Clostridium difficile in Discharged Inpatients, Germany

To the Editor: Using discharge diagnoses from US hospitals in 2000–2003, McDonald et al. recently documented a dramatic increase in the rate of Clostridium difficile–associated disease (CDAD) (1). During the same period, a new strain of C. difficile was identified; this strain appears more virulent, at least in part because it produces higher levels of toxin (2). 
 
To our knowledge, this strain has not been identified in Germany. However, to address this emerging threat, we conducted a similar analysis of discharge data to compare findings from the United States with data from Germany. We therefore determined the absolute number of inpatient discharges from all hospitals in Germany with the number of discharge diagnoses of CDAD reported in the national Statistische Bundesamt for the years 2000–2004. We then calculated the incidence of CDAD as a discharge diagnosis for each year and stratified our results by age groups (Figure). 
 
 
 
Figure 
 
Incidence of Clostridium difficile–associated disease per 100,000 inpatients upon discharge from hospitals in Germany. 
 
 
 
Our results confirm the observations from the United States. The effect of C. difficile on illness of patients in hospitals in Germany has escalated dramatically. This is true especially for patients >60 years of age. This trend indicates the need for increased awareness of this pathogen and a concerted effort to control CDAD by reducing unnecessary antimicrobial drug use and implementing currently recommended infection control measures. It also highlights the need to develop more rapid and accurate diagnostic tools and more effective prevention and treatment strategies.

fungal pathogens could be isolated from sputum by classic and molecular methods. After 4-5 days, his temperature was 40°C, a productive cough with dyspnea was noted, and his condition deteriorated. A chest radiograph showed progression of the infiltrates, and a computed tomography scan of the abdomen and chest showed infiltrates near the pleura, suggesting encapsulated fluid (Figure). An ultrasound-guided lung biopsy was performed, and mucoid material was aspirated. Microscopy and a culture from the aspirate showed a cryptococcal isolate. This isolate was further identified by internal transcribed spacer and D1/D2 sequencing, as well as amplified fragment-length polymorphism analysis (2). In addition, detailed genotyping was performed by using sequences of 7 genes (IGS, CAP10, GPD1, LAC1, MPD1, PLB1, and TEF1; GenBank accession nos. DQ861593-DQ861599) (5).
Extensive molecular research showed that this isolate belonged to the highly virulent AFLP genotype 6A (VGIIa) of Cryptococcus gattii, which is the major genotype involved in the Vancouver Island C. gattii outbreak (1-4). All 7 sequenced genes had a complete match with the sequence types specific for isolates involved in the Vancouver Island outbreak (5). Thus, we conclude that the pathogen was acquired during the patient's visit to Vancouver Island and imported to Denmark. The presence of 3 cryptococcal masses of more or less equal size suggests that the patient was exposed to a high concentration of infectious cells of C. gattii. The observed incubation time of 6 weeks is shorter than that was previously reported for infections related to the Vancouver Island outbreak (2-11 mo) (4). These observations, in combination with the absence of any known predisposing factor in this patient, such as smoking or treatment with corticosteroids, suggest that this specific AFLP6 genotype of C. gattii is highly virulent (4,5).
This case suggests a potential risk of tourists acquiring cryptococcosis while visiting Vancouver Island. Therefore, we recommend tourists and medical staff of healthcare centers worldwide be alert for symptoms of cryptococcosis after travel to Vancouver Island.  (1). During the same period, a new strain of C. difficile was identified; this strain appears more virulent, at least in part because it produces higher levels of toxin (2).
To our knowledge, this strain has not been identified in Germany. However, to address this emerging threat, we conducted a similar analy- sis of discharge data to compare findings from the United States with data from Germany. We therefore determined the absolute number of inpatient discharges from all hospitals in Germany with the number of discharge diagnoses of CDAD reported in the national Statistische Bundesamt for the years 2000-2004. We then calculated the incidence of CDAD as a discharge diagnosis for each year and stratified our results by age groups (Figure).
Our results confirm the observations from the United States. The effect of C. difficile on illness of patients in hospitals in Germany has escalated dramatically. This is true especially for patients >60 years of age. This trend indicates the need for increased awareness of this pathogen and a concerted effort to control CDAD by reducing unnecessary antimicrobial drug use and implementing currently recommended infection control measures. It also highlights the need to develop more rapid and accurate diagnostic tools and more effective prevention and treatment strategies.