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Eurosurveillance, Volume 11, Issue 4, 26 January 2006
Articles

Citation style for this article: van den Hof S, van der Kooi T, van den Berg R, Kuijper EJ, Notermans DW. Clostridium difficile PCR ribotype 027 outbreaks in the Netherlands: recent surveillance data indicate that outbreaks are not easily controlled but interhospital transmission is limited. Euro Surveill. 2006;11(4):pii=2882. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=2882

Clostridium difficile PCR ribotype 027 outbreaks in the Netherlands: recent surveillance data indicate that outbreaks are not easily controlled but interhospital transmission is limited

S van den Hof1 (susan.van.den.hof@rivm.nl), T van der Kooi1, R van den Berg2, EJ Kuijper2, DW Notermans1

1Centre for Infectious Disease Control, Rijksinstituut voor Volksgezondheid en Milieu (RIVM, National Institute of Public Health and the Environment), The Netherlands
2Medical Microbiology, Leiden University Medical Center (LUMC), The Netherlands

In June 2005, shortly after outbreaks of Clostridium difficile-associated diarrhoea (CDAD) caused by PCR ribotype 027 (toxinotype III) were reported in Britain, several Dutch healthcare institutions reported outbreaks of CDAD in patients caused by the same organism [1,2].

Surveillance of CDAD
Surveillance of CDAD in the hospitals with an epidemic increase was started. All institutions that observed a rise in the incidence of CDAD, or cases with more serious symptoms or lack of response to treatment with metronidazole, were invited to send in samples to the reference laboratory in Leiden for typing to detect 027 and send monthly updates on the outbreak situation to the national Centre for Infectious Disease Control at the RIVM (http://www.rivm.nl/).

So far, type 027 has been found in 15 of 23 participating institutions. Hospitals without 027 appeared not to have an increased incidence of CDAD. Further transmission seems to have occurred in only 8 of the 15 institutions where 027 was found: 7 hospitals and 1 nursing home.

Before the outbreaks, different testing strategies were in place in the institutions. During outbreaks, hospitals tested all patients with diarrhoea of unknown cause, all patients developing diarrhoea after a minimum of three days or all patients from a specific department (eg, geriatrics).

The hospital laboratories used several different assay types: toxin A immunoassays, toxin A/B immunoassays or cell cytotoxicity assays. Almost all hospitals started to use a rapid toxin A/B immunoassay during the outbreak. Additionally, some hospitals have started culturing C. difficile.

Preliminary results
The course of the epidemic differed between institutions (Figure). In one region where three hospitals use a single regional laboratory, the incidence C. difficile rose in 2004 or earlier. Unfortunately, no samples from that period were kept for typing. In some other hospitals, a sharp increase was seen in 2005. Not all patients with 027 had severe infection, some had mild colitis and were detected because of increased CDAD incidence. The median age was 74 years, but a wide range was observed: 13% of patients were under 50 years of age, 17% 50-64 years, 37% 65-79 years, and 35% over 80 years.

Figure. Monthly incidence of C. difficile-associated diarrhoea in seven hospitals with transmission of PCR-ribotype 027*.


*The dotted line represents an estimation of the incidence as admission numbers are not available yet. The ovals indicate the timing of several measures in the specific hospital, such as contact isolation and restriction of the use on fluoroquinolones. The rectangle indicates the easing of measure(s).


A number of guidelines for diagnosis and outbreak control of 027 were issued by a national expert group (in Dutch available at http://www.infectieziekten.info. These guidelines were produced in July-August 2005 and have been used since in all institutions, but not all measures have been followed up to the full extent in each hospital. By the end of 2005, the incidence had decreased in several institutions. However, the outbreaks are difficult to control: most hospitals have continued to have new cases for a long time.

It appears that institutions where stricter measures were agreed on had a sharper decline in CDAD incidence. However, as numbers are small and in some hospitals guidelines were better complied with than in others, conclusions can only be drawn cautiously.

Conclusion
The transmission in 2005 to other hospitals not already affected appears to have been limited. However, to maintain vigilance into the development of CDAD (027) outbreaks in Dutch health care institutions, this surveillance will be continued for at least another half year. Updates of the results will be published on the Centre for Infectious Disease Control website (http://www.rivm.nl/gezondheid/infectieziekten/centrum_izb/).

Acknowledgements:
We would like to acknowledge all medical microbiologists and infection control professionals for their contribution in the control and surveillance of CDAD.

References:
  1. van Steenbergen J, Debast S, van Kregten E, van den Berg R, Notermans D, Kuijper E. Isolation of Clostridium difficile ribotype 027, toxinotype III in the Netherlands after increase in C. difficile-associated diarrhoea. Eurosurveillance 2005; 10(7): 050714. (http://www.eurosurveillance.org/ew/2005/050714.asp#1)
  2. Smith A. Outbreak of Clostridium difficile infection in an English hospital linked to hypertoxin-producing strains in Canada and the US. Eurosurveillance 2005; 10(6): 050630. (http://www.eurosurveillance.org/ew/2005/050630.asp#2)

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