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C. difficile infection induces severe diarrhea in patients compromised by antibiotic usage and underlying disease conditions. Elderly patients are especially at risk. The recent outbreak in a hospital in St. Hyacinthe, Quebec [link widoczny dla zalogowanych], has caused concern - nine people have died due to complications from C. difficile-associated disease (CDAD). Media reports have suggested that the strain of C. difficile involved is different from a previous hypervirulent strain, which caused outbreaks at 30 Quebec hospitals between 2002 and 2004. However, at present, there is no evidence to support speculation that the current outbreak strain is an alternative strain that is even more virulent than the previous hypervirulent strain.
In Sherbrooke, Quebec (140 km southeast of Montreal), the incidence of CDAD increased 10-times between 1991 and 2003. Pepin et al. found that 37% of 161 patients with CDAD had died within one year after diagnosis, compared with 21% of control subjects, and in Sherbrooke, in 2003, 13.8% died within 30 days after diagnosis, compared with only 4.7% in 1991/92. Patients also tended to have longer hospital stays with the outbreak strain, and were more likely to have to undergo emergency surgery. Why haven’t outbreaks occurred in other Canadian hospitals? They have, and do sporadically; however, the hypervirulent strain causing infection in Quebec has not, as yet, been identified in other provinces, although it has been encountered in the the United Kingdom and the Netherlands. Did it make its way to Quebec by way of an infected patient from one of these other countries? Possibly.
Quebec does not differ geographically from other areas in North America in population size of elderly hospital patients or the use of antibiotics – two of the known predisposing factors for C. difficile infection. However [link widoczny dla zalogowanych], it has been suggested that there are more older hospitals in use than in the rest of Canada. Some of the hospitals are a century old. C. difficile can survive on environmental surfaces in its spore form; therefore, in environments where it is already endemic, it is very difficult to get rid of.
What makes this strain of C. difficile so virulent? The 2002 outbreak strain produces levels of toxins A and B that are 16 to 23 times higher than those of previous strains identified. The outbreak strain causes severe diarrhea; therefore, increased spread is also a concern due to incontinent patients – more fecal matter containing C. difficile released to the environm
Until laboratory testing types the strain, there is no reason to believe that this recent outbreak is not a re-emergence of the previous outbreak strain. C. difficile is pretty much endemic in hospitals – while it may seem that you’ve gotten rid of it, it is not surprising that it may recur sometime in the future. C. difficile forms spores when environmental conditions are insufficient to support its growth.
A study published in 2005 in the Canadian Medical Association Journal (CMAJ) in Quebec (Pepin et al.), indicated that a more virulent strain of the bacteria was present in Quebec hospitals. The study found that C. difficile was indirectly responsible for 108 deaths during a six-month period - many of these patients were elderly with underlying conditions that contributed to their deaths.
In 1995 the incidence of C. difficile-associated disease (CDAD) in Quebec was estimated at 3.6 per 10,000 patient-days, while in January 2005, the rate of nosocomial or hospital-acquired CDAD was higher than 15 per 10 [link widoczny dla zalogowanych],000 patient-days in 30 hospitals in Quebec.
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