title: [Emergence of clostridium difficile ribotype 027 in Germany: epidemiological and clinical characteristics].
abstract: BACKGROUND
  In September 2007 an increase of severe Clostridium difficile-associated infections (CDI) was noticed in a hospital in the city of Trier, Germany. It was assumed that a new, possibly hypervirulent strain (PCR ribotype 027) was related to these events. An outbreak investigation was initiated by the local health authorities and the Robert Koch Institute to describe the epidemiology of the possible outbreak and to identify and control the possible sources.
  
  
  METHODS
  In addition to retrospective case-finding of severe CDI and ribotype 027 infections by analysis of patient documents and certificates of death, an active surveillance system for severe CDI and ribotype 027 infections was established in the 6 hospitals of the affected region. In all suspected cases, a test for toxin A/B and a stool culture for C. difficile were conducted simultaneously. Bacterial isolates were further characterised by PCR ribotyping. Data on the course of disease, case fatality, and possible risk factors for CDI-related deaths were assessed using a standardised questionnaire. Environmental investigations were done.
  
  
  RESULTS
  By 31 January 2008, 27 cases of severe CDI and 21 cases with C. difficile ribotype 027 infections were found in the area under investigation. Active surveillance found 76 of 399 (19 %) patients positive for C. difficile. In 20 patients, PCR ribotyp 027 could be proven. In total, 9 deaths occurred (19 %). An existing immunosupressive therapy (OR 35.8; 95 % CI 2.8 - 464.5) was related to case fatality in the multivariate analysis. Severe cases of CDI were also observed in non-ribotype 027 infections. In the screening of hospital personnel (n = 161), 6 % were found positive for toxin A/B.
  
  
  CONCLUSIONS
  This investigation demonstrated the endemicity of C. difficile PCR ribotype 027 in Germany for the first time. As a consequence from this study, severe CDI became a reportable disease in Germany at the end of 2007. In addition to hygienic measures, the critical use of antibiotics is an important measure to prevent a further increase of CDI.
authors.affiliation: Robert Koch-Institut, Abteilung für Infektionsepidemiologie, Berlin. JansenA@rki.de
authors.forename: Andreas
authors.initials: A
authors.lastname: Jansen
authors.forename: N
authors.initials: N
authors.lastname: Kleinkauf
authors.forename: B
authors.initials: B
authors.lastname: Weiss
authors.forename: N H
authors.initials: NH
authors.lastname: Zaiss
authors.forename: W
authors.initials: W
authors.lastname: Witte
authors.forename: B
authors.initials: B
authors.lastname: Bornhofen
authors.forename: M
authors.initials: M
authors.lastname: Kist
authors.forename: C
authors.initials: C
authors.lastname: von Eichel-Streiber
authors.forename: M
authors.initials: M
authors.lastname: Neumann
authors.forename: H
authors.initials: H
authors.lastname: Michels
authors.forename: T
authors.initials: T
authors.lastname: Eckmanns
mesh_terms: D016360:Clostridioides difficile / Q000235:genetics / Q000302:isolation & purification; D003015:Clostridium Infections / Q000382:microbiology / Q000401:mortality*; D021821:Communicable Diseases, Emerging / Q000382:microbiology / Q000401:mortality*; D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D004761:Enterocolitis, Pseudomembranous / Q000382:microbiology / Q000401:mortality*; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008297:Male; D021521:Ribotyping; D016019:Survival Analysis; D015996:Survival Rate