Dramatischer Anstieg von Clostridium-difficile-assoziierter Diarrhoe in Deutschland: Ist der neue Stamm PCR-Ribotyp 027 bereits angekommen?

Zusammenfassung

In den letzten Jahren wurde in Nordamerika und Großbritannien ein drastischer Anstieg von Fällen nosokomialer Clostridium difficile-assoziierter Diarrhoe (CDAD) verzeichnet. Ebenso ist in Deutschland ein Anstieg der Patienten mit der Diagnose CDAD von 7,4 pro 100 000 stationärer Aufnahmen im Jahre 2000 auf 39,3 im Jahre 2004 festzustellen.

In Pittsburgh, USA wurde ein Anstieg der Inzidenz von CDAD-Fällen von 0,74 % im Jahre 1999 auf 1,2 % im Jahre 2000 beobachtet. Im gleichen Zeitraum stieg die Clostridium difficile (CD)-assoziierte Letalität von 0,5 % auf 2,0 %. Während eines Ausbruches (04/2001 - 03/2002) wurde ein neuer CD-Stamm für 87,5 % der schweren CDAD-Fälle verantwortlich gemacht. Seit März 2003 wurden in Kanada und in den USA gehäuft Ausbrüche durch diesen neuen CD-Stamm beobachtet, welcher mit einer besonders hohen Erkrankungsschwere und Letalität einhergeht. Darüber hinaus hat der Stamm auch bei jüngeren, ambulanten Patienten ohne Risikofaktoren zu Erkrankungen mit zum Teil sehr schweren Verläufen geführt.

Zeitgleich kam es auch in Großbritannien, den Niederlanden, Belgien und Frankreich zu mehreren Ausbrüchen, in denen dieser neue CD-Stamm nachgewiesen werden konnte.

In der Restriktions-Endonukleasen-Analyse wird er als Typ B1, in der PCR als Ribotyp 027, Toxintyp III und in der Pulsfeld-Gel-Elektrophorese als North American Profile 1 (NAP1) charakterisiert. Der Stamm besitzt durch ein zusätzliches binäres Toxin und durch auf ein Vielfaches erhöhte Spiegel der Toxine A und B eine erhöhte Virulenz. In Deutschland ist dieser Stamm bisher noch nicht nachgewiesen worden.

Diese Arbeit gibt einen Überblick über die bisherige Verbreitung des Erregers sowie Hinweise für die Diagnostik und Prävention.

Summary

There has been a dramatic increase of Clostridium difficile-associated diarrhea (CDAD) in North America and the UK over the last few years. A similar change in the epidemiology of CDAD has been noted in Germany where in 2004, of 100000 patients hospitalized in Germany, 39.3 were found to have CDAD, compared to 7,4 per 100 000 in 2000.

An increased incidence of CDAD was also observed in Pittsburgh, USA, from 0.74% in 1999 to 1,2% in 2000. At the same time, the mortality from CDAD rose from 0.48% to 2%. A new Clostridum difficile strain was responsible for 87.5% of severe CDAD cases during an outbreak in Pittsburgh between April 2001 and March 2002. Since March 2003 there has been an increasing number of nosocomial outbreaks due to a new Clostridium difficile strain in Canada and USA, a high proportion being severe and fatal cases of CDAD. Moreover, there have been community-acquired cases of severe CDAD in young patients without any specific risk factors for developing CDAD.

At the same time, outbreaks of CDAD involving the new Clostridium difficile strain have been reported from the UK, the Netherlands, Belgium and France. The new strain is characterized as type B1 by restriction enzyme analysis, as ribotype 027 and toxinotype III by PCR, and as North Amerikan Profile 1 (NAP 1) by pulsed-field gel electrophoresis. The extraordinary virulence of this strain is thought to be associated with an additional binary toxin and increased levels of toxins A and B.

This report provides information on the current epidemiological situation as well as recommendations for diagnosis and prevention.

Schlüsselwörter

Clostridium difficile - Clostridium difficile-
assoziierte Diarrhoe - Prävention - Epidemiologie

Key words

Clostridium difficile - Clostridium difficile-associated diarrhoea - prevention - epidemiology

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