1
|
Freeman J, Viprey V, Ewin D, Spittal W, Clark E, Vernon J, Fawley W, Davis G, Tkalec V, Wilcox M, Rupnik M, Davies K. Antimicrobial susceptibility in Clostridioides difficile varies according to European region and isolate source. JAC Antimicrob Resist 2024; 6:dlae112. [PMID: 39045220 PMCID: PMC11264405 DOI: 10.1093/jacamr/dlae112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/29/2024] [Indexed: 07/25/2024] Open
Abstract
Objectives Clostridioides difficile epidemiology is evolving with country-associated emerging and resistant ribotypes (RT). Antimicrobial susceptibility testing of C. difficile isolated from clinical and animal samples collected across Europe in 2018 was performed to provide antimicrobial resistance data and according to C. difficile RTs and source. Methods Samples were cultured for C. difficile and isolates PCR ribotyped. Metronidazole, vancomycin, fidaxomicin, moxifloxacin, clindamycin, imipenem, tigecycline, linezolid, rifampicin and meropenem minimum inhibitory concentrations (MICs) for 280 clinical and 126 animal isolates were determined by Wilkins-Chalgren agar dilution. Results Fidaxomicin was the most active antimicrobial (all isolates geometric mean MIC = 0.03 mg/L) with no evidence of reduced susceptibility. Metronidazole MICs were elevated among RT027 (1.87 mg/L) and RT181 clinical isolates (1.03 mg/L). RT027 and RT181 had elevated geometric mean moxifloxacin MICs (14.49 mg/L, 16.88 mg/L); clindamycin (7.5 mg/L, 9.1 mg/L) and rifampicin (0.6 mg/L, 21.5 mg/L). Five isolates (RT002, RT010 and RT016) were metronidazole resistant (MIC = 8 mg/L) and 10 (RT027; RT198) had intermediate resistance (4 mg/L). Metronidazole MICs were not elevated in animal isolates. Increased geometric mean vancomycin MICs were observed among RT078, mostly isolated from animals, but there was no resistance (MIC ≥ 4 mg/L). Clinical and animal isolates of multiple RTs showed resistance to moxifloxacin and clindamycin. No resistance to imipenem or meropenem was observed. Conclusion Increased antimicrobial resistance was detected in eastern Europe and mostly associated with RT027 and related emerging RT181, while clinical isolates from northern and western Europe had the lowest general levels of resistance.
Collapse
Affiliation(s)
- Jane Freeman
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Study Group for Clostridioides difficile (ESGCD), Basel, Switzerland
| | - Virginie Viprey
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Duncan Ewin
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - William Spittal
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Emma Clark
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jon Vernon
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Warren Fawley
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- C. difficile Ribotyping Network for England and Wales, UK Health Security Agency, Leeds, UK
| | - Georgina Davis
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Valerija Tkalec
- National Laboratory for Health, Environment and Food (NLZOH), Centre for Medical Microbiology, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Mark Wilcox
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Study Group for Clostridioides difficile (ESGCD), Basel, Switzerland
| | - Maja Rupnik
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Study Group for Clostridioides difficile (ESGCD), Basel, Switzerland
- National Laboratory for Health, Environment and Food (NLZOH), Centre for Medical Microbiology, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Kerrie Davies
- Healthcare Associated Infections Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Study Group for Clostridioides difficile (ESGCD), Basel, Switzerland
| |
Collapse
|
2
|
Quan M, Zhang X, Fang Q, Lv X, Wang X, Zong Z. Fighting against Clostridioides difficile infection: Current medications. Int J Antimicrob Agents 2024; 64:107198. [PMID: 38734214 DOI: 10.1016/j.ijantimicag.2024.107198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/18/2024] [Accepted: 05/04/2024] [Indexed: 05/13/2024]
Abstract
Clostridioides difficile (formerly Clostridium difficile) has been regarded as an 'urgent threat' and a significant global health problem, as life-threatening diarrhoea and refractory recurrence are common in patients with C. difficile infection (CDI). Unfortunately, the available anti-CDI drugs are limited. Recent guidelines recommend fidaxomicin and vancomycin as first-line drugs to treat CDI, bezlotoxumab to prevent recurrence, and faecal microbiota transplantation for rescue treatment. Currently, researchers are investigating therapeutic antibacterial drugs (e.g. teicoplanin, ridinilazole, ibezapolstat, surotomycin, cadazolid, and LFF571), preventive medications against recurrence (e.g. Rebyota, Vowst, VP20621, VE303, RBX7455, and MET-2), primary prevention strategies (e.g. vaccine, ribaxamase, and DAV132) and other anti-CDI medications in the preclinical stage (e.g. Raja 42, Myxopyronin B, and bacteriophage). This narrative review summarises current medications, including newly marketed drugs and products in development against CDI, to help clinicians treat CDI appropriately and to call for more research on innovation.
Collapse
Affiliation(s)
- Min Quan
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoxia Zhang
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Qingqing Fang
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoju Lv
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaohui Wang
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, China.
| | - Zhiyong Zong
- Center for Infectious Diseases, West China Hospital of Sichuan University, Chengdu, China; Division of Infectious Diseases, State Key Laboratory of Biotherapy, West China Hospital of Sichuan University, Chengdu, China
| |
Collapse
|
3
|
Brouwer L, Carroll A, McNamara E. Genotypic and phenotypic antimicrobial resistance of Irish Clostridioides difficile isolates, 2022. Anaerobe 2024; 88:102857. [PMID: 38670525 DOI: 10.1016/j.anaerobe.2024.102857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVES Infection with Clostridioides difficile usually occurs after antibiotic treatment for other infections and can cause gastro-intestinal disorders of variable severity. C. difficile can be resistant to a wide spectrum of antimicrobials. Detection of antimicrobial resistance (AMR) is important to direct optimal treatment and surveillance of AMR patterns in the overall population. Correlation between genotypic markers and phenotypic AMR is not yet well defined. The aim for this study is to assess whether and to what extent genotypic determinants of AMR correlate with phenotypic resistance. METHODS C. difficile isolates (n = 99) were phenotypically characterized for resistance to eight antibiotics using Sensititre plates or E-tests. Their genomes were screened for genetic markers of resistance. Accuracy, sensitivity, specificity, positive and negative predictive values were calculated. RESULTS We found high rates of resistance (>50 %) to cefoxitin and clindamycin, intermediate rates of resistance (10 %-50 %) to moxifloxacin and tetracycline and low rates of resistance (<10 %) to imipenem, metronidazole, vancomycin, and rifampicin. For moxifloxacin, tetracycline, and clindamycin, we found a good correlation between genotypic and phenotypic AMR, with an overall accuracy of 98 % (95 % CI 93%-100 %), 78 % (95 % CI 68%-86 %) and 86 % (95 % CI 77%-92 %) respectively. For the other five antibiotics, accurate estimates on the correlation could not be made. CONCLUSION Our results suggest that for moxifloxacin, tetracycline and clindamycin, phenotypic resistance in C. difficile can be predicted by genetic indicators and used for public health purposes. However, for the other five antibiotics, the model is not accurate and further development is necessary.
Collapse
Affiliation(s)
- Lieke Brouwer
- Clostridioides Difficile National Reference Laboratory, Public Health Laboratory, Health Service Executive, Cherry Orchard Hospital, Dublin, Ireland; European Public Health Microbiology Training Programme (EUPHEM), European Centre for Disease Prevention and Control, Stockholm, Sweden.
| | - Anne Carroll
- Clostridioides Difficile National Reference Laboratory, Public Health Laboratory, Health Service Executive, Cherry Orchard Hospital, Dublin, Ireland; European Public Health Microbiology Training Programme (EUPHEM), European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Eleanor McNamara
- Clostridioides Difficile National Reference Laboratory, Public Health Laboratory, Health Service Executive, Cherry Orchard Hospital, Dublin, Ireland; European Public Health Microbiology Training Programme (EUPHEM), European Centre for Disease Prevention and Control, Stockholm, Sweden
| |
Collapse
|
4
|
Couturier J, Davies K, Barbut F. Ribotypes and New Virulent Strains Across Europe. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:151-168. [PMID: 38175475 DOI: 10.1007/978-3-031-42108-2_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Clostridioides (formerly Clostridium) difficile is a major bacterial cause of post-antibiotic diarrhoea. The epidemiology of C. difficile infections (CDIs) has dramatically changed since the early 2000s, with an increasing incidence and severity across Europe. This trend is partly due to the emergence and rapid worldwide spread of the hypervirulent and epidemic PCR ribotype 027. Profiles of patients with CDI have also evolved, with description of community-acquired (CA) infections in patients with no traditional risk factors for CDI. However, epidemiological studies indicated that some European countries have successfully controlled the dissemination of the 027 clone whereas other countries reported the emergence of other virulent or unusual strains. The aims of this review are to summarize the current European CDI epidemiology and to describe the new virulent C. difficile strains circulating in Europe, as well as other potential emerging strains described elsewhere. Standardized typing methods and surveillance programmes are mandatory for a better understanding and monitoring of CDI in Europe.
Collapse
Affiliation(s)
- Jeanne Couturier
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France.
- Université Paris Cité, UMR INSERM 1139, Paris, France.
| | - Kerrie Davies
- Healthcare Associated Infections Research Group, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, UK
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study group for Clostridioides difficile (ESGCD), Basel, Switzerland
| | - Frédéric Barbut
- National Reference Laboratory for C. difficile, Hôpital Saint-Antoine, Paris, France
- Université Paris Cité, UMR INSERM 1139, Paris, France
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) study group for Clostridioides difficile (ESGCD), Basel, Switzerland
| |
Collapse
|
5
|
Spigaglia P, Mastrantonio P, Barbanti F. Antibiotic Resistances of Clostridioides difficile. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:169-198. [PMID: 38175476 DOI: 10.1007/978-3-031-42108-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The rapid evolution of antibiotic resistance in Clostridioides difficile and the consequent effects on prevention and treatment of C. difficile infections (CDIs) are a matter of concern for public health. Antibiotic resistance plays an important role in driving C. difficile epidemiology. Emergence of new types is often associated with the emergence of new resistances, and most of the epidemic C. difficile clinical isolates is currently resistant to multiple antibiotics. In particular, it is to worth to note the recent identification of strains with reduced susceptibility to the first-line antibiotics for CDI treatment and/or for relapsing infections. Antibiotic resistance in C. difficile has a multifactorial nature. Acquisition of genetic elements and alterations of the antibiotic target sites, as well as other factors, such as variations in the metabolic pathways or biofilm production, contribute to the survival of this pathogen in the presence of antibiotics. Different transfer mechanisms facilitate the spread of mobile elements among C. difficile strains and between C. difficile and other species. Furthermore, data indicate that both genetic elements and alterations in the antibiotic targets can be maintained in C. difficile regardless of the burden imposed on fitness, and therefore resistances may persist in C. difficile population in absence of antibiotic selective pressure.
Collapse
Affiliation(s)
- Patrizia Spigaglia
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy.
| | - Paola Mastrantonio
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Fabrizio Barbanti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| |
Collapse
|
6
|
Serrano M, Martins D, Henriques AO. Clostridioides difficile Sporulation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1435:273-314. [PMID: 38175480 DOI: 10.1007/978-3-031-42108-2_13] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Some members of the Firmicutes phylum, including many members of the human gut microbiota, are able to differentiate a dormant and highly resistant cell type, the endospore (hereinafter spore for simplicity). Spore-formers can colonize virtually any habitat and, because of their resistance to a wide variety of physical and chemical insults, spores can remain viable in the environment for long periods of time. In the anaerobic enteric pathogen Clostridioides difficile the aetiologic agent is the oxygen-resistant spore, while the toxins produced by actively growing cells are the main cause of the disease symptoms. Here, we review the regulatory circuits that govern entry into sporulation. We also cover the role of spores in the infectious cycle of C. difficile in relation to spore structure and function and the main control points along spore morphogenesis.
Collapse
Affiliation(s)
- Mónica Serrano
- Instituto de Tecnologia Química e Biológica António Xavier, Oeiras, Portugal.
| | - Diogo Martins
- Instituto de Tecnologia Química e Biológica António Xavier, Oeiras, Portugal
| | - Adriano O Henriques
- Instituto de Tecnologia Química e Biológica António Xavier, Oeiras, Portugal
| |
Collapse
|
7
|
Boven A, Vlieghe E, Engstrand L, Andersson FL, Callens S, Simin J, Brusselaers N. Clostridioides difficile infection-associated cause-specific and all-cause mortality: a population-based cohort study. Clin Microbiol Infect 2023; 29:1424-1430. [PMID: 37473840 DOI: 10.1016/j.cmi.2023.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/29/2023] [Accepted: 07/10/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVES Clostridioides difficile infection (CDI) is a common healthcare-associated infection and leading cause of gastroenteritis-related mortality worldwide. However, data on CDI-associated mortality are scarce. We aimed to examine the association between CDI and all-cause and cause-specific mortality. We additionally explored contributing causes of mortality, including recurrent CDI, hospital- or community-acquired CDI, chronic comorbidities, and age. METHODS This nationwide population-based cohort study (from 2006 to 2019) compared individuals with CDI with the entire Swedish background population using standardized mortality ratios. In addition, a matched-cohort design (1:10), utilizing multivariable Poisson-regression models, provided incidence rate ratios (IRRs) with 95% CIs. RESULTS This study included 43 150 individuals with CDI and 355 172 controls. In total, 69.7% were ≥65 years, and 54.9% were female. CDI was associated with a 3- to 7-fold increased mortality rate (IRR = 3.5, 95% CI: 3.3-3.6; standardized mortality ratio = 6.8, 95% CI: 6.7-6.9) compared with the matched controls and Swedish background population, respectively. Mortality rates were highest for hospital-acquired CDI (IRR = 2.4, 95% CI: 1.9-3.2) and during the first CDI episode (IRR = 0.2, 95% CI: 0.2-0.3 for recurrent versus first CDI). Individuals with CDI had more chronic comorbidities than controls, yet mortality remained higher among CDI cases even after adjustment and stratification for comorbidity; CDI was associated with increased mortality (IRR = 6.1, 95% CI: 5.5-6.8), particularly among those without any chronic comorbidities. DISCUSSION CDI was associated with elevated all-cause and cause-specific mortality, despite possible confounding by ill health. Mortality rates were consistently increased across sexes, all age groups, and comorbidity groups.
Collapse
Affiliation(s)
- Annelies Boven
- Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Department of Family Medicine and Population Health, Antwerp University, Antwerp, Belgium
| | - Erika Vlieghe
- Department of Family Medicine and Population Health, Antwerp University, Antwerp, Belgium; General Internal Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Lars Engstrand
- Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | | | - Steven Callens
- General Internal Medicine, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Johanna Simin
- Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Department of Family Medicine and Population Health, Antwerp University, Antwerp, Belgium
| | - Nele Brusselaers
- Centre for Translational Microbiome Research, Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Department of Family Medicine and Population Health, Antwerp University, Antwerp, Belgium; Department of Head and Skin, Ghent University, Ghent, Belgium.
| |
Collapse
|
8
|
Anwar F, Clark M, Lindsey J, Claus-Walker R, Mansoor A, Nguyen E, Billy J, Lainhart W, Shehab K, Viswanathan VK, Vedantam G. Prevalence of diagnostically-discrepant Clostridioides difficile clinical specimens: insights from longitudinal surveillance. Front Med (Lausanne) 2023; 10:1238159. [PMID: 37928470 PMCID: PMC10622765 DOI: 10.3389/fmed.2023.1238159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023] Open
Abstract
Background Clostridioides difficile Infection (CDI) is a healthcare-associated diarrheal disease prevalent worldwide. A common diagnostic algorithm relies on a two-step protocol that employs stool enzyme immunoassays (EIAs) to detect the pathogen, and its toxins, respectively. Active CDI is deemed less likely when the Toxin EIA result is negative, even if the pathogen-specific EIA is positive for C. difficile. We recently reported, however, that low-toxin-producing C. difficile strains recovered from Toxin-negative ('discrepant') clinical stool specimens can be fully pathogenic, and cause lethality in a rodent CDI model. To document frequency of discrepant CDI specimens, and evaluate C. difficile strain diversity, we performed longitudinal surveillance at a Southern Arizona tertiary-care hospital. Methods Diarrheic stool specimens from patients with clinical suspicion of CDI were obtained over an eight-year period (2015-2022) from all inpatient and outpatient Units of a > 600-bed Medical Center in Southern Arizona. Clinical laboratory EIA testing identified C. difficile-containing specimens, and classified them as Toxin-positive or Toxin-negative. C. difficile isolates recovered from the stool specimens were DNA fingerprinted using an international phylogenetic lineage assignment system ("ribotyping"). For select isolates, toxin abundance in stationary phase supernatants of pure cultures was quantified via EIA. Results Of 8,910 diarrheic specimens that underwent diagnostic testing, 1733 (19.4%) harbored C. difficile. Our major findings were that: (1) C. difficile prevalence and phylogenetic diversity was stable over the 8-year period; (2) toxigenic C. difficile was recovered from 69% of clinically Tox-neg ('discrepant') specimens; (3) the six most prevalent USA ribotypes were recovered in significant proportions (>60%) from Tox-neg specimens; and (4) toxin-producing C. difficile recovered from discrepant specimens produced less toxin than strains of the same ribotype isolated from non-discrepant specimens. Conclusion Our study highlights the dominance of Toxin EIA-negative CDI specimens in a clinical setting and the high frequency of known virulent ribotypes in these specimens. Therefore, a careful reevaluation of the clinical relevance of diagnostically-discrepant specimens particularly in the context of missed CDI diagnoses and C. difficile persistence, is warranted.
Collapse
Affiliation(s)
- Farhan Anwar
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Marielle Clark
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Jason Lindsey
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Rachel Claus-Walker
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Asad Mansoor
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Evy Nguyen
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - Justin Billy
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
| | - William Lainhart
- Department of Pathology, Clinical Microbiology Laboratories, Banner University Medical Center, Tucson, AZ, United States
| | - Kareem Shehab
- Department of Pediatrics, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - V. K. Viswanathan
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
- Bio5 Institute for Collaborative Research, University of Arizona, Tucson, AZ, United States
| | - Gayatri Vedantam
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, AZ, United States
- Bio5 Institute for Collaborative Research, University of Arizona, Tucson, AZ, United States
- Southern Arizona VA Healthcare System, Tucson, AZ, United States
| |
Collapse
|
9
|
Blau K, Berger FK, Mellmann A, Gallert C. Clostridioides difficile from Fecally Contaminated Environmental Sources: Resistance and Genetic Relatedness from a Molecular Epidemiological Perspective. Microorganisms 2023; 11:2497. [PMID: 37894155 PMCID: PMC10608975 DOI: 10.3390/microorganisms11102497] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/28/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Clostridioides difficile is the most important pathogen causing antimicrobial-associated diarrhea and has recently been recognized as a cause of community-associated C. difficile infection (CA-CDI). This study aimed to characterize virulence factors, antimicrobial resistance (AMR), ribotype (RT) distribution and genetic relationship of C. difficile isolates from diverse fecally contaminated environmental sources. C. difficile isolates were recovered from different environmental samples in Northern Germany. Antimicrobial susceptibility testing was determined by E-test or disk diffusion method. Toxin genes (tcdA and tcdB), genes coding for binary toxins (cdtAB) and ribotyping were determined by PCR. Furthermore, 166 isolates were subjected to whole genome sequencing (WGS) for core genome multi-locus sequence typing (cgMLST) and extraction of AMR and virulence-encoding genes. Eighty-nine percent (148/166) of isolates were toxigenic, and 51% (76/148) were positive for cdtAB. Eighteen isolates (11%) were non-toxigenic. Thirty distinct RTs were identified. The most common RTs were RT127, RT126, RT001, RT078, and RT014. MLST identified 32 different sequence types (ST). The dominant STs were ST11, followed by ST2, ST3, and ST109. All isolates were susceptible to vancomycin and metronidazole and displayed a variable rate of resistance to moxifloxacin (14%), clarithromycin (26%) and rifampicin (2%). AMR genes, such as gyrA/B, blaCDD-1/2, aph(3')-llla-sat-4-ant(6)-la cassette, ermB, tet(M), tet(40), and tetA/B(P), conferring resistance toward fluoroquinolone, beta-lactam, aminoglycoside, macrolide and tetracycline antimicrobials, were found in 166, 137, 29, 32, 21, 72, 17, and 9 isolates, respectively. Eleven "hypervirulent" RT078 strains were detected, and several isolates belonged to RTs (i.e., RT127, RT126, RT023, RT017, RT001, RT014, RT020, and RT106) associated with CA-CDI, indicating possible transmission between humans and environmental sources pointing out to a zoonotic potential.
Collapse
Affiliation(s)
- Khald Blau
- Department of Microbiology–Biotechnology, Faculty of Technology, University of Applied Sciences Emden/Leer, 26723 Emden, Germany;
| | - Fabian K. Berger
- Institute of Medical Microbiology and Hygiene, Saarland University Medical Center, 66421 Homburg, Germany;
- German National Reference Center for Clostridioides Difficile, 66421 Homburg, Germany;
| | - Alexander Mellmann
- German National Reference Center for Clostridioides Difficile, 66421 Homburg, Germany;
- Institute of Hygiene, University of Münster, 48149 Münster, Germany
| | - Claudia Gallert
- Department of Microbiology–Biotechnology, Faculty of Technology, University of Applied Sciences Emden/Leer, 26723 Emden, Germany;
| |
Collapse
|
10
|
Mori N, Hirai J, Ohashi W, Asai N, Shibata Y, Mikamo H. Clinical Efficacy of Fidaxomicin and Oral Metronidazole for Treating Clostridioides difficile Infection and the Associated Recurrence Rate: A Retrospective Cohort Study. Antibiotics (Basel) 2023; 12:1323. [PMID: 37627743 PMCID: PMC10451525 DOI: 10.3390/antibiotics12081323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Clostridioides difficile infection (CDI) has significant implications for healthcare economics. Although clinical trials have compared fidaxomicin (FDX) and vancomycin, comparisons of FDX and oral metronidazole (MNZ) are limited. Therefore, we compared the therapeutic effects of FDX and oral MNZ. Patients diagnosed with CDI between January 2015 and March 2023 were enrolled. Those treated with oral MNZ or FDX were selected and retrospectively analyzed. The primary outcome was the global cure rate. Secondary outcomes included factors contributing to the CDI global cure rate; the rate of medication change owing to initial treatment failure; and incidence rates of clinical cure, recurrence, and all-cause mortality within 30 days. Of the 264 enrolled patients, 75 and 30 received initial oral MNZ and FDX treatments, respectively. The corresponding CDI global cure rates were 53.3% and 70% (p = 0.12). In multivariate analysis, FDX was not associated with the global cure rate. In the MNZ group, 18.7% of the patients had to change medications owing to initial treatment failure. The FDX group had a higher clinical cure rate and lower recurrence rate than the MNZ group, although not significant. However, caution is necessary owing to necessary treatment changes due to MNZ failure.
Collapse
Affiliation(s)
- Nobuaki Mori
- Department of Clinical Infectious Diseases, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
- Department of Infection Prevention and Control, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
| | - Jun Hirai
- Department of Clinical Infectious Diseases, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
- Department of Infection Prevention and Control, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
| | - Wataru Ohashi
- Division of Biostatistics, Clinical Research Center, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
| | - Nobuhiro Asai
- Department of Clinical Infectious Diseases, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
- Department of Infection Prevention and Control, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
| | - Yuichi Shibata
- Department of Infection Prevention and Control, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
- Department of Infection Prevention and Control, Aichi Medical University, 1-1 Yazakokarimata Nagakute-shi, Aichi 480-1195, Japan
| |
Collapse
|
11
|
Spigaglia P, Barbanti F, Faccini S, Vescovi M, Criscuolo EM, Ceruti R, Gaspano C, Rosignoli C. Clostridioides difficile in Pigs and Dairy Cattle in Northern Italy: Prevalence, Characterization and Comparison between Animal and Human Strains. Microorganisms 2023; 11:1738. [PMID: 37512910 PMCID: PMC10383565 DOI: 10.3390/microorganisms11071738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
It has been observed that novel strains of Clostridioides difficile can rapidly emerge and move between animal and human hosts. The aim of this study was to investigate the prevalence of C. difficile in pigs and dairy cattle in northern Italy and to characterize and compare C. difficile animal strains with those from patients from the same geographical area. The C. difficile strains were isolated from animals from farms and slaughterhouses (cross-sectional studies) and from neonatal animals with enteric disorders in routine diagnostic investigations (passive surveillance). Samples positive for C. difficile were found in 87% of the pig farms and in 40% of the cattle farms involved in the cross-sectional studies, with a 20% prevalence among suckling piglets and 6.7% prevalence in neonatal calves, with no significant difference between animals with and without diarrheal symptoms. The prevalence of C. difficile in older animal categories was significantly lower. This result suggests that young age is an important risk factor for C. difficile colonization. In cross-sectional studies at slaughterhouses, in both the heavy pigs and dairy cows examined, only 2% of the intestinal content samples were positive for C. difficile and no contamination was found on the surface of the carcasses. Considering passive surveillance, the prevalence rates of positive samples were 29% in piglets and 1.4% in calves. Overall, 267 strains of animal origin and 97 from humans were collected. In total, 39 ribotypes (RTs) were identified, with RT 078 and RT 018 being predominant among animals and humans, respectively. Several RTs overlapped between animals and patients. In particular, RT 569 was identified as an emergent type in our country. Resistance to erythromycin and moxifloxacin was widely diffused among C. difficile strains, regardless of origin. This study supports C. difficile as a pathogen of one-health importance and highlights the need for a collaborative approach between physicians and veterinarians to control and prevent infections that are able to cross species and geographical barriers.
Collapse
Affiliation(s)
- Patrizia Spigaglia
- Dipartimento di Malattie Infettive, Istituto Superiore di Sanità, 00161 Roma, Italy
| | - Fabrizio Barbanti
- Dipartimento di Malattie Infettive, Istituto Superiore di Sanità, 00161 Roma, Italy
| | - Silvia Faccini
- Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia Romagna "B. Ubertini", Sede Territoriale di Mantova, 46100 Mantova, Italy
| | - Mariella Vescovi
- Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia Romagna "B. Ubertini", Sede Territoriale di Mantova, 46100 Mantova, Italy
| | | | - Rossella Ceruti
- Servizio di Medicina di Laboratorio, ASST Ospedale "Carlo Poma", 46100 Mantova, Italy
| | - Clara Gaspano
- Servizio di Medicina di Laboratorio, ASST Ospedale "Carlo Poma", 46100 Mantova, Italy
| | - Carlo Rosignoli
- Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia Romagna "B. Ubertini", Sede Territoriale di Mantova, 46100 Mantova, Italy
| |
Collapse
|
12
|
Liu C, Monaghan T, Yadegar A, Louie T, Kao D. Insights into the Evolving Epidemiology of Clostridioides difficile Infection and Treatment: A Global Perspective. Antibiotics (Basel) 2023; 12:1141. [PMID: 37508237 PMCID: PMC10376792 DOI: 10.3390/antibiotics12071141] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
Clostridioides difficile remains an important public health threat, globally. Since the emergence of the hypervirulent strain, ribotype 027, new strains have been reported to cause C. difficile infection (CDI) with poor health outcomes, including ribotypes 014/020, 017, 056, 106, and 078/126. These strains differ in their geographic distribution, genetic makeup, virulence factors, and antimicrobial susceptibility profiles, which can affect their ability to cause disease and respond to treatment. As such, understanding C. difficile epidemiology is increasingly important to allow for effective prevention measures. Despite the heightened epidemiological surveillance of C. difficile over the past two decades, it remains challenging to accurately estimate the burden and international epidemiological trends given the lack of concerted global effort for surveillance, especially in low- and middle-income countries. This review summarizes the changing epidemiology of C. difficile based on available data within the last decade, highlights the pertinent ribotypes from a global perspective, and discusses evolving treatments for CDI.
Collapse
Affiliation(s)
- Crystal Liu
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Tanya Monaghan
- National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
| | - Abbas Yadegar
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran 1985717411, Iran
| | - Thomas Louie
- Medicine and Microbiology, School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Dina Kao
- Division of Gastroenterology, University of Alberta, Edmonton, AB T6G 2P8, Canada
| |
Collapse
|
13
|
Markovska R, Dimitrov G, Gergova R, Boyanova L. Clostridioides difficile, a New “Superbug”. Microorganisms 2023; 11:microorganisms11040845. [PMID: 37110267 PMCID: PMC10140992 DOI: 10.3390/microorganisms11040845] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/19/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Clostridioides difficile is a Gram-positive, spore-forming, anaerobic bacterium. The clinical features of C. difficile infections (CDIs) can vary, ranging from the asymptomatic carriage and mild self-limiting diarrhoea to severe and sometimes fatal pseudomembranous colitis. C. difficile infections (CDIs) are associated with disruption of the gut microbiota caused by antimicrobial agents. The infections are predominantly hospital-acquired, but in the last decades, the CDI patterns have changed. Their prevalence increased, and the proportion of community-acquired CDIs has also increased. This can be associated with the appearance of hypervirulent epidemic isolates of ribotype 027. The COVID-19 pandemic and the associated antibiotic overuse could additionally change the patterns of infections. Treatment of CDIs is a challenge, with only three appropriate antibiotics for use. The wide distribution of C. difficile spores in hospital environments, chronic persistence in some individuals, especially children, and the recent detection of C. difficile in domestic pets can furthermore worsen the situation. “Superbugs” are microorganisms that are both highly virulent and resistant to antibiotics. The aim of this review article is to characterise C. difficile as a new member of the “superbug” family. Due to its worldwide spread, the lack of many treatment options and the high rates of both recurrence and mortality, C. difficile has emerged as a major concern for the healthcare system.
Collapse
|
14
|
Magnusson C, Mernelius S, Bengnér M, Norén T, Serrander L, Forshell S, Matussek A. Characterization of a Clostridioides difficile outbreak caused by PCR ribotype 046, associated with increased mortality. Emerg Microbes Infect 2022; 11:850-859. [PMID: 35240942 PMCID: PMC8942542 DOI: 10.1080/22221751.2022.2049981] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study describes a large nosocomial outbreak of Clostridioides difficile infections (CDI) dominated by ribotype (RT) 046 in a Swedish hospital. The present study aimed to examine the pathogenicity of this RT, explore epidemiological links by whole genome sequencing (WGS), and evaluate different interventions implemented to stop the outbreak. Clinical isolates (n = 366) collected during and after the outbreak were ribotyped and 246 isolates were subjected to WGS. Medical records of patients infected with the seven most common RTs were evaluated. RT046 was spread effectively throughout the hospital and was the most common among the 44 different RTs found (114/366 isolates). Infection with RT046 was associated with higher mortality compared to other strains (20.2% to 7.8%), although there were no differences in concomitant disease, age or antibiotic treatment. To control the outbreak, several measures were successfully implemented.
Collapse
Affiliation(s)
- Cecilia Magnusson
- Department of Infectious Diseases, Region Jönköping County, Jönköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Sara Mernelius
- Laboratory Medicine, Region Jönköping County, Jönköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Malin Bengnér
- Office for control of Communicable Diseases, Region Jönköping County, Jönköping, Sweden
| | - Torbjörn Norén
- Faculty of Medicine and Health, Department of Laboratory Medicine, National Reference Laboratory for Clostridioides difficile, Clinical Microbiology, Örebro University, Örebro, Sweden
| | - Lena Serrander
- Division of Clinical Microbiology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Sophie Forshell
- Department of Infectious Diseases, Region Jönköping County, Jönköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Andreas Matussek
- Laboratory Medicine, Region Jönköping County, Jönköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Division of Laboratory Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Laboratory Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
15
|
Make It Less difficile: Understanding Genetic Evolution and Global Spread of Clostridioides difficile. Genes (Basel) 2022; 13:genes13122200. [PMID: 36553467 PMCID: PMC9778335 DOI: 10.3390/genes13122200] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/14/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022] Open
Abstract
Clostridioides difficile is an obligate anaerobic pathogen among the most common causes of healthcare-associated infections. It poses a global threat due to the clinical outcomes of infection and resistance to antibiotics recommended by international guidelines for its eradication. In particular, C. difficile infection can lead to fulminant colitis associated with shock, hypotension, megacolon, and, in severe cases, death. It is therefore of the utmost urgency to fully characterize this pathogen and better understand its spread, in order to reduce infection rates and improve therapy success. This review aims to provide a state-of-the-art overview of the genetic variation of C. difficile, with particular regard to pathogenic genes and the correlation with clinical issues of its infection. We also summarize the current typing techniques and, based on them, the global distribution of the most common ribotypes. Finally, we discuss genomic surveillance actions and new genetic engineering strategies as future perspectives to make it less difficile.
Collapse
|
16
|
Wiese M, Schuren FHJ, Smits WK, Kuijper EJ, Ouwens A, Heerikhuisen M, Vigsnaes L, van den Broek TJ, de Boer P, Montijn RC, van der Vossen JMBM. 2'-Fucosyllactose inhibits proliferation of Clostridioides difficile ATCC 43599 in the CDi-screen, an in vitro model simulating Clostridioides difficile infection. Front Cell Infect Microbiol 2022; 12:991150. [PMID: 36389156 PMCID: PMC9650113 DOI: 10.3389/fcimb.2022.991150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/10/2022] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Clostridioides difficile is a Gram-positive anaerobic bacterium that can produce the toxins TcdA and/or TcdB and is considered an opportunistic pathogen. C. difficile is mainly transmitted as endospores, which germinate to produce the pathogenic vegetative cells under suitable conditions in the gut. To efficiently screen novel therapeutic- interventions against the proliferation of C. difficile within a complex microbial community, platforms are needed that facilitate parallel experimentation. In order to allow for screening of novel interventions a medium-to-high throughput in vitro system is desirable. To this end, we have developed the 96-well CDi-screen platform that employs an adapted simulated ileal effluent medium (CDi-SIEM) and allows for culturing of pathogenic C. difficile. METHODS C. difficile strain ATCC 43599 was inoculated in the form of vegetative cells and spores into the CDi-screen in the presence and absence of a cultured fecal microbiota and incubated for 48h. To demonstrate its utility, we investigated the effect of the human milk oligosaccharide 2'-Fucosyllactose (2'-FL) at 4 and 8 mg/mL on C. difficile outgrowth and toxin production in the CDi-screen. The test conditions were sampled after 24 and 48 hours. C. difficile -specific primers were used to monitor C. difficile growth via qPCR and barcoded 16S rRNA gene amplicon sequencing facilitated the in-depth analysis of gut microbial community dynamics. RESULTS C. difficile ATCC 43599 proliferated in CDi-SIEM, both when inoculated as spores and as vegetative cells. The strain reached cell numbers expressed as C. difficile genome equivalents of up to 10 8 cells per mL after 24h of incubation. 2'-FL significantly inhibited the outgrowth of the ATTC 43599 strain within a complex human gut microbial community in the CDi-screen. In addition, a dose-dependent modulation of the gut microbial community composition by 2'-FL supplementation was detected, with a significant increase in the relative abundance of the genus Blautia in the presence of 2'-FL. CONCLUSION The CDi-screen is suitable for studying C. difficile proliferation in a complex gut ecosystem and for screening for anti-pathogenic interventions that target C. difficile directly and/or indirectly through interactions with the gut microbiota. Different doses of compounds such as in this study the dose of the human milk oligosaccharide 2'-FL can be screened for efficacy in the inhibition of C. difficile proliferation.
Collapse
Affiliation(s)
- Maria Wiese
- Microbiology and Systems Biology, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, Netherlands
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - Frank H. J. Schuren
- Microbiology and Systems Biology, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, Netherlands
| | - Wiep Klaas Smits
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - Ed J. Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, Netherlands
| | - Anita Ouwens
- Microbiology and Systems Biology, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, Netherlands
| | - Margreet Heerikhuisen
- Microbiology and Systems Biology, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, Netherlands
| | - Louise Vigsnaes
- Glycom A/S—DSM Nutritional Products Ltd., Kogle Allé 4, Hørsholm, Denmark
- Department of Technology, Faculty of Health, University College Copenhagen, Copenhagen, Denmark
| | - Tim J. van den Broek
- Microbiology and Systems Biology, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, Netherlands
| | - Paulo de Boer
- Microbiology and Systems Biology, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, Netherlands
| | - Roy C. Montijn
- Microbiology and Systems Biology, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, Netherlands
| | - Jos M. B. M. van der Vossen
- Microbiology and Systems Biology, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, Netherlands
| |
Collapse
|
17
|
Collins DA, Riley TV. Ridinilazole: a novel, narrow-spectrum antimicrobial agent targeting Clostridium (Clostridioides) difficile. Lett Appl Microbiol 2022; 75:526-536. [PMID: 35119124 PMCID: PMC9541751 DOI: 10.1111/lam.13664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 01/12/2022] [Accepted: 01/31/2022] [Indexed: 11/26/2022]
Abstract
Clostridium (Clostridioides) difficile infection (CDI) remains an urgent threat to patients in health systems worldwide. Recurrent CDI occurs in up to 30% of cases due to sustained dysbiosis of the gut microbiota which normally protects against CDI. Associated costs of initial and recurrent episodes of CDI impose heavy financial burdens on health systems. Vancomycin and metronidazole have been the mainstay of therapy for CDI for many years; however, these agents continue to cause significant disruption to the gut microbiota and thus carry a high risk of recurrence for CDI patients. Treatment regimens are now turning towards novel narrow spectrum antimicrobial agents which target C. difficile while conserving the commensal gut microbiota, thus significantly reducing risk of recurrence. One such agent, fidaxomicin, has been in therapeutic use for several years and is now recommended as a first-line treatment for CDI, as it is superior to vancomycin in reducing risk of recurrence. Another narrow spectrum agent, ridnilazole, was recently developed and is undergoing evaluation of its potential clinical utility. This review aimed to summarize experimental reports of ridinilazole and assess its potential as a first-line agent for treatment of CDI. Reported results from in vitro assessments, and from hamster models of CDI, show potent activity against C. difficile, non-inferiority to vancomycin for clinical cure and non-susceptibility among most gut commensal bacteria. Phase I and II clinical trials have been completed with ridinilazole showing high tolerability and efficacy in treatment of CDI, and superiority over vancomycin in reducing recurrence of CDI within 30 days of treatment completion. Phase III trials are currently underway, the results of which may prove its potential to reduce recurrent CDI and lessen the heavy health and financial burden C. difficile imposes on patients and healthcare systems.
Collapse
Affiliation(s)
- Deirdre A Collins
- School of Medical and Health SciencesEdith Cowan UniversityJoondalupWesternAustralia
| | - Thomas V. Riley
- School of Medical and Health SciencesEdith Cowan UniversityJoondalupWesternAustralia
- Department of MicrobiologyPathWest Laboratory MedicineNedlandsWesternAustralia
- Medical, Molecular and Forensic SciencesMurdoch UniversityMurdochWestern AustraliaAustralia
- School of Biomedical SciencesThe University of Western AustraliaQueen Elizabeth II Medical CentreNedlandsWAAustralia
| |
Collapse
|
18
|
Antibiotic Resistance Profile of RT 027/176 Versus Other Clostridioides difficile Isolates in Silesia, Southern Poland. Pathogens 2022; 11:pathogens11080949. [PMID: 36015069 PMCID: PMC9416131 DOI: 10.3390/pathogens11080949] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2022] Open
Abstract
Clostridioides difficile is an important health care-associated pathogen. The aim of this study was to analyze the antibiotic susceptibility of C. difficile isolates from feces of patients from 13 hospitals in Silesia, Poland. The incidence of CDI per 100.000 people in Silesia in 2018−2019 was higher than the average in Poland (39.3−38.7 vs. 30.2−29.5, respectively). The incidence doubled from 26.4 in 2020 to 55.1 in 2021. Two hundred and thirty stool samples tested positive for GDH (glutamate dehydrogenase) and toxins were cultured anaerobically for C. difficile. The isolates were characterized, typed, and tested for susceptibility to 11 antibiotics by E-test (EUCAST, 2021). The genes of toxins A/B and binary were detected by mPCR. Of 215 isolates, 166 (77.2%) were classified as RT 027 and 6 (2.8%) as related RT 176. Resistance to ciprofloxacin (96.7%), moxifloxacin (79.1%), imipenem (78.1%), penicillin (67%), and rifampicin (40.5%) was found. The ermB gene was detected in 79 (36.7%) strains. Multidrug resistance (MDR) was confirmed in 50 (23.3%) strains of RT 027 (94%). We concluded that a high prevalence of MDR among hypervirulent RT 027/176 C. difficile was found in the Silesian region of Poland, emphasizing the need to enhance regional infection control on CDI and antibiotic stewardships.
Collapse
|
19
|
Influence of Binary Toxin Gene Detection and Decreased Susceptibility to Antibiotics among Clostridioides difficile Strains on Disease Severity: a Single-Center Study. Antimicrob Agents Chemother 2022; 66:e0048922. [PMID: 35861541 PMCID: PMC9380565 DOI: 10.1128/aac.00489-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Clostridioides difficile infection (CDI) is the fifth leading cause of death from nonmalignant gastrointestinal disease in the United States. The contribution of resistance to C. difficile-active antibiotics to the outcomes of CDI is unclear. We evaluated the antimicrobial susceptibility of C. difficile isolates in a U.S. hospital and determined associations of clinical variables and binary toxin positivity with antibiotic resistance. C. difficile spores were cultured from fecal specimens of adult patients with CDI for genotyping and antimicrobial susceptibility assay (for clindamycin [CLI], fidaxomicin [FDX], metronidazole [MTZ], moxifloxacin [MXF], tigecycline [TGC], and vancomycin [VAN]). Electronic medical records were reviewed for clinical data extraction. Ninety-seven of 130 (75%) fecal samples grew toxigenic C. difficile in culture. Most of the isolates were tcdA+ tcdB+ cdtB- (80.4%), and 18.6% and 1% were tcdA+ tcdB+ cdtB+ and tcdA-tcdB+ cdtB+, respectively. Susceptibility to VAN, MTZ, FDX, TGC, MXF, and CLI was 96%, 94%, 100%, 100%, 8%, and 79%, respectively. Six isolates, all cdtB positive and belonging to the 027 ribotype, were resistant to VAN and/or MTZ. Higher MICs were found in isolates with a mutation in the VAN-related resistance gene vanR, but not vanS. In addition, cdtB+ isolates exhibited higher MICs of VAN, MTZ, TGC, CLI, and MXF compared to cdtB- strains. Patients with greater intestinal inflammation or severe disease were more likely to be infected with cdtB+ strains. Decreased susceptibility to antibiotics is not directly associated with either severe or recurrent CDI. However, antimicrobial susceptibility of C. difficile is decreased in strains positive for the binary toxin gene.
Collapse
|
20
|
Schnizlein MK, Young VB. Capturing the environment of the Clostridioides difficile infection cycle. Nat Rev Gastroenterol Hepatol 2022; 19:508-520. [PMID: 35468953 DOI: 10.1038/s41575-022-00610-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 12/11/2022]
Abstract
Clostridioides difficile (formerly Clostridium difficile) infection is a substantial health and economic burden worldwide. Great strides have been made over the past several years in characterizing the physiology of C. difficile infection, particularly regarding how gut microorganisms and their host work together to provide colonization resistance. As mammalian hosts and their indigenous gut microbiota have co-evolved, they have formed a complex yet stable relationship that prevents invading microorganisms from establishing themselves. In this Review, we discuss the latest advances in our understanding of C. difficile physiology that have contributed to its success as a pathogen, including its versatile survival factors and ability to adapt to unique niches. Using discoveries regarding microorganism-host and microorganism-microorganism interactions that constitute colonization resistance, we place C. difficile within the fiercely competitive gut environment. A comprehensive understanding of these relationships is required to continue the development of precision medicine-based treatments for C. difficile infection.
Collapse
Affiliation(s)
- Matthew K Schnizlein
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA
| | - Vincent B Young
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA.
- Department of Internal Medicine/Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA.
| |
Collapse
|
21
|
Aleksić A, Stojanović-Radić Z, Harmanus C, Kuijper E, Stojanović P. In vitro anti-clostridial action and potential of the spice herbs essential oils to prevent biofilm formation of hypervirulent Clostridioides difficile strains isolated from hospitalized patients with CDI. Anaerobe 2022; 76:102604. [PMID: 35709937 DOI: 10.1016/j.anaerobe.2022.102604] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clostridioides difficile is the most common causative agent of antibiotic-acquired diarrhea in hospitalized patients associated with substantial morbidity and mortality. The global epidemic of CDI (Clostridioides difficile infection) began in the early 20th century with the emergence of the hypervirulent and resistant ribotype 027 strains, and requires an urgent search for new therapeutic agents. OBJECTIVE The aim of this study is to investigate the antibacterial activity of the three essential oils isolated from spice herbs (wild oregano, garlic and black pepper) against C. difficile clinical isolates belonging to 6 different PCR ribotypes and their potential inhibitory effect on the biofilm production in in vitro conditions. RESULTS Wild oregano essential oil showed strong inhibitory activity in concentrations 0.02-1.25 mg/mL and bactericidal activity in concentrations from 0.08 to 10 mg/mL. Garlic essential oil was effective in the concentration range of 0.02-40 mg/mL, and 0.16 - > 40 mg/mL. MIC and MBC for black pepper oil ranged from 0.04 to 40 mg/mL, and 0.08 - > 40 mg/mL, respectively. All the tested oils reduced in vitro biofilm production, with the best activity of oregano oil. CONCLUSION Essential oils of wild oregano, black pepper and garlic are candidates for adjunctive therapeutics in the treatment of CDI. Oregano oil should certainly be preferred due to the lack of selectivity of action in relation to the ribotype, the strength of the produced biofilm and/or antibiotic-susceptibility patterns.
Collapse
Affiliation(s)
- Ana Aleksić
- Faculty of Sciences and Mathematics, Department of Biology and Ecology, University of Nis, Serbia
| | - Zorica Stojanović-Radić
- Faculty of Sciences and Mathematics, Department of Biology and Ecology, University of Nis, Serbia.
| | - Celine Harmanus
- National Reference Laboratory for Clostridioides Difficile, Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - EdJ Kuijper
- National Reference Laboratory for Clostridioides Difficile, Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Predrag Stojanović
- Faculty of Medicine, University of Nis, Serbia; Institute for Public Health Nis, Center of Microbiology, Serbia
| |
Collapse
|
22
|
Greentree DH, Rice LB, Donskey CJ. Houston, We Have a Problem: Reports of Clostridioides difficile Isolates with Reduced Vancomycin Susceptibility. Clin Infect Dis 2022; 75:1661-1664. [PMID: 35653393 DOI: 10.1093/cid/ciac444] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Indexed: 11/14/2022] Open
Abstract
During the past 4 decades, oral vancomycin has been a mainstay of Clostridioides difficile infection (CDI) therapy with no reports of treatment failure due to emergence of vancomycin resistance. However, C. difficile isolates with high-level phenotypic resistance to vancomycin have recently been reported in 3 distinct geographic regions. There is an urgent need for surveillance to determine if strains with reduced vancomycin susceptibility are circulating in other areas. In a Cleveland area hospital, screening of 176 CDI stool specimens yielded no C. difficile isolates with reduced vancomycin susceptibility and highlighted the potential for false-positive results due to contamination with vancomycin-resistant enterococci. Additional studies are needed to clarify whether reduced vancomycin susceptibility is an emerging problem that will alter clinical practice. Clinicians should alert their health department if they observe a substantial increase in the frequency of vancomycin treatment failure in patients diagnosed with CDI with no alternative explanation for diarrhea.
Collapse
Affiliation(s)
| | - Louis B Rice
- Department of Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Curtis J Donskey
- Geriatric Research, Education and Clinical Center, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
23
|
Finsterwalder SK, Loncaric I, Cabal A, Szostak MP, Barf LM, Marz M, Allerberger F, Burgener IA, Tichy A, Feßler AT, Schwarz S, Monecke S, Ehricht R, Ruppitsch W, Spergser J, Künzel F. Dogs as carriers of virulent and resistant genotypes of Clostridioides difficile. Zoonoses Public Health 2022; 69:673-681. [PMID: 35546073 PMCID: PMC9544694 DOI: 10.1111/zph.12956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/19/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
While previous research on zoonotic transmission of community-acquired Clostridioides difficile infection (CA-CDI) focused on food-producing animals, the present study aimed to investigate whether dogs are carriers of resistant and/or virulent C. difficile strains. Rectal swabs were collected from 323 dogs and 38 C. difficile isolates (11.8%) were obtained. Isolates were characterized by antimicrobial susceptibility testing, whole-genome sequencing (WGS) and a DNA hybridization assay. Multilocus sequence typing (MLST), core genome MLST (cgMLST) and screening for virulence and antimicrobial resistance genes were performed based on WGS. Minimum inhibitory concentrations for erythromycin, clindamycin, tetracycline, vancomycin and metronidazole were determined by E-test. Out of 38 C. difficile isolates, 28 (73.7%) carried genes for toxins. The majority of isolates belonged to MLST sequence types (STs) of clade I and one to clade V. Several isolates belonged to STs previously associated with human CA-CDI. However, cgMLST showed low genetic relatedness between the isolates of this study and C. difficile strains isolated from humans in Austria for which genome sequences were publicly available. Four isolates (10.5%) displayed resistance to three of the tested antimicrobial agents. Isolates exhibited resistance to erythromycin, clindamycin, tetracycline and metronidazole. These phenotypic resistances were supported by the presence of the resistance genes erm(B), cfr(C) and tet(M). All isolates were susceptible to vancomycin. Our results indicate that dogs may carry virulent and antimicrobial-resistant C. difficile strains.
Collapse
Affiliation(s)
- S K Finsterwalder
- Institute of Microbiology, University of Veterinary Medicine Vienna, Vienna, Austria.,Clinical Unit of Internal Medicine Small Animals, University of Veterinary Medicine Vienna, Vienna, Austria
| | - I Loncaric
- Institute of Microbiology, University of Veterinary Medicine Vienna, Vienna, Austria
| | - A Cabal
- AGES - Austrian Agency for Health and Food Safety, Vienna, Austria
| | - M P Szostak
- Institute of Microbiology, University of Veterinary Medicine Vienna, Vienna, Austria
| | - L M Barf
- Faculty of Mathematics and Computer Science, Friedrich Schiller University Jena, Jena, Germany.,Max Planck Institute for Science of Human History, Jena, Germany
| | - M Marz
- Faculty of Mathematics and Computer Science, Friedrich Schiller University Jena, Jena, Germany.,FLI Leibniz Institute for Age Research, Jena, Germany.,InfectoGnostics Research Campus Jena, Jena, Germany
| | - F Allerberger
- AGES - Austrian Agency for Health and Food Safety, Vienna, Austria
| | - I A Burgener
- Clinical Unit of Internal Medicine Small Animals, University of Veterinary Medicine Vienna, Vienna, Austria
| | - A Tichy
- Department of Biomedical Science, University of Veterinary Medicine Vienna, Vienna, Austria
| | - A T Feßler
- Department of Veterinary Medicine, Centre of Infection Medicine, Institute of Microbiology and Epizootics, Freie Universität Berlin, Berlin, Germany.,Department of Veterinary Medicine, Veterinary Centre for Resistance Research (TZR), Freie Universität Berlin, Berlin, Germany
| | - S Schwarz
- Department of Veterinary Medicine, Centre of Infection Medicine, Institute of Microbiology and Epizootics, Freie Universität Berlin, Berlin, Germany.,Department of Veterinary Medicine, Veterinary Centre for Resistance Research (TZR), Freie Universität Berlin, Berlin, Germany
| | - S Monecke
- InfectoGnostics Research Campus Jena, Jena, Germany.,Leibniz Institute of Photonic Technology (IPHT), Jena, Germany.,Institut für Medizinische Mikrobiologie und Hygiene, Universitätsklinik Dresden, Dresden, Germany
| | - R Ehricht
- InfectoGnostics Research Campus Jena, Jena, Germany.,Leibniz Institute of Photonic Technology (IPHT), Jena, Germany.,Institute of Physical Chemistry, Friedrich Schiller University Jena, Jena, Germany
| | - W Ruppitsch
- AGES - Austrian Agency for Health and Food Safety, Vienna, Austria
| | - J Spergser
- Institute of Microbiology, University of Veterinary Medicine Vienna, Vienna, Austria
| | - F Künzel
- Clinical Unit of Internal Medicine Small Animals, University of Veterinary Medicine Vienna, Vienna, Austria
| |
Collapse
|
24
|
Du T, Choi KB, Silva A, Golding GR, Pelude L, Hizon R, Al-Rawahi GN, Brooks J, Chow B, Collet JC, Comeau JL, Davis I, Evans GA, Frenette C, Han G, Johnstone J, Kibsey P, Katz KC, Langley JM, Lee BE, Longtin Y, Mertz D, Minion J, Science M, Srigley JA, Stagg P, Suh KN, Thampi N, Wong A, Hota SS. Characterization of Healthcare-Associated and Community-Associated Clostridioides difficile Infections among Adults, Canada, 2015-2019. Emerg Infect Dis 2022; 28:1128-1136. [PMID: 35470794 PMCID: PMC9155897 DOI: 10.3201/eid2806.212262] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
We investigated epidemiologic and molecular characteristics of healthcare-associated (HA) and community-associated (CA) Clostridioides difficile infection (CDI) among adult patients in Canadian Nosocomial Infection Surveillance Program hospitals during 2015–2019. The study encompassed 18,455 CDI cases, 13,735 (74.4%) HA and 4,720 (25.6%) CA. During 2015–2019, HA CDI rates decreased by 23.8%, whereas CA decreased by 18.8%. HA CDI was significantly associated with increased 30-day all-cause mortality as compared with CA CDI (p<0.01). Of 2,506 isolates analyzed, the most common ribotypes (RTs) were RT027, RT106, RT014, and RT020. RT027 was more often associated with CDI-attributable death than was non-RT027, regardless of acquisition type. Overall resistance C. difficile rates were similar for all drugs tested except moxifloxacin. Adult HA and CA CDI rates have declined, coinciding with changes in prevalence of RT027 and RT106. Infection prevention and control and continued national surveillance are integral to clarifying CDI epidemiology, investigation, and control.
Collapse
|
25
|
Wu Y, Wang YY, Bai LL, Zhang WZ, Li GW, Lu JX. A narrative review of Clostridioides difficile infection in China. Anaerobe 2022; 74:102540. [DOI: 10.1016/j.anaerobe.2022.102540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 12/26/2022]
|
26
|
Short communication: Contamination of home-grown and retail vegetables with Clostridioides difficile. Anaerobe 2022; 74:102512. [DOI: 10.1016/j.anaerobe.2021.102512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/17/2021] [Accepted: 12/31/2021] [Indexed: 01/09/2023]
|
27
|
van Prehn J, Reigadas E, Vogelzang EH, Bouza E, Hristea A, Guery B, Krutova M, Norén T, Allerberger F, Coia JE, Goorhuis A, van Rossen TM, Ooijevaar RE, Burns K, Scharvik Olesen BR, Tschudin-Sutter S, Wilcox MH, Vehreschild MJGT, Fitzpatrick F, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults. Clin Microbiol Infect 2021; 27 Suppl 2:S1-S21. [PMID: 34678515 DOI: 10.1016/j.cmi.2021.09.038] [Citation(s) in RCA: 220] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
Abstract
SCOPE In 2009, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) published the first treatment guidance document for Clostridioides difficile infection (CDI). This document was updated in 2014. The growing literature on CDI antimicrobial treatment and novel treatment approaches, such as faecal microbiota transplantation (FMT) and toxin-binding monoclonal antibodies, prompted the ESCMID study group on C. difficile (ESGCD) to update the 2014 treatment guidance document for CDI in adults. METHODS AND QUESTIONS Key questions on CDI treatment were formulated by the guideline committee and included: What is the best treatment for initial, severe, severe-complicated, refractory, recurrent and multiple recurrent CDI? What is the best treatment when no oral therapy is possible? Can prognostic factors identify patients at risk for severe and recurrent CDI and is there a place for CDI prophylaxis? Outcome measures for treatment strategy were: clinical cure, recurrence and sustained cure. For studies on surgical interventions and severe-complicated CDI the outcome was mortality. Appraisal of available literature and drafting of recommendations was performed by the guideline drafting group. The total body of evidence for the recommendations on CDI treatment consists of the literature described in the previous guidelines, supplemented with a systematic literature search on randomized clinical trials and observational studies from 2012 and onwards. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) system was used to grade the strength of our recommendations and the quality of the evidence. The guideline committee was invited to comment on the recommendations. The guideline draft was sent to external experts and a patients' representative for review. Full ESCMID endorsement was obtained after a public consultation procedure. RECOMMENDATIONS Important changes compared with previous guideline include but are not limited to: metronidazole is no longer recommended for treatment of CDI when fidaxomicin or vancomycin are available, fidaxomicin is the preferred agent for treatment of initial CDI and the first recurrence of CDI when available and feasible, FMT or bezlotoxumab in addition to standard of care antibiotics (SoC) are preferred for treatment of a second or further recurrence of CDI, bezlotoxumab in addition to SoC is recommended for the first recurrence of CDI when fidaxomicin was used to manage the initial CDI episode, and bezlotoxumab is considered as an ancillary treatment to vancomycin for a CDI episode with high risk of recurrence when fidaxomicin is not available. Contrary to the previous guideline, in the current guideline emphasis is placed on risk for recurrence as a factor that determines treatment strategy for the individual patient, rather than the disease severity.
Collapse
Affiliation(s)
- Joffrey van Prehn
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Elena Reigadas
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Erik H Vogelzang
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Adriana Hristea
- University of Medicine and Pharmacy Carol Davila, National Institute for Infectious Diseases Prof Dr Matei Bals, Romania
| | - Benoit Guery
- Infectious Diseases Specialist, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Marcela Krutova
- Department of Medical Microbiology, Charles University in Prague and Motol University Hospital, Czech Republic
| | - Torbjorn Norén
- Faculty of Medicine and Health, Department of Laboratory Medicine, National Reference Laboratory for Clostridioides difficile, Clinical Microbiology, Örebro University Hospital, Örebro, Sweden
| | | | - John E Coia
- Department of Clinical Microbiology, Hospital South West Jutland and Department of Regional Health Research IRS, University of Southern Denmark, Esbjerg, Denmark
| | - Abraham Goorhuis
- Department of Infectious Diseases, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Tessel M van Rossen
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Rogier E Ooijevaar
- Department of Gastroenterology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Karen Burns
- Departments of Clinical Microbiology, Beaumont Hospital & Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Sarah Tschudin-Sutter
- Department of Infectious Diseases and Infection Control, University Hospital Basel, University Basel, Universitatsspital, Basel, Switzerland
| | - Mark H Wilcox
- Department of Microbiology, Old Medical, School Leeds General Infirmary, Leeds Teaching Hospitals & University of Leeds, Leeds, United Kingdom
| | - Maria J G T Vehreschild
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ed J Kuijper
- Department of Medical Microbiology, Centre for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands; National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
| | | |
Collapse
|
28
|
Kabała M, Gofron Z, Aptekorz M, Sacha K, Harmanus C, Kuijper E, Martirosian G. Clostridioides difficile Ribotype 027 (RT027) Outbreak Investigation Due to the Emergence of Rifampicin Resistance Using Multilocus Variable-Number Tandem Repeat Analysis (MLVA). Infect Drug Resist 2021; 14:3247-3254. [PMID: 34429622 PMCID: PMC8380304 DOI: 10.2147/idr.s324745] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/24/2021] [Indexed: 12/29/2022] Open
Abstract
Objective The aim of this study was Clostridioides difficile outbreak investigation due to the emergence of rifampicin resistant ribotype 027 (RT 027) fecal isolates from patients of Polish tertiary care hospital between X. 2017 and II. 2018 using multilocus variable tandem repeat analysis (MLVA). Materials and Methods Twenty-nine C. difficile fecal isolates from patients of tertiary care hospital in Southern Poland were ribotyped and analyzed by MLVA. Multiplex PCR (mPCR) for genes encoding GDH (gluD), toxins A (tcdA)/ B (tcdB), 16S rDNA and binary toxin genes (ctdA and ctdB) was performed. The antibiotic susceptibility profile was determined by E-test. Results The A, B and binary toxins encoding genes were detected in all 29 C. difficile strains which were sensitive to metronidazole, vancomycin and were resistant to erythromycin, clindamycin, and moxifloxacin; resistance to imipenem demonstrated 97%, to rifampicin – 45% isolates. C. difficile strains could be grouped by MLVA into 5 distinct clusters, and the largest cluster II contains 16 strains. The comparison of rifampicin GM MIC of cluster II (n=16 strains) with all others (n=13) showed that strains from clusters I, III, IV and V possessed significantly (p <0.005) higher GM MIC and were more resistant to rifampicin. Conclusion MLVA analysis proved transmission and recognized outbreak due to multidrug-resistant RT 027 C. difficile among patients of tertiary care hospital in Southern Poland. The reason for this is probably the widespread occurrence of spores in the hospital environment, which includes, among others, neglect of hygienic procedures and epidemic supervision. High resistance to imipenem (97%) and to rifampicin (45%) among C. difficile RT 027 Silesian isolates is threatening and requires further studies to elucidate this phenomenon.
Collapse
Affiliation(s)
- Monika Kabała
- Department of Medical Microbiology Medical University of Silesia in Katowice, Katowice, Poland
| | - Zygmunt Gofron
- Department of Medical Microbiology Medical University of Silesia in Katowice, Katowice, Poland
| | - Małgorzata Aptekorz
- Department of Medical Microbiology Medical University of Silesia in Katowice, Katowice, Poland
| | - Krzysztof Sacha
- Department of Medical Microbiology Medical University of Silesia in Katowice, Katowice, Poland
| | - Celine Harmanus
- Department of Medical Microbiology Leiden University Medical Center, Leiden, the Netherlands
| | - Ed Kuijper
- Department of Medical Microbiology Leiden University Medical Center, Leiden, the Netherlands
| | - Gayane Martirosian
- Department of Medical Microbiology Medical University of Silesia in Katowice, Katowice, Poland
| |
Collapse
|
29
|
Antimicrobial resistance progression in the United Kingdom: A temporal comparison of Clostridioides difficile antimicrobial susceptibilities. Anaerobe 2021; 70:102385. [PMID: 34048922 DOI: 10.1016/j.anaerobe.2021.102385] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/29/2021] [Accepted: 05/17/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Clostridioides difficile (CD) is widely reported as one of the most prevalent multi-drug resistant (MDR) organisms. Assessment of temporally disparate isolate collections can give valuable epidemiological data to further the understanding of antimicrobial resistance progression. METHODS A collection of 75 CD isolates (1980-86) was characterised by PCR ribotyping, cell cytotoxicity assay and susceptibility testing with a panel of 16 antimicrobials and compared to a modern surveillance collection consisting of 416 UK isolates (2012-2016). Agar-incorporation was performed to ascertain susceptibility data for vancomycin, metronidazole, rifampicin, fidaxomicin, moxifloxacin, clindamycin, imipenem, chloramphenicol, tigecycline, linezolid, ciprofloxacin, piperacillin/tazobactam, ceftriaxone, amoxicillin, tetracycline and erythromycin. Genomes were obtained using Illumina HiSeq3000 sequencing and assembled using CLC Genomics Workbench. Resistance genes were identified using the Comprehensive Antibiotic Research Database's Resistance Gene Identifier and ResFinder3.0. RESULTS Twenty-six known and one previously unobserved ribotype (RT) were detected. RT015 and RT020 dominated; 21.3% and 17.3%, respectively. Three moxifloxacin resistant (16-32 mg/L) RT027 isolates were recovered, pre-dating the earliest reports of this phenotype/genotype. Phenotypic resistance was observed to moxifloxacin (9.3% of isolates), ciprofloxacin (100%), erythromycin (17.3%), tetracycline (9.3%), linezolid and chloramphenicol (4.0%). Phenotypic comparisons with modern strains revealed increasing minimum inhibitory concentrations (MIC), with MIC50 elevations of one doubling-dilution for the majority of compounds, excluding clindamycin and imipenem. Moxifloxacin MIC90 comparisons revealed a two doubling-dilution increase between temporal isolate collections. Historical genomes revealed twenty different resistance determinants, including ermB (8.0% of isolates), tetM (9.3%), cfr (5.3%) and gyrA substitution Thr-82→Ile (9.3%). Seventeen isolates (22.7%) were resistant to ≥3 compounds (MDR), demonstrating ten different combinations. Intra-RT diversity was observed. CONCLUSIONS Antibiotic resistance in CD has increased since the early 1980s, across the majority of classes. Moxifloxacin resistance determinants may pre-date its introduction.
Collapse
|
30
|
Molecular epidemiology and clinical risk factors for rifaximin-non-susceptible Clostridioides difficile infection in South Korea: a prospective, multicentre, observational study. J Glob Antimicrob Resist 2021; 27:46-50. [PMID: 34320416 DOI: 10.1016/j.jgar.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 06/03/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES This study was designed to investigate the molecular epidemiology of Clostridioides difficile isolates in South Korea and to evaluate risk factors for rifaximin-non-susceptible C. difficile infection (CDI). METHODS A total of 413 patients with CDI from two sentinel hospitals in South Korea were enrolled in this study. Putative clinical risk factors for CDI were identified using digital medical records of the patients. Pathogen profiles, including antimicrobial susceptibility, toxin production and ribotype, were evaluated for each of the causative C. difficile isolates. RESULTS Of the 413 C. difficile isolates, 81 (19.6%) were shown to be rifaximin-non-susceptible, with the most common ribotypes being 018 (56.8%; 46/81), 017 (16.0%; 13/81) and 027 (6.2%; 5/81). Rifaximin-non-susceptible C. difficile isolates exhibited higher non-susceptibility rates to most of the other drugs tested in this study compared with rifaximin-susceptible isolates. Previous history of pulmonary tuberculosis and prior rifaximin treatment were shown to be associated with the occurrence of rifaximin-non-susceptible CDI compared with susceptible CDI. CONCLUSION Non-susceptibility rates to rifaximin for the C. difficile isolates identified in this study were reasonably high with most of the resistant strains belonging to either ribotype 018 or 017. Widespread dissemination of these clones may be the result of antimicrobial selection pressure introduced by the widespread use of rifaximin. These results suggest that a sustainable surveillance programme for CDI and C. difficile resistance is needed in order to better control CDIs and to improve therapeutic efficacy.
Collapse
|
31
|
Wickramage I, Spigaglia P, Sun X. Mechanisms of antibiotic resistance of Clostridioides difficile. J Antimicrob Chemother 2021; 76:3077-3090. [PMID: 34297842 DOI: 10.1093/jac/dkab231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Clostridioides difficile (CD) is one of the top five urgent antibiotic resistance threats in USA. There is a worldwide increase in MDR of CD, with emergence of novel strains which are often more virulent and MDR. Antibiotic resistance in CD is constantly evolving with acquisition of novel resistance mechanisms, which can be transferred between different species of bacteria and among different CD strains present in the clinical setting, community, and environment. Therefore, understanding the antibiotic resistance mechanisms of CD is important to guide optimal antibiotic stewardship policies and to identify novel therapeutic targets to combat CD as well as other bacteria. Epidemiology of CD is driven by the evolution of antibiotic resistance. Prevalence of different CD strains and their characteristic resistomes show distinct global geographical patterns. Understanding epidemiologically driven and strain-specific characteristics of antibiotic resistance is important for effective epidemiological surveillance of antibiotic resistance and to curb the inter-strain and -species spread of the CD resistome. CD has developed resistance to antibiotics with diverse mechanisms such as drug alteration, modification of the antibiotic target site and extrusion of drugs via efflux pumps. In this review, we summarized the most recent advancements in the understanding of mechanisms of antibiotic resistance in CD and analysed the antibiotic resistance factors present in genomes of a few representative well known, epidemic and MDR CD strains found predominantly in different regions of the world.
Collapse
Affiliation(s)
- Ishani Wickramage
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Down Blvd, Tampa, FL 33612, USA
| | - Patrizia Spigaglia
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Xingmin Sun
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Down Blvd, Tampa, FL 33612, USA
| |
Collapse
|
32
|
Yepez Guevara EA, Aitken SL, Olvera AV, Carlin L, Fernandes KE, Bhatti MM, Garey KW, Adachi J, Okhuysen PC. Clostridioides difficile Infection in Cancer and Immunocompromised Patients: Relevance of a Two-step Diagnostic Algorithm and Infecting Ribotypes on Clinical Outcomes. Clin Infect Dis 2021; 72:e460-e465. [PMID: 32803229 DOI: 10.1093/cid/ciaa1184] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/10/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Patients with cancer are particularly vulnerable to Clostridioides difficile infection (CDI). Guidelines recommend a two-step diagnostic algorithm to differentiate carriers from CDI; however, there are limited data for this approach while including other confounding risk factors for diarrhea such as radiation, cytotoxic chemotherapy, and adoptive cell based therapies. METHODS We conducted a prospective, non-interventional, single center, cohort study of cancer patients with acute diarrhea and C. difficile, identified in stools by nucleic acid amplification tests (NAAT) and culture. Fecal toxin A/B was detected by enzyme immunoassay (EIA) and isolates were ribotyped using 16s rRNA fluorescent sequencing. Patients were followed for 90 days to compare outcomes according to malignancy type, infecting ribotype, and EIA status. RESULTS We followed 227 patients with a positive NAAT. Of these, 87% were hospitalized and 83% had an active malignancy. EIA was confirmed positive in 80/227 (35%) of patients. Those with EIA+ were older (60 ± 18 years vs 54 ± 19 years., P = .01), more likely to fail therapy [24/80 (30%) vs 26/147 (18%), P = .04] and experience recurrence [20/80 (25%) vs 21/147(14%), P < .05]. We found a low prevalence (22%) of ribotypes historically associated with poor outcomes (002, 018, 027, 56, F078-126, 244) but their presence were associated with treatment failure [17/50 (34%) vs 33/177 (19%), P = .02]. CONCLUSIONS When compared to cancer patients with fecal NAAT+/EIA-, patients with NAAT+/EIA+ CDI are less likely to respond to therapy and more likely to experience recurrence, particularly when due to ribotypes associated with poor outcomes.
Collapse
Affiliation(s)
- Eduardo A Yepez Guevara
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Adilene V Olvera
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lily Carlin
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kerri E Fernandes
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Micah M Bhatti
- Department of Clinical Microbiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kevin W Garey
- College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Javier Adachi
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pablo C Okhuysen
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
33
|
Putsathit P, Hong S, George N, Hemphill C, Huntington PG, Korman TM, Kotsanas D, Lahra M, McDougall R, McGlinchey A, Moore CV, Nimmo GR, Prendergast L, Robson J, Waring L, Wehrhahn MC, Weldhagen GF, Wilson RM, Riley TV, Knight DR. Antimicrobial resistance surveillance of Clostridioides difficile in Australia, 2015-18. J Antimicrob Chemother 2021; 76:1815-1821. [PMID: 33895826 DOI: 10.1093/jac/dkab099] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/05/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Clostridioides difficile was listed as an urgent antimicrobial resistance (AMR) threat in a report by the CDC in 2019. AMR drives the evolution of C. difficile and facilitates its emergence and spread. The C. difficile Antimicrobial Resistance Surveillance (CDARS) study is nationwide longitudinal surveillance of C. difficile infection (CDI) in Australia. OBJECTIVES To determine the antimicrobial susceptibility of C. difficile isolated in Australia between 2015 and 2018. METHODS A total of 1091 strains of C. difficile were collected over a 3 year period by a network of 10 diagnostic microbiology laboratories in five Australian states. These strains were tested for their susceptibility to nine antimicrobials using the CLSI agar incorporation method. RESULTS All strains were susceptible to metronidazole, fidaxomicin, rifaximin and amoxicillin/clavulanate and low numbers of resistant strains were observed for meropenem (0.1%; 1/1091), moxifloxacin (3.5%; 38/1091) and vancomycin (5.7%; 62/1091). Resistance to clindamycin was common (85.2%; 929/1091), followed by resistance to ceftriaxone (18.8%; 205/1091). The in vitro activity of fidaxomicin [geometric mean MIC (GM) = 0.101 mg/L] was superior to that of vancomycin (1.700 mg/L) and metronidazole (0.229 mg/L). The prevalence of MDR C. difficile, as defined by resistance to ≥3 antimicrobial classes, was low (1.7%; 19/1091). CONCLUSIONS The majority of C. difficile isolated in Australia did not show reduced susceptibility to antimicrobials recommended for treatment of CDI (vancomycin, metronidazole and fidaxomicin). Resistance to carbapenems and fluoroquinolones was low and MDR was uncommon; however, clindamycin resistance was frequent. One fluoroquinolone-resistant ribotype 027 strain was detected.
Collapse
Affiliation(s)
- Papanin Putsathit
- School of Medical and Health Sciences, Edith Cowan University, Joondalup 6027, WA, Australia
| | - Stacey Hong
- Marshall Centre for Infectious Diseases Research and Training, School of Biomedical Sciences, The University of Western Australia, Queen Elizabeth II Medical Centre, Nedlands 6009, WA, Australia.,Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch 6150, WA, Australia
| | - Narelle George
- Pathology Queensland, Royal Brisbane and Women's Hospital, Herston 4029, QLD, Australia
| | | | - Peter G Huntington
- Department of Microbiology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, 2065, NSW, Australia
| | - Tony M Korman
- Monash Infectious Diseases, Monash Health, Monash Medical Centre, Clayton 3168, VIC, Australia
| | - Despina Kotsanas
- Monash Infectious Diseases, Monash Health, Monash Medical Centre, Clayton 3168, VIC, Australia
| | - Monica Lahra
- Department of Microbiology, The Prince of Wales Hospital, Randwick 2031, NSW, Australia
| | | | | | - Casey V Moore
- Microbiology and Infectious Diseases Laboratories, SA Pathology, Adelaide 5000, SA, Australia
| | - Graeme R Nimmo
- Pathology Queensland, Royal Brisbane and Women's Hospital, Herston 4029, QLD, Australia
| | | | | | | | | | - Gerhard F Weldhagen
- Microbiology and Infectious Diseases Laboratories, SA Pathology, Adelaide 5000, SA, Australia
| | - Richard M Wilson
- Australian Clinical Labs, Microbiology Department, Wayville 5034, SA, Australia
| | - Thomas V Riley
- School of Medical and Health Sciences, Edith Cowan University, Joondalup 6027, WA, Australia.,Marshall Centre for Infectious Diseases Research and Training, School of Biomedical Sciences, The University of Western Australia, Queen Elizabeth II Medical Centre, Nedlands 6009, WA, Australia.,Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch 6150, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands 6009, WA, Australia
| | - Daniel R Knight
- Marshall Centre for Infectious Diseases Research and Training, School of Biomedical Sciences, The University of Western Australia, Queen Elizabeth II Medical Centre, Nedlands 6009, WA, Australia.,Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch 6150, WA, Australia
| |
Collapse
|
34
|
Sommermeyer H, Pituch HM, Wultanska D, Wojtyla-Buciora P, Piatek J, Bernatek M. Inhibition of Quinolone- and Multi-Drug-Resistant Clostridioides Difficile Strains by Multi Strain Synbiotics-An Option for Diarrhea Management in Nursing Facilities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115871. [PMID: 34070727 PMCID: PMC8198539 DOI: 10.3390/ijerph18115871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/18/2021] [Accepted: 05/28/2021] [Indexed: 12/17/2022]
Abstract
Diarrhea is a common problem in nursing homes. A survey among nursing facilities in Poland was used to characterize diarrhea outbreaks, the burden caused for residents and caregivers and the employed measures. Survey results confirmed that diarrhea is a common problem in nursing homes and in most cases affects groups of residents. The related burden is high or very high for 27% of residents and 40% of caregivers. In 80% of nursing facilities pro or synbiotics are part of the measures used to manage diarrhea. Administration of these kinds of products has been suggested for the management of diarrhea, especially in cases caused by Clostridioides (C.) difficile. C. difficile is one of many potential causes for diarrhea, but is of particular concern for nursing homes because it is responsible for a large proportion of diarrhea outbreaks and is often caused by multi-drug resistant strains. In vitro inhibition of a quinolone-resistant and a multi-drug resistant C. difficile strain was used to evaluate the growth inhibitory effects of commonly used products containing probiotic microorganisms. Growth of both strains was best inhibited by multi-strain synbiotic preparations. These findings suggest that multi-strain synbiotics can be considered as an interventional option for diarrhea caused by C. difficile.
Collapse
Affiliation(s)
- Henning Sommermeyer
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
| | - Hanna M. Pituch
- Department of Medical Microbiology, Medical University of Warsaw, ul. Żwirki i Wigury 61, 02-091 Warsaw, Poland; (H.M.P.); (D.W.)
| | - Dorota Wultanska
- Department of Medical Microbiology, Medical University of Warsaw, ul. Żwirki i Wigury 61, 02-091 Warsaw, Poland; (H.M.P.); (D.W.)
| | - Paulina Wojtyla-Buciora
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
| | - Jacek Piatek
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
- Correspondence: ; Tel.: +48-883389788
| | - Malgorzata Bernatek
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
| |
Collapse
|
35
|
Martínez-Meléndez A, Tijerina-Rodríguez L, Collins N, Baines SD, Morfin-Otero R, Camacho-Ortíz A, Villarreal-Treviño L, Garza-González E. Diversity of Circulating Clostridioides difficile Ribotypes in Mexico and Susceptibility to Fidaxomicin, Vancomycin, and Metronidazole. Microb Drug Resist 2021; 27:1672-1676. [PMID: 34037477 DOI: 10.1089/mdr.2020.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In this study, we report the results of the epidemiological analysis of Clostridioides difficile ribotypes (RTs) and antimicrobial susceptibility testing. Most isolates were RT027, representing 73% (84/115) of isolates. No isolates with reduced susceptibility to fidaxomicin were found; however, 38 (33.04%) isolates had reduced susceptibility to metronidazole, and 7 isolates (6.1%) had reduced susceptibility to vancomycin. These findings highlight the need for continuous surveillance of C. difficile RTs and antimicrobial susceptibility testing.
Collapse
Affiliation(s)
- Adrián Martínez-Meléndez
- Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| | - Laura Tijerina-Rodríguez
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| | - Nathania Collins
- Department of Clinical, Pharmaceutical, and Biological Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Simon D Baines
- Department of Clinical, Pharmaceutical, and Biological Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Rayo Morfin-Otero
- Centro Universitario de Ciencias de la Salud, Hospital Civil de Guadalajara "Fray Antonio Alcalde" e Instituto de Patología Infecciosa y Experimental, Universidad de Guadalajara, Guadalajara, Mexico
| | - Adrián Camacho-Ortíz
- Hospital Universitario "Dr. José Eleuterio González," Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Licet Villarreal-Treviño
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| | - Elvira Garza-González
- Hospital Universitario "Dr. José Eleuterio González," Universidad Autónoma de Nuevo León, Monterrey, Mexico
| |
Collapse
|
36
|
Novel fidaxomicin antibiotics through site-selective catalysis. Commun Chem 2021; 4:59. [PMID: 36697765 PMCID: PMC9814943 DOI: 10.1038/s42004-021-00501-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/31/2021] [Indexed: 01/28/2023] Open
Abstract
Fidaxomicin (FDX) is a marketed antibiotic for the treatment of Clostridioides difficile infections (CDI). Fidaxomicin displays antibacterial properties against many Gram-positive bacteria, yet the application of this antibiotic is currently limited to treatment of CDI. Semisynthetic modifications present a promising strategy to improve its pharmacokinetic properties and also circumvent resistance development by broadening the structural diversity of the derivatives. Here, based on a rational design using cryo-EM structural analysis, we implement two strategic site-selective catalytic reactions with a special emphasis to study the role of the carbohydrate units. Site-selective introduction of various ester moieties on the noviose as well as a Tsuji-Trost type rhamnose cleavage allow the synthesis of novel fidaxomicin analogs with promising antibacterial activities against C. difficile and Mycobacterium tuberculosis.
Collapse
|
37
|
Collins DA, Wu Y, Tateda K, Kim HJ, Vickers RJ, Riley TV. Evaluation of the antimicrobial activity of ridinilazole and six comparators against Chinese, Japanese and South Korean strains of Clostridioides difficile. J Antimicrob Chemother 2021; 76:967-972. [PMID: 33351917 PMCID: PMC7953319 DOI: 10.1093/jac/dkaa522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/20/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Clostridioides difficile is the most common cause of antimicrobial-associated diarrhoea in high-income countries. Fluoroquinolone resistance enabled the emergence and intercontinental spread of the epidemic ribotype (RT) 027 strain of C. difficile in the early 2000s. Despite frequent inappropriate antimicrobial use in Asia, RT 027 is rarely isolated in the region, but the often fluoroquinolone- and clindamycin-resistant RT 017 strain predominates. OBJECTIVES This study evaluated the antimicrobial activity of ridinilazole, a novel antimicrobial agent with highly specific activity for C. difficile, against clinical strains of C. difficile from Asia. METHODS C. difficile strains from Japan (n = 64), South Korea (n = 32) and China (n = 44) were tested by the agar dilution method for susceptibility to ridinilazole, metronidazole, vancomycin, clindamycin, moxifloxacin, rifaximin and fidaxomicin. RESULTS All strains were susceptible to ridinilazole, with low MICs (0.03-0.25 mg/L). Several strains showed multiresistance profiles, particularly RT 017 (100% clindamycin resistant, 91.3% moxifloxacin resistant, 82.6% rifaximin resistant) and RT 369 (94.4% clindamycin resistant, 100% moxifloxacin resistant). Rifaximin resistance was absent in all strains from Japan. Multiresistance to clindamycin, moxifloxacin and rifaximin was found in 19 RT 017 strains (from China and South Korea), 2 RT 001 strains (South Korea) and 1 RT 046 strain (South Korea). CONCLUSIONS Ridinilazole showed potent activity against a range of Asian C. difficile strains, which otherwise frequently displayed resistance to several comparator antimicrobial agents. Ongoing surveillance of antimicrobial resistance profiles is required to monitor and control the spread of resistant strains.
Collapse
Affiliation(s)
- Deirdre A Collins
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia
| | - Yuan Wu
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Kazuhiro Tateda
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo, Japan
| | - Hee-Jung Kim
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Thomas V Riley
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia
- Department of Microbiology, PathWest Laboratory Medicine, Nedlands, Western Australia
| |
Collapse
|
38
|
Yaghoubi S, Zekiy AO, Krutova M, Gholami M, Kouhsari E, Sholeh M, Ghafouri Z, Maleki F. Tigecycline antibacterial activity, clinical effectiveness, and mechanisms and epidemiology of resistance: narrative review. Eur J Clin Microbiol Infect Dis 2021; 41:1003-1022. [PMID: 33403565 PMCID: PMC7785128 DOI: 10.1007/s10096-020-04121-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/02/2020] [Indexed: 12/14/2022]
Abstract
Tigecycline is unique glycylcycline class of semisynthetic antimicrobial agents developed for the treatment of polymicrobial infections caused by multidrug-resistant Gram-positive and Gram-negative pathogens. Tigecycline evades the main tetracycline resistance genetic mechanisms, such as tetracycline-specific efflux pump acquisition and ribosomal protection, via the addition of a glycyclamide moiety to the 9-position of minocycline. The use of the parenteral form of tigecycline is approved for complicated skin and skin structure infections (excluding diabetes foot infection), complicated intra-abdominal infections, and community-acquired bacterial pneumonia in adults. New evidence also suggests the effectiveness of tigecycline for the treatment of severe Clostridioides difficile infections. Tigecycline showed in vitro susceptibility to Coxiella spp., Rickettsia spp., and multidrug-resistant Neisseria gonnorrhoeae strains which indicate the possible use of tigecycline in the treatment of infections caused by these pathogens. Except for intrinsic, or often reported resistance in some Gram-negatives, tigecycline is effective against a wide range of multidrug-resistant nosocomial pathogens. Herein, we summarize the currently available data on tigecycline pharmacokinetics and pharmacodynamics, its mechanism of action, the epidemiology of tigecycline resistance, and its clinical effectiveness.
Collapse
Affiliation(s)
- Sajad Yaghoubi
- Department of Clinical Microbiology, Iranshahr University of Medical Sciences, Iranshahr, Iran
| | - Angelina Olegovna Zekiy
- Department of Prosthetic Dentistry, Sechenov First Moscow State Medical University, Russian Federation, Trubetskaya st., 8-2, 119991, Moscow, Russia
| | - Marcela Krutova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Mehrdad Gholami
- Department of Microbiology and Virology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ebrahim Kouhsari
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, P.O. Box 6939177143, Gorgan- Sari Road, Golestan Province, Gorgan, Iran. .,Department of Laboratory Sciences, Faculty of Paramedicine, Golestan University of Medical Sciences, P.O. Box 6939177143, Gorgan- Sari Road, Golestan Province, Gorgan, Iran.
| | - Mohammad Sholeh
- Department of Microbiology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Ghafouri
- Department of Biochemistry, Biophysics and Genetics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Farajolah Maleki
- Department of Laboratory Sciences, School of Allied Medical Sciences, Ilam University of Medical sciences, Ilam, Iran.
| |
Collapse
|
39
|
Buckley AM, Moura IB, Wilcox MH. Is there a causal relationship between trehalose consumption and Clostridioides difficile infection? Curr Opin Gastroenterol 2021; 37:9-14. [PMID: 33105252 DOI: 10.1097/mog.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Trehalose metabolism appears to play a role in the pathogenicity of some microbes. It has been claimed that trehalose consumption may be a risk factor for Clostridioides difficile infection (CDI), but the evidence for a causal link is contentious. RECENT FINDINGS Epidemic ribotypes of C. difficile harbour mutations or have acquired extra genes that mean these strains can utilize lower concentrations of bioavailable trehalose, providing a competitive metabolic advantage in some CDI animal models. By contrast, evidence has emerged to show that trehalose-induced microbiota changes can help protect/reduce CDI in other models. In addition, C. difficile trehalose metabolic variants are widespread among epidemic and nonepidemic ribotypes alike, and the occurrence of these trehalose variants was not associated with increase disease severity or mortality. SUMMARY Currently, there is no proven causal association between the incidence or severity of human CDI and the presence of trehalose metabolism variants. Furthermore, microbial metabolism reduces trehalose bioavailability, potentially removing this competitive advantage for C. difficile trehalose metabolism variants. Taken together, trehalose consumed as part of a normal diet has no increased risk of CDI.
Collapse
Affiliation(s)
- Anthony M Buckley
- Healthcare-Associated Infections Group, Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds
| | - Ines B Moura
- Healthcare-Associated Infections Group, Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds
| | - Mark H Wilcox
- Healthcare-Associated Infections Group, Leeds Institute of Medical Research, Faculty of Medicine and Health, University of Leeds
- Department of Microbiology, Leeds Teaching Hospital NHS Trust, Old Medical School, Leeds General Infirmary, Leeds, UK
| |
Collapse
|
40
|
Aguilar-Zamora E, Weimer BC, Torres RC, Gómez-Delgado A, Ortiz-Olvera N, Aparicio-Ozores G, Barbero-Becerra VJ, Torres J, Camorlinga-Ponce M. Molecular Epidemiology and Antimicrobial Resistance of Clostridioides difficile in Hospitalized Patients From Mexico. Front Microbiol 2021; 12:787451. [PMID: 35360652 PMCID: PMC8960119 DOI: 10.3389/fmicb.2021.787451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/29/2021] [Indexed: 01/05/2023] Open
Abstract
Clostridioides difficile is a global public health problem, which is a primary cause of antibiotic-associated diarrhea in humans. The emergence of hypervirulent and antibiotic-resistant strains is associated with the increased incidence and severity of the disease. There are limited studies on genomic characterization of C. difficile in Latin America. We aimed to learn about the molecular epidemiology and antimicrobial resistance in C. difficile strains from adults and children in hospitals of México. We studied 94 C. difficile isolates from seven hospitals in Mexico City from 2014 to 2018. Whole-genome sequencing (WGS) was used to determine the genotype and examine the toxigenic profiles. Susceptibility to antibiotics was determined by E-test. Multilocus sequence typing (MLST) was used to determine allelic profiles. Results identified 20 different sequence types (ST) in the 94 isolates, mostly clade 2 and clade 1. ST1 was predominant in isolates from adult and children. Toxigenic strains comprised 87.2% of the isolates that were combinations of tcdAB and cdtAB (tcdA+/tcdB+/cdtA+/cdtB+, followed by tcdA+/tcdB+/cdtA-/cdtB-, tcdA-/tcdB+/cdtA-/ cdtB-, and tcdA-/tcdB-/cdtA+/cdtB+). Toxin profiles were more diverse in isolates from children. All 94 isolates were susceptible to metronidazole and vancomycin, whereas a considerable number of isolates were resistant to clindamycin, fluroquinolones, rifampicin, meropenem, and linezolid. Multidrug-resistant isolates (≥3 antibiotics) comprised 65% of the isolates. The correlation between resistant genotypes and phenotypes was evaluated by the kappa test. Mutations in rpoB and rpoC showed moderate concordance with resistance to rifampicin and mutations in fusA substantial concordance with fusidic acid resistance. cfrE, a gene recently described in one Mexican isolate, was present in 65% of strains linezolid resistant, all ST1 organisms. WGS is a powerful tool to genotype and characterize virulence and antibiotic susceptibility patterns.
Collapse
Affiliation(s)
- Emmanuel Aguilar-Zamora
- Unidad de Investigación Medica en Enfermedades Infecciosas y Parasitarias, UMAE Pediatría, CMN Siglo XXI, IMSS, México City, Mexico
- Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, México City, Mexico
| | - Bart C. Weimer
- Department of Population Health and Reproduction, School of Veterinary Medicine, 100K Pathogen Genome Project, University of California, Davis, Davis, CA, United States
| | - Roberto C. Torres
- Unidad de Investigación Medica en Enfermedades Infecciosas y Parasitarias, UMAE Pediatría, CMN Siglo XXI, IMSS, México City, Mexico
| | - Alejandro Gómez-Delgado
- Unidad de Investigación Medica en Enfermedades Infecciosas y Parasitarias, UMAE Pediatría, CMN Siglo XXI, IMSS, México City, Mexico
| | - Nayeli Ortiz-Olvera
- Departamento de Gastroenterología, UMAE Hospital de Especialidades, Instituto Mexicano del Seguro Social, México City, Mexico
| | - Gerardo Aparicio-Ozores
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, México City, Mexico
| | | | - Javier Torres
- Unidad de Investigación Medica en Enfermedades Infecciosas y Parasitarias, UMAE Pediatría, CMN Siglo XXI, IMSS, México City, Mexico
- *Correspondence: Javier Torres,
| | - Margarita Camorlinga-Ponce
- Unidad de Investigación Medica en Enfermedades Infecciosas y Parasitarias, UMAE Pediatría, CMN Siglo XXI, IMSS, México City, Mexico
- Margarita Camorlinga-Ponce,
| |
Collapse
|
41
|
Optimization of an Assay To Determine Colonization Resistance to Clostridioides difficile in Fecal Samples from Healthy Subjects and Those Treated with Antibiotics. Antimicrob Agents Chemother 2020; 65:AAC.01401-20. [PMID: 33139292 DOI: 10.1128/aac.01401-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/21/2020] [Indexed: 01/05/2023] Open
Abstract
A healthy, intact gut microbiota is often resistant to colonization by gastrointestinal pathogens. During periods of dysbiosis, however, organisms such as Clostridioides difficile can thrive. We describe an optimized in vitro colonization resistance assay for C. difficile in stool (CRACS) and demonstrate the utility of this assay by assessing changes in colonization resistance following antibiotic exposure. Fecal samples were obtained from healthy volunteers (n = 6) and from healthy subjects receiving 5 days of moxifloxacin (n = 11) or no antibiotics (n = 10). Samples were separated and either not manipulated (raw) or sterilized (autoclaved or filtered) prior to inoculation with C. difficile ribotype 027 spores and anaerobic incubation for 72 h. Different methods of storing fecal samples were also investigated in order to optimize the CRACS. In healthy, raw fecal samples, incubation with spores did not lead to increased C. difficile total viable counts (TVCs) or cytotoxin detection. In contrast, increased C. difficile TVCs and cytotoxin detection occurred in sterilized healthy fecal samples or those from antibiotic-treated individuals. The CRACS was functional with fecal samples stored at either 4°C or -80°C but not with those stored with glycerol (12% or 30% [vol/vol]). Our data show that the CRACS successfully models in vitro the loss of colonization resistance and subsequent C. difficile proliferation and toxin production. The CRACS could be used as a proxy for C. difficile infection in clinical studies or to determine if an individual is at risk of developing C. difficile infection or other potential infections occurring due to a loss of colonization resistance.
Collapse
|
42
|
Korać M, Rupnik M, Nikolić N, Jovanović M, Tošić T, Malinić J, Mitrović N, Marković M, Vujović A, Peruničić S, Bojović K, Djordjević V, Barać A, Milošević I. Clostridioides difficile ribotype distribution in a large teaching hospital in Serbia. Gut Pathog 2020; 12:26. [PMID: 32477428 PMCID: PMC7243319 DOI: 10.1186/s13099-020-00364-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/16/2020] [Indexed: 12/11/2022] Open
Abstract
Background The global epidemic of nosocomial diarrhea caused by Clostridioides (Clostridium) difficile started in 2000, with high mortality rates and emergence of a new hypervirulent strain NAP1/BI/027. The aim of this study was to assess the presence of ribotype 027 and other C. difficile ribotypes in a Serbian University Hospital, compare the temporal variability of ribotypes 3 years apart, as well as to compare clinical, demographic and laboratory characteristics and disease outcome among patients infected with 027 and non-027 ribotype. This was a prospective observational cohort study addressing 4-month intervals during 2014/2015 and 2017/2018. Results Ribotyping was performed in 64 non-duplicate C. difficile strains. Ribotype 027 was the most prevalent, and was detected in 53 (82.8%) patients (43/45 and 10/19 patients in 2014-2015 and 2017/2018, respectively). Other detected ribotypes were 001/072 in 4 (6.3%), 002 in 4 (6.3%), 014/020 in 2 (3.1%) and 176 in 1 (1.5%) patient. The percentage of the patients infected with ribotype 027 significantly decreased during the 3-year period, from 95.6 to 52.6% (p < 0.001). Ribotype 027 infection was associated with fluoroquinolone treatment more frequently than infection with other ribotypes [33 (62.3%) vs. 2 (18.2%), p = 0.010)]. A severe C. difficile infection was diagnosed more often in patients with the detected ribotype 027 compared to those infected with non-027 ribotypes (p = 0.006). No significant difference in the mortality and recurrence rates was found between the patients infected with ribotype 027 and those infected with other ribotypes [10/53 (18.8%) vs. 2/11 (18.2%), p = 0.708, and 10/35 (28.6%) vs. 0/2 (0%), p = 1.000, respectively]. Conclusion Clostridium difficile ribotype 027 was the most prevalent ribotype among patients in a large Serbian hospital, but there is a clear decreasing trend.
Collapse
Affiliation(s)
- Miloš Korać
- 1University of Belgrade, Faculty of Medicine, Dr Subotića 8, 11000 Belgrade, Serbia.,2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| | - Maja Rupnik
- 4Department for Microbiological Research, Centre for Medical Microbiology, National Laboratory for Health, Environment and Food, Prvomajska 1, 2000 Maribor, Slovenia.,5University of Maribor, Faculty of Medicine, Taborska 8, 2000 Maribor, Slovenia
| | - Nataša Nikolić
- 1University of Belgrade, Faculty of Medicine, Dr Subotića 8, 11000 Belgrade, Serbia.,2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| | - Milica Jovanović
- 3Microbiology Department, Clinical Centre of Serbia, Pasterova 4, Belgrade, Serbia
| | - Tanja Tošić
- 3Microbiology Department, Clinical Centre of Serbia, Pasterova 4, Belgrade, Serbia
| | - Jovan Malinić
- 1University of Belgrade, Faculty of Medicine, Dr Subotića 8, 11000 Belgrade, Serbia.,2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| | - Nikola Mitrović
- 1University of Belgrade, Faculty of Medicine, Dr Subotića 8, 11000 Belgrade, Serbia.,2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| | - Marko Marković
- 2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| | - Ankica Vujović
- 1University of Belgrade, Faculty of Medicine, Dr Subotića 8, 11000 Belgrade, Serbia.,2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| | - Sanja Peruničić
- 2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| | - Ksenija Bojović
- 1University of Belgrade, Faculty of Medicine, Dr Subotića 8, 11000 Belgrade, Serbia.,2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| | - Vladimir Djordjević
- 1University of Belgrade, Faculty of Medicine, Dr Subotića 8, 11000 Belgrade, Serbia.,6Clinic for Digestive Surgery, Clinical Centre of Serbia, Dr Koste Todorovića 6, 11000 Belgrade, Serbia
| | - Aleksandra Barać
- 1University of Belgrade, Faculty of Medicine, Dr Subotića 8, 11000 Belgrade, Serbia.,2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| | - Ivana Milošević
- 1University of Belgrade, Faculty of Medicine, Dr Subotića 8, 11000 Belgrade, Serbia.,2University Hospital for Infectious and Tropical Diseases, Clinical Centre of Serbia, Bulevar oslobođenja 16, 11000 Belgrade, Serbia
| |
Collapse
|