title: Clostridium difficile infection in Europe: a hospital-based survey.
abstract: BACKGROUND
  Little is known about the extent of Clostridium difficile infection in Europe. Our aim was to obtain a more complete overview of C difficile infection in Europe and build capacity for diagnosis and surveillance.
  
  
  METHODS
  We set up a network of 106 laboratories in 34 European countries. In November, 2008, one to six hospitals per country, relative to population size, tested stool samples of patients with suspected C difficile infection or diarrhoea that developed 3 or more days after hospital admission. A case was defined when, subsequently, toxins were identified in stool samples. Detailed clinical data and stool isolates were collected for the first ten cases per hospital. After 3 months, clinical data were followed up.
  
  
  RESULTS
  The incidence of C difficile infection varied across hospitals (weighted mean 4·1 per 10,000 patient-days per hospital, range 0·0-36·3). Detailed information was obtained for 509 patients. For 389 of these patients, isolates were available for characterisation. 65 different PCR ribotypes were identified, of which 014/020 (61 patients [16%]), 001 (37 [9%]), and 078 (31 [8%]) were the most prevalent. The prevalence of PCR-ribotype 027 was 5%. Most patients had a previously identified risk profile of old age, comorbidity, and recent antibiotic use. At follow up, 101 (22%) of 455 patients had died, and C difficile infection played a part in 40 (40%) of deaths. After adjustment for potential confounders, an age of 65 years or older (adjusted odds ratio 3·26, 95% CI 1·08-9·78; p=0·026), and infection by PCR-ribotypes 018 (6·19, 1·28-29·81; p=0·023) and 056 (13·01; 1·14-148·26; p=0·039) were significantly associated with complicated disease outcome.
  
  
  CONCLUSIONS
  PCR ribotypes other than 027 are prevalent in European hospitals. The data emphasise the importance of multicountry surveillance to detect and control C difficile infection in Europe.
  
  
  BACKGROUND
  European Centre for Disease Prevention and Control.
authors.affiliation: Centre for Infectious Disease Control Netherlands, National Institute for Public Health and the Environment, Bilthoven, Netherlands. m.p.bauer@lumc.nl
authors.forename: Martijn P
authors.initials: MP
authors.lastname: Bauer
authors.forename: Daan W
authors.initials: DW
authors.lastname: Notermans
authors.forename: Birgit H B
authors.initials: BH
authors.lastname: van Benthem
authors.forename: Jon S
authors.initials: JS
authors.lastname: Brazier
authors.forename: Mark H
authors.initials: MH
authors.lastname: Wilcox
authors.forename: Maja
authors.initials: M
authors.lastname: Rupnik
authors.forename: Dominique L
authors.initials: DL
authors.lastname: Monnet
authors.forename: Jaap T
authors.initials: JT
authors.lastname: van Dissel
authors.forename: Ed J
authors.initials: EJ
authors.lastname: Kuijper
mesh_terms: D016360:Clostridioides difficile / Q000302:isolation & purification*; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis / Q000453:epidemiology*; D005060:Europe / Q000453:epidemiology; D006306:Health Surveys; D006801:Humans