Dear Sir,
In December 2013, we reported a Clostridium difficile (CD) outbreak caused by the hyper-virulent ribotype 027 in the Provence-Alpes-Côte d’Azur (PACA) area, southeastern France [1]. Sixty-one patients were hospitalized from March 2013 to April 2014 in the four university hospitals of Marseille (Timone, Conception, North and Sainte-Marguerite) for CD 027 infection, with a mortality of 43% [2]. Following this outbreak, we developed an automated epidemiological surveillance system for CD cases.
Cloatridium difficile is associated with an elevated lethality worldwide [2], [3], [4]. This lethality has gradually increased, exceeding that of many other bacterial species. In the present retrospective study, from January 2012 to December 2015, we compared the lethality rates of CD isolated in enterocolitis and the three most common bacterial pathogens isolated from any specimen (Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa) in the university hospitals of Marseille, in the PACA area, France. The analysed data include the numbers of patients infected by each of the four above-mentioned bacterial species and the associated lethality for patients over 65 years old. The data at the Marseille and regional levels were obtained using our epidemiological surveillance system whereas national data were obtained by the medical information service in Timone hospital (National Data obtained by Convention de droit d’usage des données PMSI, N°d’agrément 2015-111111-88-46). Duplicates were removed. For a given patient, only the first infection caused by a given microorganism was registered. We calculated the annual lethality rates (for the years 2012 to 2015) by dividing the number of deaths by the number of patients affected by the respective bacterial species by each year. All data collection and descriptive epidemiological analyses were performed in Excel.
Within Marseille university hospitals, we observed a stable lethality rate of E. coli urinary-tract infections between 2012 and 2015 (3.6%–5.6%, Table 1). For E. coli bacteraemia, the lethality increased from 2012 to 2014 (11.8%–18.3%, Table 1) and decreased in 2015 (10.7%). For S. aureus bacteraemia, the lethality decreased constantly from 22.9% in 2012 to 19.1% in 2014 (Table 1) then increased in 2015 (20.3%). For P. aeruginosa bacteraemia the lethality increased from 2012 (28.6%) to 2013 (31.7%), then decreased in 2014 (23.1%) and increased in 2015 (30.4%; Table 1). The CD lethality rate was lower in 2012 (10.6%) than in other years and reached a peak of 18.3% in 2013 (1.7-fold increase) and then decreased in 2014 (17.9%) and 2015 (12.4%).
Table 1.
Bacterial species | Marseille University Hospitals |
PACA Region |
France |
||||||
---|---|---|---|---|---|---|---|---|---|
Numbera of patients | Number of deaths | Lethality rate | Number of patients | Number of deaths | Lethality rate | Number of patients | Number of deaths | Lethality rate | |
2012 | |||||||||
Global mortalityb | 30 890 | 1581 | 5.1 | 339 182 | 19 037 | 5.6 | 3 502 943 | 215 945 | 6.2 |
Clostridium difficile | 47 | 5 | 10.6 | 566 | 86 | 15.2 | 7500 | 1288 | 17.2 |
Escherichia coli bacteraemia | 136 | 16 | 11.8 | 1146 | 298 | 26.0 | 10 752 | 2575 | 23.9 |
Escherichia coli UTI | 380 | 21 | 5.5 | 8 562 | 688 | 8.0 | 97 357 | 5891 | 6.1 |
Staphylococcus aureus bacteraemia | 105 | 24 | 22.9 | 660 | 238 | 36.1 | 8131 | 2539 | 31.2 |
Pseudomonas aeruginosa bacteraemia | 28 | 8 | 28.6 | 324 | 131 | 40.4 | 3028 | 1176 | 38.8 |
2013 | |||||||||
Global mortalityb | 31 723 | 1583 | 5.0 | 347 520 | 19 220 | 5.5 | 3 588 311 | 215 303 | 6.0 |
Clostridium difficile | 142* | 26* | 18.3 | 710 | 142 | 20.0 | 8461 | 1511 | 17.9 |
Escherichia coli bacteraemia | 133 | 22 | 16.5 | 1201 | 313 | 26.1 | 11 574 | 2923 | 25.3 |
Escherichia coli UTI | 478 | 17 | 3.6 | 9023 | 642 | 7.1 | 103 746 | 6549 | 6.3 |
Staphylococcus aureus bacteraemia | 104 | 21 | 20.2 | 687 | 222 | 32.3 | 7988 | 2669 | 33.4 |
Pseudomonas aeruginosa bacteraemia | 41 | 13 | 31.7 | 333 | 122 | 36.6 | 3155 | 1168 | 37.0 |
2014 | |||||||||
Global mortalityb | 32 335 | 1559 | 4.8 | 356 108 | 19 427 | 5.5 | 3 695 116 | 216 734 | 5.9 |
Clostridium difficile | 148 | 27 | 18.2 | 914 | 175 | 19.1 | 8883 | 1580 | 17.8 |
Escherichia coli bacteraemia | 197 | 36 | 18.3 | 1365 | 310 | 22.7 | 13 069 | 3095 | 23.7 |
Escherichia coli UTI | 534 | 29 | 5.4 | 9679 | 733 | 7.6 | 110 565 | 6939 | 6.3 |
Staphylococcus aureus bacteraemia | 173 | 33 | 19.1 | 771 | 269 | 34.9 | 8350 | 2774 | 33.2 |
Pseudomonas aeruginosa bacteraemia | 52 | 12 | 23.1 | 404 | 126 | 31.2 | 3325 | 1158 | 34.8 |
2015 | |||||||||
Global mortalityb | 32 555 | 1645 | 5.1 | N/A | N/A | N/A | 3 836 118 | 229 608 | 6.0 |
Clostridium difficile | 153* | 19* | 12.4 | N/A | N/A | N/A | 11 336 | 1972 | 17.4 |
Escherichia coli bacteraemia | 242 | 26 | 10.7 | N/A | N/A | N/A | 21 901 | 4152 | 19.0 |
Escherichia coli UTI | 1 111 | 62 | 5.6 | N/A | N/A | N/A | 114 962 | 7507 | 6.5 |
Staphylococcus aureus bacteraemia | 143 | 29 | 20.3 | N/A | N/A | N/A | 11 481 | 3608 | 31.4 |
Pseudomonas aeruginosa bacteraemia | 56 | 17 | 30.4 | N/A | N/A | N/A | 4301 | 1483 | 34.5 |
UTI, urinary tract infection.
*p 0.09, not significant.
National Data obtained by: Convention de droit d’usage des données PMSI, N°d’agrément 2015-111111-88-46.
Includes all causes of death, infectious or not.
At the PACA level, in 2012, 2013 and 2014, the lethality rate of CD infections was also lower than those of other pathogens (Table 1). At the country level, the highest lethality rate in 2012 and 2013 was that of P. aeruginosa, which was slightly higher than that of C. difficile.
When considering the evolution of lethality rates over time (Table 1), we observed that CD-related mortality had the greatest variation among bacterial pathogens in Marseille and PACA, which may be explained by the 2013–2014 CD 027 outbreak [2]. We also observed a great reduction in CD-related lethality in 2015, although non-significant (two-sided Pearson’s chi-square test, p 0.09). This reduction followed the implementation of systematic faecal microbiota transplantation for patients hospitalized in Marseille university hospitals with CD 027 infections [2].
Together, these results confirmed that CD is a major life-threatening bacterial pathogen, especially for the elderly, like P. aeruginosa. This confirms what was previously observed in our region [1], [5] and also in northern France and other countries [6], [7]. The rapid decrease in the lethality of CD infections in Marseille university hospitals (18.3% to 12.4%) and the PACA region can be explained by the introduction of new treatment for all patients in PACA, the faecal microbiota transplantation [5].
Our study demonstrated that the CD-related lethality was similar in Marseille university hospitals and at the regional and national levels and was lower than those caused by P. aeruginosa or S. aureus. CD remains a major public health concern. Moreover, our results should encourage hospitals to extensively survey CD infections by the implementation of automatic monitoring systems, and also by developing rapid screening procedures to identify and isolate infected patients and healthy carriers upon hospitalization.
References
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