Supplementary Table S1: Overview of Results from International Multicentre Clostridium

Supplementary table S1: Overview of results from international multicentre Clostridium difficile infection studies in Europe

Study / Barbutet al., 2007 [3] / Bauer MP et al., 2011 [4] / ECDC PPS [36] / Davies et al., 2014 [5] / Davies et al., 2016 [6] / van Dorpet al., 2016 [7]
Surveillance period / 4 – 6/2005 / 11/2008 / 2011 – 2012 / 9/2011 – 8/2012; 9/2012 to 8/2013 / two days in 2012–2013 / 5/2013 – 11/2013
Study population / 38 hospitals/14 countries / 106 laboratories/34 countries / 947 hospitals/33 countries / 482 hospitals/20 countries / 37 hospitals/14 countries
Indicator
Country* / Mean CDI incidence density / Mean CDI incidence / Prevalent
ribotype / Weighted mean HA CDI incidence density / Weighted mean
HA CDI incidence / Most prevalent
ribotypes / Prevalence / Mean CDI
incidence density / Mean CDI
incidence / Most prevalent
ribotypes / Median HA CDI incidence density / Median HA CDI incidence
10,000
pbds / 10,000 adms / RT (%) / 10,000
pbds / 10,000
adms / RT (%) / (%) / 10,000
pbds / 10,000
pbds / RT (%) / 10,000
pbds / 10,000
dischs
Austria / 7.5 / 36 / 053 (18.2) / 5.9 / 4.4 / 4.1 / 027 (26.7) / 3.2 / 15.8
Belgium / 3.2 / 31.1 / 027 (31.4) / 2.8 / 19 / 014 (33.3) / 3.4 / 5.5 / 4.0 / 020 (12.0) / 2.7 / 17.7
Bulgaria / 0.6 / 3 / 046 (66.7) / 0.0 / 0.8 / 0.7 / 001/072 (36.8)
Croatia / 0.7 / 6 / 001, 056 (50.0 each) / 2.2
Cyprus / 1.2 / 5 / 046 (100.0) / 2.5
Czech Republic / 1.1 / 7 / 017 (50.0) / 6.8 / 4.4 / 6.2 / 176 (35.3)
Denmark / 5.5 / 18 / 005 (18.8) / 1.4 / 5.3 / 17.7
Estonia / NA / NA / NA / 1.6 / 1.2 / 8.6
Finland / 19.1 / 80 / 002, 014 (21.1 each) / 5.2 / 14.9 / 28.7 / 001/072 (23.1) / 4.4 / 14.9
France / 2.3 / 17.9 / 014 (21.2) / 2.1 / 15 / 014 (23.1) / 1.4 / 3.9 / 3.3 / 140 (12.5) / 3.8 / 26.7
Germany / NA / NA / 168 (21.4) / 7.4 / 60 / 001 (43.5) / 7.0 / 10.2 / 11.0 / 027 (22.8) / 3.6 / 23.1
Greece / 2.8 / 14.0 / 078 (27.3) / 3.7 / 29 / 012 (32.4) / 0.7 / 3.4 / 3.9 / 017, 046 (21.4, 21.4)
Hungary / 1.0 / 15.6 / 014 (11.9) / 2.0 / 9 / 014 (26.9) / 10.6 / 12.3 / 15.5 / 027 (59.1) / 14.9 / 121.6
Iceland / NA / NA / 001, 139 (40.0) / 0.0
Ireland / 7.1 / 73.5 / 017 (18.2) / 7.3 / 63 / 106 (27.8) / 5.8 / 4.8 / 9.1 / 078 (27.3)
Italy / 0.9 / 6.8 / 020 (26.3) / 3.6 / 22 / 018 (65.5) / 2.8 / 9.5 / 7.2 / 018 (21.7)
Latvia / 1.9 / 13 / 6.1
Lithuania / NA / NA / 0.0
Luxembourg / 0.0 / 0 / 10.8
Malta / NA / NA / 2.9
The Netherlands / 4.0 / 24.9 / 027 (40.0) / 4.0 / 23 / 001 (33.3) / 1.4 / 7.4 / 5.3 / 001/072 (22.2) / 1.9 / 10.5
Norway / 7.6 / 56 / 014 (35.7) / 3.3 / 1.9 / 9.6
Poland / NA / NA / 017 (56.3) / 12.5 / 76 / 014, 017,070 (18.8) / 4.6 / 8.6 / 8.2 / 027 (41.4) / 7.6 / 42.6
Portugal / 2.6 / 13 / 078 (27.3) / 2.3 / 2.9 / 3.0 / 302 (12.5)
Romania / 0.3 / 2 / 017 (100.0) / 2.6 / 3.9 / 7.4 / 027 (40.0) / 6.7 / 12.1
Serbia / 10.0 / 89.8
Slovakia / 1.4 / 11 / NA / 1.2 / 5.3 / 1.2 / 001/072 (60.9)
Slovenia / 2.8 / 19 / 014 (50.0) / 0.5 / NA / NA / NA
Spain / 3.0 / 25.9 / 001 (73.0) / 4.3 / 30 / 014 (29.6) / 0.7 / 3.5 / 3.2 / 001/072 (12.0)
Sweden / 2.5 / 31.7 / 017 (18.8) / 9.8 / 50 / 014 (20.7) / 4.0 / 16.2 / 13.3 / 045 (15.8)
Switzerland / NA / NA / 002 (28.6) / 4.8 / 50 / 056 (25.0)
Turkey / 0.6 / 3.7 / 001 (28.6) / NA / NA / 014 (100.0)
UK-England / NA / NA / 077 (37.5) / 10.6 / 50 / 106 (29.5) / 5.6 / 3.8 / 3.7 / 140 (10.5)
UK-N. Ireland / 4.7
UK-Scotland / 5.2 / 1.4 / 5.3
UK-Wales / 11.3
Total / 2.5 / 20.2 / 001 (12.7) / 4.1 / 23 / 014/020 (15.7) / 3.7 / 6.6 / 7.3 / 027 (19.0) / 3.7 / 16.4

Key: CDI - Clostridium difficile infection, HA – healthcare-associated, Pbds – patient bed-days, RT – ribotype,adms – admissions, dischs – discharges, NA- Not Available, ECDC – European Centre for Disease Prevention and Control, PPS-Point Prevalence Survey, HAI – healthcare-associated infection

Supplementarytable S2: Description of current national Clostridium difficile infection (CDI) surveillance systems and reference/central laboratories for C. difficile typing by national experts in CDI surveillance and/or microbiology in Europe, 2017

Country* / National C. difficile infection surveillance system / C. difficile reference laboratory (underline) / C. difficile central laboratory service / National reference centre for healthcare-associated infections
Name / Reported data / Name / Typing support / Annual report / Name / Annual report
Austria / None / No / Austrian Agency for Health and Food Safety (AGES)National reference centre for Clostridium difficile, Vienna / Ribotyping/free of charge for "severe cases" (i.e. mandatorily reportable) only / Yes / Austrian Nosocomial Infection Surveillance System, Medical University of Vienna (ANISS) / No
Belgium / National Surveillance of Infections in Hospitals (NSIH) / HA CDI: I (1,000 pa/6 months), Id (10,000 pd/6 months)
Severe CDI: ICU-adm/death within 30 days related to CDI / National Reference Center /Clostridium difficile/, Université catholique
de Louvain, Pôle de microbiologie, Brussels. / Ribotyping, MLVA / Yes / National Surveillance of Healthcare-associated infections and antimicrobial resistance, Scientific Institute of Public Health (IPH), Brussels (NSIH) / yes
Bulgaria / None / No / National Referent laboratory for Control and Monitoring of Antibiotic Resistance (NRL-CMAR), Sofia / Submission of faecal samples, Ribotyping, MLVA/free of charge / No / National centre of infectious and parasitic diseases, Reference Lab for AMR control and monitoring-sector HAI, Sofia / No
Croatia / None / No / None / No / No / Reference Centre for Hospital Infections, Zagreb / No
Czech Republic / None / No / Department of Medical Microbiology, Motol University Hospital, Prague / Ribotyping, MLVA, antibiotic susceptibility testing of resistant isolates/free of charge/Motol University Hospital grant support (MH CZ – DRO 00064203) / No / National reference centre for healthcare associated infections (NRC-HAI), National Institute of Public Health, Prague / No
Denmark / National Surveillance of Hospital-Onset - Hospital-Acquired and Community-Onset - Hospital-Acquired CDIs / Number and incidence per 10,000 risk days of Community-Onset - Hospital-Acquired and Hospital-Onset - Hospital-Acquired in DK, per region, per hospital, per department / Statens Serum Institute, Copenhagen / Tandem Repeat Sequence Typing (TRST)/Free of charge / No / Hospital Acquired Infections dataBAse (HAIBA), Statens Serum Institute, Copenhagen. / Yes
Finland / 1. National Infectious Diseases Register, 2. Finnish Hospital Infection Programme (SIRO), 3. National Hospital Discharge Register (HILMO) / 1. I (100,000 inh), 2. HA CDI: I (100 pa), Id (1000 pd), Severe CDI: ICU-adm/surgery/dead within 30 days related to CDI, 3. I (CDI hospitalisations/100,000 inh) / National Institute for Health and Welfare, Bacteriology Unit, Helsinki / Ribotyping /free of charge for severe cases or suspected outbreaks / Yes / Finnish Hospital Infection Programme (SIRO), National Public Health Institute (THL), Helsinki / Yes
France / Healthcare acquired Infections Early warning and Response system / Severe CDI: Total number I (1,000 pa), Id (10,000 pd) / Laboratory "Clostridium difficile" Reference Centre for Anaerobes, CHU Saint Antoine, Paris / Ribotyping, MLVA, free of charge / yes / Network of Alert, Investigation and Surveillance of Nosocomial Infections (RAISIN), under
the auspices of Public Health France, Paris / yes
Germany / 1. CDAD-KISS, 2. Survnet / 1. HA CDI/severe CDI: I (100 adm), Id (1,000 pd) 2. Severe CDI:Total number I (100,000 inh/ICU-adm/surgery/death within 30 days related to CDI) / Cross-institutional National Reference Centre for C. difficile: Institute for Hygiene, University of Saarland Medical Center, Homburg/Saar, Institute for Hygiene, University of Münster, Münster, Institute for Laboratory Medicine, Microbiology and Hygiene, ChristophorusKliniken, Coesfeld. / PCR Ribotyping, MLVA, whole genome sequencing / free of charge: severe cases (mandatory reporting), suspected outbreaks / No / German Nosocomial Infection Surveillance System (KISS), National Reference Centre for Nosocomial Infection Surveillance, Charité Medical University, Berlin / Yes
Greece / None / No / Microbiology Department, Medical School, National and Kapodistrian University of Athens / Ribotyping, free of charge-grant sources / No / None / No
Hungary / OSZIR NNSR CDI modul (part of the National Nosocomial Surveillance System) / 1. HA CDI: total number, I (10,000 discharges), Id (100, 000 pd), 2. Overall CDI burden in hospitalised patients (HA CDI, CA CDI, UO CDI): total number, I (10,000 discharges), Id (100, 000 pd) / National Institute of Public Health, Budapest (de facto)/University of Szeged, Institute of Clinical Microbiology, Szeged / Ribotyping: (1) outbreak cases (covered by the local public health authority), (2) surveillance isolates related to the EU CDI surveillance (covered by internal resources at national level), (3) upon request in severe cases, multiple recurrence, CDI-related death, suspected antibiotic resistance relevant for therapy (covered by hospital resources) / No / Ministry of Human Capacities, Budapest / Yes
Ireland / 1. Notifiable C. difficile Surveillance, 2. C. difficile Enhanced Surveillance / 1. I (100,000 inh), 2. HA CDI: Id (10,000 pd), Severe CDI: ICU-adm/surgery related to CDI / None - Specimens referred to UK labs for typing / No / No / Health Protection Surveillance Centre (HPSC), Dublin / Yes
Italy / None / No / Department of Infectious Diseases, IstitutoSuperiore di Sanità (ISS), Rome / Ribotyping and antibiotic susceptibility testing /free of charge / No / Regional Health and Care Agency - Emilia Romagna region; Bologna / No
Latvia / Aggregated data from medical institutions / number of positive samples (CDI cases) / Riga East University Hospital, Latvian Centre of Infectious Diseases / No / No / Centre for Disease Prevention and Control of Latvia, Riga / No
Lithuania / National Epidemiological Surveillance and Management of HCAI / CDI cases in hospitalised patients, HA CDI, CA CDI/pbds, adm / None / No / No / Institute of Hygiene, Vilnius / No
Luxembourg / Sentinel surveillance of C. difficile / 1. number of HA CDI calculated per 1000 patient admission, 2. number of CA CDI calculated per 1000 patient admission, 3. incidence density: number of HA CDI calculated per 10 000 patient-day, 4. total number of new patients CDI toxin+/year / Laboratoire National de Santé, Dudelange (Service MycoBac-ARH) / Ribotyping, MLVA/free of charge / No / Luxembourg Institute of Health (NOSIX) / No
The Netherlands / Sentinel surveillance of C. difficile / 1. CDI in hospitalized patients: I (CDI cases/pa), Id (CDI cases/pd) 2. Severe CDI 3. Complicated CDI (surgery, ICU admission, death) / Department of Medical Microbiology, Leiden Medical Centre, Leiden / Ribotyping, MLVA, antimicrobial susceptibility testing and whole genome sequencing, free of charge / Yes / Prevention of Nosocomial Infection through Surveillance (PREZIES), National Institute for Public Health and Environment (RIVM) and the Dutch Institute for Healthcare Improvement (CBO) / Yes
Norway / MSIS - Norwegian Surveillance System for Communicable Diseases / Anonymous case based reporting / Oslo University Hospital, Oslo / Ribotyping, MLVA / Yes / Norwegian Institute of Public Health (NIPH), Oslo / Yes
Poland / National Laboratory-based CD surveillance System / 1. I (100,000 inh), 2. HA CDI: I (10.000 pd) / Department of Medical Microbiology, Medical University of Warsaw / Ribotyping/free of charge / No / Polish Society of Hospital Infections;National Institute of Public Health, Warsaw / Yes
Portugal / None / No / Department of Infectious Diseases, National institute of Health Dr Ricardo Jorge, Lisbon / Ribotyping, MLVA and WGS, antibiotic susceptibility testing, free of charge / No / Department of Infectious Diseases, National institute of Health Dr Ricardo Jorge, Lisbon / No
Slovakia / Epidemiological information system (EPIS) / CDI cases per 10 000 population(HA CDI, CA CDI) / Department of microbiology and immunology JLF Martin UK Bratislava / Ribotyping on way of introduction/will be free of charge/grant sources / No / Regional Authority of Public Health BanskáBystrica (EPIS) / No
Slovenia / Notifiable C. difficile Surveillance / I (100 000 inhabitants) / National laboratory for health, environment and food, NLZOH, Maribor / Ribotyping, toxinotyping/partially free of charge / No / National Institute of Public Health, NIJZ, Communicable Diseases Centre, Ljubljana / No
Spain / None / No / University Hospital Gregorio Marañón, Madrid / Ribotyping, MLVA /free of charge / No / Envin: Hopital Val d’Hebron,Barcelona; SSI surveillance by Carlos III Institute of Health, Madrid, ENVIN (ICU), EPINE (prevalence). / No
Sweden / National Laboratory-based CD surveillance System / Total Number, new cases (excluding cases with a prior episode 8 weeks earlier) stratified on age, gender, geographical region. / University hospital Örebro and Public Health Agency of Sweden / Surveillance programme free of charge (4 weeks/year). Outbreak typing are charged for. Methods: PCR ribotyping, MALDI typing, WGS. / Yes / No / No
Switzerland / None / No / Division of Clinical Microbiology, Basel University Hospital, Basel / Ribotyping, WGS/on request / No / Swissnoso (national centre for prevention of HAI) / Yes
UK-England / Public health England - HCAI Data Capture System / All types of CDI: Id (adm > 65 y/1,000 pd), HA CDI: Id (cases > 2 y/10,000 pd) Severe CDI: Death within 30 days related to CDI / Reference Laboratory, Leeds General Infirmary/Bristol Royal Infirmary, Heartlands Hospital in Birmingham, Addenbrooke’s Hospital in Cambridge, Barts Health in London, Manchester Royal Infirmary, Southampton General Hospital / Submission of faecal samples, ribotyping, MLVA on request-Free of charge / Yes / Public health England - HCAI Data Capture System / Yes
UK-Northern Ireland / Enhanced HCAI Web-based Surveillance System / HA CDI and CA CDI, Total Number Id (1,000 pd) / Reference Laboratory, Leeds General Infirmary/Royal Victoria Hospital in Belfast / Submission of faecal samples, ribotyping, MLVA on request - Free of charge / Yes / Northern Ireland Public Health Agency, Belfast / No
UK - Scotland / Scottish Mandatory Surveillance Programme for CDI / CDI in all settings (including HA CDI and CA CDI): Id (cases ≥ 15 y/pd) / Scottish Microbiology Reference Laboratories, Glasgow / Ribotyping, MLVA free of charge / Yes / The Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP), Health Protection Scotland, Glasgow / Yes
UK - Wales / Wales Mandatory Surveillance Programme for C. difficile (via DataStore) / aged 2 years +, rate per 1000 admissions and per 100,000 population / Reference Laboratory, Leeds General Infirmary/UK Anaerobe Reference Laboratory (UKARU) - Central Wales Laboratory for culture and typing of all double positive cases / Submission of faecal samples, Ribotyping, free of charge. / Yes / Healthcare Associated Infection Programme, Public Health Wales NHS Trust / Yes

Key: * Cyprus, Iceland, Estonia, Malta - no data reported,Romania - no response; CDI - Clostridium difficile infection; CA – community–associated; HA-healthcare–associated; I-incidence; Id-Incidence density; Pd-patient-days; Adm-admissions;MLVA-Multilocus Variable Tandem-repeats Analysis; UK-United Kingdom.

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