EpidemicClostridium difficile

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Abstract
The two articles by McDonald et al.1 and Loo et al.2 (Dec. 8 issue) document the spread of NAP1 Clostridium difficile isolates of toxinotype III in North America. This emerging strain is thought to be more virulent than earlier strains, perhaps related to its increased capacity to produce toxins.3 However, NAP1 is not solely responsible for the increasing prevalence and severity of C. difficile–associated disease. At our hospital, the rate of C. difficile–associated disease has greatly increased, and we have documented substantial treatment failure and mortality.4 Only 18 percent of isolates have been of the epidemic NAP1, toxinotype III strain; most were NAP2, toxinotype 0. Whereas McDonald et al. found that NAP1 caused at least 50 percent of C. difficile–associated disease at five hospitals, non-NAP1 strains predominated at three others.