Introduction After recognition of European outbreaks of Clostridium difficile
infections (CDIs) associated with the emergence of PCR ribotype 027/NAP1 in
2005, CDI surveillance at country level was encouraged by the European Centre
for Disease Prevention and Control (ECDC) [1]. In 2008, an ECDC-supported
European CDI survey (ECDIS) identified large intercountry variations in
incidence rates and distribution of prevalent PCR ribotypes, with the
outbreak-related PCR ribotype 027 being detected in 5% (range: 0–26) of the
characterised isolates [2]. The surveillance period was limited to one month
and the representation of European hospitals was incomplete; however, this has
been the only European (comprising European Union (EU)/European Economic Area
(EEA) and EU candidate countries) CDI surveillance study. The authors
highlighted the need for national and European surveillance to control CDI.
Yet, European countries were found to have limited capacity for diagnostic
testing, particularly in terms of standard use of optimal methods and absence
of surveillance protocols and a fully validated, standardised and exchangeable
typing system for surveillance and/or outbreak investigation. As of 2011, 14
European countries had implemented national CDI surveillance, with various
methodologies [3]. National surveillance systems have since reported a
decrease in CDI incidence rate and/or prevalence of PCR ribotype 027 in some
European countries [4-8]. However, CDI generally remains poorly controlled in
Europe [9], and PCR ribotype 027 continues to spread in eastern Europe [10-12]
and globally [13]. In 2010, ECDC launched a new project, the European C.
difficile Infection Surveillance Network (ECDIS-Net), to enhance surveillance
of CDI and laboratory capacity to test for CDI in Europe. The goal of ECDIS-
Net was to establish a standardised CDI surveillance protocol suitable for
application all over Europe in order to: (i) estimate the incidence rate and
total infection rate of CDI (including recurrent CDI cases) in European acute
care hospitals; (ii) provide participating hospitals with a standardised tool
to measure and compare their own incidence rates with those observed in other
participating hospitals; (iii) assess adverse outcomes of CDI such as
complications and death; and (iv) describe the epidemiology of CDI concerning
antibiotic susceptibility, PCR ribotypes, presence of tcdA, tcdB and binary
toxins and detect new emerging types at local, national and European level.
The primary objectives of the present study were to: (i) test the pilot
protocol for the surveillance of CDI in European acute care hospitals
developed by ECDIS-Net (methodology, variables and indicators); (ii) assess
the feasibility and workload of collecting the required hospital data, case-
based epidemiological and microbiological data; and (iii) evaluate the quality
of data collected, whether in the presence or absence of existing national CDI
surveillance activities. A secondary aim was to assess the relationship
between patient and microbiological characteristics and in-hospital outcome of
CDI to confirm the added value of collecting detailed epidemiological and
microbiological data on CDI at European level
