A hyper-virulent epidemic strain of Clostridium difficile – PCR ribotype 027 has been recently found in England, Belgium, France and the Netherlands [1,2,3,4,5,6]. This PCR ribotype causes more severe disease than the more frequent type and is associated with a higher mortality. We report the first isolate of C. difficile 027 documented in Austria.

On 9 March 2006, in a local hospital in Tyrol, west Austria, a 69 year old British woman was admitted to hospital with a five day history of nausea, watery diarrhoea and lower abdominal pain. She had been vomiting on the day she was admitted. The patient was a tourist who arrived in Austria on 5 March from England. The day before the onset of diarrhoea, she was reportedly taking antibiotics prescribed by her physician to treat bronchitis. An abdominal x-ray revealed fluid levels consistent with paralytic ileus (paralysis of the intestine) without indication of perforation.

Antimicrobial therapy was started with ciprofloxacin (500mg orally, twice per day for four days), but the patient’s condition did not improve. On 10 March, computerised tomography revealed a massive oedematous thickening of the entire colon wall with excess fluid in the peritoneal cavity. A stool specimen was obtained, therapy was switched to metronidazole (500mg orally twice per day) on 10 March, followed by 500mg orally, three times per day for 10 days, again without noticeable improvement. On 11 March, test results revealed that the patient was infected with C. difficile.

By 20 March, the patient had developed an urticarial rash and her poor response to treatment (further diarrhoea and feeling unwell), led to a change of therapy to vancomycin (125mg orally, four times per day for 10 days). Within a few days, the frequency of bowel movements was reduced and fluid in the abdomen also diminished. Results of a colonoscopy on 20 March showed that there was still active pseudo-membranous colitis reaching to the sigmoid part of the colon. Histopathology revealed infiltration of neutrophils through the damaged mucous layer, compatible with pseudo-membranous colitis. The patient was discharged from the hospital and returned to England on 29 March.

Detection of C. difficile PCR ribotype 027
After a request from the European Centre for Disease Prevention and Control to European member states in January 2006 to look for C. difficile 027 in their countries, a prospective C. difficile typing facility was set up, and regional hospitals were invited to send in specimens for PCR ribotyping. Between January and June 2006, 102 C. difficile isolates were collected from 14 healthcare facilities in all nine provinces of Austria. An isolate from the above case was typed in September and found positive for 027. This is the first time that ribotype 027 has been documented in Austria. PCR was used to detect the binary toxin CDT and a deletion in the pathogenicity locus gene, tcdC. The identified 027 isolate contained an 18bp deletion in the gene (tcdC) which normally regulates toxin production. The strain was positive for binary toxin genes. This strain was resistant to fluoroquinolone antibiotics such as ciprofloxacin and moxifloxacin (MIC= >32), and metronidazole (MIC= >256) [7].

Conclusions
Among outpatients exposed to antibiotics, clinically recognised C. difficile-associated diarrhoea due to PCR ribotype 027 is uncommon. C. difficile is known to colonise the colon in 3% of healthy adults and in up to 20%-30% of patients in hospital [7]. We believe that the patient initially acquired the strain in her home country. This case demonstrates how C. difficile ribotype 027 can spread between European countries.

All C. Difficile isolates coming from this hospital will be typed for some months.

Acknowledgments:
We are grateful to Céline Harmanus and Renate van den Berg from Leiden University (Medische Microbiologie, Leids Unversitair Medisch Centrum) for their methodological help and for providing reference strains and to Jon Brazier from the University Hospital of Wales (Anaerobe Reference Laboratory, NPHS Microbiology Cardiff)