title: Outbreak of Clostridium difficile PCR ribotype 027--the recent experience of a regional hospital.
abstract: BACKGROUND
  Clostridium difficile infection (CDI) is the leading cause of healthcare-associated diarrhea, and several outbreaks with increased severity and mortality have been reported. In this study we report a C. difficile PCR ribotype 027 outbreak in Portugal, aiming to contribute to a better knowledge of the epidemiology of this agent in Europe.
  
  
  METHODS
  Outbreak report with retrospective study of medical records and active surveillance data of all inpatients with the diagnosis of CDI, from 1st January to 31th December 2012, in a Portuguese hospital. C. difficile isolates were characterized regarding ribotype, toxin genes and moxifloxin resistance. Outbreak control measures were taken, concerning communication, education, reinforcement of infection control measures, optimization of diagnosis and treatment of CDI, and antibiotic stewardship.
  
  
  RESULTS
  Fifty-three inpatients met the case definition of C. difficile-associated infection: 55% males, median age was 78.0 years (interquartile range: 71.0-86.0), 75% had co-morbidities, only 15% had a nonfatal condition, 68% had at least one criteria of severe disease at diagnosis, 89% received prior antibiotherapy, 79% of episodes were nosocomial. CDI rate peak was 13.89/10,000 bed days. Crude mortality rate at 6 months was 64.2% while CDI attributable cause was 11.3%. Worse outcome was related to older age (P = 0.022), severity criteria at diagnosis (leukocytosis (P = 0.008) and renal failure), and presence of fatal underlying condition (P = 0.025). PCR ribotype 027 was identified in 16 of 22 studied samples.
  
  
  CONCLUSIONS
  This is the first report of a 027-CDI outbreak in Portugal. We emphasize the relevance of the measures taken to control the outbreak and highlight the importance of implementing a close and active surveillance of CDI.
authors.affiliation: National Reference Laboratory for Gastrointestinal Infections, Department of Infectious Diseases, National Institute of Health Dr, Ricardo Jorge, Av, Padre Cruz, 1649-016 Lisbon, Portugal. monica.oleastro@insa.min-saude.pt.
authors.forename: Mónica
authors.initials: M
authors.lastname: Oleastro
authors.forename: Marta
authors.initials: M
authors.lastname: Coelho
authors.forename: Marília
authors.initials: M
authors.lastname: Gião
authors.forename: Salomé
authors.initials: S
authors.lastname: Coutinho
authors.forename: Sandra
authors.initials: S
authors.lastname: Mota
authors.forename: Andrea
authors.initials: A
authors.lastname: Santos
authors.forename: João
authors.initials: J
authors.lastname: Rodrigues
authors.forename: Domitília
authors.initials: D
authors.lastname: Faria
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016360:Clostridioides difficile / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology; D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D004761:Enterocolitis, Pseudomembranous / Q000453:epidemiology* / Q000382:microbiology; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D011174:Portugal / Q000453:epidemiology; D012189:Retrospective Studies; D016896:Treatment Outcome
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