDI surveillance systems from
14 European countries (Austria, Belgium, Bulgaria, Denmark, Finland, France,
Germany, Hungary, Ireland, the Netherlands, Sweden and three countries of the
United Kingdom (UK), England, Northern Ireland and Scotland) remained
available for analysis. Of the 18 surveillance systems, all but one reported
national CDI rates annually.
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