Enhanced surveillance of Clostridium difficile infection occurring outside hospital, England, 2011 to 2013

Abstract

There are limited national epidemiological data for community-associated (CA)-Clostridium difficile infections (CDIs). Between March 2011 and March 2013, laboratories in England submitted to the Clostridium difficile Ribotyping Network (CDRN) up to 10 diarrhoeal faecal samples from successive patients with CA-CDI, defined here as C. difficile toxin-positive diarrhoea commencing outside hospital (or less than 48 hours after hospital admission), including those cases associated with community-based residential care, with no discharge from hospital within the previous 12 weeks. Patient demographics and C. difficile PCR ribotypes were compared for CA-CDIs in our study and presumed healthcare-associated (HA) CDIs via CDRN. Ribotype diversity indices, ranking and relative prevalences were very similar in CA- vs HA-CDIs, although ribotypes 002 (p ≤ 0.0001),020 (p = 0.009) and 056 (p < 0.0001) predominated in CA-CDIs; ribotype 027 (p = 0.01) predominated in HA-CDIs. Epidemic ribotypes 027 and 078 predominated in institutional residents with CDI (including care/nursing homes) compared with people with CDI living at home. Ribotype diversity decreased with increasing age in HA-CDIs, but not in CA-CDIs. Ribotype 078 CA-CDIs were significantly more common in elderly people (3.4% (6/174) vs 8.7% (45/519) in those aged < 65 and ≥ 65 years, respectively; p = 0.019). No antibiotics were prescribed in the previous four weeks in about twofold more CA-CDI vs HAs (38.6% (129/334) vs 20.3% (1,226/6,028); p < 0.0001). We found very similar ribotype distributions in CA- and HA-CDIs, although a few ribotypes significantly predominated in one setting. These national data emphasise the close interplay between, and likely common reservoirs for, CDIs, particularly when epidemic strains are not dominant.

A role for tetracycline selection in the evolution of Clostridium difficile PCR-ribotype 078

“…Around the same time, a ten fold increase was noted in North America (Jhung et al, 2008). Similar increases and occasional outbreaks were subsequently recorded throughout Europe (Barbut et al, 2007; Bauer et al, 2011; Burns et al, 2010) and C. difficile RT078 has recently increased to 4.4%, 9.7% and 8.1% of total Clostridium difficile infection cases in North America, England and Scotland, respectively (Lessa et al, 2015; Mulvey et al, 2010; Fawley et al, 2016; Health Protection Scotland (2017). Three distinctive features of RT078-associated Clostridium difficile infection raise specific concerns, namely: increased severity of disease with the highest genotype-specific mortality rate (Goorhuis et al, 2008; Walker et al, 2013), a higher proportion of community-associated disease, and more infections in younger age groups compared with other genotypes (Lessa et al, 2015; He et al, 2013; Taori et al, 2014).…”

Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study

“…This is consistent with a small portion of case patients requiring hospitalization and no occurrence of severe complications (eg, colectomy). Among the predominant strains in this study, ribotypes 020, 056, and 015 were also detected among CA-CDI in England [36], whereas ribotype 106 was more prevalent overall in Scotland [37]. Notably, high frequencies of resistance to clindamycin, fluoroquinolones, and cephalosporins in ribotype 106 and associated outbreaks have been described [37, 38], indicating the need for continued surveillance for changes in the molecular epidemiology of CA-CDI to help guide prevention efforts.…”

National Surveillance forClostridioides difficileInfection, Sweden, 2009–2016

“…An increase occurred in PCR ribotype diversity over time (Figure 3, panel A and B). Similarly, a study in England indicated that ribotype diversity increased as outbreak-prone types decreased ( 13 ). These results (i.e., the disappearance of major types, increase in type diversity, and decrease in incidence) suggest that hospitals adopted improved infection control during the study period.…”