Abstract
BackgroundClostridium difficile (CD) has increasingly become recognised as a significant international health burden, often associated with the healthcare environment. The upsurge in incidence of CD coincided with the emergence of a hypervirulent strain of CD characterized as 027.In 2010, 8 cases of CD 027 infections were identified in Italy. Since then, no further reports have been published. We describe 10 new cases of CD 027 infection occurring in Italy.MethodsSince December 2010, stool samples of patients with severe diarrhea and clinical suspicion of the presence of a hypervirulent strain, were tested for CD 027 by the Xpert C. difficile PCR assay (Cepheid, Sunnyvale, CA). Clinical, epidemiological and laboratory data were collected.ResultsFrom December 2010 to April 2012, 24 faecal samples from 19 patients who fit the above criteria were submitted to our laboratory. Samples were collected from 7 different hospitals.Of these, 17 had a positive PCR for CD and 10 were the epidemic 027 strain (59%). All PCR positive samples had a positive EIA toxin A/B test. Nine of 10 patients were recently exposed to antimicrobials and were healthcare-associated, including 4 with a history of long term care facility (LTCF) admission; the remaining case was community-associated, namely the wife of a patient with hospital-acquired CD 027 infection. Five patients experienced at least one recurrence of CD associated diarrhea (CDAD) with a total of 12 relapsing episodes. Of these, two patients had 5 and 6 relapses respectively.We compared the 10 patients with 027 CDAD versus the 7 patients with non-027 CDAD. None of the 7 patients with non-027 CDAD had a recent history of LTCF admission and no subsequent relapses were observed (p = 0.04).ConclusionsOur study shows that CD 027 is emerging in healthcare facilities in Italy. Whilst nosocomial acquisition accounted for the majority of such cases, 4 patients had history of a recent stay in a LTCF. We highlight the substantial risks of this highly transmissible organism in such environments. Moreover, 50% of our patients with CDAD from the 027 strain had high relapse rates which may serve to further establish this strain within the Italian health and social care systems.
Highlights
Clostridium difficile (CD) has increasingly become recognised as a significant international health burden, often associated with the healthcare environment
This changing epidemiology in developed countries coincided with the emergence of a hypervirulent strain of CD characterized as toxinotype III, North American pulsed-field type 1, restriction-endonuclease analysis group type BI and polymerase chain reaction (PCR) ribotype 027 [7,8]
Surrounding local hospitals have the capacity to perform CD toxin testing by enzyme immunoassay (EIA) but they refer to our centre to perform CD PCR on stool samples of patients with severe diarrhea i.e. in those who they have a clinical suspicion of the presence of a hypervirulent strain as suggested by symptom severity
Summary
Clostridium difficile (CD) has increasingly become recognised as a significant international health burden, often associated with the healthcare environment. Canada reported an increase in Clostridium difficile associated disease (CDAD) from 35.6 cases per 100,000 persons in 1991 to 156.3 per 100,000 in 2003 [5] and in the United Kingdom (UK) a six fold increase in Clostridium difficile infection (CDI) related mortality was observed from 1999 to 2006 [6] This changing epidemiology in developed countries coincided with the emergence of a hypervirulent strain of CD characterized as toxinotype III, North American pulsed-field type 1, restriction-endonuclease analysis group type BI and polymerase chain reaction (PCR) ribotype 027 [7,8]. These “epidemic” strains isolated in North America and Europe appear to be genetically similar [9] and in recent months, cases of CDI caused by PCR ribotype 027 have been reported in Asia [10], providing further evidence of worldwide spread
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