Epidemic Clostridium difficile

Thomas V Riley
Med J Aust 2006; 185 (3): . || doi: 10.5694/j.1326-5377.2006.tb00497.x
Published online: 7 August 2006

We need to know if and when this organism arrives in Australia

There is world-wide concern about a new infectious diseases threat following the recent emergence, in Canada,1 the United States,2 and now Europe,3 of a highly virulent strain of Clostridium difficile (called PCR ribotype 027 in Europe and NAP1 in the US). Rates of detection of C. difficile have risen dramatically: at the Centre Hospitalier Universitaire de Sherbrooke in Quebec Province (population, 7.5 million in 2003) in Canada, the incidence among patients aged ≥ 65 years increased from 102 per 100 000 population in 1991 to 867 per 100 000 in 2003.4 C. difficile disease has been more severe, with the proportion of complicated cases in Sherbrooke increasing from 7.1% (12/169) in 1991–92 to 18.2% (71/390) in 2003,4 suggesting a more virulent strain of the organism is emerging. The Quebec Health Ministry reported a total of 7004 cases of C. difficile infection between 1 April 2003 and 31 March 2004, with 1270 deaths (a crude mortality rate of 18%).5 Loo and colleagues1 reported an attributable mortality of greater than 10% in those aged over 60 years — a remarkably high figure.

  • Microbiology and Immunology, University of Western Australia, Perth, WA.


  • 1. Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005; 353: 2442-2449.
  • 2. McEllistrem MC, Carman RJ, Gerding DN, et al. A hospital outbreak of Clostridium difficile disease associated with isolates carrying binary toxin genes. Clin Infect Dis 2005; 40: 265-272.
  • 3. Kuijper Ed J, van den Berg RJ, Debast S, et al. Clostridium difficile ribotype 027, toxinotype III, the Netherlands. Emerg Infect Dis 2006; 12: 827-830.
  • 4. Pépin J, Valiquette L, Alary M-E, et al. Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ 2004; 171: 466-472.
  • 5. Eggertson L. C. difficile: by the numbers. CMAJ 2004; 171: 1331-1332. Erratum in: CMAJ 2005; 172: 19.
  • 6. Riley TV. Nosocomial diarrhoea due to Clostridium difficile. Curr Opin Infect Dis 2004; 17: 323-327.
  • 7. Barbut F, Decre D, Lalande V, et al. Clinical features of Clostridium difficile-associated diarrhoea due to binary toxin (actin-specific ADP-ribosyltransferase)-producing strains. J Med Microbiol 2005; 54 (Pt 2): 181-185.
  • 8. Geric B, Carman RJ, Rupnik M, et al. Binary toxin-producing, large clostridial toxin-negative Clostridium difficile strains are enterotoxic but do not cause disease in hamsters. J Infect Dis 2006; 193: 1143-1150.
  • 9. Warny M, Pépin J, Fang A, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 2005; 366: 1079-1084.
  • 10. Pépin J, Saheb N, Coulombe M-A, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 2005; 41: 1254-1260.
  • 11. Ackermann G, Tang-Feldman YJ, Schaumann R, et al. Antecedent use of fluoroquinolones is associated with resistance to moxifloxacin in Clostridium difficile. Clin Microbiol Infect 2003; 9: 526-530.
  • 12. Golledge CL, Carson CF, O’Neil GL, et al. Ciprofloxacin and Clostridium difficile-associated diarrhoea. J Antimicrob Chemother 1992; 30: 141-148.
  • 13. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis 2006; 12: 409-415.
  • 14. Dial S, Delaney JA, Barkun AN, et al. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005; 294: 2989-2995.
  • 15. Centers for Disease Control and Prevention (CDC). Severe Clostridium difficile-associated disease in populations previously at low risk – four states, 2005. MMWR Morb Mortal Wkly Rep 2005; 54: 1201-1205.
  • 16. Thomas C, Stevenson M, Williamson DJ, Riley TV. Clostridium difficile-associated diarrhoea: epidemiological data from Western Australia following a change in antibiotic policy. Clin Infect Dis 2002; 35: 1457-1462.
  • 17. Eggertson L. Quebec puts up $20 million for C. difficile fight. CMAJ 2005; 172: 622.


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