Eurosurveillance - Volume 13, Issue 31, 31 July 2008

Since 2006, the European Centre for Disease Prevention and Control (ECDC) has been addressing the new CDI situation. Considering the worrying evolution of CDI in Northern America, reports of Type 027 CDI outbreaks in Belgium, The Netherlands and the UK in 2005, and the preliminary results of an EU-wide study conducted in 2005 by the ESCMID Study Group for C. difficile (ESGCD), ECDC convened a group of experts consisting of members of ESGCD, epidemiologists from healthcare-associated surveillance networks from the European Union (EU) and from the US Centers for Disease Control and Prevention (CDC). This ECDC working group recognised the emergence of a new CDI problem in some EU Member States and the potential for spread to other countries and decided to act.

Q fever is a worldwide zoonosis caused by the bacterium Coxiella burnetii which is common in a wide range of wild and domestic animals. Cattle and small ruminants, in particular sheep and goats, have been associated with large human outbreaks. Humans become infected primarily by inhaling aerosols that are contaminated by C. burnetii. Most infections remain asymptomatic but in about 40% lead to a febrile disease, pneumonia and/or hepatitis. Chronic infections, mainly endocarditis, are observed in 3 to 5% of cases, with an increased risk for pregnant women and persons with heart valve disorders or impaired immunity. Q fever in pregnancy, whether symptomatic or asymptomatic, may also result in adverse pregnancy outcomes [1]. Q fever in humans is a notifiable disease in The Netherlands. The notification criteria for a confirmed case of acute Q fever are clinical symptoms consistent with Q fever and a positive serology defined by immunofluoresence assay (IFA) test or a C. burnetii complement fixation test [2]. Also clinical patients diagnosed by PCR are considered as confirmed cases. Between 1997 and 2006, Q fever was notified rarely with an average of 11 (range 5-16) cases annually [3]. In 2007, we reported in this journal the first community outbreak of Q fever in the south of The Netherlands [4].

An ongoing outbreak of measles linked to anthroposophic communities in The Hague, The Netherlands has been identified since mid-June 2008. Thirty-four cases have been reported until 25 July. In addition, two cases have been reported in other cities (Leiderdorp and Utrecht). Both are epidemiologically linked to the cluster in The Hague.

We report on the first documented extensively drug-resistant tuberculosis (XDR-TB) case in Austria, diagnosed this year. The term XDR-TB was used for the first time in March 2006, in a report jointly published by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to describe a disease caused by Mycobacterium tuberculosis that was resistant not only to isoniazid and rifampicin (i.e. multi-drug resistant tuberculosis, MDR-TB), but also to at least three of the six classes of second-line anti-TB drugs - aminoglycosides, polypeptides, fluoroquinolones, thioamides, cycloserine, and para-aminosalycilic acid [1,2]. As this definition was dependent on unstandardised drug susceptibility testing (DST) methodologies and did not necessarily distinguish the most difficult-to-treat cases using the current drug armamentarium, it was eventually modified in October 2006 [1]. XDR-TB is now defined as: resistance to at least rifampicin and isoniazid, in addition to any fluoroquinolone, and to at least one of the three following injectable drugs used in anti-TB treatment: capreomycin, kanamycin, and amikacin [3]. .

Outbreaks of Clostridium difficile infections (CDI) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America and Europe. This emerging strain is referred to as PCR ribotype 027 (Type 027). Since 2005, individual countries have developed surveillance studies about the spread of type 027. C. difficile Type 027 has been reported in 16 European countries. It has been responsible for outbreaks in Belgium, Germany, Finland, France, Ireland, Luxembourg, The Netherlands, Switzerland and the United Kingdom (England, Wales, Northern Ireland and Scotland). It has also been detected in Austria, Denmark, Sweden, Norway, Hungary, Poland and Spain. Three countries experienced imported patients with CDI due to Type 027 who acquired the infection abroad. The antimicrobial resistance pattern is changing, and outbreaks due to clindamycin-resistant ermB positive Type 027 strains have occurred in three European countries. Ongoing epidemiological surveillance of cases of CDI, with periodic characterisation of the strains involved, is required to detect clustering of cases in time and space and to monitor the emergence of new, highly virulent clones.

Limited information is available on the burden and epidemiology of Clostridium difficile infection (CDI) in Spain. The present report communicates the secular trends in prevalence of CDI among hospitalised patients in Spain from 1999 through 2007. Data were obtained through the EPINE study (Estudio de prevalencia de las infecciones nosocomiales en los hospitales españoles), a point prevalence study series of nosocomial infections among patients admitted to hospital in Spain.A total of 378 cases with CDI were identified. Median age was 74 years. Prevalence rates of CDI increased from 3.9 to 12.2 cases per 10,000 hospitalised patients and showed a significantly increasing secular trend from 1999 through 2007 (prevalence rate ratio per each year increment 1.09; 95% CI 1.05 - 1.14). Percentage of hospitalised patients receiving antimicrobials increased linearly from 36.0% in 1999 to 40.7% in 2007 (p <0.001) and was strongly correlated to CDI prevalence (R square = 0.73; regression coefficient =1.194, 95% CI= 1.192 - 1.196).