Gas-liquid chromatography and Clostridium difficile

Laboratory diagnosis of Clostridium difficile-associated diarrhoea

This paper reviews the various laboratory procedures available for the isolation and identification of Clostridium difficile and the detection of toxins produced by this organism. Laboratories should be selective in determining which patients require investigation for Clostridium difficile-associated diarrhoea. Transport and storage of stool specimens at 4 degrees C is recommended when delays in processing may occur. Tissue culture techniques are still the best method for detection of cytotoxin and a variety of cell lines can be used. Other methods for detecting cytotoxin, and methods for detecting other toxins are not sufficiently developed yet to warrant introduction into diagnostic laboratories. Culture techniques remain the most sensitive for diagnosis, particularly since the development of a variety of enrichment techniques. Cycloserine cefoxitin fructose agar is still adequate, although reduced concentrations of antimicrobial agents are necessary, and improvements, such as the addition of sodium taurocholate, increase the recovery of spores. Enrichment cultures have markedly increased isolation rates for Clostridium difficile but the significance of these isolates needs to be carefully evaluated. Until simpler and more reliable tests are available in clinical laboratories for the detection of toxins, the isolation of Clostridium difficile from patients with diarrhoeal disease should be considered paramount.

Diagnosis of Clostridium difficile-associated intestinal disease

Toxigenic Clostridium difficile is the major cause of antimicrobial agent-associated pseudomembranous colitis and is the etiological agent of approximately 30% of cases of nonspecific colitis and diarrhea (without colitis) induced by antimicrobial agents. In addition, C. difficile has been implicated in certain intestinal diseases not related to prior antimicrobial administration. C. difficile has been reported to be one of the most common enteropathogens isolated from stool specimens submitted to hospital laboratories. Thus, diagnosis of C. difficile-associated intestinal disease should now be routinely performed in diagnostic clinical laboratories. The diagnosis of C. difficile-associated intestinal disease relies on the demonstration of either the organism or the toxin(s) in stool specimens or antibody response in serum to the toxin(s). Several selective medium are available for the recovery of C. difficile from stool specimens. The toxin(s) of C. difficile can be demonstrated using a variety of techniques, including biological assays as well as immunological assays. This article will review the techniques currently available to aid in the diagnosis of C. difficile-associated intestinal disease.

Evaluation of gas-liquid chromatography for the rapid diagnosis of Clostridium difficile associated disease

Direct gas-liquid chromatography of faecal specimens with isocaproic acid as a marker was used for the rapid diagnosis of Clostridium difficile associated diarrhoeal diseases. Ninety stools were examined and results were compared with conventional culture on selective medium and cytotoxin assay in tissue culture. Using a combined analysis of isocaproic acid and butyric acid peak heights we defined three categories: positive, negative, and indeterminate. When the indeterminate group was excluded, the positive and negative predictive values of gas-liquid chromatography analysis were 86.9% and 85% respectively compared with culture and 71.4% and 95% respectively compared with cytotoxin assay.

Short-chain fatty acids in intestinal content of germfree mice monocontaminated with Escherichia coli or Clostridium difficile

The short-chain fatty acids (SCFAs) have been analysed in coecal and small-intestinal content of conventional (CONV) and germfree (GF) mice, in germfree mice monocontaminated with Escherichia coli (MEC) or Clostridium difficile (MCD), and in germfree mice conventionalized by the visitor technique (EXG). The total concentrations of SCFAs in coecal content, measured by gas chromatography, were (mean (SD), mmol/kg): CONV, 125.2 (32.9); GF, 1.02 (0.39); MEC, 6.88 (0.76); MCD, 4.50 (0.12); and EXG, 115.6 (17.4). The concentrations of SCFAs were 3- to 25-fold higher in the coecum than in the small intestine in CONV, MEC, and EXG mice (p less than 0.05). The fermentation patterns (that is, the relative composition of the acids) of E. coli and Cl. difficile were distinctively different under defined in vitro conditions and similar to those found in intestinal content of monocontaminated animals. Combined gas chromatography and mass spectrometry showed that Cl. difficile produced an unusual metabolite, 2-methylbutyric acid, in vitro and in vivo. The findings indicate that the fermentation patterns are closely related to the bacteria. Variations in the bacterial flora may be more important in determining the concentrations and patterns of SCFAs in intestinal content than variations in the intake of substrate for SCFAs formation as dietary fibre.

Frequency-pulsed electron capture gas-liquid chromatographic analysis of metabolites produced by Clostridium difficile in broth enriched with amino acids

Clostridium difficile strain CDC A-567 was cultured in Trypticase (BBL Microbiology Systems)-yeast-salt broth supplemented with 0.2% L-leucine, L-norleucine, L-isoleucine, L-tyrosine, or L-tryptophan. Four extractions were done on the spent medium, three at pH 2 and one at pH 10, using CHCL3 or ether. Derivatizations were done with trichloroethanol, heptafluorobutyric anhydride, and heptafluorobutyric anhydride-ethanol. All samples were analyzed with frequency-pulsed electron capture gas-liquid chromatography. A dedicated computer was used to assist in data analysis. C. difficile produced both short-chain and aromatic acids in Trypticase-yeast-salt broth; hydroxy acids were also detected. p-Cresol, indoleacetic acid, 4-methylthio-2-hydroxybutyric acid, and some unidentified alcohols were observed. The basic chloroform extraction contained cadaverine and putrescine. Leucine, norleucine, and isoleucine influenced the production of C5 and C6 acids and alcohols. L-Tyrosine underwent successive degradation to produce p-cresol and aromatic acids as final products. Tryptophan increased the production of indoleacetic, indolepropionic, and indolebutyric acids. Isocaproic acid was produced in relatively high concentrations regardless of medium substitution. The consistent production of iC6 under various substrate conditions indicates that the production of this compound might be consistent enough in vitro to form the basis of a rapid test for detection of C. difficile in stool specimens by frequency-pulsed electron capture gas-liquid chromatography.

Studies of stools from pseudomembranous colitis, rotaviral, and other diarrheal syndromes by frequency-pulsed electron capture gas-liquid chromatography

Thirty-five patients with various diarrheal syndromes and 22 controls were studied. All stool samples were carefully cultured for Clostridium difficile, using selective isolation media. Cytotoxin assays with proper antitoxin neutralization were done in MRC-5 cells. The stool samples were extracted four times, three times at pH 2 and once at pH 10, using CHCl3 or ether. Derivatizations of extracts were done with trichloroethanol, heptafluorobutyric anhydride, and heptafluorobutyric anhydride-ethanol, and all derivatives were analyzed by frequency-pulsed electron capture gas-liquid chromatography (FPEC-GLC). A dedicated computer was used to assist in both qualitative and quantitative data analysis. Isocaproic acid (iC6) was always found in stool from which C. difficile was isolated and was absent in C. difficile-negative specimens. p-Cresol was found frequently in both persons with pseudomembranous colitis and controls. Tryptamine was found in stool containing C. bifermentans. The FPEC-GLC profiles of persons with acute diarrhea were very different from those of normal persons. Diarrhea associated with adenovirus and rotavirus, Klebsiella spp., and Escherichia spp. showed different FPEC-GLC patterns. Stools from well persons consistently contained full-scale peaks of pyruvic, acetic, propionic, isobutyric, butyric, isovaleric, and valeric acids. In rotavirus stools isobutyric, isovaleric, and valeric acids were reduced in quantity from those found in control stools, whereas propionic and butyric acids were increased.

Detection of Clostridium difficile in faeces by direct gas liquid chromatography

Stool specimens examined for the presence of Clostridium difficile and its cytotoxin were screened by gas liquid chromatography for the presence of volatile fatty acids and p-cresol. Twenty seven of 110 (25%) stools yielded C difficile or cytotoxin; iso-valeric acid was detected in 63/110 (57%) and iso-caproic acid in 18/110 (16%) stools. Para-cresol was found in 24/71 (34%) stools examined. Iso-valeric acid was detected in 85% of stools positive for C difficile, whereas iso-caproic acid (41%) and p-cresol (52%) were found in much lower numbers of C difficile-positive stools. It is concluded that gas chromatographic detection of volatile fatty acids or p-cresol in faeces are not satisfactory screening tests for the presence of C difficile.

Use of gas-liquid chromatography as a screening test for toxigenic Clostridium difficile in diarrhoeal stools

In order to determine if gas-liquid chromatography (GLC) on concentrated stool extracts could be substituted to cell culture assay for cytotoxicity, we prospectively studied 154 diarrhoeal stools submitted for detection of Clostridium difficile toxin. Isocaproic-positive samples were cultured on egg yolk agar supplemented with cycloserine, cefoxitin and fructose for isolation of C difficile, and on egg yolk agar plus kanamycin for isolation of other clostridium species. Of the 154 samples, 129 were GLC-negative (height of the isocaproic peak less than 1.2 cm) and were toxin-negative. Twenty-five stools yielded isocaproic acid; C difficile isolated from 13 of them, six of which were also toxin-positive. Four other isocaproic-positive samples yielded C bifermentans and C sordellii; all were toxin-negative. These results indicate that a negative GLC is an excellent screening test for excluding C difficile infection; positive results must be checked by toxin testing and culture since they are not necessarily associated with the presence of C difficile or its toxin.

A selective broth for Clostridium difficile

A selective broth for the isolation of Clostridium difficile from stool specimens is described. The broth contains gentamicin, cycloserine and cefoxitin (GCC broth) and gives rapid presumptive evidence of the presence of C. difficile using gas-liquid chromatography. The broth may also be used for the detection of cytotoxin. Final recovery of C. difficile was significantly improved with an increase in isolation rate of 20% in patients in whom fecal cytotoxin could be detected and 125% in patients where fecal cytotoxin could not be detected. Until the pathogenesis of C. difficile-associated diseases is more clearly defined we would stress the importance of isolating the organism, and we advocate the use of a selective broth such as GCC to improve the isolation rate.