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Tsai BY, Tsai PJ, Lee CC, Chiu CW, Lai YH, Lee JC, Ko WC, Hung YP. Association of Single Nucleotide Polymorphisms in Nucleotide-Binding Domain Leucine-Rich Repeat Protein 1 with Clostridioides difficile Colonization or Infection. Infect Drug Resist 2023; 16:413-421. [PMID: 36718463 PMCID: PMC9883994 DOI: 10.2147/idr.s392510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/14/2023] [Indexed: 01/25/2023] Open
Abstract
Introduction Nucleotide-binding domain leucine-rich repeat protein (NLRP) is critical in the inflammasome-activation pathway, which is important for host survival and the clearance of Clostridioides difficile. Therefore, the influence of NLRP1 polymorphisms on C. difficile colonization (CdC) or infection (CDI) was analyzed. Materials and Methods A prospective cohort study consisted of hospitalized adults was conducted from January 2011 to January 2013. Single nucleotide polymorphisms (SNPs) of NLRP1, including rs12150220, rs2670660, rs6502867, rs878329, rs8182352, rs3744717, and rs11078571, were incorporating in analyses. The episodes of CdC and CDI were the primary and secondary outcome, respectively. Results Of the total of 509 eligible patients, 376 (73.9%) had neither CdC nor CDI, 104 (21.8%) had CdC without developing CDI, and 29 (4.3%) developed CDI during the study period. Through multivariate analyses, comorbid diabetes mellitus (adjusted odds ratio [AOR] 1.59, P=0.04) and CC genotype in NLRP1 rs3744717 (AOR 1.70, P=0.02) were recognized as the risk factor of CdC. After adjusting the independent predictors of CDI, in terms of comorbid diabetes mellitus (AOR 3.18, P=0.005) and prior exposure to ceftazidime/ceftriaxone (AOR 2.87, P=0.04) or proton pump inhibitors (AOR 3.86, P=0.001), patients with CC+GC genotype in NLRP1, rs878329 (AOR 2.39, P=0.03) remained a higher risk of CDI. Conclusion For hospitalized adults, the association of CC genotype in NLRP1 rs3744717 and CdC as well as the CC+GC genotype in NLRP1 rs878329 and CDI was respectively evidenced. We believed the prompt identification of patients having specific genotype in NLRP1 would prevent and improve the quality of care in CDI.
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Affiliation(s)
- Bo-Yang Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Jane Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Centers of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Chi Lee
- Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Wei Chiu
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Yi-Hsin Lai
- Centers of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Department of Microbiology & Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Correspondence: Yuan-Pin Hung; Wen-Chien Ko, Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan, Email ;
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Lee CC, Chiu CW, Lee JC, Tsai PJ, Ko WC, Hung YP. Risk Factors and Clinical Impact of Carbapenem-Resistant Enterobacterales Coinfections Among Hospitalized Patients with Clostridioides difficile Infection. Infect Drug Resist 2022; 15:6287-6295. [PMID: 36337933 PMCID: PMC9635385 DOI: 10.2147/idr.s386309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The risk factors and clinical impact of carbapenem-resistant Enterobacterales (CRE) coinfection among hospitalized patients with Clostridioides difficile infection (CDI) were analyzed in this study. Materials and Methods A clinical study was performed at the medical wards of Tainan Hospital, Ministry of Health and Welfare in southern Taiwan. Patients with CDI between January 2013 and April 2020 were included. Results Among 238 patients included for analysis, 22 (9.2%) patients developed CRE coinfections within 14 days before or after the onset of CDI. CDI patients with CRE coinfection had longer hospitalization stays (103.0 ± 97.0 days vs 42.5 ± 109.6 days, P = 0.01) than those without CRE coinfection. In the multivariate analysis, age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.01–1.10, P = 0.02) was independently associated with CRE coinfection. In contrast, underlying old stroke (OR 0.15, 95% CI 0.03–0.70, P = 0.02) was negatively linked to CRE coinfection. Conclusion Among patients with CDI, CRE coinfections were associated with prolonged hospitalization for CDI. Age was an independent risk factor for CRE coinfection among patients with CDI.
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Affiliation(s)
- Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan,Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, 711, Taiwan,Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
| | - Chun-Wei Chiu
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, College of Medicine, Tainan, 704, Taiwan,Department of Pathology, National Cheng Kung University Hospital, Tainan, Taiwan,Centers of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan,Wen-Chien Ko, Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, Email
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan,Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan,Department of Microbiology & Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Correspondence: Yuan-Pin Hung, Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan, Email
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Tsai BY, Chien CC, Huang SH, Zheng JY, Hsu CY, Tsai YS, Hung YP, Ko WC, Tsai PJ. The emergence of Clostridioides difficile PCR ribotype 127 at a hospital in northeastern Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:896-909. [PMID: 35042668 DOI: 10.1016/j.jmii.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/27/2021] [Accepted: 12/25/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Several studies have highlighted the incidence of Clostridioides difficile infections (CDIs) in Taiwan and certain ribotypes have been related to severe clinical diseases. A study was conducted to investigate the polymerase chain reaction (PCR) ribotypes and genetic relatedness of clinical C. difficile strains collected from January 2009 to December 2015 at a hospital in northeastern Taiwan. MATERIAL AND METHODS A modified two-step typing algorithm for C. difficile was used by combining a modified 8-plex and 3'-truncated tcdA screening PCR. In addition, MLVA typing was adopted for investigation of bacterial clonality and transmission. RESULTS Among a total of 86 strains, 24 (28%) were nontoxigenic and 62 (72%) had both tcdA and tcdB (A + B+). No tcdA-negative and tcdB-positive (A-B+) strains were identified. Binary toxin (CDT)-producing (cdtA+/cdtB+) strains were started to be identified in 2013. The 21 (34%) A+B+ clinical strains with binary toxin and tcdC deletion were identified as RT127 strains, which contained both RT078-lineage markers and fluoroquinolone (FQ)-resistant mutations (Thr82Ile in gyrA). Multiple loci variable-number tandem repeat analysis (MLVA) for phylogenetic relatedness of RT127 strains indicated that 20 of 21 strains belonged to a clonal complex that was identical to a clinical strain collected from southern Taiwan in 2011, suggestive of a clonal expansion in Taiwan. CONCLUSION A two-step typing method could rapidly confirm species identification and define the toxin gene profile of C. difficile isolates. The clonal expansion of RT127 strains in Taiwan indicates monitoring and surveillance of toxigenic C. difficile isolates from human, animal, and environment are critical to develop One Health prevention strategies.
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Affiliation(s)
- Bo-Yang Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Chun-Chih Chien
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan.
| | - Shu-Huan Huang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Kee-Lung, Keelung, Taiwan.
| | - Jun-Yuan Zheng
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Kee-Lung, Kee-Lung, Taiwan.
| | - Chih-Yu Hsu
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan.
| | - Yau-Sheng Tsai
- Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Yuan-Pin Hung
- Departments of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Pei-Jane Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan; Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan; Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Lee CC, Lee JC, Chiu CW, Tsai PJ, Ko WC, Hung YP. Impacts of Corticosteroid Therapy at Acute Stage of Hospital-Onset Clostridioides difficile Infections. Infect Drug Resist 2022; 15:5387-5396. [PMID: 36119637 PMCID: PMC9473547 DOI: 10.2147/idr.s377967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/07/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The influence of corticosteroid therapy before or after the onset of Clostridioides difficile infections (CDIs) on the clinical outcomes of adults with hospital-onset CDIs was investigated. Materials and Methods A clinical study was conducted on the medical wards of a teaching hospital between January 2013 and April 2020. Adults (aged ≥ 20 years) with hospital-onset CDIs (ie, symptom onset at least 48 hours after hospitalization) were included. "Corticosteroid therapy during acute CDIs" was defined as the receipt of a corticosteroid at the prednisolone equivalent (PE) dose of ≥10 mg for at least 48 hours within one week after the CDI diagnosis. "Prior corticosteroid exposure" was defined as the receipt of a corticosteroid at the PE dose of ≥5 mg PE for at least 48 hours within one month before the CDI diagnosis. Results Of the 243 adults with hospital-onset CDIs, patients (44, 18.1%) who received corticosteroid therapy during acute CDIs were more likely to have prior corticosteroid exposure (86.4% vs 11.9%, P <0.001) and CDI episodes in intensive care units (31.8% vs 10.8%, P =0.001). Of note, a crucial association between corticosteroid therapy during acute CDIs and CDI recurrence was evidenced (13.6% vs 1.5%, P =0.002). Prior corticosteroid exposure was not associated with favorable CDI outcomes in terms of successful treatment (78.3% vs 74.9%, P =0.89), in-hospital crude mortality (17.4% vs 24.0%, P =0.61), or CDI recurrence (4.3% vs 5.3%, P = 1.00). However, for 177 patients without prior corticosteroid exposure, corticosteroid therapy during acute CDIs was linked to a higher proportion of CDI recurrence (33.3% vs 5.3%, P =0.046). Conclusion Corticosteroid therapy during acute CDIs might impact the recurrence of CDIs, particularly in those with a lack of prior corticosteroid exposure.
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Affiliation(s)
- Ching-Chi Lee
- Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
| | - Chun-Wei Chiu
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan.,Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Centers of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan.,Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan.,Department of Microbiology & Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Lee JC, Chiu CW, Tsai PJ, Lee CC, Huang IH, Ko WC, Hung YP. Clostridium butyricum therapy for mild-moderate Clostridioides difficile infection and the impact of diabetes mellitus. BIOSCIENCE OF MICROBIOTA, FOOD AND HEALTH 2022; 41:37-44. [PMID: 35433161 PMCID: PMC8970652 DOI: 10.12938/bmfh.2021-049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/19/2021] [Indexed: 01/26/2023]
Abstract
The therapeutic effect of Clostridium butyricum for adults with
Clostridioides difficile infection (CDI) was investigated. A
retrospective study was conducted in medical wards of Tainan Hospital, Ministry of Health
and Welfare, between January 2013 and April 2020. The disease severity of CDI was scored
based on the Clinical Practice Guidelines of the IDSA/SHEA. Treatment success was defined
as the resolution of diarrhea within six days of a therapeutic intervention without the
need to modify the therapeutic regimen. In total, 241 patients developed CDI during
hospitalization in the study period. The treatment success rates for the 99 patients with
mild-moderate CDI among them were as follows: metronidazole, 69.4%; C.
butyricum, 68.2%; metronidazole plus C. butyricum, 66.7%; and
oral vancomycin, 66.7% (p=1.00). Patients with treatment success were less likely to have
diabetes mellitus than those with treatment failure (38.2% vs. 61.3%, p=0.05). Patients
treated with C. butyricum alone or in combination with metronidazole had
shorter durations of diarrhea than those treated with metronidazole alone (3.1 ± 2.0 days
or 3.5 ± 2.4 days vs. 4.2 ± 3.5 days; p=0.43 or 0.71), although the differences were not
statistically significant. In conclusion, the treatment success rate of C.
butyricum alone or in combination with metronidazole for patients with CDI was
non inferior to that of metronidazole alone. The presence of diabetes mellitus in affected
individuals is a risk factor for treatment failure.
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Affiliation(s)
- Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, North Dist., Tainan 704, Taiwan
| | - Chun-Wei Chiu
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, No. 125, Jhongshan Rd., West Central Dist., Tainan 70043, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, No.1, University Road, Tainan 701, Taiwan.,Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 1, Dasyue Rd, East District, Tainan 701, Taiwan.,Center of Infectious Disease and Signaling Research, National Cheng Kung University, No.138, Sheng Li Road, North Dist., Tainan 704, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, North Dist., Tainan 704, Taiwan.,Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 1, Dasyue Rd, East District, Tainan 701, Taiwan
| | - I-Hsiu Huang
- Department of Biochemistry and Microbiology, Oklahoma State University Center for Health Sciences, 1111 W. 17th Street Tulsa, OK 74107, USA
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, North Dist., Tainan 704, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, 1 University Road, Tainan City 70101, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No.138, Sheng Li Road, North Dist., Tainan 704, Taiwan.,Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, No. 125, Jhongshan Rd., West Central Dist., Tainan 70043, Taiwan
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Lee CC, Lee JC, Chiu CW, Tsai PJ, Ko WC, Hung YP. Neutrophil Ratio of White Blood Cells as a Prognostic Predictor of Clostridioides difficile Infection. J Inflamm Res 2022; 15:1943-1951. [PMID: 35342296 PMCID: PMC8943478 DOI: 10.2147/jir.s353814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/11/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction A leukocyte count ≥15,000 cells/mL and serum creatinine of >1.5 mg/dL have been reported as two important predictors of severe CDI. However, the association of the differential ratios of blood leukocytes, and the prognosis of Clostridioides difficile infection (CDI) is not clear. Materials and Methods A clinical study was conducted at medical wards of Tainan Hospital, Ministry of Health and Welfare in southern Taiwan between January 2013 and April 2020. Hospitalized adults (aged ≥20 years) with hospital-onset CDI (ie, symptom onset after at least 48 hours of admission) were included. Results A total of 235 adults with an average age of 75.7 years and female predominance (51.5%), including 146 (62%) adults with non-severe CDI and 87 (38%) severe CDI, were included for analysis. Patients with severe CDI had a higher crude in-hospital mortality rate than patients with non-severe CDI (35.6% vs 18.5%, P = 0.005). Multivariate analysis revealed no association between a leukocyte count >15,000 cell/mL at the onset of CDI and in-hospital mortality (odds ratio [OR] 1.66, P = 0.21). In contrast, a neutrophil ratio >75% (OR 2.65, P = 0.02), serum creatinine >1.5 mg/L (OR 3.42, P = 0.03), and CDI caused by isolates harboring the tcdC gene (OR 3.54, P = 0.02) were independently associated with in-hospital mortality. Patients with a neutrophil ratio >85%, 80–85%, or 75–80% of serum leukocytes had a higher mortality rate (34.8%, 30.3%, or 34.4%, respectively) than patients with a neutrophil ratio of 70–75% or ≤75% (12.5% or 13.9%, respectively). Conclusion Serum creatinine >1.5 mg/L, a high neutrophil ratio of blood leukocytes (>75%), and the causative C. difficile harboring the tcdC gene was independent prognostic predictors in hospitalized adults with CDI.
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Affiliation(s)
- Ching-Chi Lee
- Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
| | - Chun-Wei Chiu
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Centers of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
- Wen-Chien Ko, Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan, Email
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
- Correspondence: Yuan-Pin Hung, Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, 700, Taiwan, Email
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Clinical Significance of Toxigenic Clostridioides difficile Growth in Stool Cultures during the Era of Nonculture Methods for the Diagnosis of C. difficile Infection. Microbiol Spectr 2021; 9:e0079921. [PMID: 34668727 PMCID: PMC8528117 DOI: 10.1128/spectrum.00799-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The importance of the detection of relevant toxins or toxin genes to diagnose Clostridioides difficile infection (CDI) or the prediction of clinical outcomes of CDI has been emphasized in recent years. Although stool culture of C. difficile is not routinely recommended in the era of nonculture methods as the preferred tools for CDI diagnosis, the clinical significance of toxigenic C. difficile growth (tCdG) in stool cultures was analyzed. A clinical study was conducted in medical wards of Tainan Hospital, Ministry of Health and Welfare, in southern Taiwan. Diarrheal adults with fecal glutamate dehydrogenase and C. difficile toxin between January 2013 and April 2020 were included. Of the 209 patients with CDI, 158 (75.6%) had tCdG found in stool cultures, and the rest (51, 24.4%) had no tCdG in stool. Only prior ceftazidime or ceftriaxone therapy was independently associated with no tCdG in stool (odds ratio [OR] 2.17, P = 0.02). Compared to the patients with tCDG in stool, those without tCdG in stool experienced treatment success more often (97.1% versus 67.0%, P < 0.001) if treated with metronidazole or vancomycin but had a similar in-hospital mortality or recurrence rate. In the multivariate analysis among 114 patients with CDI treated with metronidazole or vancomycin, treatment success was independently associated with no tCdG in stool (OR 12.7, P = 0.02). Despite the limited utility of stool cultures in CDI diagnoses, no tCdG in stool culture heralds a favorable therapeutic outcome among adults with CDI treated with metronidazole or vancomycin. IMPORTANCE The importance of detecting toxins or toxin genes when diagnosing Clostridioides difficile infections (CDIs) or predicting the severity and outcomes of CDI has been emphasized in recent years. Although the yielding of C. difficile from stool cultures might implicate higher bacterial loads in fecal samples, in an era of nonculture methods for the standard diagnosis of CDIs, clinical significance of positive stool cultures of toxigenic C. difficile was analyzed in this study. Despite the limited ability of stool cultures in CDI diagnoses, no yielding of C. difficile growth might predict the successful CDI therapy.
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Lai YH, Tsai BY, Hsu CY, Chen YH, Chou PH, Chen YL, Liu HC, Ko WC, Tsai PJ, Hung YP. The Role of Toll-Like Receptor-2 in Clostridioides difficile Infection: Evidence From a Mouse Model and Clinical Patients. Front Immunol 2021; 12:691039. [PMID: 34322122 PMCID: PMC8313301 DOI: 10.3389/fimmu.2021.691039] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/24/2021] [Indexed: 01/12/2023] Open
Abstract
Background Clostridioides difficile is the leading cause of nosocomial infectious diarrhea. Toll-like receptors (TLRs) are the major components of innate immunity that sense pathogens. The relationship between TLRs and C. difficile infection (CDI) was analyzed in clinical patients and a mouse model. Materials and Methods A prospective investigation was conducted in medical wards of Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan, from January 2011 to January 2013. Adult patients were followed up for the development of CDI. Single nucleotide polymorphisms (SNPs) of TLR2 and TLR4 were analyzed to assess the relationship between genetic polymorphisms and the development of CDI. A mouse model of CDI was used to investigate the pathogenic role of TLRs in CDI, TLR2 and TLR4 knockout (Tlr2-/- and Tlr4-/-) mice. Results In the prospective study, 556 patients were enrolled, and 6.5% (36) of patients, accounting for 3.59 episodes per 1000 patient-days, developed CDI. Of 539 patients with available blood samples, the TLR2 rs3804099 polymorphism was more often noted in those with CDI than in those without CDI (64.5% vs. 46.1%; P = 0.046) but was not significant in multivariate analysis. Because the TLR2 rs3804099 polymorphism was moderately associated with CDI, the role of TLR2 and TLR4 was further evaluated in a mouse model. Both Tlr2-/- and Tlr4-/- mice showed more severe CDI disease than wild-type mice in terms of body weight change and fecal content five days after oral challenge with C. difficile. Furthermore, Tlr2-/- mice suffered from more severe disease than Tlr4-/- mice, as evidenced by stool consistency, cecum weight, and survival rate. Conclusion The TLR2 rs3804099 polymorphism is marginally associated with the development of CDI, and the pathogenic role of TLR2 is further supported by a mouse model.
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Affiliation(s)
- Yi-Hsin Lai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Bo-Yang Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Yu Hsu
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Hsuan Chen
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan
| | - Po-Han Chou
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan
| | - Yueh-Lin Chen
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan
| | - Hsiao-Chieh Liu
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Departments of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Pei-Jane Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan
- Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan City, Taiwan
- Department of Pathology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Departments of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
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9
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Risk factors of Clostridium difficile-associated diarrhea in hospitalized adults: Vary by hospitalized duration. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:276-283. [DOI: 10.1016/j.jmii.2019.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/17/2019] [Accepted: 07/29/2019] [Indexed: 02/06/2023]
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10
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Hung YP, Tsai CS, Tsai BY, Tsai PJ, Lee YT, Lee JC, Liu HC, Hsueh PR, Lee CC, Ko WC. Clostridioides difficile infection in patients with hematological malignancy: A multicenter study in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:1101-1110. [PMID: 33678554 DOI: 10.1016/j.jmii.2021.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/26/2021] [Accepted: 02/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Among the individuals with hematological malignancy (HM) complicated with Clostridioides difficile infection (CDI), the variables associated with in-hospital mortality and recurrence of CDI were investigated. MATERIAL AND METHODS Including adults with HM and those without malignancy suffering from CDI from January 2015 to December 2016 in three hospitals in Taiwan. RESULTS Totally 314 patients including 77 with HM and 237 patients without malignancy were included. HM patients more often had low leukocyte counts (<500 cells/mL: 28.6% vs. 2.1%) than those without malignancy and more patients without malignancy had severe CDI than patients with HM (31.6% vs. 14.3%, P = .003), according to the severity score of IDSA/SHEA. Patients with HM had a higher recurrence rate of CDI (14.3%, 11/77 vs. 7.2%, 17/237; P = .07) and longer hospital stay (47.2 ± 40.8 days vs. 33.3 ± 37.3 days; P = .006) than those without malignancy. In the multivariate analyses for those with HM and CDI, the in-hospital mortality was associated with vancomycin-resistant Enterococcus (VRE) colonization or infection (odds ratio [OR] 7.72; P = .01), and C. difficile ribotype 078 complex infection (OR 9.22; P = .03). Moreover underlying hematological malignancy (OR 2.74; P = .04) and VRE colonization/infection (OR 2.71; P = .02) were independently associated with CDI recurrence. CONCLUSION Patients with HM complicated with CDI were often regarded as non-severe infection, but had a similar in-hospital mortality rate as those without malignancy. CDI due to ribotype 078 complex isolates heralded a poor prognosis among HM patients.
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Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Shiang Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Bo-Yang Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Ti Lee
- Department of Internal Medicine and Division of Infectious Diseases, Chung Shan Medical University Hospital, and School of Medicine, Chung Shan Medical University Taichung, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Chuan Liu
- Department of Experiment and Diagnosis, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan
| | - Po-Ren Hsueh
- Department of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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11
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Lee JC, Hung YP, Tsai BY, Tsai PJ, Ko WC. Severe Clostridium difficile infections in intensive care units: Diverse clinical presentations. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2020; 54:1111-1117. [DOI: 10.1016/j.jmii.2020.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 06/14/2020] [Accepted: 07/27/2020] [Indexed: 12/19/2022]
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12
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Clostridium difficile in Asia: Opportunities for One Health Management. Trop Med Infect Dis 2018; 4:tropicalmed4010007. [PMID: 30597880 PMCID: PMC6473466 DOI: 10.3390/tropicalmed4010007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 12/22/2018] [Accepted: 12/23/2018] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile is a ubiquitous spore-forming bacterium which causes toxin-mediated diarrhoea and colitis in people whose gut microflora has been depleted by antimicrobial use, so it is a predominantly healthcare-associated disease. However, there are many One Health implications to C. difficile, given high colonisation rates in food production animals, contamination of outdoor environments by use of contaminated animal manure, increasing incidence of community-associated C. difficile infection (CDI), and demonstration of clonal groups of C. difficile shared between human clinical cases and food animals. In Asia, the epidemiology of CDI is not well understood given poor testing practices in many countries. The growing middle-class populations of Asia are presenting increasing demands for meat, thus production farming, particularly of pigs, chicken and cattle, is rapidly expanding in Asian countries. Few reports on C. difficile colonisation among production animals in Asia exist, but those that do show high prevalence rates, and possible importation of European strains of C. difficile like ribotype 078. This review summarises our current understanding of the One Health aspects of the epidemiology of CDI in Asia.
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13
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Hung YP, Tsai PJ, Lee YT, Tang HJ, Lin HJ, Liu HC, Lee JC, Tsai BY, Hsueh PR, Ko WC. Nationwide surveillance of ribotypes and antimicrobial susceptibilities of toxigenic Clostridium difficile isolates with an emphasis on reduced doxycycline and tigecycline susceptibilities among ribotype 078 lineage isolates in Taiwan. Infect Drug Resist 2018; 11:1197-1203. [PMID: 30147348 PMCID: PMC6101014 DOI: 10.2147/idr.s162874] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives The information of antimicrobial susceptibility, toxin gene, and ribotype distribution of toxigenic Clostridium difficile isolates in Taiwan remain limited. Patients and methods The study was conducted from January 2015 to December 2016 in 5 hospitals in Taiwan. Adults aged ≥20 years with a hospital stay for >5 days were included, and those with colectomy or intestinal infection due to other enteropathogens were excluded. Multiplex PCR was used to detect tcdA, tcdB, cdtA, cdtB, and tcdC deletions, and antimicrobial susceptibility for metronidazole, vancomycin, doxycycline, and tigecycline was investigated. Ribotypes of those isolates with tcdC deletion and tcdA+/tcdB+ were determined. Results Of 1112 C. difficile isolates collected from adults at 5 hospitals, 842 were toxigenic, including 749 (89.0%) tcdA+/tcdB+ isolates and 93 (11.0%) tcdA−/tcdB+. Of the toxigenic isolates, 76 (9.0%) had a tcdC deletion and were cdtA+/cdtB+, indicative of hypervirulence, and RT078 lineage, including RT126, RT127, and RT078, predominated (n=53, 76.3%). Similar to the susceptibility data in Asia countries, metronidazole or vancomycin resistance was rare, noted in 1.2% or 2.1%, respectively. Reduced doxycycline susceptibility (minimum inhibitory concentration [MIC] of ≥8 mg/L) was more common among RT078 lineage than non-RT078 lineage (75.9%, 44/58 vs 6.0%, 47/784; P<0.001). Also reduced tigecycline susceptibility (MIC ≥0.125 mg/L) was more common among RT078 lineage (20.7%, 12/58 vs 6.5%, 51/784; P<0.001). Conclusion In Taiwan, toxigenic C. difficile isolates remain susceptible to metronidazole and vancomycin. RT078 lineage predominated among toxigenic isolates with cdtA, cdtB, and tcdC deletion, and more often had reduced doxycycline and tigecycline susceptibility than the isolates other than RT078 lineage.
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Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, .,Graduate Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Ti Lee
- Institute of Medicine and School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Division of Infectious Diseases, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Hung-Jen Tang
- Department of Internal Medicine, Chi-Mei Hospital, Tainan, Taiwan
| | - Hsiao-Ju Lin
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, .,Graduate Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiu-Chuan Liu
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan,
| | - Bo-Yang Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan,
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, .,Center of Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan, .,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan,
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14
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Wang L, Luo Y, Huang C, Wu S, Ye J, Song X, Jin D, Wang X. Coinfection with 2 Clostridium difficile ribotypes in China: A case report. Medicine (Baltimore) 2018; 97:e9946. [PMID: 29595702 PMCID: PMC5895390 DOI: 10.1097/md.0000000000009946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/30/2018] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Clostridium difficile infections (CDIs) have been reported in China, but detailed clinical symptoms of coinfection by 2 C difficile ribotypes have not been documented. PATIENTS CONCERNS An 83-year-old male with a 10-day history of diarrhea and urinary tract infection was admitted to the hospital. The patient had received ofloxacin for several days, but his clinical response was poor. Laboratory workup revealed high white blood cell (WBC), serum creatinine (Scr), and C-reactive protein (CRP) levels. Based on these abnormal lab results, rapid detection of glutamate dehydrogenase and toxin A and B was performed. DIAGNOSIS Severe CDI. INTERVENTIONS Oral vancomycin was administered for 8 days. OUTCOMES Diarrhea symptoms improved and C difficile culture was negative after oral vancomycin administration for 8 days. Clostridium difficile was isolated from 3 consecutive stool samples at 2-day intervals because the patient was admitted to the hospital. Polymerase chain reaction ribotyping revealed ribotype (RT) 017 in the first 2 samples and RT 001 in the third sample. RT 017 caused significantly higher increases in the levels of WBC, Scr, and CRP than RT 001. LESSONS It is necessary to improve clinicians' awareness of CDI and reduce the severity of CDI caused by RT 017 in China.
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Affiliation(s)
- Liqian Wang
- Department of Laboratory Medicine, Zhejiang Chinese Medical University Affiliated Hangzhou First Hospital
| | - Yun Luo
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention
| | - Chen Huang
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention
| | - Shenghai Wu
- Department of Laboratory Medicine, Hangzhou First Hospital, Huansha road, Hangzhou, Zhejiang, China
| | - Julian Ye
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention
| | - Xiaojun Song
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention
| | - Dazhi Jin
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention
| | - Xianjun Wang
- Department of Laboratory Medicine, Hangzhou First Hospital, Huansha road, Hangzhou, Zhejiang, China
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15
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Suzuki H, Tomita M, Tsai PJ, Ko WC, Hung YP, Huang IH, Chen JW. Comparative genomic analysis of Clostridium difficile ribotype 027 strains including the newly sequenced strain NCKUH-21 isolated from a patient in Taiwan. Gut Pathog 2017; 9:70. [PMID: 29213333 PMCID: PMC5708112 DOI: 10.1186/s13099-017-0219-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/21/2017] [Indexed: 01/05/2023] Open
Abstract
Background Clostridium difficile is a Gram-positive anaerobe and the leading cause of antibiotic-associated diarrhea worldwide. The emergence of ribotype 027 (RT027) strains is associated with increased incidence of infection and mortality. To further understand the relationship between C. difficile NCKUH-21, a RT027 strain isolated from a patient in Taiwan, and other RT027 strains, we performed whole-genome shotgun sequencing on NCKUH-21 and comparative genomic analyses. Results The genome size, G+C content, and gene number for the NCKUH-21 strain were determined to be similar to those for other C. difficile strains. The core genome phylogeny indicated that the five RT027 strains R20291, CD196, NCKUH-21, BI1, and 2007855 formed a clade. A pathogenicity locus, tcdR-tcdB-tcdE-orf-tcdA-tcdC, was conserved in the genome. A genomic region highly similar to the Clostridium phage \documentclass[12pt]{minimal}
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\begin{document}$$\upvarphi$$\end{document}φCD38-2 was present in the NCKUH-21 strain but absent in the other RT027 strains and designated as the prophage \documentclass[12pt]{minimal}
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\begin{document}$$\upvarphi$$\end{document}φNCKUH-21. The prophage \documentclass[12pt]{minimal}
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\begin{document}$$\upvarphi$$\end{document}φNCKUH-21 genes were significantly higher in G+C content than the other genes in the NCKUH-21 genome, indicating that the prophage does not match the base composition of the host genome. Conclusions This is the first whole-genome analysis of a RT027 C. difficile strain isolated from Taiwan. Due to the high identity with \documentclass[12pt]{minimal}
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\begin{document}$$\upvarphi$$\end{document}φCD38-2, the prophage identified in the NCKUH-21 genome has the potential to regulate toxin production. These results provide important information for understanding the pathogenicity of RT027 C. difficile in Taiwan. Electronic supplementary material The online version of this article (10.1186/s13099-017-0219-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Haruo Suzuki
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Yamagata Japan.,Faculty of Environment and Information Studies, Keio University, Fujisawa, Kanagawa Japan
| | - Masaru Tomita
- Institute for Advanced Biosciences, Keio University, Tsuruoka, Yamagata Japan.,Faculty of Environment and Information Studies, Keio University, Fujisawa, Kanagawa Japan
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Medicine, College of Medicine, National Cheng Kung University , Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - I-Hsiu Huang
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 70101 Taiwan
| | - Jenn-Wei Chen
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, 1 University Road, Tainan, 70101 Taiwan
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16
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Hung YP, Lee JC, Lin HJ, Chiu CW, Wu JL, Liu HC, Huang IH, Tsai PJ, Ko WC. Perceptions of Clostridium difficile infections among infection control professionals in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 50:521-526. [DOI: 10.1016/j.jmii.2017.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 12/17/2022]
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17
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Tsai CS, Hung YP, Lee JC, Lee NY, Chen PL, Syue LS, Li MC, Li CW, Ko WC. Community-onset Clostridium difficile infection at a tertiary medical center in southern Taiwan, 2007-2015. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 51:243-250. [PMID: 28089100 DOI: 10.1016/j.jmii.2016.08.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is well-known as the major cause of infectious diarrhea in hospitalized patients. Community-onset CDI (CO-CDI) is an emerging threat. However, clinical information of CO-CDI in Taiwan remains scarce. METHODS A retrospective study was conducted at a medical center in southern Taiwan. Symptomatic patients between 2007 and 2015 with C. difficile toxin or tcdB detected in stool were identified as CDI, and were classified as CO-CDI [including community-associated CDI (CA-CDI) and community-onset health care facility-associated CDI (CO-HCFA-CDI)] and health care facility-onset CDI (HCFO-CDI). RESULTS Of 427 patients, 15 (3.5%) were CA-CDI, 49 (11.5%) CO-HCFA-CDI, and 363 (85.0%) HCFO-CDI. Despite major involvement of the elderly (mean age: 66.1 years vs. 69.9 years, p = 0.46), no significant differences were noted between CA-CDI and CO-HCFA-CDI groups, except that solid organ cancer was more common in the CO-HCFA-CDI group. The CO-CDI group more often presented with abdominal pain but had shorter hospital stays and less exposure of proton-pump inhibitors or broad-spectrum antibiotics than the HCFO-CDI group did. The mortality rate related to CDI was 4.7% (3 patients) in the CO-CDI group. Despite a lower in-hospital mortality rate in the CO-CDI group (10.9% vs. 22.0%; p = 0.04), the recurrence rate was similar (10.9% vs. 7.2%; p = 0.3). CONCLUSIONS CO-CDI is not common but associated with substantial morbidity and mortality. Physicians should put CDI into consideration among patients who present community-onset fever, diarrhea, or abdominal pain alone or in combination.
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Affiliation(s)
- Chin-Shiang Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Executive Yuan, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Nan-Yao Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan
| | - Ling-Shan Syue
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Chi Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Wen Li
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medicine, National Cheng Kung University Medical College, Tainan, Taiwan.
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18
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Hung YP, Huang IH, Lin HJ, Tsai BY, Liu HC, Liu HC, Lee JC, Wu YH, Tsai PJ, Ko WC. Predominance of Clostridium difficile Ribotypes 017 and 078 among Toxigenic Clinical Isolates in Southern Taiwan. PLoS One 2016; 11:e0166159. [PMID: 27861606 PMCID: PMC5115699 DOI: 10.1371/journal.pone.0166159] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 10/24/2016] [Indexed: 01/24/2023] Open
Abstract
Ribotypes and toxin genotypes of clinical C. difficile isolates in Taiwan are rarely reported. A prospective surveillance study from January 2011 to January 2013 was conducted at the medical wards of a district hospital in southern Taiwan. Of the first toxigenic isolates from 120 patients, 68 (56.7%) of 120 isolates possessed both tcdA and tcdB. Of 52 (43.3%) with tcdB and truncated tcdA (tcdA-/tcdB+), all were ribotype 017 and none had binary toxin or tcdC deletion. Eighteen (15%) toxigenic isolates harbored binary toxins (cdtA and cdtB) and all had tcdC deletion, including Δ39 (C184T) deletion (14 isolates), Δ18 in-frame deletion (3 isolates), and Δ18 (Δ117A) deletion (1 isolate). Eleven of 14 isolates with Δ39 (C184T) deletion belonged to the ribotype 078 family, including ribotype 127 (6 isolates), ribotype 126 (4 isolates), and ribotype 078 (1 isolate). Among 8 patients with consecutive C. difficile isolates, these isolates from 6 (75%) patients were identical, irrespective of the presence or absence of diarrhea, suggestive of persistent fecal carriage or colonization. In conclusion in southern Taiwan, ribotype 017 isolates with a tcdA-/tcdB+ genotype were not uncommon and of C. difficile isolates with binary toxin, the ribotype 078 family was predominant.
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Affiliation(s)
- Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Graduate Institute of Clinical Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - I-Hsiu Huang
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan
| | - Hsiao-Ju Lin
- Department of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Graduate Institute of Clinical Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Bo-Yang Tsai
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiao-Chieh Liu
- Department of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan
- Department of Experiment and Diagnosis, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan
| | - Hsiu-Chuan Liu
- Department of Experiment and Diagnosis, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan
| | - Jen-Chieh Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yi-Hui Wu
- Department of Internal Medicine, E-da Hospital, Kaohsiung, Taiwan
| | - Pei-Jane Tsai
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan
- * E-mail: (WCK); (PJT)
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Center of Infection Control, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- * E-mail: (WCK); (PJT)
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Shin JH, Chaves-Olarte E, Warren CA. Clostridium difficile Infection. Microbiol Spectr 2016; 4:10.1128/microbiolspec.EI10-0007-2015. [PMID: 27337475 PMCID: PMC8118380 DOI: 10.1128/microbiolspec.ei10-0007-2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Indexed: 02/07/2023] Open
Abstract
Clostridium difficile is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus that has long been recognized to be the most common etiologic pathogen of antibiotic-associated diarrhea. C. difficile infection (CDI) is now the most common cause of health care-associated infections in the United States and accounts for 12% of these infections (Magill SS et al., N Engl J Med370:1198-1208, 2014). Among emerging pathogens of public health importance in the United States, CDI has the highest population-based incidence, estimated at 147 per 100,000 (Lessa FC et al., N Engl J Med372:825-834, 2015). In a report on antimicrobial resistance, C. difficile has been categorized by the Centers for Disease Control and Prevention as one of three "urgent" threats (http://www.cdc.gov/drugresistance/threat-report-2013/). Although C. difficile was first described in the late 1970s, the past decade has seen the emergence of hypertoxigenic strains that have caused increased morbidity and mortality worldwide. Pathogenic strains, host susceptibility, and other regional factors vary and may influence the clinical manifestation and approach to intervention. In this article, we describe the global epidemiology of CDI featuring the different strains in circulation outside of North America and Europe where strain NAP1/027/BI/III had originally gained prominence. The elderly population in health care settings has been disproportionately affected, but emergence of CDI in children and healthy young adults in community settings has, likewise, been reported. New approaches in management, including fecal microbiota transplantation, are discussed.
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Affiliation(s)
- Jae Hyun Shin
- Department of Medicine, Division of Infectious Disease and International Health, University of Virginia, Charlottesville, VA 22908
| | - Esteban Chaves-Olarte
- Centro de Investigación en Enfermedades Tropicales, Facultad de Microbiología, Universidad de Costa Rica, Costa Rica
| | - Cirle A Warren
- Department of Medicine, Division of Infectious Disease and International Health, University of Virginia, Charlottesville, VA 22908
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Wu YC, Lee JJ, Tsai BY, Liu YF, Chen CM, Tien N, Tsai PJ, Chen TH. Potentially hypervirulent Clostridium difficile PCR ribotype 078 lineage isolates in pigs and possible implications for humans in Taiwan. Int J Med Microbiol 2016; 306:115-22. [PMID: 26915500 DOI: 10.1016/j.ijmm.2016.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 02/02/2016] [Accepted: 02/07/2016] [Indexed: 12/30/2022] Open
Abstract
Clostridium difficile is a human and animal pathogen. Recently, the incidence of community-acquired C. difficile infection has increased, and many studies have indicated that C. difficile might be food-borne. The correlation between C. difficile infection in humans and in animals has been a topic of debate. The objective of this study was to determine the genetic relatedness of C. difficile from human and pigs in Taiwan. We investigated the molecular epidemiology of C. difficile in healthy humans and pigs from 2011 to 2015. The isolation rate of C. difficile from pigs in 13 commercial farms was 49% (100/204), and a high proportion of hypervirulent (C. difficile carrying tcdA, tcdB, and cdtA/B genes and a 39-bp deletion in the tcdC gene) ribotype 078 lineage isolates (90%, 90/100; including 078, 126, 127, and 066-like isolates) were identified. In addition, the C. difficile ribotype 127 isolates from pigs typically exhibited moxifloxacin resistance (37/43; 86%). In healthy humans, the isolation rate was 4.3% (3/69), and all healthy human isolates were non-toxigenic. In particular, we compared the porcine isolates with two patient strains (ribotype 127) obtained from two hospitals in central Taiwan. The multilocus variable number tandem repeat analysis revealed a high genetic relatedness between ribotype 127 from patients and pigs. This study indicated that isolates of the ribotype 078 lineage, and especially ribotype 127, were widely distributed in pig farms and showed a high frequency of moxifloxacin resistance. The closely related ribotype 127 from patients and pigs may have had a common origin or low diversity. In conclusion, C. difficile ribotype 127 is a noteworthy pathogen in pigs and poses a potential public health threat.
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Affiliation(s)
- Ying-Chen Wu
- Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, No.250, Guoguang Rd., South Dist., Taichung 402, Taiwan.
| | - Jen-Jie Lee
- Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, No.250, Guoguang Rd., South Dist., Taichung 402, Taiwan.
| | - Bo-Yang Tsai
- Department of Microbiology and Immunology, National Cheng Kung University, Medical College, No. 1, University Rd., Tainan 70101, Taiwan.
| | - Yi-Fen Liu
- Graduate Institute of Microbiology and Public Health, College of Veterinary Medicine, National Chung Hsing University, No.250, Guoguang Rd., South Dist., Taichung 402, Taiwan.
| | - Chih-Ming Chen
- Department of Internal Medicine, Tungs' Taichung MetroHarbor Hospital, No.699, Sec. 8, Taiwan Blvd., Taichung 435, Taiwan.
| | - Ni Tien
- Department of Laboratory Medicine, China Medical University Hospital, No.91 Hsuehshih Rd., Taichung 404, Taiwan.
| | - Pei-Jane Tsai
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Medical College, No. 1, University Rd., Tainan 70101, Taiwan.
| | - Ter-Hsin Chen
- Graduate Institute of Veterinary Pathobiology, College of Veterinary Medicine, National Chung Hsing University, No.250, Guoguang Rd., South Dist., Taichung 402, Taiwan.
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