Legal Obligation to Notify Severe Clostridiodes difficile Infections - Data from Frankfurt am Main, Germany. Overview and Discussion

Abstract

Clostridioides difficile (C. difficile) is the most frequently identified causative agent of antibiotic-associated diarrhea in industrialized countries. As early as 2007, severe C. difficile infections (CDI) were to be notified in Germany as a "threatening disease with an indication of grave danger to the general public". In 2016, the Notification Adjustment Ordinance put in force a duty to notify CDI with a clinically severe course. Here, the necessity and suitability of mandatory notification of severe CDI in Frankfurt am Main, Germany, 2014-2018 is examined. Cases of CDI reported to the health department Frankfurt am Main were compared with the C. difficile-associated deaths in Frankfurt for 2014-2018. The results were compared with data from the literature, the national reporting data according to the Infection Protection Act (IfSG), the mortality statistics, the hospital treatment data as well as the hospital surveillance data of the German hospital infection surveillance system for C difficile-associated diarrhea (CDAD). With the entry into force of the new Notification Adjustment Ordinance, the number of CDIs reported annually in Frankfurt am Main increased from 5-8 to 13-14; however, in all years (with the exception of 2016), the number of deaths (death-leading illness or previous cause) was -17-50 per year and thus well above the number of reported CDI-cases according to the German Infection Protection Act. The notification data from Frankfurt am Main show an approx. 2-fold lower score compared to the CDI-associated deaths. From the data of the Hospital Surveillance System (CDAD-KISS), it can be estimated that the majority of the cases are not notified. While an increase in CDI notifications is reported nationwide, there is a decrease in data from nationwide death statistics, hospital treatment data and CDI prevalence, and an increase in incidence of severe CDI. Therefore, and taking into account legal requirements of the IfSG and the options for action of the health authorities according to § 23 (4) Infection prevention act (IfSG), and regarding European recommendations and available data on CDI surveillance, the obligation to notify CDI should be lifted.