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Suboptimal laboratory diagnostics for infection (CDI) impedes its surveillance and control across Europe. We evaluated changes in local laboratory CDI diagnostics and changes in national diagnostic and typing capacity for CDI during the European Infection Surveillance Network (ECDIS-Net) project, through cross-sectional surveys in 33 European countries in 2011 and 2014. In 2011, 126 (61%) of a convenience sample of 206 laboratories in 31 countries completed a survey on local diagnostics. In 2014, 84 (67%) of these 126 laboratories in 26 countries completed a follow-up survey. Among laboratories that participated in both surveys, use of CDI diagnostics deemed ‘optimal’ or ‘acceptable’ increased from 19% to 46% and from 10% to 15%, respectively (p  < 0.001). The survey of national capacity was completed by national coordinators of 31 and 32 countries in 2011 and 2014, respectively. Capacity for any typing method increased from 22/31 countries in 2011 to 26/32 countries in 2014; for PCR ribotyping from 20/31 countries to 23/32 countries, and specifically for capillary PCR ribotyping from 7/31 countries to 16/32 countries. While our study indicates improved diagnostic capability and national capacity for capillary PCR ribotyping across European laboratories between 2011 and 2014, increased use of ‘optimal’ diagnostics should be promoted.


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  1. Kuijper EJ, Coignard B, Tüll PESCMID Study Group for Clostridium difficileEU Member StatesEuropean Centre for Disease Prevention and Control. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect. 2006;12(Suppl 6):2-18.  https://doi.org/10.1111/j.1469-0691.2006.01580.x  PMID: 16965399 
  2. European Centre for Disease Prevention and Control (ECDC). Point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals. 2011-2012. Stockholm: ECDC; 2013. Available from: http://www.ecdc.europa.eu/en/publications/Publications/healthcare-associated-infections-antimicrobial-use-PPS.pdf
  3. Davies KA, Longshaw CM, Davis GL, Bouza E, Barbut F, Barna Z, et al. Underdiagnosis of Clostridium difficile across Europe: the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID). Lancet Infect Dis. 2014;14(12):1208-19.  https://doi.org/10.1016/S1473-3099(14)70991-0  PMID: 25455988 
  4. Alcalá L, Martín A, Marín M, Sánchez-Somolinos M, Catalán P, Peláez T, et al. The undiagnosed cases of Clostridium difficile infection in a whole nation: where is the problem? Clin Microbiol Infect. 2012;18(7):E204-13.  https://doi.org/10.1111/j.1469-0691.2012.03883.x  PMID: 22563775 
  5. Wilcox MH. Overcoming barriers to effective recognition and diagnosis of Clostridium difficile infection. Clin Microbiol Infect. 2012;18(Suppl 6):13-20.  https://doi.org/10.1111/1469-0691.12057  PMID: 23121550 
  6. Crobach MJ, Dekkers OM, Wilcox MH, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): data review and recommendations for diagnosing Clostridium difficile-infection (CDI). Clin Microbiol Infect. 2009;15(12):1053-66.  https://doi.org/10.1111/j.1469-0691.2009.03098.x  PMID: 19929972 
  7. Planche T, Wilcox M. Reference assays for Clostridium difficile infection: one or two gold standards? J Clin Pathol. 2011;64(1):1-5.  https://doi.org/10.1136/jcp.2010.080135  PMID: 21118850 
  8. Carroll KC. Tests for the diagnosis of Clostridium difficile infection: the next generation. Anaerobe. 2011;17(4):170-4.  https://doi.org/10.1016/j.anaerobe.2011.01.002  PMID: 21376826 
  9. Shetty N, Wren MW, Coen PG. The role of glutamate dehydrogenase for the detection of Clostridium difficile in faecal samples: a meta-analysis. J Hosp Infect. 2011;77(1):1-6.  https://doi.org/10.1016/j.jhin.2010.07.024  PMID: 21145132 
  10. O’Horo JC, Jones A, Sternke M, Harper C, Safdar N. Molecular techniques for diagnosis of Clostridium difficile infection: systematic review and meta-analysis. Mayo Clin Proc. 2012 Jul;87(7):643-51. DOI: http://dx.doi.org/10.1016%2Fj.mayocp.2012.02.024 PMID: 22766084
  11. Crobach MJ, Planche T, Eckert C, Barbut F, Terveer EM, Dekkers OM, et al. European Society of Clinical Microbiology and Infectious Diseases: update of the diagnostic guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2016. Forthcoming.
  12. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32(9):920-4.  https://doi.org/10.3109/00365529709011203  PMID: 9299672 
  13. Bartlett JG, Gerding DN. Clinical recognition and diagnosis of Clostridium difficile infection. Clin Infect Dis. 2008;46(s1) Suppl 1;S12-8.  https://doi.org/10.1086/521863  PMID: 18177217 
  14. Barbut F, Surgers L, Eckert C, Visseaux B, Cuingnet M, Mesquita C, et al. Does a rapid diagnosis of Clostridium difficile infection impact on quality of patient management? Clin Microbiol Infect. 2014;20(2):136-44.  https://doi.org/10.1111/1469-0691.12221  PMID: 23565919 
  15. Longtin Y, Trottier S, Brochu G, Paquet-Bolduc B, Garenc C, Loungnarath V, et al. Impact of the type of diagnostic assay on Clostridium difficile infection and complication rates in a mandatory reporting program. Clin Infect Dis. 2013;56(1):67-73.  https://doi.org/10.1093/cid/cis840  PMID: 23011147 
  16. Huber CA, Foster NF, Riley TV, Paterson DL. Challenges for standardization of Clostridium difficile typing methods. J Clin Microbiol 2013 Sep;51(9):2810-4. DOI: http://dx.doi.org/10.1128%2FJCM.00143-13 PMID: 23784128
  17. Fawley WN, Knetsch CW, MacCannell DR, Harmanus C, Du T, Mulvey MR, et al. Development and validation of an internationally-standardized, high-resolution capillary gel-based electrophoresis PCR-ribotyping protocol for Clostridium difficile. PLoS One. 2015;10(2):e0118150.  https://doi.org/10.1371/journal.pone.0118150  PMID: 25679978 
  18. Knetsch CW, Lawley TD, Hensgens MP, Corver J, Wilcox MW, Kuijper EJ. Current application and future perspectives of molecular typing methods to study Clostridium difficile infections. Euro Surveill. 2013;18(4):20381. PMID: 23369393 
  19. He M, Miyajima F, Roberts P, Ellison L, Pickard DJ, Martin MJ, et al. Emergence and global spread of epidemic healthcare-associated Clostridium difficile. Nat Genet 2013 Jan;45(1):109-13. DOI: http://dx.doi.org/10.1038%2Fng.2478 PMID: 23222960
  20. Bauer MP, Notermans DW, van Benthem BH, Brazier JS, Wilcox MH, Rupnik M, et al. Clostridium difficile infection in Europe: a hospital-based survey. Lancet. 2011;377(9759):63-73.  https://doi.org/10.1016/S0140-6736(10)61266-4  PMID: 21084111 
  21. European Clostridium difficile Surveillance Network (ECDIS-Net). Protocols and documents. Berlin: ECDIS-Net. [Accessed 16 May 2016]. Available from: http://ecdisnet.eu/index.php/home/protocol
  22. Rossi E, Vita A, Baccetti S, Di Stefano M, Voller F, Zanobini A. Complementary and alternative medicine for cancer patients: results of the EPAAC survey on integrative oncology centres in Europe. Support Care Cancer. 2015;23(6):1795-806.  https://doi.org/10.1007/s00520-014-2517-4  PMID: 25471177 
  23. Planche TD, Davies KA, Coen PG, Finney JM, Monahan IM, Morris KA, et al. Differences in outcome according to Clostridium difficile testing method: a prospective multicentre diagnostic validation study of C difficile infection. Lancet Infect Dis. 2013;13(11):936-45.  https://doi.org/10.1016/S1473-3099(13)70200-7  PMID: 24007915 
  24. Bowker AH. A test for symmetry in contingency tables. J Am Stat Assoc. 1948;43(244):572-4.  https://doi.org/10.1080/01621459.1948.10483284  PMID: 18123073 
  25. The Clostridium difficile subcommittee of the Scientific Advisory Committee of the Health Protection Surveillance Centre (HPSC) Surveillance, diagnosis and management of Clostridium difficile infection in Ireland. National Clinical Guideline No. 3. Dublin: Department of Health; 2014. Available from: http://health.gov.ie/wp-content/uploads/2015/01/National-Clinical-Guideline-No.-3-Clostridium-difficile.pdf
  26. ADH/HCAI/ infectious disease. Updated guidance on the diagnosis and reporting of Clostridium difficile. London: Department of Health; 2012. Available from: https://www.gov.uk/government/publications/updated-guidance-on-the-diagnosis-and-reporting-of-clostridium-difficile
  27. Barbut F, Delmée M, Brazier JS, Petit JC, Poxton IR, Rupnik M, et al. A European survey of diagnostic methods and testing protocols for Clostridium difficile. Clin Microbiol Infect. 2003;9(10):989-96.  https://doi.org/10.1046/j.1469-0691.2003.00683.x  PMID: 14616740 
  28. Gould CV, Edwards JR, Cohen J, Bamberg WM, Clark LA, Farley MM, et al. Effect of nucleic acid amplification testing on population-based incidence rates of Clostridium difficile infection. Clin Infect Dis. 2013;57(9):1304-7.  https://doi.org/10.1093/cid/cit492  PMID: 23899677 
  29. Wilcox MH, Shetty N, Fawley WN, Shemko M, Coen P, Birtles A, et al. Changing epidemiology of Clostridium difficile infection following the introduction of a national ribotyping-based surveillance scheme in England. Clin Infect Dis. 2012;55(8):1056-63.  https://doi.org/10.1093/cid/cis614  PMID: 22784871 
  30. Alcalá L, Marín M, Martín A, Sánchez-Somolinos M, Catalán P, Peláez MT, et al. Laboratory diagnosis of Clostridium difficile infection in Spain: a population-based survey. J Hosp Infect. 2011;79(1):13-7.  https://doi.org/10.1016/j.jhin.2011.05.017  PMID: 21741114 
  31. Alcalá L, Reigadas E, Marín M, Martín A, Catalán P, Bouza ESpanish Clostridium difficile Study Group. Impact of clinical awareness and diagnostic tests on the underdiagnosis of Clostridium difficile infection. Eur J Clin Microbiol Infect Dis. 2015;34(8):1515-25.  https://doi.org/10.1007/s10096-015-2380-3  PMID: 25904126 
  32. Bouza E, Marín M, Peláez T, Alcalá LGroup for Clostridium difficile Infection of the Spanish Society for Chemotherapy. The situation and management of Clostridium difficile infection in Spain: an opinion document. Rev Esp Quimioter. 2013;26(3):261-86. PMID: 24080894 
  33. Pituch H, Obuch-Woszczatyński P, Lachowicz D, Wultańska D, Karpiński P, Młynarczyk G, et al. Hospital-based Clostridium difficile infection surveillance reveals high proportions of PCR ribotypes 027 and 176 in different areas of Poland, 2011 to 2013. Euro Surveill. 2015;20(38):30025.  https://doi.org/10.2807/1560-7917.ES.2015.20.38.30025  PMID: 26536049 
  34. European Centre for Disease Prevention and Control (ECDC). Minutes of the 39th meeting of the Advisory Forum, Stockholm, 24-25 September 2014. Stockholm: ECDC; 2014. Available from: http://ecdc.europa.eu/en/aboutus/governance/af/AF%20%20Meeting%20Minutes/Advisory-Forum-minutes-meeting-39.pdf

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