Clinical and molecular characteristics of community-acquired Clostridium difficile infections in comparison with those of hospital-acquired C. difficile

Clinical characteristics of community-onset Clostridioides difficile infections at a tertiary hospital in mainland China: A fourteen-year (2010-2023) retrospective study

BACKGROUND

Clostridioides difficile infection (CDI) is an increasingly common disease in healthcare facilities and community settings. However, there are limited reports of community-onset CDI (CO-CDI) in China.

METHODS

We collected diarrheal stool samples from 3885 patients who went to outpatient department or emergency department in a tertiary hospital in China during 2010-2023, analyzed the correlation between patients' basic information and the detection rate of CDI. Besides, all stool samples from 3885 outpatients included were tested by culturing. Moreover, we randomly selected 89 patients' stools during the 14 years and isolated 126 C. difficile strains from them. The presence of toxin genes (tcdA, tcdB, cdtA, and cdtB) were confirmed by PCR. Toxigenic strains were typed using multilocus sequence typing (MLST). Susceptibility to 9 antimicrobials was evaluated using the E-test.

RESULTS

528 of 3885 patients (13.6 %) with diarrhea were finally diagnosed as CDI. The median age of patients included was 51 years (6 months-95 years), while the median of patients with CDI was older than patients with negative results [55.5 years (6 months-93 years) vs. 50 years (9 months -95 years), p < 0.001]. In winter, patients with diarrhea might be more likely to have CDI. The detection rate of CDI of patients in emergency department was much higher than those in other outpatients (20.7 % vs. 12.4 %, p < 0.001), and did differ from each outpatient departments (p < 0.05). There were 95 isolated strains detected as toxigenic C. difficile. Among these strains, 82 (86.3 %) had the tcdA and tcdB genes (A+B+) and 5 of these 82 strains were positive for the binary toxin genes (cdtA and cdtB) (A+B+CDT+). There were 15 different sequence types (STs) by multilocus sequence typing (MLST), while the most ST was ST-54 (23.2 %). ST types composition was relatively stable over the time span of this study. Some strains had high resistance to ciprofloxacin, clindamycin, and erythromycin. Twenty-three isolates (24.2 %) were multidrug-resistant.

CONCLUSIONS

Outpatients with CDI were common among patients having diarrhea during this period in our hospital. Elderly patients and patients went to emergency department may be susceptible to CDI. Based on MLST, the result revealed that the C. difficile isolates had high genetic diversity and maintained stability in this period. All isolates were susceptible to metronidazole and vancomycin, and nearly one quarter of all isolates had multidrug resistance.

Antibiotic-Specific Risk for Community-Acquired Clostridioides difficile Infection in the United States from 2008 to 2020

Antibiotic exposure is a crucial risk factor for community-acquired Clostridioides difficile infection (CA-CDI). However, the relative risks associated with specific antibiotics may vary over time, and the absolute risks have not been clearly established. This is a retrospective cohort study. Adults were included if they received an outpatient antibiotic prescription within the IBM MarketScan databases between 2008 and 2020. The primary exposure was an outpatient antibiotic prescription, and the receipt of doxycycline was used as the reference comparison. The primary outcome was CA-CDI, defined as the presence of an International Classification of Diseases (ICD) diagnosis code for CDI within 90 days of receiving an outpatient antibiotic prescription, and subsequent treatment for CDI. There were 36,626,794 unique patients who received outpatient antibiotics, including 11,607 (0.03%) who developed CA-CDI. Relative to doxycycline, the antibiotics conferring the highest risks for CA-CDI were clindamycin (adjusted odds ratio [aOR], 8.81; 95% confidence interval [CI], 7.76 to 10.00), cefdinir (aOR, 5.86; 95% CI, 5.03 to 6.83), cefuroxime (aOR, 4.57; 95% CI, 3.87 to 5.39), and fluoroquinolones (aOR, 4.05; 95% CI, 3.58 to 4.59). Among older patients with CA-CDI risk factors, nitrofurantoin was also associated with CA-CDI (aOR, 3.05; 95% CI, 1.92 to 4.84), with a smaller number needed to harm, compared to the fluoroquinolones. While clindamycin, cefuroxime, and fluoroquinolone use declined from 2008 to 2020, nitrofurantoin use increased by 40%. Clindamycin was associated with the greatest CA-CDI risk, overall. Among older patients with an elevated baseline risk for CA-CDI, multiple antibiotics, including nitrofurantoin, had strong associations with CA-CDI. These results may guide antibiotic selection and future stewardship efforts.

Characteristics and management of children with Clostridioides difficile infection at a tertiary pediatric hospital in China

Background

Clostridiodes difficile infection (CDI) is one of the most common causes of antibiotic-associated diarrhea in children. Conventional antibiotics and emerging fecal microbiota transplantation (FMT) are used to treat CDI.

Methods

Children with CDI admitted to the Shanghai Children's Hospital, from September 2014 to September 2020, were retrospectively included to this observational study. Pediatric patients were assigned as initial CDI and recurrent CDI (RCDI), and symptoms, comorbidities, imaging findings, laboratory tests, and treatments were systematically recorded and analyzed.

Results

Of 109 pediatric patients with CDI, 58 were boys (53.2%), and the median age was 5 years (range, 2-9 years). The main clinical symptoms of CDI children were diarrhea (109/109, 100%), hematochezia (55/109, 50.46%), abdominal pain (40/109, 36.70%); fever, pseudomembrane, vomit, and bloating were observed in 39 (35.78%), 33 (30.28%), and 24 (22.02%) patients, respectively. For the primary therapy with conventional antibiotics, 68 patients received metronidazole, and 41 patients received vancomycin. RCDI occurred in 48.53% (33/68) of those initially treated with metronidazole compared with 46.33% (19/41) of those initially treated with vancomycin (p=0.825). The total resolution rate of FMT for RCDI children was significantly higher than with vancomycin treatment (28/29, 96.55% vs 11/23, 47.83%, p < 0.001). There were no serious adverse events (SAEs) reported after two months of FMT.

Conclusions

The major manifestations of children with CDI were diarrhea, hematochezia, and abdominal pain. The cure rate of FMT for pediatric RCDI is superior to vancomycin treatment.

Characterization of Healthcare-Associated and Community-Associated Clostridioides difficile Infections among Adults, Canada, 2015-2019

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.

Clostridioides difficile epidemiology in the Middle and the Far East

OBJECTIVES

Clostridioides difficile is an important pathogen of healthcare-associated gastrointestinal infections. Recently, an increased number of C. difficile infection (CDI) surveillance data has been reported from Asia. The aim of this review is to summarize the data on the prevalence, distribution and molecular epidemiology of CDI in the Middle and the Far East.

METHODS

Literature was drawn from a search of PubMed up to September 30, 2021.

RESULTS

The meta-analysis of data from 111 studies revealed the pooled CDI prevalence rate in the Middle and the Far East of 12.4% (95% CI 11.4-13.3); 48 studies used PCR for CDI laboratory diagnoses. The predominant types (RT)/sequence type (ST) differ between individual countries (24 studies, 14 countries). Frequently found RTs were 001, 002, 012, 017, 018 and 126; RT017 was predominant in the Far East. The epidemic RT027 was detected in 8 countries (22 studies), but its predominance was reported only in three studies (Israel and Iran). The contamination of vegetable and meat or meat products and/or intestinal carriage of C. difficile in food and companion animals have been reported; the C. difficile RTs/STs identified overlapped with those identified in humans.

CONCLUSIONS

A large number of studies on CDI prevalence in humans from the Middle and the Far East have been published; countries with no available data were identified. The number of studies on C. difficile from non-human sources is limited. Comparative genomic studies of isolates from different sources are needed.

Molecular epidemiology and clinical risk factors for rifaximin-non-susceptible Clostridioides difficile infection in South Korea: a prospective, multicentre, observational study

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.

Comparing the epidemiology of community- and hospital-associated Clostridium difficile infections in Northern Ireland, 2012-2016: a population data linkage and case-case study

The burden of community-associated Clostridium difficile infection (CA-CDI) has increased. We aimed to describe the epidemiology of CA-CDI to inform future interventions. We used population-based linked surveillance data from 2012 to 2016 to describe socio-demographic factors, ribotype and mortality for all CA (n = 1303) and hospital-associated (HA, n = 1356) CDI. For 483 community-onset (CO) CA-CDI and 287 COHA-CDI cases, a questionnaire on risk factors was completed and we conducted a case-case study using logistic regression models for univariate and multivariable analysis. CA-CDI cases had lower odds of being male (adjusted odds ratio (AOR) 0.71, 95% confidence interval (CI) 0.58-0.87; P &lt; 0.001), and higher odds of living in rural rather than urban settlement (AOR 1.5, 95% CI 1.1-2.1; P = 0.05) compared with HA-CDI cases. The distribution of ribotypes was similar in both groups with RT078 being most prevalent. CDI-specific death was lower in CA-CDI than HA-CDI (7% vs. 11%, P &lt; 0.001). COCA-CDI had lower odds of having had an outpatient appointment in the previous 4 weeks compared with COHA-CDI (AOR 0.61; 95% CI 0.41-0.9, P = 0.01) and lower odds of being in a care home or hospice when compared with their own home, than COHA-CDI (AOR 0.66; 95% CI 0.45-0.98 and AOR 0.35; 95% CI 0.13-0.92, P = 0.02). Exposure to gastric acid suppressants (50% in COCA-CDI and 55% in COHA-CDI) and antimicrobial therapy (18% in COCA-CDI and 20% in COHA-CDI) prior to CDI was similar. Our analysis of community-onset cases suggests that other risk factors for COHA-CDI may be equally important for COCA-CDI. Opportunities to safely reduce antibiotic and gastric acid suppressants use should be investigated in all healthcare settings.

Clostridium difficile Infection: An Epidemiology Update

Clostridium (reclassified as " Clostridioides ") difficile infection (CDI) is a healthcare-associated infection and significant source of potentially preventable morbidity, recurrence, and death, particularly among hospitalized older adults. Additional risk factors include antibiotic use and severe underlying illness. The increasing prevalence of community-associated CDI is gaining recognition as a novel source of morbidity in previously healthy patients. Even after recovery from initial infection, patients remain at risk for recurrence or reinfection with a new strain. Some pharmaco-epidemiologic studies have suggested an increased risk associated with proton pump inhibitors and protective effect from statins, but these findings have not been uniformly reproduced in all studies. Certain ribotypes of C. difficile , including the BI/NAP1/027, 106, and 018, are associated with increased antibiotic resistance and potential for higher morbidity and mortality. CDI remains a high-morbidity healthcare-associated infection, and better understanding of ribotypes and medication risk factors could help to target treatment, particularly for patients with high recurrence risk.

Clostridioides difficile uses amino acids associated with gut microbial dysbiosis in a subset of patients with diarrhea

The gut microbiota plays a critical role in pathogen defense. Studies using antibiotic-treated mice reveal mechanisms that increase susceptibility to Clostridioides difficile infection (CDI), but risk factors associated with CDI in humans extend beyond antibiotic use. Here, we studied the dysbiotic gut microbiota of a subset of patients with diarrhea and modeled the gut microbiota of these patients by fecal transplantation into germ-free mice. When challenged with C. difficile, the germ-free mice transplanted with fecal samples from patients with dysbiotic microbial communities showed increased gut amino acid concentrations and greater susceptibility to CDI. A C. difficile mutant that was unable to use proline as an energy source was unable to robustly infect germ-free mice transplanted with a dysbiotic or healthy human gut microbiota. Prophylactic dietary intervention using a low-proline or low-protein diet in germ-free mice colonized by a dysbiotic human gut microbiota resulted in decreased expansion of wild-type C. difficile after challenge, suggesting that amino acid availability might be important for CDI. Furthermore, a prophylactic fecal microbiota transplant in mice with dysbiosis reduced proline availability and protected the mice from CDI. Last, we identified clinical risk factors that could potentially predict gut microbial dysbiosis and thus greater susceptibility to CDI in a retrospective cohort of patients with diarrhea. Identifying at-risk individuals and reducing their susceptibility to CDI through gut microbiota-targeted therapies could be a new approach to preventing C. difficile infection in susceptible patients.

Clostridioides difficile uses amino acids associated with gut microbial dysbiosis in a subset of patients with diarrhea

The gut microbiota plays a critical role in pathogen defense. Studies using antibiotic-treated mice reveal mechanisms that increase susceptibility to Clostridioides difficile infection (CDI), but risk factors associated with CDI in humans extend beyond antibiotic use. Here, we studied the dysbiotic gut microbiota of a subset of patients with diarrhea and modeled the gut microbiota of these patients by fecal transplantation into germ-free mice. When challenged with C. difficile, the germ-free mice transplanted with fecal samples from patients with dysbiotic microbial communities showed increased gut amino acid concentrations and greater susceptibility to CDI. A C. difficile mutant that was unable to use proline as an energy source was unable to robustly infect germ-free mice transplanted with a dysbiotic or healthy human gut microbiota. Prophylactic dietary intervention using a low-proline or low-protein diet in germ-free mice colonized by a dysbiotic human gut microbiota resulted in decreased expansion of wild-type C. difficile after challenge, suggesting that amino acid availability might be important for CDI. Furthermore, a prophylactic fecal microbiota transplant in mice with dysbiosis reduced proline availability and protected the mice from CDI. Last, we identified clinical risk factors that could potentially predict gut microbial dysbiosis and thus greater susceptibility to CDI in a retrospective cohort of patients with diarrhea. Identifying at-risk individuals and reducing their susceptibility to CDI through gut microbiota-targeted therapies could be a new approach to preventing C. difficile infection in susceptible patients.

Characteristics of Faecal Microbiota in Korean Patients with Clostridioides difficile-associated Diarrhea

Background

The intestinal microbiota plays an important role in the pathogenesis of Clostridioides difficile-associated diarrhea, and regional and racial characteristics influence the microbiome composition and diversity. We investigated the intestinal microbiome characteristics of patients with C. difficile colitis (CD+) compared to those of patients with colitis not due to C. difficile (CD−), patients with vancomycin-resistant enterococci (VRE) colonization, and healthy controls, in Korea.

Materials and Methods

We collected stool samples from 24, 18, 11 and 13 subjects within CD+, CD−, VRE and healthy control groups, respectively. The microbial communities were evaluated by 454-pyrosequencing of bacterial 16s rRNA.

Results

The species richness and microbial diversity were significantly lower in the CD+ group compared to those in healthy controls, but not compared to those in CD− and VRE groups. Phylum-level analysis showed that the proportion of Actinobacteria in the CD+ group was significantly lower than in the healthy control, but was unchanged compared to that in CD− and VRE groups. At the genus level, compared to the healthy group, the CD+ group showed significantly lower proportions of Blautia, Bifidobacterium, Faecalibacterium et al. Compared to the VRE group, the CD+ group showed a significantly higher proportion of Anaerostipes.

Conclusions

We could identify the intestinal microbiome characteristics of Koreans with C. difficile colitis. It might help to develop microbiome based diagnostic and treatment modalities.

Increasing prevalence of the epidemic ribotype 106 in healthcare facility-associated and community-associated Clostridioides difficile infection

Clostridioides difficile is the leading cause of nosocomial diarrhea and antibiotics associated diarrhea, but it is also an increasingly common cause of community diarrhea. In recent years we have observed a progressive increase in the incidence of C. difficile infection (CDI) both at the hospital and community setting that could be explained by the dynamic epidemiology of C. difficile. The present study analyzes changes in the epidemiology of CDI for two years comparing healthcare facility-associated (HCFA) and community-associated (CA) CDI epidemiology, observed in a single laboratory setting. All new episodes of CDI diagnosed during the years 2015-2016 were included in the study and classified as HFCA-, CA- or indeterminate CDI. Isolates were characterized by ribotyping and antimicrobial susceptibility was also determined. A total of 272 primary episodes of different patients were included in the study and classified 55.5% as CA-, 32% as HO-HCFA, 6.25% as CO-HCFA and 6.25% as indeterminate CDI. Overall, ribotype 106 was the most prevalent and also, many patients who suffered recurrent episodes were associated with this ribotype (29%). In fact, ribotype 106 showed a significantly higher recurrence rate than other ribotypes (26% vs 11%, p = 0.03). Moreover, 46% of the moxifloxacin resistant isolates were ribotype 106. No significant differences of antimicrobial resistance were observed between HCFA- and CA-CDI isolates, although fluoroquinolone resistance rates were slightly higher in HCFA-CDI isolates (25% vs 18.5%), and fluoroquinolone resistant ribotypes 106 and 126 were more frequently associated to CA-CDI and ribotype 078 to HCFA-CDI. The increasing incidence of CDI in our health care area is partially explained by the growing prevalence of the epidemic ribotype 106, both in HFCA- and CA-CDI, probably favored by the higher resistance and recurrence rate associated to ribotype 106 isolates.