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Pourliotopoulou E, Karampatakis T, Kachrimanidou M. Exploring the Toxin-Mediated Mechanisms in Clostridioides difficile Infection. Microorganisms 2024; 12:1004. [PMID: 38792835 PMCID: PMC11124097 DOI: 10.3390/microorganisms12051004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Clostridioides difficile infection (CDI) is the leading cause of nosocomial antibiotic-associated diarrhea, and colitis, with increasing incidence and healthcare costs. Its pathogenesis is primarily driven by toxins produced by the bacterium C. difficile, Toxin A (TcdA) and Toxin B (TcdB). Certain strains produce an additional toxin, the C. difficile transferase (CDT), which further enhances the virulence and pathogenicity of C. difficile. These toxins disrupt colonic epithelial barrier integrity, and induce inflammation and cellular damage, leading to CDI symptoms. Significant progress has been made in the past decade in elucidating the molecular mechanisms of TcdA, TcdB, and CDT, which provide insights into the management of CDI and the future development of novel treatment strategies based on anti-toxin therapies. While antibiotics are common treatments, high recurrence rates necessitate alternative therapies. Bezlotoxumab, targeting TcdB, is the only available anti-toxin, yet limitations persist, prompting ongoing research. This review highlights the current knowledge of the structure and mechanism of action of C. difficile toxins and their role in disease. By comprehensively describing the toxin-mediated mechanisms, this review provides insights for the future development of novel treatment strategies and the management of CDI.
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Affiliation(s)
- Evdokia Pourliotopoulou
- Department of Microbiology, Medical School, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | | | - Melania Kachrimanidou
- Department of Microbiology, Medical School, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
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Perry DA, Shirley D, Micic D, Patel CP, Putler R, Menon A, Young VB, Rao K. External Validation and Comparison of Clostridioides difficile Severity Scoring Systems. Clin Infect Dis 2021; 74:2028-2035. [PMID: 34459885 DOI: 10.1093/cid/ciab737] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Many models have been developed to predict severe outcomes from Clostridioides difficile infection. These models are usually developed at a single institution and largely are not externally validated. This aim of this study was to validate previously published risk scores in a multicenter cohort of patients with CDI. METHODS Retrospective study on four separate inpatient cohorts with CDI from three distinct sites: The Universities of Michigan (2010-2012 and 2016), Chicago (2012), and Wisconsin (2012). The primary composite outcome was admission to an intensive care unit, colectomy, and/or death attributed to CDI within 30 days of positive testing. Both within each cohort and combined across all cohorts, published CDI severity scores were assessed and compared to each other and the IDSA guideline definitions of severe and fulminant CDI. RESULTS A total of 3,646 patients were included for analysis. Including the two IDSA guideline definitions, fourteen scores were assessed. Performance of scores varied within each cohort and in the combined set (mean area under the receiver operator characteristic curve(AUC 0.61, range 0.53-0.66). Only half of the scores had performance at or better than IDSA severe and fulminant definitions (AUCs 0.64 and 0.63, respectively). Most of the scoring systems had more false than true positives in the combined set (mean: 81.5%, range:0-91.5%). CONCLUSIONS No published CDI severity score showed stable, good predictive ability for adverse outcomes across multiple cohorts/institutions or in a combined multicenter cohort.
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Affiliation(s)
- D Alexander Perry
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, Ann Arbor, MI, USA
| | - Daniel Shirley
- Division of Infectious Disease, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - C Pratish Patel
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rosemary Putler
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, Ann Arbor, MI, USA
| | - Anitha Menon
- University of Michigan Medical School, Ann Arbor, MI, Ann Arbor, MI, USA
| | - Vincent B Young
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,Department of Microbiology and Immunology, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, Ann Arbor, MI, USA
| | - Krishna Rao
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, Ann Arbor, MI, USA
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Chiu PJ, Rathod J, Hong YP, Tsai PJ, Hung YP, Ko WC, Chen JW, Paredes-Sabja D, Huang IH. Clostridioides difficile spores stimulate inflammatory cytokine responses and induce cytotoxicity in macrophages. Anaerobe 2021; 70:102381. [PMID: 34082120 DOI: 10.1016/j.anaerobe.2021.102381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/30/2021] [Accepted: 05/04/2021] [Indexed: 02/08/2023]
Abstract
Clostridioides difficile is a gram-positive, spore-forming anaerobic bacterium, and the leading cause of antibiotic-associated diarrhea worldwide. During C. difficile infection, spores germinate in the presence of bile acids into vegetative cells that subsequently colonize the large intestine and produce toxins. In this study, we demonstrated that C. difficile spores can universally adhere to, and be phagocytosed by, murine macrophages. Only spores from toxigenic strains were able to significantly stimulate the production of inflammatory cytokines by macrophages and subsequently induce significant cytotoxicity. Spores from the isogenic TcdA and TcdB double mutant induced significantly lower inflammatory cytokines and cytotoxicity in macrophages, and these activities were restored by pre-exposure of the spores to either toxins. These findings suggest that during sporulation, spores might be coated with C. difficile toxins from the environment, which could affect C. difficile pathogenesis in vivo.
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Affiliation(s)
- Po-Jung Chiu
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jagat Rathod
- Department of Earth Sciences National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ping Hong
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Jane Tsai
- 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
| | - Yuan-Pin Hung
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Jenn-Wei Chen
- 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
| | - Daniel Paredes-Sabja
- Department of Biology, Texas A&M University, College Station, TX, 77843, USA; Millennium Nucleus in the Biology of Intestinal Microbiota, Santiago, Chile
| | - I-Hsiu Huang
- Department of Biochemistry and Microbiology, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA; Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, OK, USA.
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4
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McKee HK, Kajiwara C, Yamaguchi T, Ishii Y, Shimizu N, Ohara A, Tateda K. Clostridioides difficile toxins enhanced the in vitro production of CXC chemokine ligand 2 and tumor necrosis factor-α via Toll-like receptors in macrophages. J Med Microbiol 2021; 70. [PMID: 33830910 DOI: 10.1099/jmm.0.001342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Introduction. Clostridioides difficile infection (CDI) causes toxin-mediated enteropathy, such as antibiotic-associated diarrhoea and pseudomembranous colitis. Rho-glucosylating toxin A (TcdA) and toxin B (TcdB) have been clearly implicated in pathogenesis, whereas the virulence of binary toxin (CDT) is still debated.Hypothesis statement. We hypothesized that CDT is involved in the host immune response and plays a pivotal role in establishing virulence by modulating pro-inflammatory cytokine production; this is achieved through the integral Toll-like receptor (TLR) signalling pathways.Aim. The aim of the present study was to determine whether and how CDT impacts macrophages compared to TcdA or TcdB by examining the induction of CXC chemokine ligand 2 (CXCL2) and tumour necrosis factor-α (TNF-α), both of which are crucial in mediating local and systematic inflammatory responses.Methodology. RAW264.7 cells or transfected human embryonic kidney (HEK) 293 T cells were incubated with TcdA, TcdB, or CDT. In some experiments, a neutralizing antibody against TLR2 or TLR4, or myeloid differentiation 88 inhibitory peptide were added. The amount of CXCL2 and TNF-α secreted was then measured.Results. In RAW264.7 macrophages, CXCL2 and TNF-α were produced via the Toll-like receptor 2 (TLR2) or Toll-like receptor 4 (TLR4) pathway in a TcdA, TcdB, or CDT dose-dependent manner. Interleukin-8 secretion was induced in TLR4/MD2/CD14-transfected, but not in TLR2-transfected, HEK 293 T cells following TcdB or CDT exposure.Conclusion. Our results showed that C. difficile toxins, including CDT, enhanced macrophage-mediated CXCL2 and TNF-α production via TLR2 and TLR4, indicating that CDT affects host immune responses.
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Affiliation(s)
- Hiroe Konishi McKee
- Department of Pediatrics, Toho University Ohashi Medical Center, Tokyo 153-8515, Japan.,Department of Pediatrics, Toho University Graduate School of Medicine, Tokyo 143-8540, Japan
| | - Chiaki Kajiwara
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo 143-8540, Japan
| | - Tetsuo Yamaguchi
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo 143-8540, Japan
| | - Yoshikazu Ishii
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo 143-8540, Japan
| | - Norikazu Shimizu
- Department of Pediatrics, Toho University Ohashi Medical Center, Tokyo 153-8515, Japan.,Department of Pediatrics, Toho University Graduate School of Medicine, Tokyo 143-8540, Japan
| | - Akira Ohara
- Department of Pediatrics, Toho University Graduate School of Medicine, Tokyo 143-8540, Japan
| | - Kazuhiro Tateda
- Department of Microbiology and Infectious Diseases, Toho University School of Medicine, Tokyo 143-8540, Japan
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Redding L, Huang E, Ryave J, Webb T, Barnhart D, Baker L, Bender J, Kristula M, Kelly D. Clostridioides difficile on dairy farms and potential risk to dairy farm workers. Anaerobe 2021; 69:102353. [PMID: 33639290 DOI: 10.1016/j.anaerobe.2021.102353] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/07/2021] [Accepted: 02/19/2021] [Indexed: 11/15/2022]
Abstract
Clostridioides difficile causes severe colitis in people and is a significant enteric pathogen in many species of animals, including swine, horses, and potentially cattle. C. difficile is shed in feces, and transmission occurs horizontally via the fecal-oral route. Livestock has been suggested as a potential reservoir for C. difficile, and while studies have shown that swine and farm workers can be colonized with identical clones of C. difficile, the zoonotic transmission of C. difficile from livestock to people has not been definitively demonstrated. The goal of this study was to determine whether dairy calves and dairy farm workers harbored genetically similar isolates of C. difficile. First, we validated a glove juice protocol for detecting C. difficile on farm workers' hands. We then visited 23 farms and collected 1) fecal samples from 92 dairy calves, 2) hand rinsates from 38 dairy farm workers, and 3) fecal samples from five of the dairy farm workers who were willing to submit them. All samples underwent anaerobic culture and qPCR to detect C. difficile. C. difficile was detected on 15 of the farms (65.2%, 95% confidence interval (CI) 42.7%-83.6%) and in 28 calves (30.4%, 95% CI 21.2-40.9%) but in none of the hand rinsates or human fecal samples. Thus, the zoonotic transmission of C. difficile on dairy farms could not be demonstrated, and dairy farmers did not appear to be at increased risk of acquiring C. difficile via the fecal-oral route.
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Affiliation(s)
- Laurel Redding
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA.
| | - Elizabeth Huang
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Jacob Ryave
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
| | - Terry Webb
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
| | - Denise Barnhart
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
| | - Linda Baker
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
| | - Joseph Bender
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
| | - Michaela Kristula
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
| | - Donna Kelly
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
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Castro-Córdova P, Díaz-Yáñez F, Muñoz-Miralles J, Gil F, Paredes-Sabja D. Effect of antibiotic to induce Clostridioides difficile-susceptibility and infectious strain in a mouse model of Clostridioides difficile infection and recurrence. Anaerobe 2020; 62:102149. [PMID: 31940467 DOI: 10.1016/j.anaerobe.2020.102149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/16/2019] [Accepted: 01/09/2020] [Indexed: 02/08/2023]
Abstract
The anaerobic bacterium Clostridioides difficile is the leading cause of antibiotic-associated diarrhea that can culminate in life-threating colitis. During the C. difficile infection (CDI), C. difficile produces toxins that generate the clinical symptoms of the disease, and produce spores, which persist in the host during antibiotic treatment and can cause recurrent CDI (R-CDI). In this work, we aimed to compare three antibiotic regimens in the susceptibility of mice to CDI and R-CDI (i.e., antibiotic cocktail followed by clindamycin, 5 days of cefoperazone and 10 days of cefoperazone) with three different C. difficile isolates (i.e., strains 630; R20291, and VPI 10463). We observed that the severity of the clinical symptoms of CDI and R-CDI was dependent on the antibiotic treatment used to induce C. difficile-susceptibility, and that the three strains generated a different onset to diarrhea and weight loss in mice that were administrated with the same antibiotic treatment and which differed in comparison to the effect previously reported by other research groups. Our results suggest that, in our experimental conditions, in those animals treated with antibiotic cocktail followed by clindamycin, infection with strain R20291 had the highest diarrhea manifestation in comparison to strains 630 and VPI 10463. In animals treated with cefoperazone for 5 days, infection with strains R20291 or 630 had the highest diarrhea manifestation in comparison to VPI 10463, while in animals treated with cefoperazone for 10 days, infection with strain R20291 or VPI 10463, but not 630, had the highest diarrhea manifestation.
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Affiliation(s)
- Pablo Castro-Córdova
- Millennium Nucleus in the Biology of Intestinal Microbiota, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile; Microbiota-Host Interactions & Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile
| | - Fernando Díaz-Yáñez
- Millennium Nucleus in the Biology of Intestinal Microbiota, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile; Microbiota-Host Interactions & Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile
| | - Juan Muñoz-Miralles
- Microbiota-Host Interactions & Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile
| | - Fernando Gil
- Millennium Nucleus in the Biology of Intestinal Microbiota, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile; Microbiota-Host Interactions & Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile
| | - Daniel Paredes-Sabja
- Millennium Nucleus in the Biology of Intestinal Microbiota, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile; Microbiota-Host Interactions & Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile.
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7
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Diverting loop ileostomy with colonic lavage as an alternative to colectomy for fulminant Clostridioides difficile: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:1-8. [PMID: 31748820 DOI: 10.1007/s00384-019-03447-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical consultation is recommended for all patients with fulminant Clostridioides difficile infection (CDI). If surgery is required, total abdominal colectomy (TAC) is most commonly performed. However, diverting loop ileostomy and colonic lavage have been recently developed as a potential colon-sparing approach to fulminant CDI. The aim of this review is to compare TAC and diverting loop ileostomy with colonic lavage for fulminant CDI. METHODS Search of MEDLINE, EMBASE, CENTRAL, and PubMed was performed. Articles were eligible for inclusion if they compared TAC and diverting loop ileostomy with colonic lavage. The primary outcome was postoperative mortality, and the secondary outcome was postoperative complications. Quality of included studies was assessed using Newcastle-Ottawa Scale. RESULTS From 64 relevant citations, 5 studies (4 retrospective cohorts, 1 case series) with 3683 patients were included. Compared to TAC, diverting loop ileostomy with colonic lavage did not significantly reduce overall mortality (RR 1.10, 95% CI 0.60 to 1.99, P = 0.77), rate of reoperation (RR 1.02, 95% CI, 0.63 to 1.63, P = 0.94), or overall postoperative complications (RR 0.51, 95% CI, 0.22 to 1.17, P = 0.11). Rates of colonic preservation with the use of diverting loop ileostomy with colonic lavage ranged from 76% to 100%. CONCLUSION There does not appear to be a survival advantage with the use of diverting loop ileostomy with colonic lavage compared to TAC for fulminant CDI. However, diverting loop ileostomy with colonic lavage results in increased rates of colonic preservation, restoration of intestinal continuity, and laparoscopic surgery. This review is limited by the small number of included studies.
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8
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von Bechtolsheim F, Varga A, Szereday L, Polgar B, Balassa T, Kocsis B, Peterfi Z, Miko E. Development of a new serological assay for the diagnosis of Clostridium difficile infections with prognostic value. J Microbiol Methods 2019; 167:105777. [PMID: 31733265 DOI: 10.1016/j.mimet.2019.105777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/10/2019] [Accepted: 11/12/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE The most common hospital-acquired enteral infection is caused by Clostridium difficile. Unfortunately, Clostridium difficile infections (CDI) are of high risk to recur and little is known about how to predict recurrences. Previous findings have shown that high risk for recurrence correlates with low levels of C. difficile toxin-A and -B specific antibodies suggesting the protective role of humoral immunity against bacterial virulence factors. Therefore, the aim of this study was to develop an immunoassay, which specifically measures C.difficile toxin-specific antibodies in the serum that might be correlated with the risk of recurrence. METHODS We developed a simple ELISA to measure the quantity of toxin-A and -B-specific antibodies in human serum. The assay was then used to test anti-toxin immune response in healthy controls, in patients with primary CDI and patients with CDI recurrence. RESULTS The developed assay is simple, reproducible and fast. When using this test in a small clinical trial our results showed a trend toward a higher antibody level in those patients with only one episode of CDI, whereas patients with recurrent CDI had less anti-toxin A or B-specific antibodies in their serum indicating inadequate C. difficile anti-toxin immunity may facilitate recurrent infections. CONCLUSIONS It has already been observed that low antibody levels are associated with recurrent CDI (Bauer et al., 2014). The findings of our clinical trial show a similar trend. Our developed ELISA test could help to conduct further research and it might be helpful in clinical use to detect patients of high risk for CDI recurrence.
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Affiliation(s)
- Felix von Bechtolsheim
- Department of Visceral-, Thoracic- and Vascular Surgery, University Hospital, Technical University Dresden, Germany
| | - Adorjan Varga
- Department of Medical Microbiology and Immunology, Medical School, University of Pecs, Pecs, Hungary; 1st Department of Medicine, Division of infectious diseases, Medical School, University of Pecs, Pecs, Hungary
| | - Laszlo Szereday
- Department of Medical Microbiology and Immunology, Medical School, University of Pecs, Pecs, Hungary; Janos Szentagothai Research Centre, Pecs, Hungary
| | - Beata Polgar
- Department of Medical Microbiology and Immunology, Medical School, University of Pecs, Pecs, Hungary; Janos Szentagothai Research Centre, Pecs, Hungary
| | - Timea Balassa
- Department of Medical Biology and Central Electron Microscope Laboratory, Medical School, University of Pecs, Pecs, Hungary
| | - Bela Kocsis
- Department of Medical Microbiology and Immunology, Medical School, University of Pecs, Pecs, Hungary
| | - Zoltan Peterfi
- 1st Department of Medicine, Division of infectious diseases, Medical School, University of Pecs, Pecs, Hungary
| | - Eva Miko
- Department of Medical Microbiology and Immunology, Medical School, University of Pecs, Pecs, Hungary; Janos Szentagothai Research Centre, Pecs, Hungary.
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9
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Emele MF, Joppe FM, Riedel T, Overmann J, Rupnik M, Cooper P, Kusumawati RL, Berger FK, Laukien F, Zimmermann O, Bohne W, Groß U, Bader O, Zautner AE. Proteotyping of Clostridioides difficile as Alternate Typing Method to Ribotyping Is Able to Distinguish the Ribotypes RT027 and RT176 From Other Ribotypes. Front Microbiol 2019; 10:2087. [PMID: 31552001 PMCID: PMC6747054 DOI: 10.3389/fmicb.2019.02087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 08/23/2019] [Indexed: 12/17/2022] Open
Abstract
Clostridioides difficile, a Gram-positive spore-forming bacterium, is the leading cause of nosocomial diarrhea worldwide and therefore a substantial burden to the healthcare system. During the past decade, hypervirulent PCR-ribotypes (RT) e.g., RT027 or RT176 emerged rapidly all over the world, associated with both, increased severity and mortality rates. It is thus of great importance to identify epidemic strains such as RT027 and RT176 as fast as possible. While commonly used diagnostic methods, e.g., multilocus sequence typing (MLST) or PCR-ribotyping, are time-consuming, proteotyping offers a fast, inexpensive, and reliable alternative solution. In this study, we established a MALDI-TOF-based typing scheme for C. difficile. A total of 109 ribotyped strains representative for five MLST clades were analyzed by MALDI-TOF. MLST, based on whole genome sequences, and PCR-ribotyping were used as reference methods. Isoforms of MS-detectable biomarkers, typically ribosomal proteins, were related with the deduced amino acid sequences and added to the C. difficile proteotyping scheme. In total, we were able to associate nine biomarkers with their encoding genes and include them in our proteotyping scheme. The discriminatory capacity of the C. difficile proteotyping scheme was mainly based on isoforms of L28-M (2 main isoforms), L35-M (4 main isoforms), and S20-M (2 main isoforms) giving rise to at least 16 proteotyping-derived types. In our test population, five of these 16 proteotyping-derived types were detected. These five proteotyping-derived types did not correspond exactly to the included five MLST-based C. difficile clades, nevertheless the subtyping depth of both methods was equivalent. Most importantly, proteotyping-derived clade B contained only isolates of the hypervirulent RT027 and RT176. Proteotyping is a stable and easy-to-perform intraspecies typing method and a promising alternative to currently used molecular techniques. It is possible to distinguish the group of RT027 and RT176 isolates from non-RT027/non-RT176 isolates using proteotyping, providing a valuable diagnostic tool.
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Affiliation(s)
- Matthias F Emele
- Institut für Medizinische Mikrobiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Felix M Joppe
- Institut für Medizinische Mikrobiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Thomas Riedel
- Leibniz-Institut DSMZ-Deutsche Sammlung von Mikroorganismen und Zellkulturen GmbH, Braunschweig, Germany.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Hannover-Braunschweig, Braunschweig, Germany
| | - Jörg Overmann
- Leibniz-Institut DSMZ-Deutsche Sammlung von Mikroorganismen und Zellkulturen GmbH, Braunschweig, Germany.,Deutsches Zentrum für Infektionsforschung (DZIF), Standort Hannover-Braunschweig, Braunschweig, Germany
| | - Maja Rupnik
- National Laboratory for Health, Environment and Food (NLZOH), Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | | | - R Lia Kusumawati
- Department of Microbiology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Fabian K Berger
- National Reference Center for Clostridioides (Clostridium) difficile, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Friederike Laukien
- Institut für Medizinische Mikrobiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Ortrud Zimmermann
- Institut für Medizinische Mikrobiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Wolfgang Bohne
- Institut für Medizinische Mikrobiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Uwe Groß
- Institut für Medizinische Mikrobiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Oliver Bader
- Institut für Medizinische Mikrobiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Andreas E Zautner
- Institut für Medizinische Mikrobiologie, Universitätsmedizin Göttingen, Göttingen, Germany
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10
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Pizarro-Guajardo M, Ravanal MC, Paez MD, Callegari E, Paredes-Sabja D. Identification of Clostridium difficile Immunoreactive Spore Proteins of the Epidemic Strain R20291. Proteomics Clin Appl 2018; 12:e1700182. [PMID: 29573213 DOI: 10.1002/prca.201700182] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 01/25/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE Clostridium difficile infections are the leading cause of diarrhea associated with the use of antibiotics. During infection, C. difficile initiates a sporulation cycle leading to the persistence of C. difficile spores in the host and disease dissemination. The development of vaccine and passive immunization therapies against C. difficile has focused on toxins A and B. In this study, an immunoproteome-based approach to identify immunogenic proteins located on the outer layers of C. difficile spores as potential candidates for the development of immunotherapy and/or diagnostic methods against this devastating infection is used. EXPERIMENTAL DESIGN To identify potential immunogenic proteins on the surface of C. difficile R20291, spore coat/exosporium extracts are separated by 2D electrophoresis (2-DE) and analyzed for reactivity against C. difficile spore-specific goat sera. Finally, the selected spots are in-gel digested with chymotrypsin, peptides generated are separated by nanoUPLC followed by MS/MS using Quad-TOF-MS, corroborated by Ultimate 3000RS-nano-UHPLC coupled to Q-Exactive-Plus-Orbitrap MS. RESULTS The analysis identify five immunoreactive proteins: spore coat proteins CotE, CotA, and CotCB; exosporium protein CdeC; and a cytosolic methyltransferase. CONCLUSION This data provides a list of spore surface protein candidates as antigens for vaccine development against C. difficile infections.
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Affiliation(s)
- Marjorie Pizarro-Guajardo
- Microbiota-Host Interactions and Clostridia Research Group, Facultad de Ciencias Biológicas, Department of Biological Sciences, Universidad Andrés Bello, Santiago, 8370146, Chile
| | - María Cristina Ravanal
- Center for Bioinformatics and Integrative Biology, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, 8370146, Chile.,Instituto de Ciencia y Tecnología de los Alimentos, Facultad de Ciencias Agrarias, Universidad Austral de Chile, Isla Teja, Valdivia, 5090000, Chile
| | - Maria Daniela Paez
- SD-BRIN Proteomics Core Facility, Sanford School of Medicine, University of South Dakota,, Vermillion, SD, 57069, USA
| | - Eduardo Callegari
- SD-BRIN Proteomics Core Facility, Sanford School of Medicine, University of South Dakota,, Vermillion, SD, 57069, USA
| | - Daniel Paredes-Sabja
- Microbiota-Host Interactions and Clostridia Research Group, Facultad de Ciencias Biológicas, Department of Biological Sciences, Universidad Andrés Bello, Santiago, 8370146, Chile
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11
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Aktories K, Papatheodorou P, Schwan C. Binary Clostridium difficile toxin (CDT) - A virulence factor disturbing the cytoskeleton. Anaerobe 2018. [PMID: 29524654 DOI: 10.1016/j.anaerobe.2018.03.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clostridium difficile infection causes antibiotics-associated diarrhea and pseudomembranous colitis. Major virulence factors of C. difficile are the Rho-glucosylating toxins TcdA and TcdB. In addition, many, so-called hypervirulent C. difficile strains produce the binary actin-ADP-ribosylating toxin CDT. CDT causes depolymerization of F-actin and rearrangement of the actin cytoskeleton. Thereby, many cellular functions, which depend on actin, are altered. CDT disturbs the dynamic balance between actin and microtubules in target cells. The toxin increases microtubule polymerization and induces the formation of microtubule-based protrusions at the plasma membrane of target cells. Moreover, CDT causes a redistribution of vesicles from the basolateral side to the apical side, where extracellular matrix proteins are released. These processes may increase the adherence of clostridia to target cells. Here, we review the effects of the action of CDT on the actin cytoskeleton and on the microtubule system.
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Affiliation(s)
- Klaus Aktories
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Albertstr. 25, 79104 Freiburg, Germany; Centre for Biological Signalling Studies (BIOSS), University of Freiburg, 79104 Freiburg, Germany.
| | - Panagiotis Papatheodorou
- Faculty of Natural Sciences, University of Ulm, 89081 Ulm, Germany; Institute of Pharmacology and Toxicology, University of Ulm Medical Center, Albert-Einstein-Allee 11, 89081 Ulm, Germany
| | - Carsten Schwan
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Albertstr. 25, 79104 Freiburg, Germany
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12
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Yang HT, Chen JW, Rathod J, Jiang YZ, Tsai PJ, Hung YP, Ko WC, Paredes-Sabja D, Huang IH. Lauric Acid Is an Inhibitor of Clostridium difficile Growth in Vitro and Reduces Inflammation in a Mouse Infection Model. Front Microbiol 2018; 8:2635. [PMID: 29387044 PMCID: PMC5776096 DOI: 10.3389/fmicb.2017.02635] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 12/18/2017] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile is a Gram-positive, spore-forming anaerobic human gastrointestinal pathogen. C. difficile infection (CDI) is a major health concern worldwide, with symptoms ranging from diarrhea to pseudomembranous colitis, toxic megacolon, sepsis, and death. CDI onset and progression are mostly caused by intestinal dysbiosis and exposure to C. difficile spores. Current treatment strategies include antibiotics; however, antibiotic use is often associated with high recurrence rates and an increased risk of antibiotic resistance. Medium-chain fatty acids (MCFAs) have been revealed to inhibit the growth of multiple human bacterial pathogens. Components of coconut oil, which include lauric acid, have been revealed to inhibit C. difficile growth in vitro. In this study, we demonstrated that lauric acid exhibits potent antimicrobial activities against multiple toxigenic C. difficile isolates in vitro. The inhibitory effect of lauric acid is partly due to reactive oxygen species (ROS) generation and cell membrane damage. The administration of lauric acid considerably reduced biofilm formation and preformed biofilms in a dose-dependent manner. Importantly, in a mouse infection model, lauric acid pretreatment reduced CDI symptoms and proinflammatory cytokine production. Our combined results suggest that the naturally occurring MCFA lauric acid is a novel C. difficile inhibitor and is useful in the development of an alternative or adjunctive treatment for CDI.
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Affiliation(s)
- Hsiao-Ting Yang
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jenn-Wei Chen
- 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
| | - Jagat Rathod
- Department of Earth Sciences, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Zhen Jiang
- Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Jane Tsai
- Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
- Graduate Institute of Clinical Medicine, National Cheng Kung University Hospital, Tainan, 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
| | - Daniel Paredes-Sabja
- Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - 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
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13
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Pakpour S, Bhanvadia A, Zhu R, Amarnani A, Gibbons SM, Gurry T, Alm EJ, Martello LA. Identifying predictive features of Clostridium difficile infection recurrence before, during, and after primary antibiotic treatment. MICROBIOME 2017; 5:148. [PMID: 29132405 PMCID: PMC5684761 DOI: 10.1186/s40168-017-0368-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/01/2017] [Indexed: 05/03/2023]
Abstract
BACKGROUND Colonization by the pathogen Clostridium difficile often occurs in the background of a disrupted microbial community. Identifying specific organisms conferring resistance to invasion by C. difficile is desirable because diagnostic and therapeutic strategies based on the human microbiota have the potential to provide more precision to the management and treatment of Clostridium difficile infection (CDI) and its recurrence. METHODS We conducted a longitudinal study of adult patients diagnosed with their first CDI. We investigated the dynamics of the gut microbiota during antibiotic treatment, and we used microbial or demographic features at the time of diagnosis, or after treatment, to predict CDI recurrence. To check the validity of the predictions, a meta-analysis using a previously published dataset was performed. RESULTS We observed that patients' microbiota "before" antibiotic treatment was predictive of disease relapse, but surprisingly, post-antibiotic microbial community is indistinguishable between patients that recur or not. At the individual OTU level, we identified Veillonella dispar as a candidate organism for preventing CDI recurrence; however, we did not detect a corresponding signal in the conducted meta-analysis. CONCLUSION Although in our patient population, a candidate organism was identified for negatively predicting CDI recurrence, results suggest the need for larger cohort studies that include patients with diverse demographic characteristics to generalize species that robustly confer colonization resistance against C. difficile and accurately predict disease relapse.
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Affiliation(s)
- Sepideh Pakpour
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
| | - Amit Bhanvadia
- Division of Digestive Diseases, Lenox Hill Hospital/Northwell Health, New York, NY USA
- Medicine, SUNY Downstate Medical Center, Brooklyn, NY USA
| | - Roger Zhu
- Surgery, NewYork-Presbyterian/Queens, Flushing, NY USA
- Medicine, SUNY Downstate Medical Center, Brooklyn, NY USA
| | | | - Sean M. Gibbons
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
| | - Thomas Gurry
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
| | - Eric J. Alm
- Genome Sequencing and Analysis Program, Broad Institute, Cambridge, MA USA
- Department of Biological Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA USA
- MIT Center for Microbiome Informatics and Therapeutics, Cambridge, MA USA
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14
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Chandrasekaran R, Lacy DB. The role of toxins in Clostridium difficile infection. FEMS Microbiol Rev 2017; 41:723-750. [PMID: 29048477 PMCID: PMC5812492 DOI: 10.1093/femsre/fux048] [Citation(s) in RCA: 196] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/10/2017] [Indexed: 02/06/2023] Open
Abstract
Clostridium difficile is a bacterial pathogen that is the leading cause of nosocomial antibiotic-associated diarrhea and pseudomembranous colitis worldwide. The incidence, severity, mortality and healthcare costs associated with C. difficile infection (CDI) are rising, making C. difficile a major threat to public health. Traditional treatments for CDI involve use of antibiotics such as metronidazole and vancomycin, but disease recurrence occurs in about 30% of patients, highlighting the need for new therapies. The pathogenesis of C. difficile is primarily mediated by the actions of two large clostridial glucosylating toxins, toxin A (TcdA) and toxin B (TcdB). Some strains produce a third toxin, the binary toxin C. difficile transferase, which can also contribute to C. difficile virulence and disease. These toxins act on the colonic epithelium and immune cells and induce a complex cascade of cellular events that result in fluid secretion, inflammation and tissue damage, which are the hallmark features of the disease. In this review, we summarize our current understanding of the structure and mechanism of action of the C. difficile toxins and their role in disease.
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Affiliation(s)
- Ramyavardhanee Chandrasekaran
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - D. Borden Lacy
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
- The Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN 37232, USA
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15
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Pizarro-Guajardo M, Díaz-González F, Álvarez-Lobos M, Paredes-Sabja D. Characterization of Chicken IgY Specific to Clostridium difficile R20291 Spores and the Effect of Oral Administration in Mouse Models of Initiation and Recurrent Disease. Front Cell Infect Microbiol 2017; 7:365. [PMID: 28856119 PMCID: PMC5557795 DOI: 10.3389/fcimb.2017.00365] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/28/2017] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) are the leading cause of world-wide nosocomial acquired diarrhea. The current main clinical challenge in CDI is the elevated rate of infection recurrence that may reach up to 30% of the patients, which has been associated to the formation of dormant spores during the infection. We sought to characterize the effects of oral administration of specific anti-spore IgY in mouse models of CDI and recurrent CDI. The specificity of anti-spore IgY was evaluated in vitro. In both, initiation mouse model and recurrence mouse model, we evaluated the prophylactic and therapeutic effect of anti-spore IgY, respectively. Our results demonstrate that anti-spore IgY exhibited high specificity and titers against C. difficile spores and reduced spore adherence to intestinal cells in vitro. Administration of anti-spore IgY to C57BL/6 mice prior and during CDI delayed the appearance of the diarrhea by 1.5 day, and spore adherence to the colonic mucosa by 90%. Notably, in the recurrence model, co-administration of anti-spore IgY coupled with vancomycin delayed the appearance of recurrent diarrhea by a median of 2 days. Collectively, these observations suggest that anti-spore IgY antibodies may be used as a novel prophylactic treatment for CDI, or in combination with antibiotics to treat CDI and prevent recurrence of the infection.
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Affiliation(s)
- Marjorie Pizarro-Guajardo
- Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biologicas, Universidad Andres BelloSantiago, Chile
| | - Fernando Díaz-González
- Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biologicas, Universidad Andres BelloSantiago, Chile
| | - Manuel Álvarez-Lobos
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad CatólicaSantiago, Chile
| | - Daniel Paredes-Sabja
- Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biologicas, Universidad Andres BelloSantiago, Chile
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16
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Wang F, Huang ZA, Chen X, Zhu Z, Wen Z, Zhao J, Yan GY. LRLSHMDA: Laplacian Regularized Least Squares for Human Microbe-Disease Association prediction. Sci Rep 2017; 7:7601. [PMID: 28790448 PMCID: PMC5548838 DOI: 10.1038/s41598-017-08127-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 07/04/2017] [Indexed: 02/08/2023] Open
Abstract
An increasing number of evidences indicate microbes are implicated in human physiological mechanisms, including complicated disease pathology. Some microbes have been demonstrated to be associated with diverse important human diseases or disorders. Through investigating these disease-related microbes, we can obtain a better understanding of human disease mechanisms for advancing medical scientific progress in terms of disease diagnosis, treatment, prevention, prognosis and drug discovery. Based on the known microbe-disease association network, we developed a semi-supervised computational model of Laplacian Regularized Least Squares for Human Microbe-Disease Association (LRLSHMDA) by introducing Gaussian interaction profile kernel similarity calculation and Laplacian regularized least squares classifier. LRLSHMDA reached the reliable AUCs of 0.8909 and 0.7657 based on the global and local leave-one-out cross validations, respectively. In the framework of 5-fold cross validation, average AUC value of 0.8794 +/-0.0029 further demonstrated its promising prediction ability. In case studies, 9, 9 and 8 of top-10 predicted microbes have been manually certified to be associated with asthma, colorectal carcinoma and chronic obstructive pulmonary disease by published literature evidence. Our proposed model achieves better prediction performance relative to the previous model. We expect that LRLSHMDA could offer insights into identifying more promising human microbe-disease associations in the future.
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Affiliation(s)
- Fan Wang
- School of Mechatronic Engineering, China University of Mining and Technology, Xuzhou, 221116, China
- Jiangsu Key Laboratory of Mine Mechanical and Electrical Equipment, China University of Mining and Technology, Xuzhou, 221116, China
| | - Zhi-An Huang
- College of Computer Science and Software Engineering, Shenzhen University, Shenzhen, 518060, China
| | - Xing Chen
- School of Information and Control Engineering, China University of Mining and Technology, Xuzhou, 221116, China.
| | - Zexuan Zhu
- College of Computer Science and Software Engineering, Shenzhen University, Shenzhen, 518060, China.
| | - Zhenkun Wen
- College of Computer Science and Software Engineering, Shenzhen University, Shenzhen, 518060, China
| | - Jiyun Zhao
- School of Mechatronic Engineering, China University of Mining and Technology, Xuzhou, 221116, China
| | - Gui-Ying Yan
- Academy of Mathematics and Systems Science, Chinese Academy of Sciences, Beijing, 100190, China
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17
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Amino Acid Differences in the 1753-to-1851 Region of TcdB Influence Variations in TcdB1 and TcdB2 Cell Entry. mSphere 2017; 2:mSphere00268-17. [PMID: 28776043 PMCID: PMC5541160 DOI: 10.1128/msphere.00268-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/13/2017] [Indexed: 01/24/2023] Open
Abstract
Clostridium difficile TcdB2 enters cells with a higher efficiency than TcdB1 and exhibits an overall higher level of toxicity. However, the TcdB2-specific sequences that account for more efficient cell entry have not been reported. In this study, we examined the contribution of carboxy-terminal sequence differences to TcdB activity by comparing the binding, uptake, and endosomal localization of TcdB1 and TcdB2 or selected recombinant fragments of these proteins. Our findings suggest that sequence differences in the amino acid 1753 to 1851 region proximal to the combined repetitive oligopeptide domain (CROP) support enhanced uptake of TcdB2 and localization of toxin in acidified endosomes. In the absence of this region, the CROP domains of both forms of the toxin exhibited similar levels of cell interaction, while the addition of amino acids 1753 to 1851 greatly increased toxin binding by only TcdB2. Moreover, the amino acid 1753 to 2366 fragment of TcdB2, but not TcdB1, accumulated to detectable levels in acidified endosomes. Unexpectedly, we discovered an unusual relationship between endocytosis and the efficiency of cell binding for TcdB1 and TcdB2 wherein inhibition of endocytosis by a chemical inhibitor or incubation at a low temperature resulted in a dramatic reduction in cell binding. These findings provide information on sequence variations that may contribute to differences in TcdB1 and TcdB2 toxicity and reveal a heretofore unknown connection between endocytosis and cell binding for this toxin. IMPORTANCE TcdB is a major virulence factor produced by Clostridium difficile, a leading cause of antibiotic-associated diarrhea. Hypervirulent strains of C. difficile encode a variant of TcdB (TcdB2) that is more toxic than toxin derived from historical strains (TcdB1). Though TcdB1 and TcdB2 exhibit 92% overall identity, a 99-amino-acid region previously associated with cell entry and spanning amino acids 1753 to 1851 has only 77% sequence identity. Results from the present study indicate that the substantial sequence variation in this region could contribute to the differences in cell entry between TcdB1 and TcdB2 and possibly explain TcdB2's heightened toxicity. Finally, during the course of these studies, an unusual aspect of TcdB cell entry was discovered wherein cell binding appeared to depend on endocytosis. These findings provide insight into TcdB's variant forms and their mechanisms of cell entry.
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18
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Abstract
Clostridium difficile infections (CDIs) have emerged as one of the principal threats to the health of hospitalized and immunocompromised patients. The importance of C difficile colonization is increasingly recognized not only as a source for false-positive clinical testing but also as a source of new infections within hospitals and other health care environments. In the last five years, several new treatment strategies that capitalize on the increasing understanding of the altered microbiome and host defenses in patients with CDI have completed clinical trials, including fecal microbiota transplantation. This article highlights the changing epidemiology, laboratory diagnostics, pathogenesis, and treatment of CDI.
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19
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Vargas E, Apewokin S, Madan R. Role of the leukocyte response in normal and immunocompromised host after Clostridium difficile infection. Anaerobe 2017; 45:101-105. [PMID: 28223256 DOI: 10.1016/j.anaerobe.2017.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/09/2017] [Accepted: 02/15/2017] [Indexed: 02/07/2023]
Abstract
Clostridium difficile is the leading cause of healthcare-associated infections in the United States. Clinically, C. difficile-associated disease can present as asymptomatic colonization, self-limited diarrheal illness or severe colitis (that may result in death). This variability in disease course and outcomes suggests that host factors play an important role as key determinants of disease severity. Currently, there are several scoring indices to estimate severity of C. difficile-associated disease. Leukocytosis and renal failure are considered to be the most important predictors of C. difficile disease severity in hosts with a normal immune system. The degree of leukocytosis which is considered significant for severe disease and how it is scored vary amongst scoring indices. None of the scores have been prospectively validated, and while total WBC count is useful to estimate the magnitude of the host response in most patient populations, in immune-compromised patients like those receiving chemotherapy, solid organ transplant patients or hematopoietic stem cell transplants the WBC response can be variable or even absent making this marker of severity difficult to interpret. Other cellular subsets like neutrophils, eosinophils and lymphocytes provide important information about the host immune status and play an important role in the immune response against C. difficile infection. However, under the current scoring systems the role of these cellular subsets have been underestimated and only total white blood cell counts are taken into account. In this review we highlight the role of host leukocyte response to C. difficile challenge in the normal and immunocompromised host, and propose possible ways that would allow for a better representation of the different immune cell subsets (neutrophils, lymphocytes and eosinophils) in the current scoring indices.
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Affiliation(s)
- Edwin Vargas
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, 231 Albert Sabin Way, MSB 6109, ML 0560, Cincinnati, OH 45267, USA.
| | - Senu Apewokin
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, 231 Albert Sabin Way, MSB 6109, ML 0560, Cincinnati, OH 45267, USA
| | - Rajat Madan
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, 231 Albert Sabin Way, MSB 6109, ML 0560, Cincinnati, OH 45267, USA
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20
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Secore S, Wang S, Doughtry J, Xie J, Miezeiewski M, Rustandi RR, Horton M, Xoconostle R, Wang B, Lancaster C, Kristopeit A, Wang SC, Christanti S, Vitelli S, Gentile MP, Goerke A, Skinner J, Strable E, Thiriot DS, Bodmer JL, Heinrichs JH. Development of a Novel Vaccine Containing Binary Toxin for the Prevention of Clostridium difficile Disease with Enhanced Efficacy against NAP1 Strains. PLoS One 2017; 12:e0170640. [PMID: 28125650 PMCID: PMC5268477 DOI: 10.1371/journal.pone.0170640] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 01/06/2017] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infections (CDI) are a leading cause of nosocomial diarrhea in the developed world. The main virulence factors of the bacterium are the large clostridial toxins (LCTs), TcdA and TcdB, which are largely responsible for the symptoms of the disease. Recent outbreaks of CDI have been associated with the emergence of hypervirulent strains, such as NAP1/BI/027, many strains of which also produce a third toxin, binary toxin (CDTa and CDTb). These hypervirulent strains have been associated with increased morbidity and higher mortality. Here we present pre-clinical data describing a novel tetravalent vaccine composed of attenuated forms of TcdA, TcdB and binary toxin components CDTa and CDTb. We demonstrate, using the Syrian golden hamster model of CDI, that the inclusion of binary toxin components CDTa and CDTb significantly improves the efficacy of the vaccine against challenge with NAP1 strains in comparison to vaccines containing only TcdA and TcdB antigens, while providing comparable efficacy against challenge with the prototypic, non-epidemic strain VPI10463. This combination vaccine elicits high neutralizing antibody titers against TcdA, TcdB and binary toxin in both hamsters and rhesus macaques. Finally we present data that binary toxin alone can act as a virulence factor in animal models. Taken together, these data strongly support the inclusion of binary toxin in a vaccine against CDI to provide enhanced protection from epidemic strains of C. difficile.
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Affiliation(s)
- Susan Secore
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Su Wang
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Julie Doughtry
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Jinfu Xie
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Matt Miezeiewski
- Eurofins Laboratories, Lancaster, Pennsylvania, United States of America
| | - Richard R. Rustandi
- Vaccine Analytical Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Melanie Horton
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Rachel Xoconostle
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Bei Wang
- Vaccine Drug Product Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Catherine Lancaster
- Vaccine Analytical Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Adam Kristopeit
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Sheng-Ching Wang
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Sianny Christanti
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Salvatore Vitelli
- Vaccine Analytical Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Marie-Pierre Gentile
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Aaron Goerke
- Vaccine Process Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Julie Skinner
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Erica Strable
- Vaccine Drug Product Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - David S. Thiriot
- Vaccine Drug Product Development, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Jean-Luc Bodmer
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
| | - Jon H. Heinrichs
- Vaccine Basic Research, Merck Research Laboratories, Merck and Company, Incorporated, West Point, Pennsylvania, United States of America
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Stone NE, Sidak-Loftis LC, Sahl JW, Vazquez AJ, Wiggins KB, Gillece JD, Hicks ND, Schupp JM, Busch JD, Keim P, Wagner DM. More than 50% of Clostridium difficile Isolates from Pet Dogs in Flagstaff, USA, Carry Toxigenic Genotypes. PLoS One 2016; 11:e0164504. [PMID: 27723795 PMCID: PMC5056695 DOI: 10.1371/journal.pone.0164504] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/26/2016] [Indexed: 12/18/2022] Open
Abstract
Nosocomial acquisition of Clostridium difficile is well documented, yet recent studies have highlighted the importance of community acquired infections and identified community associated reservoirs for this pathogen. Multiple studies have implicated companion pets and farm animals as possible sources of community acquired C. difficile infections in humans. To explore the potential role of pet dogs in human C. difficile infections we systematically collected canine fecal samples (n = 197) in Flagstaff, AZ. Additionally, nineteen fecal samples were collected at a local veterinary clinic from diarrheic dogs. We used these combined samples to investigate important questions regarding C. difficile colonization in pet canines: 1) What is the prevalence and diversity of C. difficile in this companion pet population, and 2) Do C. difficile isolates collected from canines genetically overlap with isolates that cause disease in humans? We used a two-step sequence typing approach, including multilocus sequence typing to determine the overall genetic diversity of C. difficile present in Flagstaff canines, and whole-genome sequencing to assess the fine-scale diversity patterns within identical multilocus sequence types from isolates obtained within and among multiple canine hosts. We detected C. difficile in 17% of the canine fecal samples with 10% containing toxigenic strains that are known to cause human disease. Sequencing analyses revealed similar genotypes in dogs and humans. These findings suggest that companion pets are a potential source of community acquired C. difficile infections in humans.
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Affiliation(s)
- Nathan E. Stone
- Center for Microbial Genetics and Genomics, Northern Arizona University, Flagstaff, AZ, 86011, United States of America
| | - Lindsay C. Sidak-Loftis
- Center for Microbial Genetics and Genomics, Northern Arizona University, Flagstaff, AZ, 86011, United States of America
| | - Jason W. Sahl
- Center for Microbial Genetics and Genomics, Northern Arizona University, Flagstaff, AZ, 86011, United States of America
| | - Adam J. Vazquez
- Center for Microbial Genetics and Genomics, Northern Arizona University, Flagstaff, AZ, 86011, United States of America
| | - Kristin B. Wiggins
- Translational Genomics Research Institute, Flagstaff, AZ, 86001, United States of America
| | - John D. Gillece
- Translational Genomics Research Institute, Flagstaff, AZ, 86001, United States of America
| | - Nathan D. Hicks
- Translational Genomics Research Institute, Flagstaff, AZ, 86001, United States of America
| | - James M. Schupp
- Translational Genomics Research Institute, Flagstaff, AZ, 86001, United States of America
| | - Joseph D. Busch
- Center for Microbial Genetics and Genomics, Northern Arizona University, Flagstaff, AZ, 86011, United States of America
| | - Paul Keim
- Center for Microbial Genetics and Genomics, Northern Arizona University, Flagstaff, AZ, 86011, United States of America
- Translational Genomics Research Institute, Flagstaff, AZ, 86001, United States of America
| | - David M. Wagner
- Center for Microbial Genetics and Genomics, Northern Arizona University, Flagstaff, AZ, 86011, United States of America
- * E-mail:
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Mora-Uribe P, Miranda-Cárdenas C, Castro-Córdova P, Gil F, Calderón I, Fuentes JA, Rodas PI, Banawas S, Sarker MR, Paredes-Sabja D. Characterization of the Adherence of Clostridium difficile Spores: The Integrity of the Outermost Layer Affects Adherence Properties of Spores of the Epidemic Strain R20291 to Components of the Intestinal Mucosa. Front Cell Infect Microbiol 2016; 6:99. [PMID: 27713865 PMCID: PMC5031699 DOI: 10.3389/fcimb.2016.00099] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 08/29/2016] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile is the causative agent of the most frequently reported nosocomial diarrhea worldwide. The high incidence of recurrent infection is the main clinical challenge of C. difficile infections (CDI). Formation of C. difficile spores of the epidemic strain R20291 has been shown to be essential for recurrent infection and transmission of the disease in a mouse model. However, the underlying mechanisms of how these spores persist in the colonic environment remains unclear. In this work, we characterized the adherence properties of epidemic R20291 spores to components of the intestinal mucosa, and we assessed the role of the exosporium integrity in the adherence properties by using cdeC mutant spores with a defective exosporium layer. Our results showed that spores and vegetative cells of the epidemic R20291 strain adhered at high levels to monolayers of Caco-2 cells and mucin. Transmission electron micrographs of Caco-2 cells demonstrated that the hair-like projections on the surface of R20291 spores are in close proximity with the plasma membrane and microvilli of undifferentiated and differentiated monolayers of Caco-2 cells. Competitive-binding assay in differentiated Caco-2 cells suggests that spore-adherence is mediated by specific binding sites. By using spores of a cdeC mutant we demonstrated that the integrity of the exosporium layer determines the affinity of adherence of C. difficile spores to Caco-2 cells and mucin. Binding of fibronectin and vitronectin to the spore surface was concentration-dependent, and depending on the concentration, spore-adherence to Caco-2 cells was enhanced. In the presence of an aberrantly-assembled exosporium (cdeC spores), binding of fibronectin, but not vitronectin, was increased. Notably, independent of the exosporium integrity, only a fraction of the spores had fibronectin and vitronectin molecules binding to their surface. Collectively, these results demonstrate that the integrity of the exosporium layer of strain R20291 contributes to selective spore adherence to components of the intestinal mucosa.
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Affiliation(s)
- Paola Mora-Uribe
- Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres BelloSantiago, Chile; Center for Bioinformatics and Integrative Biology, Facultad de Ciencias Biológicas, Universidad Andres BelloSantiago, Chile
| | - Camila Miranda-Cárdenas
- Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello Santiago, Chile
| | - Pablo Castro-Córdova
- Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres BelloSantiago, Chile; Center for Bioinformatics and Integrative Biology, Facultad de Ciencias Biológicas, Universidad Andres BelloSantiago, Chile
| | - Fernando Gil
- Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello Santiago, Chile
| | - Iván Calderón
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello Santiago, Chile
| | - Juan A Fuentes
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello Santiago, Chile
| | - Paula I Rodas
- Facultad de Medicina, Center for Integrative Medicine and Innovative Sciences, Universidad Andres Bello Santiago, Chile
| | - Saeed Banawas
- Department of Biomedical Sciences, Oregon State UniversityCorvallis, OR, USA; Medical Laboratories Department, College of Science Al-Zulfi, Majmaah UniversityAl Majma'ah, Saudi Arabia
| | - Mahfuzur R Sarker
- Department of Biomedical Sciences, Oregon State University Corvallis, OR, USA
| | - Daniel Paredes-Sabja
- Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres BelloSantiago, Chile; Center for Bioinformatics and Integrative Biology, Facultad de Ciencias Biológicas, Universidad Andres BelloSantiago, Chile
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Ultrastructure Variability of the Exosporium Layer of Clostridium difficile Spores from Sporulating Cultures and Biofilms. Appl Environ Microbiol 2016; 82:5892-8. [PMID: 27474709 DOI: 10.1128/aem.01463-16] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 07/07/2016] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED The anaerobic sporeformer Clostridium difficile is the leading cause of nosocomial antibiotic-associated diarrhea in developed and developing countries. The metabolically dormant spore form is considered the morphotype responsible for transmission, infection, and persistence, and the outermost exosporium layer is likely to play a major role in spore-host interactions during recurrent infections, contributing to the persistence of the spore in the host. A recent study (M. Pizarro-Guajardo, P. Calderón-Romero, P. Castro-Córdova, P. Mora-Uribe, and D. Paredes-Sabja, Appl Environ Microbiol 82:2202-2209, 2016, http://dx.doi.org/10.1128/AEM.03410-15) demonstrated by transmission electron microscopy the presence of two ultrastructural morphotypes of the exosporium layer in spores formed from the same sporulating culture. However, whether these distinct morphotypes appeared due to purification techniques and whether they appeared during biofilm development remain unclear. In this communication, we demonstrate through transmission electron microscopy that these two exosporium morphotypes are formed under sporulation conditions and are also present in spores formed during biofilm development. In summary, this work provides definitive evidence that in a population of sporulating cells, spores with a thick outermost exosporium layer and spores with a thin outermost exosporium layer are formed. IMPORTANCE Clostridium difficile spores are recognized as the morphotype of persistence and transmission of C. difficile infections. Spores of C. difficile are intrinsically resistant to all known antibiotic therapies. Development of spore-based removal strategies requires a detailed knowledge of the spore surface for proper antigen selection. In this context, in this work we provide definitive evidence that two types of spores, those with a thick outermost exosporium layer and those with a thin outermost exosporium layer, are formed in the same C. difficile sporulating culture or during biofilm development.
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Lee HC, Kim KO, Jeong YH, Lee SH, Jang BI, Kim TN. Clinical Outcomes in Hospitalized Patients withClostridium difficileInfection by Age Group. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 67:81-6. [DOI: 10.4166/kjg.2016.67.2.81] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ho Chan Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyeong Ok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Yo Han Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Si Hyung Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Byung Ik Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Nyeun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Plaza-Garrido Á, Miranda-Cárdenas C, Castro-Córdova P, Olguín-Araneda V, Cofré-Araneda G, Hernández-Rocha C, Carman R, Ibáñez P, Fawley WN, Wilcox MH, Gil F, Calderón IL, Fuentes JA, Guzmán-Durán AM, Alvarez-Lobos M, Paredes-Sabja D. Outcome of relapsing Clostridium difficile infections do not correlate with virulence-, spore- and vegetative cell-associated phenotypes. Anaerobe 2015; 36:30-8. [PMID: 26403333 DOI: 10.1016/j.anaerobe.2015.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 08/14/2015] [Accepted: 09/15/2015] [Indexed: 02/08/2023]
Abstract
One of the main clinical challenges of Clostridium difficile infections (CDI) is the high rate of relapse episodes. The main determinants involved in relapse of CDI include the presence of antibiotic-resistant C. difficile spores in the colonic environment and a permanent state of dysbiosis of the microbiota caused by antibiotic therapy. A possible scenario is that phenotypes related to the persistence of C. difficile spores might contribute to relapsing infections. In this study, 8 C. difficile isolates recovered from 4 cases with relapsing infection, and 9 isolates recovered from single infection cases were analyzed for PCR ribotyping and the presence of tcdA, tcdB and cdtAB genes. Factors associated to spore persistence, sporulation, spore adherence and biofilm formation and sporulation during biofilm formation were characterized. We also evaluated motility and cytotoxicity. However, we observed no significant difference in the analyzed phenotypes among the different clinical outcomes, most likely due to the high variability observed among strains within clinical backgrounds in each phenotype and the small sample size. It is noteworthy that C. difficile spores adhered to similar extents to undifferentiated and differentiated Caco-2 cells. By contrast, spores of all clinical isolates tested had increased germination efficiency in presence of taurocholate, while decreased sporulation rate during biofilm development in the presence of glucose. In conclusion, these results show that, at least in this cohort of patients, the described phenotypes are not detrimental in the clinical outcome of the disease.
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Affiliation(s)
- Ángela Plaza-Garrido
- Gut Microbiota and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - Camila Miranda-Cárdenas
- Gut Microbiota and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - Pablo Castro-Córdova
- Gut Microbiota and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - Valeria Olguín-Araneda
- Gut Microbiota and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - Glenda Cofré-Araneda
- Gut Microbiota and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - Cristian Hernández-Rocha
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Patricio Ibáñez
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Mark H Wilcox
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | - Fernando Gil
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - Iván L Calderón
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - Juan A Fuentes
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - Ana María Guzmán-Durán
- Laboratorio de Microbiología, Departamento de Laboratorio Clínico, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Manuel Alvarez-Lobos
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Daniel Paredes-Sabja
- Gut Microbiota and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile.
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26
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Vaishnavi C, Singh M, Mahmood S, Kochhar R. Prevalence and molecular types of Clostridium difficile isolates from faecal specimens of patients in a tertiary care centre. J Med Microbiol 2015; 64:1297-1304. [PMID: 26361995 DOI: 10.1099/jmm.0.000169] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile infection (CDI) leads to considerable morbidity and mortality among hospitalized patients. Faecal specimens from 1110 hospitalized patients suspected for CDI were cultured for isolation of C. difficile and characterization of virulence genes. PCR was carried out for toxigenic genes tcdA, tcdB, cdtA and cdtB and PCR-RFLP for fliC and slpA genes. Of 174 (15.7%) C. difficile isolates, 121 (69.5%) were toxigenic, amongst which 68 (56.2%) also had both tcdA and tcdB genes. The remaining 53 (43.8%) of the isolates also had at least one of the toxin genes. Binary toxin genes (cdtA and cdtB) with only one of the two components were present in 16 (9.2%) of the 174 isolates. The other virulence genes - fliC and slpA - were present in 100% of the isolates. The most frequent PCR-RFLP type of fliC gene was type I (n = 101), followed by type VII (n = 49) and type III (n = 24). The slpA gene presented with three combinations of patterns. Characterization of virulence genes in C. difficile isolates is of extreme importance for epidemiological surveillance and control of outbreaks owing to the capacity of this bacterium to adapt to new environmental circumstances, leading to the emergence of new epidemic strains.
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Affiliation(s)
- Chetana Vaishnavi
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Meenakshi Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Safrun Mahmood
- Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Mentula S, Laakso S, Lyytikäinen O, Kirveskari J. Differentiating virulent 027 and non-027 Clostridium difficile strains by molecular methods. Expert Rev Mol Diagn 2015; 15:1225-9. [PMID: 26289601 DOI: 10.1586/14737159.2015.1069710] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Hypervirulent Clostridium difficile clade has been shown to include several lineages of ribotype 027 and also other ribotypes. We present data on additional non-027 strains, identified as presumptive 027 by two commercial molecular C. difficile assays. METHODS The tested clinical isolates were selected from the national reference laboratory collection on the basis of toxin gene profile similarities with ribotype 027 and tested with XpertC. difficile/Epi and Amplidiag C. difficile+027 assay. RESULT Xpert misclassified five ribotypes (016, 019, 080, 176 and variant of type 046) as presumptive 027 and Amplidiag two ribotypes (016, 176). The misclassified strains were rare, covering 1.6% of reference laboratory strain collection. CONCLUSION Our findings confirm the concept that there are closely related outliers to hypervirulent 027 clones that can be misclassified as 027, and that these comprise numerous ribotypes, including previously reported four ribotypes (198, 176, 244, 019), and additional three (016, v046, 080) identified in the present study.
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Affiliation(s)
- Silja Mentula
- a 1 National Institute for Health and Welfare - Infectious Diseases, P.O. Box 30, Helsinki 00271, Finland
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Yamoudy M, Mirlohi M, Isfahani BN, Jalali M, Esfandiari Z, Hosseini NS. Isolation of toxigenic Clostridium difficile from ready-to-eat salads by multiplex polymerase chain reaction in Isfahan, Iran. Adv Biomed Res 2015; 4:87. [PMID: 26015913 PMCID: PMC4434448 DOI: 10.4103/2277-9175.156650] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 08/09/2014] [Indexed: 11/17/2022] Open
Abstract
Background: Since 2003, the incidence of community associated Clostridium difficile infection (CA-CDI) has increased; different types of food have been supposed to be the vectors of C. difficile strains. The purpose of this study is to investigate the occurrence of C. difficile strains in ready-to-eat salads distributed in food services. Materials and Methods: A total of 106 ready-made salad specimens were sampled from different restaurants and food services located in Isfahan, in the center of Iran. Positive isolates of C. difficile were identified and confirmed for the existence of three genes including tpi, tcdA and tcdB by multiplex PCR. Results: A total of six (5.66%) samples were positive for C. difficile strains. Of which, one strain (16.6%) was positive for A and B toxins. Conclusion: The existence of toxigenic C. difficile in ready-made salads could be a caution for public health. Further investigation is required to assess the relationship between the isolated strains in our study and those from diarrheic patients through molecular typing.
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Affiliation(s)
- Mahire Yamoudy
- Deparment of Food Science and Technology, Food Security Research Center, School of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Mirlohi
- Deparment of Food Science and Technology, Food Security Research Center, School of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahram Nasr Isfahani
- Deparment of Microbiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Jalali
- Deparment of Food Science and Technology, Food Security Research Center, School of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Esfandiari
- Department of Research and Development, Deputy of Food and Drug, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nafiseh Sadat Hosseini
- Deparment of Microbiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Drudy D, Harnedy N, Fanning S, Hannan M, Kyne L. Emergence and Control of Fluoroquinolone-Resistant, Toxin A–Negative, Toxin B–PositiveClostridium difficile. Infect Control Hosp Epidemiol 2015; 28:932-40. [PMID: 17620240 DOI: 10.1086/519181] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Accepted: 02/15/2007] [Indexed: 01/05/2023]
Abstract
Background.Clostridium difficileis a major cause of infectious diarrhea in hospitalized patients. Between August 2003 and January 2004, we experienced an increase in the incidence ofC. difficile–associated disease. We describe the investigation into and management of the outbreak in this article.Methods.A total of 73 consecutive patients with nosocomialC. difficile–associated diarrhea were identified.C. difficileisolates were characterized using toxin-specific enzyme immunoassays, a tissue-culture fibroblast cytotoxicity assay, polymerase chain reaction (PCR), and antimicrobial susceptibility tests. Rates of recurrence and ofC. difficilecolitis were recorded. Changes in antibiotic use and infection control policies were documented.Results.The incidence ofC. difficile–associated diarrhea peaked at 21 cases per 1,000 patient admissions. Of theC. difficileisolates recovered, 85 (95%) were identical toxin A–negative and toxin B-positive strains, corresponding to toxinotype VIII and PCR ribotype 017. All clonal isolates were resistant to multiple antibiotics, including ofloxacin, ciprofloxacin, levofloxacin, moxifloxacin, and gatifloxacin (minimum inhibitory concentrations [MICs] of greater than 32μg/mL) and erythromycin, clarithromycin, and clindamycin (MICs of greater than 256μg/mL). RecurrentC. difficile–associated disease occurred in 26 (36%) of the patients. At least 10 (14%) of the patients developedC. difficilecolitis. Additional infection control measures introduced included the use of ward memos, a hand-hygiene awareness campaign, increased environmental cleaning, attention to prescribing practices for antibiotics, increased awareness of diarrheal illness, and early isolation of affected patients. Total use of fluoroquinolones did not change throughout the study period. Despite persistence of this toxin-variant strain, the incidence ofC. difficile–associated disease in our institution decreased to fewer than 5 cases per 1,000 admissions.Conclusions.We report on the emergence of a fluoroquinolone- and clindamycin-resistant, toxin A–negative, and toxin B–positive strain ofC. difficileassociated with an outbreak ofC. difficile–associated disease in our institution during a 6-month period. We found that careful attention to improvement of infection control interventions was the most important means of controlling this nosocomial pathogen.
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Affiliation(s)
- Denise Drudy
- Centre for Food Safety, School of Agriculture, University College, Dublin, Ireland
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Benoit SR, McDonald LC, English R, Tokars JI. Automated Surveillance of Clostridium difficile Infections Using BioSense. Infect Control Hosp Epidemiol 2015; 32:26-33. [DOI: 10.1086/657633] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To determine the feasibility of using electronic laboratory and admission-discharge-transfer data from BioSense, a national automated surveillance system, to apply new modified Clostridium difficile infection (CDI) surveillance definitions and calculate overall and facility-specific rates of disease.Design.Retrospective, multicenter cohort study.Setting.Thirty-four hospitals sending inpatient, emergency department, and /or outpatient data to BioSense.Methods.Laboratory codes and text-parsing methods were used to extract C. difficile-positive toxin assay results from laboratory data sent to BioSense during the period from January 1, 2007, through June 30, 2008; these were merged with administrative records to determine whether cases were community associated or healthcare onset, as well as patient-day data for rate calculations. A patient was classified as having hospital-onset CDI if he or she had a C. difficile toxin-positive result on a stool sample collected 3 or more days after admission and community-onset CDI if the specimen was collected less than 3 days after admission or the patient was not hospitalized.Results.A total of 4,585 patients from 34 hospitals in 12 states had C. difficile-positive assay results. More than half (53.0%) of the cases were community-onset, and 30.8% of these occurred in patients who were recently hospitalized. The overall rate of healthcare-onset CDI was 7.8 cases per 10,000 patient-days, with a range among facilities of 1.5-27.8 cases per 10,000 patient-days.Conclusions.Electronic laboratory data sent to the BioSense surveillance system were successfully used to produce disease rates of CDI comparable to those of other studies, which shows the feasibility of using electronic laboratory data to track a disease of public health importance.
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31
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Impacts of infection with different toxigenic Clostridium difficile strains on faecal microbiota in children. Sci Rep 2014; 4:7485. [PMID: 25501371 PMCID: PMC4265774 DOI: 10.1038/srep07485] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 11/27/2014] [Indexed: 12/17/2022] Open
Abstract
Increasing evidence suggests that altered intestinal microbial composition and function result in an increased risk of Clostridium difficile-associated diarrhoea (CDAD); however, the specific changes of intestinal microbiota in children suffering from CDAD and their associations with C.difficile strain toxigenicity are poorly understood. High-throughput pyrosequencing showed that reduced faecal bacterial diversity and dramatic shifts of microbial composition were found in children with CDAD. The Firmicutes/Bacteroidetes ratio was increased significantly in patients with CDAD, which indicated that dysbiosis of faecal microbiota was closely associated with CDAD. C. difficile infection resulted in an increase in lactate-producing phylotypes, with a corresponding decrease in butyrate-producing bacteria. The decrease in butyrate and lactate buildup impaired intestinal colonisation resistance, which increased the susceptibility to C. difficile colonisation. Strains of C.difficile which were positive for both toxin A and toxin B reduced faecal bacterial diversity to a greater degree than strains that were only toxin B-positive, and were associated with unusually abundant Enterococcus, which implies that the C. difficile toxins have different impacts on the faecal microbiota of children. Greater understanding of the relationships between disruption of the normal faecal microbiota and colonisation with C. difficile that produces different toxins might lead to improved treatment.
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Nakamura I, Yamaguchi T, Tsukimori A, Sato A, Fukushima S, Mizuno Y, Matsumoto T. Fulminant colitis from Clostridium difficile infection, the epidemic strain ribotype 027, in Japan. J Infect Chemother 2014; 20:380-3. [DOI: 10.1016/j.jiac.2013.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/15/2013] [Accepted: 11/12/2013] [Indexed: 11/27/2022]
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Soriano MM, Liao S, Danziger LH. Fidaxomicin: a minimally absorbed macrocyclic antibiotic for the treatment of Clostridium difficile infections. Expert Rev Anti Infect Ther 2014; 11:767-76. [PMID: 23977933 DOI: 10.1586/14787210.2013.814767] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Fidaxomicin was approved for the treatment of Clostridium difficile infections in 2011. It has a novel mechanism of action and narrow spectrum of activity that makes it unique among the currently used therapies for this disease. Phase III clinical studies demonstrated a benefit of fidaxomicin over vancomycin for the outcomes of recurrence and global cure or sustained clinical response. This observation was confirmed within specific populations, including those of older age, immunocompromised due to active cancers, and patients taking concomitant antibiotics. Additionally, fidaxomicin significantly reduced recurrence rates compared to vancomycin among patients receiving treatment for recurrent C. difficile episodes. Fidaxomicin represents an advance in therapy for the treatment of C. difficile infections.
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Affiliation(s)
- Melinda M Soriano
- Department of Pharmacy Practice, The University of Illinois at Chicago, Chicago, IL, USA
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Valiente E, Cairns M, Wren B. The Clostridium difficile PCR ribotype 027 lineage: a pathogen on the move. Clin Microbiol Infect 2014; 20:396-404. [DOI: 10.1111/1469-0691.12619] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Barbut F, Surgers L, Eckert C, Visseaux B, Cuingnet M, Mesquita C, Pradier N, Thiriez A, Ait-Ammar N, Aifaoui A, Grandsire E, Lalande V. Does a rapid diagnosis of Clostridium difficile infection impact on quality of patient management? Clin Microbiol Infect 2014; 20:136-44. [DOI: 10.1111/1469-0691.12221] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/27/2013] [Accepted: 03/09/2013] [Indexed: 02/04/2023]
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Chao HC, Chen CC, Chen SY, Chiu CH. Bacterial enteric infections in children: etiology, clinical manifestations and antimicrobial therapy. Expert Rev Anti Infect Ther 2014; 4:629-38. [PMID: 17009942 DOI: 10.1586/14787210.4.4.629] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bacterial enteric infections have a huge impact on human health, particularly among the pediatric population. Despite the explosion of knowledge of the pathogenesis of bacterial enteric infections experienced in the past decade, the number of diarrheal episodes and childhood deaths reported continues to increase in many areas of the world. Specific antimicrobial therapy is indicated for certain confirmed infections, notably shigellosis, enterotoxigenic and enteroinvasive Escherichia coli infections, typhoid fever and cholera. Antimicrobial therapy may have a role in severe and prolonged gastrointestinal illness caused by nontyphoid Salmonella and Campylobacter. However, the use of antimicrobial agents may increase the risk of hemolytic uremic syndrome in children with E. coli O157:H7 infection. Bacterial genome sequencing and better understanding of the pathogenic mechanisms involved in the onset of diarrhea are leading to new preventive interventions, such as enteric vaccines, which may have a significant impact on the magnitude of this human plague.
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Affiliation(s)
- Hsun-Chin Chao
- Chang Gung Children's Hospital, Division of Pediatric Infectious Diseases, Department of Pediatrics, 5 Fu-Hsin Street, Kweishan 333, Taoyuan, Taiwan
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Emerging Clostridium difficile Infections. Emerg Infect Dis 2014. [DOI: 10.1016/b978-0-12-416975-3.00018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kuehne SA, Collery MM, Kelly ML, Cartman ST, Cockayne A, Minton NP. Importance of toxin A, toxin B, and CDT in virulence of an epidemic Clostridium difficile strain. J Infect Dis 2014; 209:83-6. [PMID: 23935202 PMCID: PMC3864386 DOI: 10.1093/infdis/jit426] [Citation(s) in RCA: 164] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 07/12/2013] [Indexed: 12/17/2022] Open
Abstract
Clostridium difficile infection is the main cause of healthcare-acquired diarrhea in the developed world. In addition to the main virulence factors toxin A and B, epidemic, PCR Ribotype 027 strains, such as R20291, produce a third toxin, CDT. To develop effective medical countermeasures, it is important to understand the importance of each toxin. Accordingly, we created all possible combinations of isogenic toxin mutants of R20291 and assessed their virulence. We demonstrated that either toxin A or toxin B alone can cause fulminant disease in the hamster infection model and present tantalizing data that C. difficile toxin may also contribute to virulence.
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Affiliation(s)
- Sarah A Kuehne
- Clostridia Research Group, Nottingham Digestive Diseases Centre, NIHR Biomedical Research Unit, School of Life Sciences, University of Nottingham, United Kingdom
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Shivashankar R, Khanna S, Kammer PP, Harmsen WS, Zinsmeister AR, Baddour LM, Pardi DS. Clinical factors associated with development of severe-complicated Clostridium difficile infection. Clin Gastroenterol Hepatol 2013; 11:1466-71. [PMID: 23702192 PMCID: PMC3846768 DOI: 10.1016/j.cgh.2013.04.050] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 04/11/2013] [Accepted: 04/12/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Clostridium difficile infection (CDI) can cause life-threatening complications. Severe-complicated CDI is characterized by hypotension, shock, sepsis, ileus, megacolon, and colon perforation. We created a model to identify clinical factors associated with severe-complicated CDI. METHODS We analyzed data from 1446 inpatient cases of CDI (48.6% female; median age, 62.5 years; range, 0.1-103.7 years) at the Mayo Clinic from June 28, 2007, to June 25, 2010. Patients with severe-complicated CDI (n = 487) were identified as those who required admission to the intensive care unit or colectomy, or died, within 30 days of CDI diagnosis. Logistic regression models were used to identify variables that were independently associated with the occurrence of severe-complicated CDI in 2 cohorts. One cohort comprised all hospitalized patients; the other comprised a subset of these inpatients who were residents of Olmsted County, Minnesota to assess the association of comorbid conditions with the development of severe-complicated infection in a population-based cohort. The linear combinations of variables identified by using logistic regression models provided scores to predict the risk of developing severe-complicated CDI. RESULTS In a multivariable model that included all inpatients, increasing age, leukocyte count >15 × 10(9)/L, increase in serum level of creatinine >1.5-fold from baseline, and use of proton pump inhibitors or narcotic medications were independently associated with severe-complicated CDI. In the secondary analysis, which included only patients from Olmsted County, comorbid conditions were not significantly associated with severe-complicated CDI. CONCLUSIONS Older age, high numbers of leukocytes in blood samples, an increased serum level of creatinine, gastric acid suppression, and use of narcotic medications were independently associated with development of severe-complicated CDI in hospitalized patients. Early aggressive monitoring and intervention could improve outcomes.
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Affiliation(s)
- Raina Shivashankar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia P. Kammer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - W. Scott Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Alan R. Zinsmeister
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Larry M. Baddour
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Darrell S. Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Pallis A, Jazayeri J, Ward P, Dimovski K, Svobodova S. Rapid detection of Clostridium difficile toxins from stool samples using real-time multiplex PCR. J Med Microbiol 2013; 62:1350-1356. [DOI: 10.1099/jmm.0.058339-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
In this study, a total of 650 stool samples were tested to show that our method is capable of detecting four Clostridium difficile genes; tcdA, tcdB, encoding toxin A (TcdA) and toxin B (TcdB), and the binary toxin C. difficile transferase genes (cdtA and/or cdtB) encoding CDT toxin. Besides detecting the targeted C. difficile genes, our method can be used to detect the presence of any inhibitory components in the PCR. This assay, combined with a selective culture medium, such as the chromID™ C. difficile, can be applied directly for screening C. difficile-associated disease. The PCR-based assay developed here is rapid (4 h per 21 stool samples) and accurate in diagnosing C. difficile infection, 100 % assay sensitivity and negative predictive value (NPV) were obtained. However, the assay specificity of 99.1 % and positive predictive value (PPV) of 94.9 % were slightly lower than the optimal value of 100 %. The assay protocol outlined here can be used as a rapid screening tool to assist infection control units and in managing infected patients by reducing the number of patients requiring isolation and extended hospitalization. Rapid detection can prevent unnecessary antibiotic therapy and potentially reduce the spread of infection by emerging hypervirulent C. difficile strains.
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Affiliation(s)
- Ann Pallis
- Molecular Diagnostic and Microbiology Laboratory, Austin Pathology, Melbourne, VIC 3084, Australia
| | - Jalal Jazayeri
- School of Biomedical Sciences, Charles Sturt University, Boorooma Street, Wagga Wagga, NSW 2678, Australia
| | - Peter Ward
- Molecular Diagnostic and Microbiology Laboratory, Austin Pathology, Melbourne, VIC 3084, Australia
| | | | - Suzanne Svobodova
- Molecular Diagnostic and Microbiology Laboratory, Austin Pathology, Melbourne, VIC 3084, Australia
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Escobar-Cortés K, Barra-Carrasco J, Paredes-Sabja D. Proteases and sonication specifically remove the exosporium layer of spores of Clostridium difficile strain 630. J Microbiol Methods 2013; 93:25-31. [DOI: 10.1016/j.mimet.2013.01.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 01/16/2013] [Accepted: 01/16/2013] [Indexed: 12/18/2022]
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Miller MA, Louie T, Mullane K, Weiss K, Lentnek A, Golan Y, Kean Y, Sears P. Derivation and validation of a simple clinical bedside score (ATLAS) for Clostridium difficile infection which predicts response to therapy. BMC Infect Dis 2013; 13:148. [PMID: 23530807 PMCID: PMC3618004 DOI: 10.1186/1471-2334-13-148] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 02/06/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) continues to be a frequent and potentially severe infection. There is currently no validated clinical tool for use at the time of CDI diagnosis to categorize patients in order to predict response to therapy. METHODS Six clinical and laboratory variables, measured at the time of CDI diagnosis, were combined in order to assess their correlation with treatment response in a large CDI clinical trial database (derivation cohort). The final categorization scheme was chosen in order to maximize the number of categories (discrimination) while maintaining a high correlation with clinical cure assessed two days after the end of therapy. Validation of the derived scoring scheme was done on a second large CDI clinical trial database (validation cohort). A third comparison was done on the two pooled databases (pooled cohort). RESULTS In the derivation cohort, the best discrimination and correlation with cure was seen with a five-component ATLAS score (age, treatment with systemic antibiotics, leukocyte count, albumin and serum creatinine as a measure of renal function), which divided CDI patients into 11 groups (scores of 0 to 10 inclusive) and was highly correlated with treatment outcome (R(2) = 0.95; P<0.001). This scheme showed excellent prediction of cure in the validation cohort (overall Kappa = 95.2%; P<0.0001), as well as in the pooled cohort, regardless of treatment (fidaxomicin or vancomycin). CONCLUSIONS A combination of five simple and commonly available clinical and laboratory variables measured at the time of CDI diagnosis, combined into a scoring system (ATLAS), are able to accurately predict treatment response to CDI therapy. The ATLAS scoring system may be useful in stratifying CDI patients so that appropriate therapies can be chosen to maximize cure rates, as well as for categorization of patients in CDI therapeutic studies in order allow comparisons of patient groups.
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Affiliation(s)
- Mark A Miller
- Division of Infectious Diseases, Jewish General Hospital, 3755 Cote-Ste-Catherine Rd, Montreal, QC, Canada.
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El Feghaly RE, Stauber JL, Deych E, Gonzalez C, Tarr PI, Haslam DB. Markers of intestinal inflammation, not bacterial burden, correlate with clinical outcomes in Clostridium difficile infection. Clin Infect Dis 2013; 56:1713-21. [PMID: 23487367 DOI: 10.1093/cid/cit147] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Clostridium difficile is a leading hospital-acquired infection. Many patients remain symptomatic for several days on appropriate antibiotic therapy. To assess the contribution of ongoing infection vs persistent inflammation, we examined the correlation between fecal cytokine levels, fecal C. difficile burden, and disease outcomes in C. difficile infection (CDI). METHODS We conducted a prospective cohort study in Barnes Jewish Hospital between June 2011 and May 2012 of hospitalized adults with CDI. We determined fecal interleukin 8 (IL-8) and lactoferrin protein concentrations by enzyme immunoassay. We used real-time polymerase chain reaction (PCR) to measure relative fecal IL-8 and CXCL-5 RNA transcript abundances, and quantitative PCR to enumerate C. difficile burden. RESULTS Of 120 study subjects, 101 (84%) were started on metronidazole, and 33 of those (33%) were subsequently given vancomycin. Sixty-two (52%) patients had diarrhea persistent for 5 or more days after starting CDI therapy. Initial fecal CXCL-5 messenger RNA (mRNA), IL-8 mRNA, and IL-8 protein correlated with persistent diarrhea and use of vancomycin. Time to diarrhea resolution was longer in patients with elevated fecal cytokines at diagnosis. Fecal cytokines were more sensitive than clinical severity scores in identifying patients at risk of treatment failure. Clostridium difficile burden did not correlate with any measure of illness or outcome at any point, and decreased equally with metronidazole and vancomycin. CONCLUSIONS Persistent diarrhea in CDI correlates with intestinal inflammation and not fecal pathogen burden. These findings suggest that modulation of host response, rather than adjustments to antimicrobial regimens, might be a more effective approach to patients with unremitting disease.
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Affiliation(s)
- Rana E El Feghaly
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO 63110, USA
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The role of acute care surgery in the treatment of severe, complicated Clostridium difficile-associated disease. J Trauma Acute Care Surg 2012; 73:789-800. [PMID: 23026914 DOI: 10.1097/ta.0b013e318265d19f] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Clostridium difficile associated disease (CDAD) is the result of colonic bacterial overgrowth with this gram positive anaerobic organism and the production of toxins that typically induce diarrhea. Most patients with CDAD respond to treatment with oral metronidazole or vancomycin, but a subset of patients will develop a severe systemic illness, multiple organ failure, and death. There are no reliable combinations of clinical or laboratory findings that will distinguish patients who will respond to medical therapy and those who will progress to a more complicated state. Early surgical consultation should be considered in patients with ileus, severe abdominal pain, significant tenderness, immunosuppression, advanced age, high white blood cell or band counts, acute renal failure, mental status changes, or cardiopulmonary compromise. The standard operation for fulminant colitis is subtotal colectomy but the high mortality of the operation, and the long-term morbidity even in survivors combine to act as deterrents to early surgical consultation and operation. Novel operative approaches that preserve the colon and minimize operative morbidity may prove to remove the barriers to earlier surgical treatment for fulminant CDAD and improve outcomes.
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Paredes-Sabja D, Cofre-Araneda G, Brito-Silva C, Pizarro-Guajardo M, Sarker MR. Clostridium difficile spore-macrophage interactions: spore survival. PLoS One 2012; 7:e43635. [PMID: 22952726 PMCID: PMC3428350 DOI: 10.1371/journal.pone.0043635] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 07/24/2012] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridium difficile is the main cause of nosocomial infections including antibiotic associated diarrhea, pseudomembranous colitis and toxic megacolon. During the course of Clostridium difficile infections (CDI), C. difficile undergoes sporulation and releases spores to the colonic environment. The elevated relapse rates of CDI suggest that C. difficile spores has a mechanism(s) to efficiently persist in the host colonic environment. METHODOLOGY/PRINCIPAL FINDINGS In this work, we provide evidence that C. difficile spores are well suited to survive the host's innate immune system. Electron microscopy results show that C. difficile spores are recognized by discrete patchy regions on the surface of macrophage Raw 264.7 cells, and phagocytosis was actin polymerization dependent. Fluorescence microscopy results show that >80% of Raw 264.7 cells had at least one C. difficile spore adhered, and that ∼60% of C. difficile spores were phagocytosed by Raw 264.7 cells. Strikingly, presence of complement decreased Raw 264.7 cells' ability to phagocytose C. difficile spores. Due to the ability of C. difficile spores to remain dormant inside Raw 264.7 cells, they were able to survive up to 72 h of macrophage infection. Interestingly, transmission electron micrographs showed interactions between the surface proteins of C. difficile spores and the phagosome membrane of Raw 264.7 cells. In addition, infection of Raw 264.7 cells with C. difficile spores for 48 h produced significant Raw 264.7 cell death as demonstrated by trypan blue assay, and nuclei staining by ethidium homodimer-1. CONCLUSIONS/SIGNIFICANCE These results demonstrate that despite efficient recognition and phagocytosis of C. difficile spores by Raw 264.7 cells, spores remain dormant and are able to survive and produce cytotoxic effects on Raw 264.7 cells.
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Affiliation(s)
- Daniel Paredes-Sabja
- Laboratorio de Mecanismos de Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andres Bello, Santiago, Chile.
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Potter VA, Aravinthan A. Identifying patients at risk of severe Clostridium difficile-associated disease. Br J Hosp Med (Lond) 2012; 73:265-70. [PMID: 22585325 DOI: 10.12968/hmed.2012.73.5.265] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Clostridium difficile infection is responsible for a wide spectrum of clinical presentations, ranging from mild diarrhoea to fatal toxic colitis. This article reviews factors which may identify individuals who are at high risk of severe C. difficile-associated disease, and aims to help clinicians predict patients at risk of severe disease.
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Affiliation(s)
- Valerie A Potter
- Department of Medicine, Lister Hospital, Stevenage, Hertfordshire, UK
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Paredes-Sabja D, Sarker MR. Adherence of Clostridium difficile spores to Caco-2 cells in culture. J Med Microbiol 2012; 61:1208-1218. [PMID: 22595914 DOI: 10.1099/jmm.0.043687-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Clostridium difficile is the causative agent of the majority of antibiotic associated diarrhoea cases. C. difficile spores are recognized as the persistent and infectious morphotype as well as the vehicle of transmission of CDI. However, there is a lack of knowledge on how C. difficile spores interact with the host's epithelial surfaces. In this context, we have characterized the ability of C. difficile spores to adhere to human Caco-2 cells. Despite the similarities in spore-surface hydrophobicity between spores of C. difficile and Clostridium perfringens (another enteric pathogen that also sporulates in the gut), spores of C. difficile adhere better to Caco-2 cells. Adherence to Caco-2 cells was significantly reduced when C. difficile spores were treated with trypsin. Sonication of C. difficile spores altered the ultrastructure of the outermost exosporium-like structure, releasing two protein species of ~40 kDa and significantly reduced spore hydrophobicity and adherence to Caco-2 cells. Using a trifunctional cross-linker, we were able to co-immunoprecipitate four protein species from the surface of Caco-2 cells. In conclusion, this study provides evidence that C. difficile spores adhere to human intestinal enterocyte-like cells through spore- and enterocytic-surface-specific ligand(s) and/or receptor(s).
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Affiliation(s)
- Daniel Paredes-Sabja
- Department of Biomedical Sciences, Oregon State University, Corvallis, OR 97331, USA.,Laboratorio de Mecanismos de Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Universidad Andres Bello, Santiago, Chile
| | - Mahfuzur R Sarker
- Department of Microbiology, Oregon State University, Corvallis, OR 97331, USA.,Department of Biomedical Sciences, Oregon State University, Corvallis, OR 97331, USA
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VerLee KE, Finks JL, Wilkins MJ, Wells EV. Michigan Clostridium difficile hospital discharges: frequency, mortality, and charges, 2002-2008. Public Health Rep 2012; 127:62-71. [PMID: 22298923 DOI: 10.1177/003335491212700107] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Clostridium difficile (C. difficile) causes an intestinal bacterial infection of increasing importance in Michigan residents and health-care facilities. The specific burden and health-care costs of C. difficile infection (CDI) were previously unknown. We evaluated the frequency, mortality, and health-care charges of CDI from Michigan hospital discharge data. METHODS The Michigan Department of Community Health purchased discharge data from all Michigan acute care hospitals from the Michigan Health and Hospital Association. We extracted all hospital discharges from 2002 through 2008 containing the International Classification of Diseases, Ninth Revision code for intestinal infection due to C. difficile. Discharges were stratified by principle diagnosis and comorbidity level. Total hospitalization charges were standardized to the 2008 U.S. dollar. RESULTS From 2002 through 2008, 68,686 hospital discharges with CDI occurred. The annual rate increased from 463.1 to 1096.5 CDI discharges per 100,000 discharges. CDI discharge rates were substantially higher among the elderly, females, and black people. Of all CDI discharges, 5,924 (8.6%) patients died. The mean total health-care charge for the time period was $67,149, and the annual mean increased 35% from 2002 to 2008. Hospital charges varied significantly by race/ethnicity and age. People with Medicaid insurance accrued the highest charges. CONCLUSION Across Michigan, the CDI burden is growing substantially and affecting vulnerable populations. Surveillance utilizing hospital discharge data can illuminate trends and inform intervention targets. To reduce disease and health-care charges, increased prevention and infection-control efforts should be directed toward high-risk populations, such as the elderly.
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Affiliation(s)
- Kerrie E VerLee
- Council of State and Territorial Epidemiologists, Atlanta, GA, USA.
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Multilocus sequence typing (MLST) analysis of 104Clostridium difficilestrains isolated from China. Epidemiol Infect 2012; 141:195-9. [DOI: 10.1017/s0950268812000453] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
SUMMARYThe phylogenetic and epidemic relationships of 104 clinical isolatesof Clostridium difficilefrom three hospitals of different geographical and population sources in China were investigated by multilocus sequence typing. Twenty-two sequence types (STs) were identified, four of which, ST117, ST118, ST119 and ST129, were novel. No geographically specific and host population-specific phylogenetic lineages were found and there was no correlation between geographical origin or host population and strain genotype. ST37 was the dominant type in our survey but the four novel STs underline the high genetic diversity and unique polymorphisms inC. difficilefrom China.
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