Elsevier

Microbial Pathogenesis

Volume 100, November 2016, Pages 141-148
Microbial Pathogenesis

Clostridium difficile presence in Spanish and Belgian hospitals

https://doi.org/10.1016/j.micpath.2016.09.006Get rights and content

Highlights

  • C. difficile prevalence was investigated in two European hospitals.

  • The most common PCR-ribotypes reported in Europe were found in both hospitals.

  • The variety of PCR-ribotypes detected suggests there is neither regional infection nor contamination within the hospital.

  • Paediatric service had a high number of non-toxigenic strains.

  • A great part of positive samples were referred from oncology.

Abstract

Clostridium difficile is recognised worldwide as the main cause of infectious bacterial antibiotic-associated diarrhoea in hospitals and other healthcare settings. The aim of this study was to first survey C. difficile prevalence during the summer of 2014 at the Central University Hospital of Asturias (Spain). By typing the isolates obtained, it was then possible to compare the ribotype distribution at the Spanish hospital with results from the St Luc University Hospital in Belgium over the same period. The prevalence of positive cases reported in Spain and Belgium was 12.3% and 9.3% respectively. The main PCR-ribotypes previously described in Europe were found in both hospitals, including 078, 014, 012, 020 and 002. In the Spanish hospital, most of the C. difficile-positive samples were referred from oncology, acute care and general medicine services. In the Belgian hospital the majority of positive samples were referred from the paediatric service. However, a high percentage of isolates from this service were non-toxigenic. This study finds that the presence and detection of C. difficile in paediatric and oncology services requires further investigation.

Introduction

Clostridium difficile is currently one of the most largely studied pathogenic bacteria in the world and is considered as the major cause of nosocomial antibiotic-associated diarrhoea and colitis in industrialised countries [1]. Clinical manifestations of C. difficile infection (CDI) range from mild or moderate diarrhoea to fulminant and sometimes fatal pseudomembranous colitis [2]. Normally, the diarrhoea has been described to appear 48–72 h post infection and characterised as non-haemorrhagic and watery, accompanied with abdominal pain, fever and leucocytosis [3]. However, the worst outcomes are sepsis and death, which is observed in 17% of CDI cases [4]. The highest incidence and mortality rate is usually reported among patients of advanced age who have had a stay in a healthcare setting [5].

A recent review of CDI cost-of-illness attributes a mean cost ranging from $8911 to $30,049 per hospitalised patient in the USA [6] and around 3000 million total per annum in Europe [7]. In addition, in many hospitals the diagnosis strategy remains suboptimal and a proportion of infections may remain undiagnosed [8]. In the past decade, an increase in the incidence and severity of the infection has been reported in various healthcare settings among many countries [9]. This situation was attributed to the emergence of a new epidemic and hypervirulent C. difficile strain, identified as PCR-ribotype 027 (NAP1 or North American pulsed field type 1) [10]. Since 2003, in the United States and Canada, studies have shown an increase in the number and severity of CDI cases, including an increase in the case fatality, mortality and colectomy rates [11]. The situation presented by studies in North America is mirrored in Europe. In 2008, the PCR-ribotype 027 was detected in 16 European countries and caused outbreaks in Belgium, Germany, Finland, France, Ireland, The Netherlands, Switzerland and the United Kingdom [11], [12]. However, in a further epidemiology study conducted in Europe, the most prevalent PCR-ribotypes were identified as 014/020 (15%), 001 (10%) and 078 (8%), while PCR-ribotype 027 was less prevalent (5%) [12]. Surveillance data for Belgium from 2008 to 2010 showed a stable incidence of CDI in Belgian hospitals, and even a decrease in 2010. In addition, PCR-ribotype 027 was the most prevalent type during the years 2007–2009 [13]. A further study reporting CDI ribotype distribution in Belgian hospitals between 2008 and 2010 described a decrease in cases caused by PCR-ribotype 027 (from 55% in 2008 to 28% in 2010). In contrast, the proportion of other PCR-ribotypes involved in CDI increased, such as ribotype 014 (from 20% in 2008 to 33% in 2010) and ribotype 078 (from 11% in 2009 to 23% in 2010) [14]. Meanwhile, a prospective study conducted in 2009 in the region of Barcelona (Spain) identified the main PCR-ribotypes associated with CDI as 241 (26%), 126 (18%), 078 (7%) and 020 (5%), while PCR-ribotype 027 was not detected [15]. In a later study conducted in the region of Madrid (Spain) from January to June 2013, most of the isolates associated with a CDI case possessed binary toxin and were classified as PCR-ribotype 078/126 (90.7%) [16]. Consistent with these reports, Weber et al. [17] studied C. difficile clinical isolates recovered at the reference hospital of the Balearic Islands (Spain) between August 2007 and April 2011. The authors detected a total 43 different PCR-ribotypes with a higher prevalence of types 014 (34%), 078 (13%) and 001 (5%). As in other Spanish studies, none of the isolates were identified as PCR-ribotype 027.

The aim of this study was to survey the C. difficile circulation during the summer of 2014 at the Central University Hospital of Asturias (Spain), a provincial hospital located in the North of Spain. By typing of all the isolates obtained, it was then possible to compare the ribotype distribution at the Spanish hospital with results from the St Luc University Hospital in Belgium over the same period.

Section snippets

Hospital selection, data and sampling

The Central University Hospital of Asturias (HUCA) located in Oviedo (Asturias, Spain), is the referral hospital of the Health Service of the Principality of Asturias. Overall, the hospital has 17 buildings with a total of 1324 beds, 29 operating rooms, 203 consultation rooms (for outpatients) and 123 emergency rooms.

During the 4-month period from July to October 2014, all samples from outpatients and hospitalised patients suspected of being infected with C. difficile were tested. Stool

C. difficile detection and strain characterisation in HUCA, Spain

During the four-month study period, a total of 249 samples were screened for C. difficile presence using both the rapid enzyme test and culture analysis. Twelve additional samples were only examined by culture because they were classified outside of the range established (between 4 and 7) on the BSC. The overall prevalence of C. difficile in the faecal microbiota of patients studied was 12.3% (32/261). Of these, 69% were from adults aged more than 65 years old. Only following clinical

Discussion

C. difficile continues to be the most common cause of healthcare-associated infection in the developed world. A previous European C. difficile infection hospital-based survey has shown that the incidence of CDI and the distribution of causative PCR-ribotypes differed greatly between hospitals [21]. In Spain, the number of toxin-positive cases reported varied between 5.5% and 5.6% (2008) [22], 9% (2008) [21] and 6.0%–6.5% (2013) [22]. In this study the prevalence was higher than has been

Financial support

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Declaration of interest

None.

Acknowledgements

The authors offer their most sincere thanks to the microbiology laboratory service of HUCA as well as to the microbiology unit of St Luc Hospital for technical support.

This study was presented at the 5th International Clostridium difficile Symposium (5th ICDS 2014), Bled, Slovenia, May 19–21, 2014.

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