Spread and Epidemiology of Clostridium difficile Polymerase Chain Reaction Ribotype 027/Toxinotype III in The Netherlands

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Abstract
Background. After reports of emerging outbreaks in Canada and the United States, Clostridium difficile—associated disease (CDAD) due to polymerase chain reaction ribotype 027 was detected in 2 medium-to-large hospitals in The Netherlands in 2005. Methods. National surveillance was initiated to investigate the spread and the epidemiology of CDAD. Microbiologists were asked to send strains recovered from patients with a severe course of CDAD or recovered when an increased incidence of CDAD was noted. A standardized questionnaire was used to collect demographic, clinical, and epidemiological patient data. Strains were characterized by polymerase chain reaction ribotyping, toxinotyping, the presence of toxin genes, and antimicrobial susceptibility. Results. During the period from February 2005 through November 2006, 1175 stool samples from 863 patients were sent from 50 health care facilities. of these patients, 218 (25.3%) had CDAD due to ribotype 027, and 645 patients (74.7%) had CDAD due to other ribotypes, mainly 001 (17.8%) and 014 (7.2%). Polymerase chain reaction ribotype 027 was more frequently present in general hospitals than in academic hospitals (odds ratio [OR], 4.38; 95% confidence interval [CI], 1.60–12.0). Outbreaks of CDAD were observed in 10 hospitals and in 1 nursing home. Patients infected with ribotype 027 were significantly older (OR, 2.18; 95% CI, 1.43–3.33), and significantly more patients used fluoroquinolones (OR, 2.88; 95% CI, 1.01–8.20), compared with those who were infected with other ribotypes. Clear trends were observed for more severe diarrhea (OR, 1.99; 95% CI, 0.83–4.73), higher attributable mortality (6.3% vs. 1.2%; OR, 3.30; 95% CI, 0.41–26.4), and more recurrences (OR, 1.44; 95% CI, 0.94–2.20). Conclusions. Ribotype 027 was found in 20 (18.3%) of 109 hospitals in The Netherlands, with a geographic concentration in the western and central parts of the country. The clinical syndrome in patients with CDAD differed on the basis of ribotype. Thus, early recognition of the ribotype has benefits.