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Markantonis JE, Fallon JT, Madan R, Alam MZ. Clostridioides difficile Infection: Diagnosis and Treatment Challenges. Pathogens 2024; 13:118. [PMID: 38392856 PMCID: PMC10891949 DOI: 10.3390/pathogens13020118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024] Open
Abstract
Clostridioides difficile is the most important cause of healthcare-associated diarrhea in the United States. The high incidence and recurrence rates of C. difficile infection (CDI), associated with high morbidity and mortality, pose a public health challenge. Although antibiotics targeting C. difficile bacteria are the first treatment choice, antibiotics also disrupt the indigenous gut flora and, therefore, create an environment that is favorable for recurrent CDI. The challenge of treating CDI is further exacerbated by the rise of antibiotic-resistant strains of C. difficile, placing it among the top five most urgent antibiotic resistance threats in the USA. The evolution of antibiotic resistance in C. difficile involves the acquisition of new resistance mechanisms, which can be shared among various bacterial species and different C. difficile strains within clinical and community settings. This review provides a summary of commonly used diagnostic tests and antibiotic treatment strategies for CDI. In addition, it discusses antibiotic treatment and its resistance mechanisms. This review aims to enhance our current understanding and pinpoint knowledge gaps in antimicrobial resistance mechanisms in C. difficile, with an emphasis on CDI therapies.
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Affiliation(s)
- John E. Markantonis
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA; (J.E.M.); (J.T.F.)
| | - John T. Fallon
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA; (J.E.M.); (J.T.F.)
| | - Rajat Madan
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
- Veterans Affairs Medical Center, Cincinnati, OH 45220, USA
| | - Md Zahidul Alam
- Department of Pathology and Laboratory Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27834, USA; (J.E.M.); (J.T.F.)
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Snydman DR, McDermott LA, Thorpe CM, Goldstein EJC, Schuetz AN, Johnson S, Gerding DN, Gluck L, Bourdas D, Carroll KC, Lancaster CK, Garey KW, Wang Q, Walk ST, Duperchy E. A US-based national surveillance study for the susceptibility and epidemiology of Clostridioides difficile isolates with special reference to ridinilazole: 2020-2021. Antimicrob Agents Chemother 2023; 67:e0034923. [PMID: 37728368 PMCID: PMC10583687 DOI: 10.1128/aac.00349-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/04/2023] [Indexed: 09/21/2023] Open
Abstract
We have previously reported on the susceptibility and epidemiology of Clostridioides difficile isolates from six geographically dispersed medical centers in the United States. This current survey was conducted with isolates collected in 2020-2021 from six geographically dispersed medical centers in the United States, with specific attention to susceptibility to ridinilazole as well as nine comparators. C. difficile isolates or stools from patients with C. difficile antibiotic-associated diarrhea were collected and referred to a central laboratory. After species confirmation of 300 isolates at the central laboratory, antibiotic susceptibilities were determined by the agar dilution method [M11-A9, Clinical and Laboratory Standards Institute (CLSI)] against the 10 agents. Ribotyping was performed by PCR capillary gel electrophoresis on all isolates. Ridinilazole had a minimum inhibitory concentration (MIC) 90 of 0.25 mcg/mL, and no isolate had an MIC greater than 0.5 mcg/mL. In comparison, fidaxomicin had an MIC 90 of 0.5 mcg/mL. The vancomycin MIC 90 was 2 mcg/mL with a 0.7% resistance rate [both CLSI and European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria]. The metronidazole MIC 90 was 1 mcg/mL, with none resistant by CLSI criteria, and a 0.3% resistance rate by EUCAST criteria. Among the 50 different ribotypes isolated in the survey, the most common ribotype was 014-020 (14.0%) followed by 106 (10.3%), 027 (10%), 002 (8%), and 078-126 (4.3%). Ridinilazole maintained activity against all ribotypes and all strains resistant to any other agent tested. Ridinilazole showed excellent in vitro activity against C. difficile isolates collected between 2020 and 2021 in the United States, independent of ribotype.
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Affiliation(s)
- D. R. Snydman
- Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine and the Stuart B. Levy Center for the Integrated Management of Antimicrobial Resistance, Boston, Massachusetts, USA
| | - L. A. McDermott
- Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine and the Stuart B. Levy Center for the Integrated Management of Antimicrobial Resistance, Boston, Massachusetts, USA
| | - C. M. Thorpe
- Tufts Medical Center, Boston, Massachusetts, USA
- Tufts University School of Medicine and the Stuart B. Levy Center for the Integrated Management of Antimicrobial Resistance, Boston, Massachusetts, USA
| | | | - A. N. Schuetz
- Mayo Clinic School of Medicine and Science, Rochester, Minnesota, USA
| | - S. Johnson
- Edward Hines, Jr. VA Hospital, Hines, Illinois, USA
- Loyola University Medical Center, Maywood, Illinois, USA
| | | | - L. Gluck
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - D. Bourdas
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - K. C. Carroll
- University of Houston College of Pharmacy, Houston, Texas, USA
| | | | - K. W. Garey
- Summit (Oxford) Ltd, Abingdon, United Kingdom
| | - Q. Wang
- Montana State University, Bozeman, Montana, USA
| | - S. T. Walk
- Montana State University, Bozeman, Montana, USA
| | - E. Duperchy
- Johns Hopkins Hospital, Baltimore, Maryland, USA
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Janardhanan J, Kim C, Qian Y, Yang J, Meisel J, Ding D, Speri E, Schroeder V, Wolter W, Oliver A, Mobashery S, Chang M. A dual-action antibiotic that kills Clostridioides difficile vegetative cells and inhibits spore germination. Proc Natl Acad Sci U S A 2023; 120:e2304110120. [PMID: 37155891 PMCID: PMC10193928 DOI: 10.1073/pnas.2304110120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/29/2023] [Indexed: 05/10/2023] Open
Abstract
Clostridioides difficile infection (CDI) is the most lethal of the five CDC urgent public health treats, resulting in 12,800 annual deaths in the United States alone [Antibiotic Resistance Threats in the United States, 2019 (2019), www.cdc.gov/DrugResistance/Biggest-Threats.html]. The high recurrence rate and the inability of antibiotics to treat such infections mandate discovery of new therapeutics. A major challenge with CDI is the production of spores, leading to multiple recurrences of infection in 25% of patients [C. P. Kelly, J. T. LaMont, N. Engl. J. Med. 359, 1932-1940 (2008)], with potentially lethal consequence. Herein, we describe the discovery of an oxadiazole as a bactericidal anti-C. difficile agent that inhibits both cell-wall peptidoglycan biosynthesis and spore germination. We document that the oxadiazole binds to the lytic transglycosylase SleC and the pseudoprotease CspC for prevention of spore germination. SleC degrades the cortex peptidoglycan, a critical step in the initiation of spore germination. CspC senses germinants and cogerminants. Binding to SleC is with higher affinity than that to CspC. Prevention of spore germination breaks the nefarious cycles of CDI recurrence in the face of the antibiotic challenge, which is a primary cause of therapeutic failure. The oxadiazole exhibits efficacy in a mouse model of recurrent CDI and holds promise in clinical treatment of CDI.
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Affiliation(s)
- Jeshina Janardhanan
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - Choon Kim
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - Yuanyuan Qian
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - Jingdong Yang
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - Jayda E. Meisel
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - Derong Ding
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - Enrico Speri
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - Valerie A. Schroeder
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - William R. Wolter
- Freimann Life Sciences Center, University of Notre Dame, Notre Dame, IN46556
| | - Allen G. Oliver
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - Shahriar Mobashery
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
| | - Mayland Chang
- Department of Chemistry and Biochemistry, University of Notre Dame, Notre Dame, IN46556
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Marcos P, Doyle A, Whyte P, Rogers TR, McElroy M, Fanning S, Frias J, Bolton D. Characterization of Food Chain Clostridioides difficile Isolates in Terms of Ribotype and Antimicrobial Resistance. Microorganisms 2023; 11:1296. [PMID: 37317270 DOI: 10.3390/microorganisms11051296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 06/16/2023] Open
Abstract
The aim of this study was to characterize C. difficile isolates from the farm, abattoir, and retail outlets in Ireland in terms of ribotype and antibiotic resistance (vancomycin, erythromycin, metronidazole, moxifloxacin, clindamycin, and rifampicin) using PCR and E-test methods, respectively. The most common ribotype in all stages of the food chain (including retail foods) was 078 and a variant (RT078/4). Less commonly reported (014/0, 002/1, 049, and 205) and novel (RT530, 547, and 683) ribotypes were also detected, but at lower frequencies. Approximately 72% (26/36 tested) of the isolates tested were resistant to at least one antibiotic, with the majority of these (65%; 17/26) displaying a multi-drug (three to five antibiotics) resistant phenotype. It was concluded that ribotype 078, a hypervirulent strain commonly associated with C. difficile infection (CDI) in Ireland, was the most frequent ribotype along the food chain, resistance to clinically important antibiotics was common in C. difficile food chain isolates, and there was no relationship between ribotype and antibiotic resistance profile.
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Affiliation(s)
- Pilar Marcos
- Teagasc Food Research Centre, Ashtown, Dublin 15, D15 KN3K Dublin, Ireland
- School of Veterinary Medicine, University College Dublin, Belfield, Dublin 4, D04 V1W8 Dublin, Ireland
| | - Aoife Doyle
- Department of Clinical Microbiology, Trinity College Dublin, Central Pathology Laboratory, St James's Hospital, Dublin 8, D08 RX0X Dublin, Ireland
- Central Veterinary Research Laboratory, Department of Agriculture, Food and the Marine, Backweston, Celbridge, W23 X3PH Kildare, Ireland
| | - Paul Whyte
- School of Veterinary Medicine, University College Dublin, Belfield, Dublin 4, D04 V1W8 Dublin, Ireland
| | - Thomas R Rogers
- Department of Clinical Microbiology, Trinity College Dublin, Central Pathology Laboratory, St James's Hospital, Dublin 8, D08 RX0X Dublin, Ireland
| | - Máire McElroy
- Central Veterinary Research Laboratory, Department of Agriculture, Food and the Marine, Backweston, Celbridge, W23 X3PH Kildare, Ireland
| | - Seamus Fanning
- UCD-Centre for Food Safety, School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield, Dublin 4, D04 V1W8 Dublin, Ireland
| | - Jesus Frias
- Environmental Sustainability and Health Institute, Technological University Dublin, Grangegorman, Dublin 7, D07 H6K8 Dublin, Ireland
| | - Declan Bolton
- Teagasc Food Research Centre, Ashtown, Dublin 15, D15 KN3K Dublin, Ireland
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Darkoh C, DuPont HL, Arias CA, Oyaro M, Brown EL, Hanson BM. Reply to Lutgring et al. Clin Infect Dis 2022; 75:1678-1679. [PMID: 35818862 DOI: 10.1093/cid/ciac376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Charles Darkoh
- University of Texas Health Science Center, School of Public Health, Department of Epidemiology, Human Genetics, and Environmental Sciences, Center for Infectious Diseases, Houston, Texas, USA
- University of Texas MD Anderson Cancer Center, UTHealth Graduate School of Biomedical Sciences, Microbiology and Infectious Diseases Program, Houston, Texas, USA
| | - Herbert L DuPont
- University of Texas Health Science Center, School of Public Health, Department of Epidemiology, Human Genetics, and Environmental Sciences, Center for Infectious Diseases, Houston, Texas, USA
- University of Texas MD Anderson Cancer Center, UTHealth Graduate School of Biomedical Sciences, Microbiology and Infectious Diseases Program, Houston, Texas, USA
- Kelsey Research Foundation, Houston, Texas, USA
| | - Cesar A Arias
- University of Texas Health Science Center, School of Public Health, Department of Epidemiology, Human Genetics, and Environmental Sciences, Center for Infectious Diseases, Houston, Texas, USA
- University of Texas MD Anderson Cancer Center, UTHealth Graduate School of Biomedical Sciences, Microbiology and Infectious Diseases Program, Houston, Texas, USA
- Division of Infectious Diseases and Center for Antimicrobial Resistance and Microbial Genomics, UTHealth, McGovern School of Medicine at Houston, Houston, Texas, USA
| | - Micah Oyaro
- University of Nairobi, School of Medicine, College of Health Sciences, Nairobi, Kenya
| | - Eric L Brown
- University of Texas Health Science Center, School of Public Health, Department of Epidemiology, Human Genetics, and Environmental Sciences, Center for Infectious Diseases, Houston, Texas, USA
| | - Blake M Hanson
- University of Texas Health Science Center, School of Public Health, Department of Epidemiology, Human Genetics, and Environmental Sciences, Center for Infectious Diseases, Houston, Texas, USA
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Mileto SJ, Hutton ML, Walton SL, Das A, Ioannidis LJ, Ketagoda D, Quinn KM, Denton KM, Hansen DS, Lyras D. Bezlotoxumab prevents extraintestinal organ damage induced by Clostridioides difficile infection. Gut Microbes 2022; 14:2117504. [PMID: 36045589 PMCID: PMC9450906 DOI: 10.1080/19490976.2022.2117504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Clostridioides difficile is the most common cause of infectious antibiotic-associated diarrhea, with disease mediated by two major toxins TcdA and TcdB. In severe cases, systemic disease complications may arise, resulting in fatal disease. Systemic disease in animal models has been described, with thymic damage an observable consequence of severe disease in mice. Using a mouse model of C. difficile infection, we examined this disease phenotype, focussing on the thymus and serum markers of systemic disease. The efficacy of bezlotoxumab, a monoclonal TcdB therapeutic, to prevent toxin mediated systemic disease complications was also examined. C. difficile infection causes toxin-dependent thymic damage and CD4+CD8+ thymocyte depletion in mice. These systemic complications coincide with changes in biochemical markers of liver and kidney function, including increased serum urea and creatinine, and hypoglycemia. Administration of bezlotoxumab during C. difficile infection prevents systemic disease and thymic atrophy, without blocking gut damage, suggesting the leakage of gut contents into circulation may influence systemic disease. As the thymus has such a crucial role in T cell production and immune system development, these findings may have important implications in relapse of C. difficile disease and impaired immunity during C. difficile infection. The prevention of thymic atrophy and reduced systemic response following bezlotoxumab treatment, without altering colonic damage, highlights the importance of systemic disease in C. difficile infection, and provides new insights into the mechanism of action for this therapeutic.Abbreviations: Acute kidney injury (AKI); Alanine Transaminase (ALT); Aspartate Aminotransferase (AST); C. difficile infection (CDI); chronic kidney disease (CKD); combined repetitive oligo-peptides (CROPS); cardiovascular disease (CVD); Double positive (DP); hematoxylin and eosin (H&E); immunohistochemical (IHC); multiple organ dysfunction syndrome (MODS); phosphate buffered saline (PBS); standard error of the mean (SEM); surface layer proteins (SLP); Single positive (SP); wild-type (WT).
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Affiliation(s)
- Steven J. Mileto
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia
| | - Melanie L. Hutton
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia
| | - Sarah L. Walton
- Cardiovascular Disease Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, Australia
| | - Antariksh Das
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia
| | - Lisa J. Ioannidis
- Walter and Eliza Hall Insitiute, Infectious Diseases and Immune Defence Division, Parkville, Australia,Department of Medical Biology, the University of Melbourne, Parkville, Australia
| | - Don Ketagoda
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia
| | - Kylie M. Quinn
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia,RMIT University School of Biomedical and Health Sciences, Chronic Inflammatory and Infectious Diseases Program, Bundoora, Australia
| | - Kate M. Denton
- Cardiovascular Disease Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, Australia
| | - Diana S. Hansen
- Walter and Eliza Hall Insitiute, Infectious Diseases and Immune Defence Division, Parkville, Australia,Department of Medical Biology, the University of Melbourne, Parkville, Australia
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Australia,CONTACT Dena Lyras Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, 19 Innovation Walk, Clayton, Victoria3800, Australia
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Influence of Binary Toxin Gene Detection and Decreased Susceptibility to Antibiotics among Clostridioides difficile Strains on Disease Severity: a Single-Center Study. Antimicrob Agents Chemother 2022; 66:e0048922. [PMID: 35861541 PMCID: PMC9380565 DOI: 10.1128/aac.00489-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Clostridioides difficile infection (CDI) is the fifth leading cause of death from nonmalignant gastrointestinal disease in the United States. The contribution of resistance to C. difficile-active antibiotics to the outcomes of CDI is unclear. We evaluated the antimicrobial susceptibility of C. difficile isolates in a U.S. hospital and determined associations of clinical variables and binary toxin positivity with antibiotic resistance. C. difficile spores were cultured from fecal specimens of adult patients with CDI for genotyping and antimicrobial susceptibility assay (for clindamycin [CLI], fidaxomicin [FDX], metronidazole [MTZ], moxifloxacin [MXF], tigecycline [TGC], and vancomycin [VAN]). Electronic medical records were reviewed for clinical data extraction. Ninety-seven of 130 (75%) fecal samples grew toxigenic C. difficile in culture. Most of the isolates were tcdA+ tcdB+ cdtB- (80.4%), and 18.6% and 1% were tcdA+ tcdB+ cdtB+ and tcdA-tcdB+ cdtB+, respectively. Susceptibility to VAN, MTZ, FDX, TGC, MXF, and CLI was 96%, 94%, 100%, 100%, 8%, and 79%, respectively. Six isolates, all cdtB positive and belonging to the 027 ribotype, were resistant to VAN and/or MTZ. Higher MICs were found in isolates with a mutation in the VAN-related resistance gene vanR, but not vanS. In addition, cdtB+ isolates exhibited higher MICs of VAN, MTZ, TGC, CLI, and MXF compared to cdtB- strains. Patients with greater intestinal inflammation or severe disease were more likely to be infected with cdtB+ strains. Decreased susceptibility to antibiotics is not directly associated with either severe or recurrent CDI. However, antimicrobial susceptibility of C. difficile is decreased in strains positive for the binary toxin gene.
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Dureja C, Olaitan AO, Hurdle JG. Mechanisms and impact of antimicrobial resistance in Clostridioides difficile. Curr Opin Microbiol 2022; 66:63-72. [PMID: 35077947 PMCID: PMC9064893 DOI: 10.1016/j.mib.2022.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/10/2021] [Accepted: 01/07/2022] [Indexed: 11/03/2022]
Abstract
The evolution of antimicrobial resistance in Clostridioides difficile has markedly shaped its epidemiology and detrimentally impacted patient care. C. difficile exhibits resistance to multiple classes of antimicrobials, due to accumulation of horizontally acquired resistance genes and de novo mutations to drug targets. Particularly worrying is that declines in clinical success of firstline CDI antimicrobials coincide with the spread of strains that are more resistant to these drugs. Yet, there is still much to learn regarding the prevalence of genetic elements in clinical isolates, their molecular mechanisms, and the extent to which this information can be translated to develop molecular diagnostics that improve antimicrobial prescribing and antimicrobial stewardship approaches for CDI. Thus, this perspective discusses current understanding and knowledge gaps of antimicrobial resistance mechanisms in C. difficile, emphasizing on CDI therapies.
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Affiliation(s)
- Chetna Dureja
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Department of Translational Medical Sciences, Texas A&M Health Science Center, 2121 West Holcombe Blvd, Houston, TX 77030, USA
| | - Abiola O Olaitan
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Department of Translational Medical Sciences, Texas A&M Health Science Center, 2121 West Holcombe Blvd, Houston, TX 77030, USA
| | - Julian G Hurdle
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Department of Translational Medical Sciences, Texas A&M Health Science Center, 2121 West Holcombe Blvd, Houston, TX 77030, USA.
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Xu T, Zhou F, Wang L, Wu S, Huang H. Metronidazole-Resistant Clostridioides difficile: Genomic and Transcriptomic Traits Acquired under In vitro Metronidazole Induction. Int J Antimicrob Agents 2022; 59:106570. [DOI: 10.1016/j.ijantimicag.2022.106570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/02/2022] [Accepted: 03/06/2022] [Indexed: 11/05/2022]
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10
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Wu Y, Wang YY, Bai LL, Zhang WZ, Li GW, Lu JX. A narrative review of Clostridioides difficile infection in China. Anaerobe 2022; 74:102540. [DOI: 10.1016/j.anaerobe.2022.102540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 12/26/2022]
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The Integrity of Heme Is Essential for Reproducible Detection of Metronidazole-Resistant Clostridioides difficile by Agar Dilution Susceptibility Tests. J Clin Microbiol 2021; 59:e0058521. [PMID: 34132582 DOI: 10.1128/jcm.00585-21] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Metronidazole resistance in clinical Clostridioides difficile is often described as unstable, since resistant strains reportedly appear susceptible following freezer storage or brief passage. This has presented a conundrum for adopting susceptibility testing to accurately evaluate the connection between metronidazole resistance and decreased clinical efficacy of metronidazole in patients with C. difficile infections (CDIs). We discovered that supplementation of microbiological media with the metalloporphyrin heme is crucial for detection of metronidazole-resistant C. difficile using the agar dilution susceptibility testing method. Known metronidazole-resistant strains appeared susceptible to metronidazole in media lacking heme. Similarly, these resistant strains exhibited increased susceptibility to metronidazole when tested on heme-containing agars that were exposed to room light for more than 1 day, likely due to heme photodecomposition. In parallel experiments, resistance was reproducibly detected when heme-containing agars were either prepared and used on the same day or protected from light and then used on subsequent days. Notably, heme did not influence the susceptibilities of drug-susceptible strains that were of the same ribotype as the resistant strains. These findings firmly show that the consistent detection of metronidazole-resistant C. difficile is dependent upon heme and its protection from light. Studies are warranted to determine the extent to which this heme-associated metronidazole-resistant phenotype affects the clinical efficacy of metronidazole in CDI and the underlying genetic and biochemical mechanisms.
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Wickramage I, Spigaglia P, Sun X. Mechanisms of antibiotic resistance of Clostridioides difficile. J Antimicrob Chemother 2021; 76:3077-3090. [PMID: 34297842 DOI: 10.1093/jac/dkab231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Clostridioides difficile (CD) is one of the top five urgent antibiotic resistance threats in USA. There is a worldwide increase in MDR of CD, with emergence of novel strains which are often more virulent and MDR. Antibiotic resistance in CD is constantly evolving with acquisition of novel resistance mechanisms, which can be transferred between different species of bacteria and among different CD strains present in the clinical setting, community, and environment. Therefore, understanding the antibiotic resistance mechanisms of CD is important to guide optimal antibiotic stewardship policies and to identify novel therapeutic targets to combat CD as well as other bacteria. Epidemiology of CD is driven by the evolution of antibiotic resistance. Prevalence of different CD strains and their characteristic resistomes show distinct global geographical patterns. Understanding epidemiologically driven and strain-specific characteristics of antibiotic resistance is important for effective epidemiological surveillance of antibiotic resistance and to curb the inter-strain and -species spread of the CD resistome. CD has developed resistance to antibiotics with diverse mechanisms such as drug alteration, modification of the antibiotic target site and extrusion of drugs via efflux pumps. In this review, we summarized the most recent advancements in the understanding of mechanisms of antibiotic resistance in CD and analysed the antibiotic resistance factors present in genomes of a few representative well known, epidemic and MDR CD strains found predominantly in different regions of the world.
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Affiliation(s)
- Ishani Wickramage
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Down Blvd, Tampa, FL 33612, USA
| | - Patrizia Spigaglia
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Xingmin Sun
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Down Blvd, Tampa, FL 33612, USA
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Gonzales-Luna AJ, Olaitan AO, Shen WJ, Deshpande A, Carlson TJ, Dotson KM, Lancaster C, Begum K, Alam MJ, Hurdle JG, Garey KW. Reduced Susceptibility to Metronidazole Is Associated With Initial Clinical Failure in Clostridioides difficile Infection. Open Forum Infect Dis 2021; 8:ofab365. [PMID: 34381844 PMCID: PMC8351808 DOI: 10.1093/ofid/ofab365] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/07/2021] [Indexed: 12/15/2022] Open
Abstract
Background Clinical studies have demonstrated inferior cure rates when metronidazole (MTZ) is used to treat Clostridioides difficile infection (CDI). We hypothesized that a newly identified, heme-inducible form of reduced MTZ susceptibility in C. difficile leads to higher odds of initial clinical failure in patients with CDI treated with MTZ. Methods This multicenter cohort study included adults diagnosed with CDI between 2017 and 2018. C. difficile isolated from stool samples underwent agar dilution MTZ susceptibility testing with incorporation of fresh heme. Blinded investigators reviewed medical records for initial clinical failure and other relevant clinical variables. Classification and regression tree (CART) analysis was used to identify the MTZ minimum inhibitory concentration (MIC) breakpoint that was predictive of initial clinical failure. Results were confirmed using univariate and multivariable logistic regression analyses to account for potential confounders. Results Of the 356 patients included, 72% received MTZ-based therapy and 27% experienced initial clinical failure. CART analysis identified an MTZ MIC ≥1 µg/mL above which patients had a higher rate of initial clinical failure. MTZ MICs ranged from 0.25 to 8 µg/mL (MIC50/90 = 0.25/2 µg/mL), and approximately 18% of isolates had MTZ MICs ≥1 µg/mL. In multivariable analysis, an MTZ MIC ≥1 µg/mL was an independent predictor of initial clinical failure in patients receiving an MTZ-based treatment regimen (odds ratio, 2.27 [95% confidence interval, 1.18–4.34]). Conclusions Using a reproducible method to determine C. difficile MICs to MTZ, a breakpoint of ≥1 µg/mL identified patients at higher risk of initial clinical failure.
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Affiliation(s)
- Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Abiola O Olaitan
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas, USA
| | - Wan-Jou Shen
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas, USA
| | - Aditi Deshpande
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas, USA
| | - Travis J Carlson
- Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, High Point, North Carolina, USA
| | | | - Chris Lancaster
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Khurshida Begum
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - M Jahangir Alam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Julian G Hurdle
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
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14
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Shen WJ, Deshpande A, Hevener KE, Endres BT, Garey KW, Palmer KL, Hurdle JG. Constitutive expression of the cryptic vanGCd operon promotes vancomycin resistance in Clostridioides difficile clinical isolates. J Antimicrob Chemother 2021; 75:859-867. [PMID: 31873741 DOI: 10.1093/jac/dkz513] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/01/2019] [Accepted: 11/09/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To describe, for the first time (to the best of our knowledge), the genetic mechanisms of vancomycin resistance in clinical isolates of Clostridioides difficile ribotype 027. METHODS Clinical isolates and laboratory mutants were analysed: genomically to identify resistance mutations; by transcriptional analysis of vanGCd, the vancomycin resistance operon encoding lipid II d-alanine-d-serine that is less bound by vancomycin than native lipid II d-alanine-d-alanine; by imaging of vancomycin binding to cell walls; and for changes in vancomycin bactericidal activity and autolysis. RESULTS Vancomycin-resistant laboratory mutants and clinical isolates acquired mutations to the vanSR two-component system that regulates vanGCd. The substitutions impaired VanSR's function, resulting in constitutive transcription of vanGCd. Resistance was reversed by silencing vanG, encoding d-alanine-d-serine ligase in the vanGCd operon. In resistant cells, vancomycin was less bound to the cell wall septum, the site where vancomycin interacts with lipid II. Vancomycin's bactericidal activity was reduced against clinical isolates and laboratory mutants (64 and ≥1024 mg/L, respectively) compared with WT strains (4 mg/L). Truncation of the potassium transporter TrkA occurred in laboratory mutants, which were refractory to autolysis, accounting for their survival in high drug concentrations. CONCLUSIONS Ribotype 027 evolved first-step resistance to vancomycin by constitutively expressing vanGCd, which is otherwise silent. Experimental evolutions and bactericidal assays show that ribotype 027 can acquire mutations to drastically enhance its tolerance to vancomycin. Thus, further epidemiological studies are warranted to examine the extent to which vancomycin resistance impacts clinical outcomes and the potential for these strains to evolve higher-level resistance, which would be devastating.
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Affiliation(s)
- Wan-Jou Shen
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX 77030, USA
| | - Aditi Deshpande
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX 77030, USA
| | - Kirk E Hevener
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN 38105, USA
| | - Bradley T Endres
- Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, Houston, TX 77204, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, Houston, TX 77204, USA
| | - Kelli L Palmer
- Department of Biological Sciences, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Julian G Hurdle
- Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX 77030, USA
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15
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Clostridium difficile: Diagnosis and the Consequence of Over Diagnosis. Infect Dis Ther 2021; 10:687-697. [PMID: 33770398 PMCID: PMC8116462 DOI: 10.1007/s40121-021-00417-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 02/16/2021] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) is a leading cause of healthcare-associated infections, accounting for significant disease burden and mortality. The clinical spectrum of C. difficile ranges from asymptomatic colonization to toxic megacolon and fulminant colitis. CDI is characterized by new onset of ≥ 3 unformed stools in 24 h and is confirmed by laboratory test for the presence of toxigenic C. difficile. Currently, laboratory tests to diagnose CDI include toxigenic culture, glutamate dehydrogenase (GDH), nucleic acid amplification test (NAAT), and toxins A/B enzyme immunoassay (EIA). The sensitivities of these tests are variable with toxin EIA ranging from 53 to 60% and with NAAT at about 95%. Overall, the specificity is > 90% for these methods. However, the positive predictive value (PPV) depends on the disease prevalence with lower CDI rates associated with lower PPVs. Notably, the widespread use of the highly sensitive NAAT and its relatively lower clinical specificity have led to overdiagnosis of C. difficile by identifying carriers when NAAT is used as the sole diagnostic method. Overdiagnosis of C. difficile has resulted in unwarranted treatment, possibly attributing to resistance to metronidazole and vancomycin, increased risk for overgrowth of vancomycin-resistant enterococci strains in stool specimens, and increased hospitalization thereby impacting patient safety and healthcare costs. Strategies to optimize the clinical sensitivity and specificity of current laboratory tests are critical to differentiate the clinical CDI from colonization. To achieve high diagnostic yield, if preagreed institutional criteria for stool submission are not used, a multistep approach to CDI diagnosis is recommended, such as either GDH or NAAT followed by toxins A/B EIA in conjunction with laboratory stewardship by evaluating C. difficile test orders for appropriateness and providing feedback. Furthermore, antimicrobial stewardship, along with provider education on appropriate testing for C. difficile, is vital to differentiate CDI from colonization.
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16
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Sholeh M, Krutova M, Forouzesh M, Mironov S, Sadeghifard N, Molaeipour L, Maleki A, Kouhsari E. Antimicrobial resistance in Clostridioides (Clostridium) difficile derived from humans: a systematic review and meta-analysis. Antimicrob Resist Infect Control 2020; 9:158. [PMID: 32977835 PMCID: PMC7517813 DOI: 10.1186/s13756-020-00815-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/09/2020] [Indexed: 12/17/2022] Open
Abstract
Background Clostridioides (Clostridium) difficile is an important pathogen of healthcare- associated diarrhea, however, an increase in the occurrence of C. difficile infection (CDI) outside hospital settings has been reported. The accumulation of antimicrobial resistance in C. difficile can increase the risk of CDI development and/or its spread. The limited number of antimicrobials for the treatment of CDI is matter of some concern. Objectives In order to summarize the data on antimicrobial resistance to C. difficile derived from humans, a systematic review and meta-analysis were performed. Methods We searched five bibliographic databases: (MEDLINE [PubMed], Scopus, Embase, Cochrane Library and Web of Science) for studies that focused on antimicrobial susceptibility testing in C. difficile and were published between 1992 and 2019. The weighted pooled resistance (WPR) for each antimicrobial agent was calculated using a random- effects model. Results A total of 111 studies were included. The WPR for metronidazole and vancomycin was 1.0% (95% CI 0–3%) and 1% (95% CI 0–2%) for the breakpoint > 2 mg/L and 0% (95% CI 0%) for breakpoint ≥32 μg/ml. Rifampin and tigecycline had a WPRs of 37.0% (95% CI 18–58%) and 1% (95% CI 0–3%), respectively. The WPRs for the other antimicrobials were as follows: ciprofloxacin 95% (95% CI 85–100%), moxifloxacin 32% (95% CI 25–40%), clindamycin 59% (95% CI 53–65%), amoxicillin/clavulanate 0% (0–0%), piperacillin/tazobactam 0% (0–0%) and ceftriaxone 47% (95% CI 29–65%). Tetracycline had a WPR 20% (95% CI 14–27%) and meropenem showed 0% (95% CI 0–1%); resistance to fidaxomicin was reported in one isolate (0.08%). Conclusion Resistance to metronidazole, vancomycin, fidaxomicin, meropenem and piperacillin/tazobactam is reported rarely. From the alternative CDI drug treatments, tigecycline had a lower resistance rate than rifampin. The high-risk antimicrobials for CDI development showed a high level of resistance, the highest was seen in the second generation of fluoroquinolones and clindamycin; amoxicillin/clavulanate showed almost no resistance. Tetracycline resistance was present in one fifth of human clinical C. difficile isolates.
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Affiliation(s)
- Mohammad Sholeh
- Dept. of Microbiology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Marcela Krutova
- Dept. of Medical Microbiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Mehdi Forouzesh
- Assistant professor of Legal medicine Research Center, Legal Medicine organization, Tehran, Iran
| | - Sergey Mironov
- Department of propaedeutics of dental diseases, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Nourkhoda Sadeghifard
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Leila Molaeipour
- Dept. of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Abbas Maleki
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Ebrahim Kouhsari
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran. .,Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran. .,Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran.
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17
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Tilkorn FKMT, Frickmann H, Simon IS, Schwanbeck J, Horn S, Zimmermann O, Groß U, Bohne W, Zautner AE. Antimicrobial Resistance Patterns in Clostridioides difficile Strains Isolated from Neonates in Germany. Antibiotics (Basel) 2020; 9:antibiotics9080481. [PMID: 32759868 PMCID: PMC7460221 DOI: 10.3390/antibiotics9080481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 01/15/2023] Open
Abstract
Young children are frequently colonized with Clostridioides (C.) difficile. Depending on their resistance patterns, antibiotic treatment can facilitate gastrointestinal spreading in colonized individuals, potentially leading to transmission to others. C. difficile was isolated from stool samples from infants born in two hospitals in Göttingen and Darmstadt, Germany. All isolates were subjected to phenotypic antimicrobial resistance testing, PCR-based screening for toxin genes and mass spectrometry-based exclusion of ribotypes 027 and 176. Within an initial cohort of 324 neonates with a longitudinal survey of C. difficile, 137 strains were isolated from 48 individuals. Antimicrobial resistance was recorded against metronidazole in one (0.7%), erythromycin in 16 (11.7%) and moxifloxacin in 2 (1.5%) of the strains, whereas no resistance was observed against vancomycin (0.0%) or rifampicin (0.0%). Newly observed resistance against erythromycin in children with detection of previously completely sensitive isolates was reported for C. difficile isolates from 2 out of 48 children. In 20 children (42%), non-toxigenic strains were detected, and from 27 children (56%), toxigenic strains were isolated, while both toxigenic and non-toxigenic strains were recorded for 1 child (2%). Ribotypes 027 or 176 were not observed. In conclusion, the German C. difficile strains isolated from the children showed mild to moderate resistance with predominance of macrolide resistance, a substance class which is frequently applied in children. The observed switches to the dominance of macrolide-resistant isolates suggests likely selection of resistant C. difficile strains already in children.
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Affiliation(s)
- Friederike K. M. T. Tilkorn
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Hagen Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany;
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany
| | - Isabel S. Simon
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
- Department of Pediatrics, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Julian Schwanbeck
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Sebastian Horn
- Department of Pediatrics, University Medical Center Göttingen, 37075 Göttingen, Germany;
- Department of Pediatrics, SRH Central Hospital Suhl, 98527 Suhl, Germany
| | - Ortrud Zimmermann
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Uwe Groß
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Wolfgang Bohne
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
| | - Andreas E. Zautner
- Institute for Medical Microbiology, University Medical Center Göttingen, 37075 Göttingen, Germany; (F.K.M.T.T.); (I.S.S.); (J.S.); (O.Z.); (U.G.); (W.B.)
- Correspondence: ; Tel.: +49-(0)552-395927
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18
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Snydman DR, McDermott LA, Jenkins SG, Goldstein EJC, Patel R, Forbes BA, Johnson S, Gerding DN, Thorpe CM, Walk ST. Epidemiologic trends in Clostridioides difficile isolate ribotypes in United States from 2011 to 2016. Anaerobe 2020; 63:102185. [PMID: 32387171 DOI: 10.1016/j.anaerobe.2020.102185] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Geographic and temporal trends in the distribution of PCR ribotypes for Clostridioides difficile associated diarrheal isolates obtained in the United States (US) are changing. As part of a US national surveillance program of C. difficile susceptibility to fidaxomicin, we quantified the distribution of PCR ribotypes of stool isolates collected from 2011 to 2016. METHODS C. difficile isolates or C. difficile toxin + stools from patients with C. difficile infection (CDI) were submitted for testing to Tufts Medical Center from 6 geographically distinct medical centers. Following isolation and confirmation as C. difficile, approximately 35% of the isolates were randomly sampled, stratified by center, for PCR ribotyping by capillary gel electrophoresis. Toxin gene profiling was performed on all isolates. RESULTS 939 isolates from a total of 2814 (33.4%) isolated over the 6 years were analyzed. Seventy unique ribotypes were observed, including 19 ribotypes observed 10 or more times. Sixteen ribotypes were not previously observed in our data base. Ribotype 027 declined by more than 60% over the 6 years of the survey from 35.3% to 13.1% (p < 0.001). Ribotype 106 was the most common in 2016, followed by 027 and 014-020. There were strong correlations between 027 and binary toxin with the 18 base pair deletion of tcdC and ribotype 078-126 had 100% concordance with the previously described tcdC 39 base pair deletion. CONCLUSIONS The frequency of ribotypes in the US has changed with a marked decline in 027. Each of the geographical areas had variations which differed from each other, but collectively, these results suggest that the changing epidemiology of C. difficile in the US is consistent with what is being seen in Europe. Continued surveillance and monitoring of changes in ribotype distributions of C. difficile are warranted.
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Affiliation(s)
| | | | | | | | - R Patel
- Mayo Clinic, Rochester, MN, USA
| | - B A Forbes
- Virginia Commonwealth, Richmond, VA, USA
| | - S Johnson
- Loyola University Medical Center, Maywood, IL, USA; Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - D N Gerding
- Loyola University Medical Center, Maywood, IL, USA; Edward Hines Jr. VA Hospital, Hines, IL, USA
| | | | - S T Walk
- Montana State University, Bozeman, MT, USA
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Saber T, Hawash YA, Ismail KA, Khalifa AS, Alsharif KF, Alghamdi SA, Saber T, Eed EM. Prevalence, toxin gene profile, genotypes and antibiotic susceptibility of Clostridium difficile in a tertiary care hospital in Taif, Saudi Arabia. Indian J Med Microbiol 2020; 38:176-182. [PMID: 32883931 DOI: 10.4103/ijmm.ijmm_20_300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Purpose Clostridium difficile (C. difficile) is an important causative agent of nosocomial diarrhoea and has become a major worldwide public health concern. The current study was conducted to determine the prevalence of C. difficile infection (CDI) amongst patients with nosocomial diarrhoea in a large tertiary care hospital in Taif, Saudi Arabia, and to define molecular characteristics and antimicrobial sensitivity profiles of C. difficile strains isolated from those patients. Materials and Methods Stool specimens were collected from 456 patients and were cultured for C. difficile isolation. The isolates were subjected to multiplex polymerase chain reaction (PCR) for detecting genes encoding the toxins (toxin A, toxin B and binary toxin [CDT]), genotyping by PCR ribotyping method and antimicrobial sensitivity testing using E test strips. Results Seventy-four C. difficile strains were recovered, of which 44 (59.5%) were A+B+CDT-, 14 (18.9%) were A-B+CDT-, 4 (5.4%) were A+B+CDT+ and 12 (16.2%) were A-B-CDT-. Toxigenic strains, and hence CDI, were detected in 13.6% of the patients (62/456). Fourteen different ribotypes were distinguished amongst bacterial isolates, of which ribotypes 002, 001, 017, 014 and 020 were the most prevalent (20.3%, 18.9%, 18.9%, 9.5% and 8.1%, respectively). Four isolates (5.4%) belonged to ribotype 027. All bacterial isolates showed sensitivity to metronidazole, vancomycin and piperacillin-tazobactam. The isolates exhibited resistance to linezolid (2.7%), chloramphenicol (5.4%), rifampicin (13.5%), tetracycline (21.6%), moxifloxacin (48.6%), clindamycin (54%) and imipenem (83.8%). Multiple drug resistance was observed in 56.8% of the isolates. Conclusion Further larger studies are required for an accurate understanding of CDI epidemiology in Saudi Arabia.
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Affiliation(s)
- Taisir Saber
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia; Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Yousry A Hawash
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia; Department of Molecular and Clinical Parasitology, National Liver Institute, Menoufia University, Menoufia, Egypt
| | - Khadiga A Ismail
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia; Department of Parasitology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amany S Khalifa
- Department of Medical Microbiology and Immunology, Faculty of Pharmacy, Taif University, Taif, Saudi Arabia; Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Khalaf F Alsharif
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | - Saleh A Alghamdi
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | - Tamer Saber
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Emad M Eed
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia; Department of Medical Microbiology and Immunology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
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20
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Yin J, Kociolek LK, Same RG, Hsu AJ, Amoah J, Tamma PD. Oral Vancomycin May Be Associated With Earlier Symptom Resolution Than Metronidazole for Hospitalized Children With Nonsevere Clostridiodes difficile Infections. Open Forum Infect Dis 2019; 6:ofz492. [PMID: 31950069 PMCID: PMC6954469 DOI: 10.1093/ofid/ofz492] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/12/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE National guidelines recommend oral vancomycin over oral metronidazole as first-line treatment for nonsevere Clostridioides difficile infection (CDI) in adults. Guidelines recommend metronidazole for children with nonsevere CDI, emphasizing that comparative effectiveness studies comparing the relative efficacy of vancomycin and metronidazole are lacking in children. METHOD We conducted an observational study of hospitalized children with nonsevere CDI treated with metronidazole versus vancomycin using an inverse probability of treatment-weighted propensity-score analysis. All of the following criteria had to be present for children with positive CDI testing for study eligibility: (1) ≥3 new-onset unformed stools within a 24-hour period; (2) 2-17 years of age; (3) hospitalization for ≥48 hours for CDI; (4) no laxative use ≤48 hours; (5) no alternate etiology for diarrhea; (6) no previous episode of CDI ≤3 months; (7) no concurrent non-CDI-targeted antibiotic therapy, and (8) no severe or fulminant CDI. RESULTS One hundred ninety-two patients met eligibility criteria; 141 (73.4%) received oral metronidazole and 51 (26.6%) children received oral vancomycin. Baseline characteristics were similar between the 2 groups in the weighted cohort. Of 141 patients, 101 (71.7%) children receiving metronidazole had clinical improvement by day 5, whereas 44 of 51 (86.3%) cases resolved with vancomycin (odds ratio, 0.40; 95% confidence interval, 0.17-0.97; P = .04). The odds of CDI recurrence within 12 weeks were similar between the groups. CONCLUSIONS Our study suggests that children with nonsevere CDI have earlier resolution of clinical symptoms when prescribed vancomycin compared with metronidazole. Large interventional studies are necessary to evaluate the reproducibility of our findings.
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Affiliation(s)
- Jianyi Yin
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Larry K Kociolek
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rebecca G Same
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alice J Hsu
- The Johns Hopkins Hospital, Department of Pharmacy, Baltimore, Maryland
| | - Joe Amoah
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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21
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Arcay RM, Suárez-Bode L, López-Causapé C, Oliver A, Mena A. Emergence of high-level and stable metronidazole resistance in Clostridioides difficile. Int J Antimicrob Agents 2019; 55:105830. [PMID: 31669741 DOI: 10.1016/j.ijantimicag.2019.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/15/2019] [Accepted: 10/20/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Ricardo M Arcay
- Microbiology Department, Hospital Universitari Son Espases and Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Loreto Suárez-Bode
- Microbiology Department, Hospital Universitari Son Espases and Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Carla López-Causapé
- Microbiology Department, Hospital Universitari Son Espases and Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Antonio Oliver
- Microbiology Department, Hospital Universitari Son Espases and Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Ana Mena
- Microbiology Department, Hospital Universitari Son Espases and Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain.
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22
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Metronidazole therapy as initial treatment of Clostridium difficile infection in patients with chronic kidney disease in Korea. Epidemiol Infect 2019; 147:e289. [PMID: 31607272 PMCID: PMC6805788 DOI: 10.1017/s0950268819001742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The risk of metronidazole treatment failure in Clostridium difficile infection (CDI) patients with chronic kidney disease (CKD) or end-stage renal disease in Korea has not been established. We evaluated 481 patients who had been admitted to two secondary hospitals with a diagnosis of, and treatment for, CDI during 2010–2016. CDI patients were divided into three groups according to CKD status: non-CKD (n = 363), CKD (n = 55) and those requiring dialysis (n = 63). Logistic regression analyses were performed to examine the association of CKD status with treatment failure. CDI patients receiving dialysis tended to have increased odds of metronidazole and overall treatment failure compared to non-CKD patients; adjusted odds ratios and 95% confidence intervals were 2.09 (1.03–4.21) and 2.18 (1.11–4.32) for metronidazole and overall treatment failure, respectively. However, CKD patients did not have increased odds of metronidazole or overall treatment failure compared to non-CKD patients, even where severe CDI was more prevalent in CKD patients. The incidence of symptomatic ileus or toxic megacolon did not differ among groups. Our results suggest that initial metronidazole therapy may be considered in CDI patients with non-dialysis CKD, but should not be considered in CDI patients undergoing dialysis.
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Antibiotic resistance of clinical isolates of Clostridioides difficile in China and its association with geographical regions and patient age. Anaerobe 2019; 60:102094. [PMID: 31499177 DOI: 10.1016/j.anaerobe.2019.102094] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/20/2019] [Accepted: 08/30/2019] [Indexed: 12/20/2022]
Abstract
It is known that antibiotic usage is associated with the development of Clostridioides difficile infection (CDI), especially clindamycin, third-generation cephalosporins, and fuoroquinolones. Antibiotic resistance rates to many antibiotics varies a lot by study. We performed a study focused on antibiotic resistance in clinical isolates of C. difficile from more widespread geographic regions across China. Of 319 C. difficile isolates tested against 11 antibiotics, 313 (98.1%) were resistant to at least one antibiotic. The highest rate of resistance was to ciprofloxacin, clindamycin, and erythromycin across all age groups, similar to previous studies. However, all isolates were susceptible to metronidazole and vancomycin. Overall the resistance rate to tested antibiotics was lower than other reports in China except for chloramphenicol and meropenem. Genotype ST37/RT017 in clade 4 was resistant to more antibiotics than other types. Unexpectedly, RT078 isolates in this study were susceptible to almost all tested antibiotics. In addition, the proportion of multi-drug resistant (MDR) isolates observed (17%) in this study was much lower than several European studies (up to 55%) and a previous study in China (78%). Although isolates from patients aged between 65 and 85 were more resistant to antibiotics in comparison to other age groups, MDR isolates were still detected in children below 2-years of age. The highest percentage of MDR isolates was determined in South China, an area that is most developed economically. The clade 4, RT017 (ST37) has been associated with outbreaks in Europe and North America and is responsible for most C. difficile infections (CDIs) in Asia. In addition, RT017 is often clindamycin and fluoroquinolone resistant. This study provided a relatively comprehensive description of antibiotic resistance of C. difficile in China, and further elucidates the epidemiology and antibiotic resistance of clinical isolates of C. difficile in China at a national level.
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Kouhsari E, Douraghi M, Krutova M, Fakhre Yaseri H, Talebi M, Baseri Z, Moqarabzadeh V, Sholeh M, Amirmozafari N. The emergence of metronidazole and vancomycin reduced susceptibility in Clostridium difficile isolates in Iran. J Glob Antimicrob Resist 2019; 18:28-33. [PMID: 30703583 DOI: 10.1016/j.jgar.2019.01.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 12/17/2018] [Accepted: 01/21/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Clostridium difficile (C. difficile) is the main causative agent of antibiotic-associated diarrhoea (AAD) and pseudomembranous colitis. The accumulation of antimicrobial resistance in C. difficile strains can drive C. difficile infection (CDI) epidemiology. This study was undertaken to evaluate the antimicrobial resistance patterns of toxigenic C. difficile isolates cultured from diarrhoeal stool samples of hospitalised patients with suspected CDI in three tertiary care hospitals in Tehran, Iran. METHODS Two hundred and fifty diarrhoeal stool samples were investigated by toxigenic culture using cycloserine-cefoxitin-fructose agar and the VERO cell line. Antimicrobial susceptibility to metronidazole, vancomycin, clindamycin, tetracycline, and moxifloxacin was performed by disk diffusion and Etest methods on Brucella Blood Agar supplemented with hemin and vitamin K. RESULTS Thirty-five stool samples (14.0%) proved positive using C. difficile toxigenic culture. According to Clinical and Laboratory Standards Institute breakpoints, the following resistance was identified in C. difficile isolates: metronidazole (2 of 35); moxifloxacin (7 of 35); clindamycin (18 of 35); and tetracycline (5 of 35). Using European Committee on Antimicrobial Susceptibility Testing breakpoints, three of 35 isolates showed reduced-susceptibility for vancomycin and 14 of 35 for metronidazole. In addition, the results showed a good correlation between the inhibition zone diameter (disk diffusion) and MIC values (Etest); Pearson correlation coefficient 0.7400.95 (P< 0.001). CONCLUSIONS Multidrug resistance was observed in Iranian clinical toxigenic C. difficile isolates, including reduced susceptibility to first-line CDI treatment drugs. In addition, disk diffusion can be used as a cost-effective option for the antimicrobial susceptibility testing of C. difficile isolates.
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Affiliation(s)
- Ebrahim Kouhsari
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran; Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran; Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Masoumeh Douraghi
- Division of Microbiology, Department of Pathobiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Marcela Krutova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Hashem Fakhre Yaseri
- Research Center for Gastroenterology and Liver Disease, Firouzgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Malihe Talebi
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zohreh Baseri
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Vahid Moqarabzadeh
- Department of Biostatistics, School of Health, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad Sholeh
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nour Amirmozafari
- Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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25
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Mizrahi S, Hamo Z, Azrad M, Peretz A. Molecular Characterization and Moxifloxacin Susceptibility of Clostridium difficile. Antibiotics (Basel) 2019; 8:antibiotics8030118. [PMID: 31409041 PMCID: PMC6783923 DOI: 10.3390/antibiotics8030118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/30/2019] [Accepted: 08/06/2019] [Indexed: 11/20/2022] Open
Abstract
In recent years, the incidence and severity of Clostridium difficile infections has increased. Additionally, resistance of C. difficile to frequently used antibiotics is rising. To improve our understanding of C. difficile, there is a need for molecular characterization of different strains and antibiotic resistance testing. We investigated the efficacy of GenoType CDiff kit (Hain Lifesciences) in identification of C. difficile and its various strains in northern Israel. The kit involves a molecular assay that detects C. difficile from stool samples or colonies and identifies the different strains and mutations in the gyrA gene that cause moxifloxacin resistance. Forty-nine C. difficile positive samples were examined by the kit following DNA extraction from both colonies and stool. The identification rate (95.9%) of C. difficile was much higher when DNA was extracted from colonies, compared to extraction from stool (46.9%). Low frequencies of ribotype027 strain (2%) and of ribotype078 strain (4%) were found. There was a high concordance between genotype (mutation in gyrA) and phenotype (Etest) for moxifloxacin resistance (Kappa = 0.72). A high percentage of moxifloxacin-resistant strains was found. Our findings indicate that the GenoType CDiff kit is very effective in characterization of C.difficile strains and less effective for identification of C. difficile directly from stool samples.
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Affiliation(s)
- Sarah Mizrahi
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, 1311502, Israel
| | - Zohar Hamo
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty ofMedicine, Bar Ilan University, Safed, 1311502, Israel
| | - Maya Azrad
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty ofMedicine, Bar Ilan University, Safed, 1311502, Israel
| | - Avi Peretz
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, 1311502, Israel.
- Clinical Microbiology Laboratory, Baruch Padeh Medical Center, Poriya, affiliated with the Faculty ofMedicine, Bar Ilan University, Safed, 1311502, Israel.
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26
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Saha S, Kapoor S, Tariq R, Schuetz AN, Tosh PK, Pardi DS, Khanna S. Increasing antibiotic resistance in Clostridioides difficile: A systematic review and meta-analysis. Anaerobe 2019; 58:35-46. [PMID: 31330183 DOI: 10.1016/j.anaerobe.2019.102072] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Decreases in clinical response of Clostridioides difficile to antibiotics used for its treatment have raised concerns regarding antibiotic resistance. We conducted a systematic review and meta-analysis to study the resistance rates of C. difficile to various antibiotics over time. METHODS We systematically searched MEDLINE, Embase, and Web of Science from inception through 03/31/2017 for observational studies assessing antibiotic resistance rates in C. difficile. Weighted summary estimates were calculated using inverse variance heterogeneity models [MetaXL software (v. 5.3)]. A priori subgroup analyses were done (by study year, continent, susceptibility testing method, origin of isolates); ribotype 027 strains were analyzed separately. RESULTS From 1982 to 2017, 60 studies (8336 isolates) were analyzed. Fifty-three studies reported vancomycin resistance; weighted pooled resistance (WPR), 2.1% (95% CI, 0%-5.1%; I2 = 95%). Fifty-five studies reported metronidazole resistance; WPR, 1.9% (95% CI, 0.5%-3.6%; I2 = 89%). Compared to the period before 2012, vancomycin resistance increased by 3.6% (95% CI, 2.9%-4.2%; P < 0.001) after 2012, and metronidazole resistance decreased by 0.8% (95% CI, 0.1%-1.5%; P = 0.02). No isolates were resistant to fidaxomicin. CONCLUSION Resistance of C. difficile to vancomycin is increasing, with a smaller, declining resistance to metronidazole; there is significant heterogeneity between studies. Ongoing monitoring of resistance to commonly used antibiotics is required.
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Affiliation(s)
- Srishti Saha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Saloni Kapoor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Raseen Tariq
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Audrey N Schuetz
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Pritish K Tosh
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, 55905, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA.
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27
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U.S.-Based National Surveillance for Fidaxomicin Susceptibility of Clostridioides difficile-Associated Diarrheal Isolates from 2013 to 2016. Antimicrob Agents Chemother 2019; 63:AAC.00391-19. [PMID: 31085514 DOI: 10.1128/aac.00391-19] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/06/2019] [Indexed: 12/26/2022] Open
Abstract
In 2011, we initiated a sentinel surveillance network to assess changes in Clostridioides (formerly Clostridium) difficile antimicrobial susceptibility to fidaxomicin from 6 geographically dispersed medical centers in the United States. This report summarizes data from 2013 to 2016. C. difficile isolates or toxin-positive stools from patients were referred to a central laboratory. Antimicrobial susceptibility was determined by agar dilution. CLSI, EUCAST, or FDA breakpoints were used, where applicable. Toxin gene profiles were characterized by multiplex PCR on each isolate. A random sample of approximately 40% of isolates, stratified by institution and year, was typed by restriction endonuclease analysis (REA). Among 1,889 isolates from 2013 to 2016, the fidaxomicin MIC90 was 0.5 μg/ml; all isolates were inhibited at ≤1 μg/ml. There were decreases in metronidazole and vancomycin MICs over time. Clindamycin resistance remained unchanged (27.3%). An increase in imipenem resistance was observed. By 2015 to 2016, moxifloxacin resistance decreased in all centers. The proportion of BI isolates decreased from 25.5% in 2011 to 2012 to 12.8% in 2015 to 2016 (P < 0.001). The BI REA group correlated with moxifloxacin resistance (BI 84% resistant versus non-BI 12.5% resistant). Fidaxomicin MICs have not changed among C. difficile isolates of U.S. origin over 5 years post licensure. There has been an overall decrease in MICs for vancomycin, metronidazole, moxifloxacin, and rifampin and an increase in isolates resistant to imipenem. Moxifloxacin resistance remained high among the BI REA group, but the proportion of BI isolates has decreased. Continued geographic variations in REA groups and antimicrobial resistance persist.
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28
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Mileto S, Das A, Lyras D. Enterotoxic Clostridia: Clostridioides difficile Infections. Microbiol Spectr 2019; 7:10.1128/microbiolspec.gpp3-0015-2018. [PMID: 31124432 PMCID: PMC11026080 DOI: 10.1128/microbiolspec.gpp3-0015-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Indexed: 12/17/2022] Open
Abstract
Clostridioides difficile is a Gram-positive, anaerobic, spore forming pathogen of both humans and animals and is the most common identifiable infectious agent of nosocomial antibiotic-associated diarrhea. Infection can occur following the ingestion and germination of spores, often concurrently with a disruption to the gastrointestinal microbiota, with the resulting disease presenting as a spectrum, ranging from mild and self-limiting diarrhea to severe diarrhea that may progress to life-threating syndromes that include toxic megacolon and pseudomembranous colitis. Disease is induced through the activity of the C. difficile toxins TcdA and TcdB, both of which disrupt the Rho family of GTPases in host cells, causing cell rounding and death and leading to fluid loss and diarrhea. These toxins, despite their functional and structural similarity, do not contribute to disease equally. C. difficile infection (CDI) is made more complex by a high level of strain diversity and the emergence of epidemic strains, including ribotype 027-strains which induce more severe disease in patients. With the changing epidemiology of CDI, our understanding of C. difficile disease, diagnosis, and pathogenesis continues to evolve. This article provides an overview of the current diagnostic tests available for CDI, strain typing, the major toxins C. difficile produces and their mode of action, the host immune response to each toxin and during infection, animal models of disease, and the current treatment and prevention strategies for CDI.
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Affiliation(s)
- S Mileto
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, Australia, 3800
| | - A Das
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, Australia, 3800
| | - D Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, Australia, 3800
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29
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Dingsdag SA, Hunter N. Metronidazole: an update on metabolism, structure-cytotoxicity and resistance mechanisms. J Antimicrob Chemother 2019; 73:265-279. [PMID: 29077920 DOI: 10.1093/jac/dkx351] [Citation(s) in RCA: 168] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Metronidazole, a nitroimidazole, remains a front-line choice for treatment of infections related to inflammatory disorders of the gastrointestinal tract including colitis linked to Clostridium difficile. Despite >60 years of research, the metabolism of metronidazole and associated cytotoxicity is not definitively characterized. Nitroimidazoles are prodrugs that are reductively activated (the nitro group is reduced) under low oxygen tension, leading to imidazole fragmentation and cytotoxicity. It remains unclear if nitroimidazole reduction (activation) contributes to the cytotoxicity profile, or whether subsequent fragmentation of the imidazole ring and formed metabolites alone mediate cytotoxicity. A molecular mechanism underpinning high level (>256 mg/L) bacterial resistance to metronidazole also remains elusive. Considering the widespread use of metronidazole and other nitroimidazoles, this review was undertaken to emphasize the structure-cytotoxicity profile of the numerous metabolites of metronidazole in human and murine models and to examine conflicting reports regarding metabolite-DNA interactions. An alternative hypothesis, that DNA synthesis and repair of existing DNA is indirectly inhibited by metronidazole is proposed. Prokaryotic metabolism of metronidazole is detailed to discuss new resistance mechanisms. Additionally, the review contextualizes the history and current use of metronidazole, rates of metronidazole resistance including metronidazole MDR as well as the biosynthesis of azomycin, the natural precursor of metronidazole. Changes in the gastrointestinal microbiome and the host after metronidazole administration are also reviewed. Finally, novel nitroimidazoles and new antibiotic strategies are discussed.
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Affiliation(s)
- Simon A Dingsdag
- Institute of Dental Research and Westmead Centre for Oral Health, Westmead, NSW 2145, Australia.,Department of Life Sciences Faculty of Dentistry, The University of Sydney, NSW 2006, Australia.,The Westmead Institute for Medical Research, The University of Sydney, NSW 2145, Australia
| | - Neil Hunter
- Institute of Dental Research and Westmead Centre for Oral Health, Westmead, NSW 2145, Australia.,Department of Life Sciences Faculty of Dentistry, The University of Sydney, NSW 2006, Australia.,The Westmead Institute for Medical Research, The University of Sydney, NSW 2145, Australia
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30
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Septimus EJ, Coopersmith CM, Whittle J, Hale CP, Fishman NO, Kim TJ. Sepsis National Hospital Inpatient Quality Measure (SEP-1): Multistakeholder Work Group Recommendations for Appropriate Antibiotics for the Treatment of Sepsis. Clin Infect Dis 2018; 65:1565-1569. [PMID: 29048513 DOI: 10.1093/cid/cix603] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 07/03/2017] [Indexed: 12/25/2022] Open
Abstract
The Center for Medicare and Medicaid Services adopted the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) performance measure to the Hospital Inpatient Quality Reporting Program in July 2015 to help address the high mortality and high cost associated with sepsis. The SEP-1 performance measure requires, among other critical interventions, timely administration of antibiotics to patients with sepsis or septic shock. The multistakeholder workgroup recognizes the need for SEP-1 but strongly believes that multiple antibiotics listed in the antibiotic tables for SEP-1 are not appropriate and the use of these antibiotics, as called for in the SEP-1 measure, is not in alignment with prudent antimicrobial stewardship. To promote the appropriate use of antimicrobials and combat antimicrobial resistance, the workgroup provides recommendations for appropriate antibiotics for the treatment of sepsis.
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Affiliation(s)
- Edward J Septimus
- Texas A&M Health Science Center College of Medicine.,Clinical Services Group, Hospital Corporation of America (HCA), Houston, Texas
| | | | - Jessica Whittle
- Department of Emergency Medicine, University of Tennessee College of Medicine, Chattanooga
| | - Caleb P Hale
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Thomas J Kim
- Infectious Diseases Society of America, Arlington, Virginia
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31
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Snydman DR, McDermott LA, Jacobus NV, Kerstein K, Grossman TH, Sutcliffe JA. Evaluation of the In Vitro Activity of Eravacycline against a Broad Spectrum of Recent Clinical Anaerobic Isolates. Antimicrob Agents Chemother 2018; 62:e02206-17. [PMID: 29483114 PMCID: PMC5923129 DOI: 10.1128/aac.02206-17] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 02/18/2018] [Indexed: 01/05/2023] Open
Abstract
The novel fluorocycline antibiotic eravacycline is in development for use in the treatment of serious infections caused by susceptible and multidrug-resistant (MDR) aerobic and anaerobic Gram-negative and Gram-positive pathogens. Eravacycline and 11 comparator antibiotics were tested against recent anaerobic clinical isolates, including MDR Bacteroides spp. and Clostridium difficile Eravacycline was potent in vitro against all the isolates tested, including strains with tetracycline-specific resistance determinants and MDR anaerobic pathogens resistant to carbapenems and/or β-lactam-β-lactamase inhibitor combinations.
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Affiliation(s)
- David R Snydman
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Laura A McDermott
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nilda V Jacobus
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
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32
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Martínez-Meléndez A, Tijerina-Rodríguez L, Morfin-Otero R, Camacho-Ortíz A, Villarreal-Treviño L, Sánchez-Alanís H, Rodríguez-Noriega E, Baines SD, Flores-Treviño S, Maldonado-Garza HJ, Garza-González E. Circulation of Highly Drug-Resistant Clostridium difficile Ribotypes 027 and 001 in Two Tertiary-Care Hospitals in Mexico. Microb Drug Resist 2018; 24:386-392. [DOI: 10.1089/mdr.2017.0323] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Adrián Martínez-Meléndez
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| | - Laura Tijerina-Rodríguez
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| | - Rayo Morfin-Otero
- Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Hospital Civil de Guadalajara “Fray Antonio Alcalde” e Instituto de Patología Infecciosa y Experimental, Guadalajara, Mexico
| | - Adrián Camacho-Ortíz
- Servicio de Infectología, Universidad Autónoma de Nuevo León, Hospital Universitario “Dr. José Eleuterio González,” Monterrey, Mexico
| | - Licet Villarreal-Treviño
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| | - Hugo Sánchez-Alanís
- Departamento de Microbiología e Inmunología, Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| | - Eduardo Rodríguez-Noriega
- Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Hospital Civil de Guadalajara “Fray Antonio Alcalde” e Instituto de Patología Infecciosa y Experimental, Guadalajara, Mexico
| | - Simon D. Baines
- Department of Biological and Environmental Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Samantha Flores-Treviño
- Servicio de Gastroenterología, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Héctor Jesús Maldonado-Garza
- Servicio de Gastroenterología, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elvira Garza-González
- Servicio de Gastroenterología, Hospital Universitario “Dr. José Eleuterio González,” Universidad Autónoma de Nuevo León, Monterrey, Mexico
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33
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A repeat offender: Recurrent extraintestinal Clostridium difficile infection following fecal microbiota transplantation. Anaerobe 2018; 51:68-72. [PMID: 29709869 DOI: 10.1016/j.anaerobe.2018.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/06/2018] [Accepted: 04/08/2018] [Indexed: 01/12/2023]
Abstract
Extraintestinal infection with Clostridium difficile has been reported but remains uncommon. Treatment of this unusual complication is complex given the limitations of current therapeutic options. Here we report a novel case of recurrent extraintestinal C. difficile infection that occurred following fecal microbiota transplantation. Using whole genome sequencing, we confirmed recrudescence rather than reinfection was responsible. The patient ultimately responded to prolonged, targeted antimicrobial therapy informed by susceptibility testing.
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34
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Karlowsky JA, Adam HJ, Kosowan T, Baxter MR, Nichol KA, Laing NM, Golding G, Zhanel GG. PCR ribotyping and antimicrobial susceptibility testing of isolates of Clostridium difficile cultured from toxin-positive diarrheal stools of patients receiving medical care in Canadian hospitals: the Canadian Clostridium difficile Surveillance Study (CAN-DIFF) 2013-2015. Diagn Microbiol Infect Dis 2018; 91:105-111. [PMID: 29456070 DOI: 10.1016/j.diagmicrobio.2018.01.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/21/2018] [Indexed: 12/14/2022]
Abstract
Clostridium difficile toxin-positive diarrheal stool specimens submitted to eight Canadian hospital laboratories from 2013 to 2015 were cultured. Polymerase chain reaction ribotyping of isolates was performed using an internationally standardized, high-resolution capillary gel-based electrophoresis protocol and antimicrobial susceptibility testing conducted by CLSI-defined agar dilution (M11-A8, 2012). Among the 1310 isolates of C. difficile cultured, 141 different ribotypes were identified; the most common ribotypes were 027 (24.5% of isolates), 014 (7.7%), 020 (6.6%), 106 (6.1%), and 002 (4.6%). Ribotype 027 was the commonest ribotype in all geographic regions of Canada and was more frequently isolated from patients aged ≥80 years (40.6%) than younger patients (P<0.00001). Ribotype 027 isolates were frequently moxifloxacin-resistant (92.2% of isolates) and multidrug-resistant (49.5%). Fidaxomicin demonstrated the greatest in vitro potency (lowest MIC90, 0.5 μg/mL; lowest maximum MIC, 2 μg/mL) of eight antimicrobial agents tested and was the most active agent against each of the five commonest ribotypes (MIC90, 0.25-1 μg/mL).
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Affiliation(s)
- James A Karlowsky
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Diagnostic Services Manitoba, Winnipeg, Manitoba, Canada
| | - Heather J Adam
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Diagnostic Services Manitoba, Winnipeg, Manitoba, Canada
| | - Tyler Kosowan
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; National Microbiology Laboratory-Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Melanie R Baxter
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kim A Nichol
- Diagnostic Services Manitoba, Winnipeg, Manitoba, Canada
| | - Nancy M Laing
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - George Golding
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; National Microbiology Laboratory-Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - George G Zhanel
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Peng Z, Addisu A, Alrabaa S, Sun X. Antibiotic Resistance and Toxin Production of Clostridium difficile Isolates from the Hospitalized Patients in a Large Hospital in Florida. Front Microbiol 2017; 8:2584. [PMID: 29312258 PMCID: PMC5744170 DOI: 10.3389/fmicb.2017.02584] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 12/12/2017] [Indexed: 12/15/2022] Open
Abstract
Clostridium difficile is an important cause of nosocomial acquired antibiotic-associated diarrhea causing an estimated 453,000 cases with 29,000 deaths yearly in the U.S. Both antibiotic resistance and toxin expression of C. difficile correlate with the severity of C. difficile infection (CDI). In this report, a total of 139 C. difficile isolates from patients diagnosed with CDI in Tampa General Hospital (Florida) in 2016 were studied for antibiotic resistance profiles of 12 types of antibiotics and toxin production. Antibiotic resistance determined by broth microdilution method showed that strains resistant to multi-antibiotics are common. Six strains (4.32%) showed resistance to six types of antibiotics. Twenty strains (14.39%) showed resistance to five types of antibiotics. Seventeen strains (12.24%) showed resistance to four types of antibiotics. Thirty-nine strains (28.06%) showed resistance to three types of antibiotic. Thirty-four strains (24.46%) showed resistance to two types of antibiotics. While, all isolates were susceptible to metronidazole, and rifaximin, we found that one isolate (0.72%) displayed resistance to vancomycin (MIC ≥ 8 μg/ml), and another one was resistant to fidaxomicin (MIC >1 μg/ml). The percentage of isolates resistant to cefoxitin, ceftriaxone, chloramphenicol, ampicillin, clindamycin, erythromycin, gatifloxacin, and moxifloxacin was 75.54, 10.79, 5.76, 67.63, 82.70, 45.32, 28.06, and 28.78%, respectively. Toxin profiling by PCR showed the isolates include 101 (72.66%) A+B+CDT-strains, 23 (16.55%) A+B+CDT+ strains, 3 (2.16%) A-B+CDT+ strains, 1 (0.72%) A-B+CDT-strains, and 11 (7.91%) A-B-CDT-strains. Toxin production determined by ELISA using supernatants of bacterial culture harvested at 12, 24, 48, and 72 h of post inoculation (hpi) showed that the toxins were mainly produced between 48 and 72 hpi, and toxin B (TcdB) was produced faster than toxin A (TcdA) during the experimental time (72 hpi). In addition, the binary-positive strains were likely to yield more toxins compared to the binary-negative strains. This work contributes to the current understanding of the antibiotic resistance and virulence of C. difficile clinical strains.
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Affiliation(s)
- Zhong Peng
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States.,State Key Laboratory of Agricultural Microbiology, College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, China
| | - Anteneh Addisu
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Sally Alrabaa
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Xingmin Sun
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States.,Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
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Freeman J, Vernon J, Pilling S, Morris K, Nicholson S, Shearman S, Longshaw C, Wilcox MH. The ClosER study: results from a three-year pan-European longitudinal surveillance of antibiotic resistance among prevalent Clostridium difficile ribotypes, 2011-2014. Clin Microbiol Infect 2017; 24:724-731. [PMID: 29066403 DOI: 10.1016/j.cmi.2017.10.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/29/2017] [Accepted: 10/12/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Until the introduction of fidaxomicin, antimicrobial treatment for Clostridium difficile infection (CDI) was limited to metronidazole and vancomycin. The changing epidemiology of CDI and the emergence of epidemic C. difficile PCR ribotype 027 necessitate continued surveillance to identify shifts in antibiotic susceptibility. ClosER, currently the largest pan-European epidemiological study of C. difficile ribotype distribution and antibiotic susceptibility, aimed to undertake antimicrobial resistance surveillance pre- and post-introduction of fidaxomicin. METHODS Between July 2011 and July 2014, 39 sites across 22 European countries submitted 2830 C. difficile isolates for ribotyping, toxin testing and susceptibility testing to metronidazole, vancomycin, fidaxomicin, rifampicin, moxifloxacin, clindamycin, imipenem, chloramphenicol and tigecycline. RESULTS Ribotypes 027, 014, 001, 078, 020, 002, 126, 015 and 005 were most frequently isolated, and emergent ribotypes 198 and 356 were identified in Hungary and Italy, respectively. All isolates were susceptible to fidaxomicin, with scarce resistance to metronidazole (0.2%, 6/2694), vancomycin (0.1%, 2/2694) and tigecycline (0%). Rifampicin, moxifloxacin and clindamycin resistance was evident in multiple ribotypes. Lack of ribotype diversity correlated with greater antimicrobial resistance. Epidemic ribotypes (027/001) were associated with multiple antimicrobial resistance, and ribotypes 017, 018 and 356 with high-level resistance. Additional factors may also influence local ribotype prevalence. CONCLUSIONS Fidaxomicin susceptibility was retained post-introduction, and resistance to metronidazole and vancomycin was rare. Continued surveillance is needed, with more accurate classification and clarification of ribotype subtypes to further understand their role in the spread of resistance. Other factors may also influence changes in prevalence of C. difficile ribotypes with reduced antibiotic susceptibility.
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Affiliation(s)
- J Freeman
- Department of Microbiology, Leeds Teaching Hospitals Trust, Leeds, UK; Healthcare Associated Infections Research Group, Section of Molecular Gastroenterology, Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, UK.
| | - J Vernon
- Healthcare Associated Infections Research Group, Section of Molecular Gastroenterology, Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - S Pilling
- Healthcare Associated Infections Research Group, Section of Molecular Gastroenterology, Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - K Morris
- Department of Microbiology, Leeds Teaching Hospitals Trust, Leeds, UK
| | - S Nicholson
- Healthcare Associated Infections Research Group, Section of Molecular Gastroenterology, Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - S Shearman
- Healthcare Associated Infections Research Group, Section of Molecular Gastroenterology, Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | | | - M H Wilcox
- Department of Microbiology, Leeds Teaching Hospitals Trust, Leeds, UK; Healthcare Associated Infections Research Group, Section of Molecular Gastroenterology, Leeds Institute for Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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Lai H, Huang C, Cai J, Ye J, She J, Zheng Y, Wang L, Wei Y, Fang W, Wang X, Tang YW, Luo Y, Jin D. Simultaneous detection and characterization of toxigenic Clostridium difficile directly from clinical stool specimens. Front Med 2017; 12:196-205. [PMID: 29058256 DOI: 10.1007/s11684-017-0560-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 05/17/2017] [Indexed: 02/08/2023]
Abstract
We employed a multiplex polymerase chain reaction (PCR) coupled with capillary electrophoresis (mPCR-CE) targeting six Clostridium difficile genes, including tpi, tcdA, tcdB, cdtA, cdtB, and a deletion in tcdC for simultaneous detection and characterization of toxigenic C. difficile directly from fecal specimens. The mPCR-CE had a limit of detection of 10 colony-forming units per reaction with no cross-reactions with other related bacterial genes. Clinical validation was performed on 354 consecutively collected stool specimens from patients with suspected C. difficile infection and 45 isolates. The results were compared with a reference standard combined with BD MAX Cdiff, real-time cell analysis assay (RTCA), and mPCR-CE. The toxigenic C. difficile species were detected in 36 isolates and 45 stool specimens by the mPCR-CE, which provided a positive rate of 20.3% (81/399). The mPCR-CE had a specificity of 97.2% and a sensitivity of 96.0%, which was higher than RTCA (x2 = 5.67, P = 0.017) but lower than BD MAX Cdiff (P = 0.245). Among the 45 strains, 44 (97.8%) were determined as nonribotype 027 by the mPCR-CE, which was fully agreed with PCR ribotyping. Even though ribotypes 017 (n = 8, 17.8%), 001 (n = 6, 13.3%), and 012 (n = 7, 15.6%) were predominant in this region, ribotype 027 was an important genotype monitored routinely. The mPCR-CE provided an alternative diagnosis tool for the simultaneous detection of toxigenic C. difficile in stool and potentially differentiated between RT027 and non-RT027.
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Affiliation(s)
- Hanjiang Lai
- The First People's Hospital of Xiaoshan District, Hangzhou, 311021, China
| | - Chen Huang
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, 310051, China
| | - Jian Cai
- Department of Disease Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, 310051, China
| | - Julian Ye
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, 310051, China
| | - Jun She
- The First People's Hospital of Xiaoshan District, Hangzhou, 311021, China
| | - Yi Zheng
- Biotherapy Center for Medical Oncology, the First Affiliated Hospital, Zhejiang University, Hangzhou, 310003, China
| | - Liqian Wang
- Department of Laboratory Medicine, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Yelin Wei
- The First People's Hospital of Xiaoshan District, Hangzhou, 311021, China
| | - Weijia Fang
- Biotherapy Center for Medical Oncology, the First Affiliated Hospital, Zhejiang University, Hangzhou, 310003, China
| | - Xianjun Wang
- Department of Laboratory Medicine, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Yi-Wei Tang
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.,Department of Pathology and Laboratory Medicine, Weill Medical College of Cornell University, New York, NY, 10065, USA
| | - Yun Luo
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, 310051, China.
| | - Dazhi Jin
- Department of Microbiology, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, 310051, China.
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Next-Generation Probiotics Targeting Clostridium difficile through Precursor-Directed Antimicrobial Biosynthesis. Infect Immun 2017; 85:IAI.00303-17. [PMID: 28760934 PMCID: PMC5607411 DOI: 10.1128/iai.00303-17] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/24/2017] [Indexed: 12/18/2022] Open
Abstract
Integration of antibiotic and probiotic therapy has the potential to lessen the public health burden of antimicrobial-associated diseases. Clostridium difficile infection (CDI) represents an important example where the rational design of next-generation probiotics is being actively pursued to prevent disease recurrence. Because intrinsic resistance to clinically relevant antibiotics used to treat CDI (vancomycin, metronidazole, and fidaxomicin) is a desired trait in such probiotic species, we screened several bacteria and identified Lactobacillus reuteri to be a promising candidate for adjunct therapy. Human-derived L. reuteri bacteria convert glycerol to the broad-spectrum antimicrobial compound reuterin. When supplemented with glycerol, strains carrying the pocR gene locus were potent reuterin producers, with L. reuteri 17938 inhibiting C. difficile growth at a level on par with the level of growth inhibition by vancomycin. Targeted pocR mutations and complementation studies identified reuterin to be the precursor-induced antimicrobial agent. Pathophysiological relevance was demonstrated when the codelivery of L. reuteri with glycerol was effective against C. difficile colonization in complex human fecal microbial communities, whereas treatment with either glycerol or L. reuteri alone was ineffective. A global unbiased microbiome and metabolomics analysis independently confirmed that glycerol precursor delivery with L. reuteri elicited changes in the composition and function of the human microbial community that preferentially targets C. difficile outgrowth and toxicity, a finding consistent with glycerol fermentation and reuterin production. Antimicrobial resistance has thus been successfully exploited in the natural design of human microbiome evasion of C. difficile, and this method may provide a prototypic precursor-directed probiotic approach. Antibiotic resistance and substrate bioavailability may therefore represent critical new determinants of probiotic efficacy in clinical trials.
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39
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Wyche TP, Ramos Alvarenga RF, Piotrowski JS, Duster MN, Warrack SR, Cornilescu G, De Wolfe TJ, Hou Y, Braun DR, Ellis GA, Simpkins SW, Nelson J, Myers CL, Steele J, Mori H, Safdar N, Markley JL, Rajski SR, Bugni TS. Chemical Genomics, Structure Elucidation, and in Vivo Studies of the Marine-Derived Anticlostridial Ecteinamycin. ACS Chem Biol 2017; 12:2287-2295. [PMID: 28708379 PMCID: PMC5697710 DOI: 10.1021/acschembio.7b00388] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A polyether antibiotic, ecteinamycin (1), was isolated from a marine Actinomadura sp., cultivated from the ascidian Ecteinascidia turbinata. 13C enrichment, high resolution NMR spectroscopy, and molecular modeling enabled elucidation of the structure of 1, which was validated on the basis of comparisons with its recently reported crystal structure. Importantly, ecteinamycin demonstrated potent activity against the toxigenic strain of Clostridium difficile NAP1/B1/027 (MIC = 59 ng/μL), as well as other toxigenic and nontoxigenic C. difficile isolates both in vitro and in vivo. Additionally, chemical genomics studies using Escherichia coli barcoded deletion mutants led to the identification of sensitive mutants such as trkA and kdpD involved in potassium cation transport and homeostasis supporting a mechanistic proposal that ecteinamycin acts as an ionophore antibiotic. This is the first antibacterial agent whose mechanism of action has been studied using E. coli chemical genomics. On the basis of these data, we propose ecteinamycin as an ionophore antibiotic that causes C. difficile detoxification and cell death via potassium transport dysregulation.
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Affiliation(s)
- Thomas P. Wyche
- Pharmaceutical Sciences Division, School of Pharmacy, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
| | - René F. Ramos Alvarenga
- Pharmaceutical Sciences Division, School of Pharmacy, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
| | | | - Megan N. Duster
- Department of Medicine, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
| | - Simone R. Warrack
- Department of Medicine, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
| | - Gabriel Cornilescu
- National Magnetic Resonance Facility at Madison, Department of Biochemistry, University of Wisconsin—Madison, Madison, Wisconsin 53706, United States
| | - Travis J. De Wolfe
- Department of Food Science, University of Wisconsin—Madison, Madison, Wisconsin 53706, United States
| | - Yanpeng Hou
- Pharmaceutical Sciences Division, School of Pharmacy, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
| | - Doug R. Braun
- Pharmaceutical Sciences Division, School of Pharmacy, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
| | - Gregory A. Ellis
- Pharmaceutical Sciences Division, School of Pharmacy, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
| | - Scott W. Simpkins
- Department of Computer Science and Engineering, University of Minnesota-Twin Cities, Minneapolis, Minnesota 55455, United States
| | - Justin Nelson
- Department of Computer Science and Engineering, University of Minnesota-Twin Cities, Minneapolis, Minnesota 55455, United States
| | - Chad L. Myers
- Department of Computer Science and Engineering, University of Minnesota-Twin Cities, Minneapolis, Minnesota 55455, United States
| | - James Steele
- Department of Food Science, University of Wisconsin—Madison, Madison, Wisconsin 53706, United States
| | - Hirotada Mori
- Graduate School of Biological Sciences, Nara Institute of Science and Technology, Ikoma, Nara 630-0101, Japan
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
| | - John L. Markley
- National Magnetic Resonance Facility at Madison, Department of Biochemistry, University of Wisconsin—Madison, Madison, Wisconsin 53706, United States
| | - Scott R. Rajski
- Pharmaceutical Sciences Division, School of Pharmacy, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
| | - Tim S. Bugni
- Pharmaceutical Sciences Division, School of Pharmacy, University of Wisconsin—Madison, Madison, Wisconsin 53705, United States
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Cheng JW, Yang QW, Xiao M, Yu SY, Zhou ML, Kudinha T, Kong F, Liao JW, Xu YC. High in vitro activity of fidaxomicin against Clostridium difficile isolates from a university teaching hospital in China. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 51:411-416. [PMID: 28693926 DOI: 10.1016/j.jmii.2017.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/06/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a significant cause of morbidity and mortality in both the acute care setting and the wider healthcare system. The purpose of this study was to evaluate the in vitro activity of fidaxomicin against C. difficile isolates from a university teaching hospital in China. METHODS One hundred and one C. difficile isolates were collected and analyzed for toxin genes by multiplex PCR. The toxin gene positive strains were also typed by multilocus sequence typing (MLST) and PCR-ribotyping. The MICs of the isolates were determined against fidaxomicin, metronidazole, vancomycin, tigecycline and moxifloxacin, by the agar dilution method. RESULTS All the 101 isolates exhibited low MICs to fidaxomicin (0.032-1 mg/L), metronidazole (0.125-1 mg/L), vancomycin (0.25-2 mg/L) and tigecycline (0.016-0.5 mg/L). Tigecycline showed the lowest geometric mean MIC value (0.041 mg/L), followed by fidaxomicin (0.227 mg/L), metronidazole (0.345 mg/L), and vancomycin (0.579 mg/L). About 35% of the strains (n = 35) were resistant to moxifloxacin, and the resistance rate to moxifloxacin for A-B+CDT- isolates (85.0%) was much higher than that of A+B+CDT- (15.7%) and A-B-CDT- (29.2%) isolates (P < 0.001). The MIC values of fidaxomicin, metronidazole, vancomycin and moxifloxacin against the 3 ST1 isolates were higher than for other STs. All the 28 moxifloxacin-resistant toxigenic isolates carried a mutation either in gyrA or/and gyrB. CONCLUSION Fidaxomicin exhibited high antimicrobial activity against all C. difficile isolates tested, which shows promise as a new drug for treating Chinese CDI patients.
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Affiliation(s)
- Jing-Wei Cheng
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi-Wen Yang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| | - Meng Xiao
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shu-Ying Yu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Meng-Lan Zhou
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Timothy Kudinha
- The Charles Sturt University, Leeds Parade, Orange, New South Wales, Australia; Centre for Infectious Diseases and Microbiology Laboratory Services, Westmead Hospital, Westmead, New South Wales, Australia
| | - Fanrong Kong
- The Charles Sturt University, Leeds Parade, Orange, New South Wales, Australia
| | - Jian-Wei Liao
- ZheJiang Hisun Pharmaceutical Co. ltd, Taizhou, Zhejiang, China
| | - Ying-Chun Xu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
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The Contribution of Bacteriophages to the Biology and Virulence of Pathogenic Clostridia. ADVANCES IN APPLIED MICROBIOLOGY 2017; 101:169-200. [PMID: 29050666 DOI: 10.1016/bs.aambs.2017.05.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Bacteriophages are key players in the evolution of most bacteria. Temperate phages have been associated with virulence of some of the deadliest pathogenic bacteria. Among the most notorious cases, the genes encoding the botulinum neurotoxin produced by Clostridium botulinum types C and D and the α-toxin (TcnA) produced by Clostridium novyi are both encoded within prophage genomes. Clostridium difficile is another important human pathogen and the recent identification of a complete binary toxin locus (CdtLoc) carried on a C. difficile prophage raises the potential for horizontal transfer of toxin genes by mobile genetic elements. Although the TcdA and TcdB toxins produced by C. difficile have never been found outside the pathogenicity locus (PaLoc), some prophages can still influence their production. Prophages can alter the expression of several metabolic and regulatory genes in C. difficile, as well as cell surface proteins such as CwpV, which confers phage resistance. Homologs of an Agr-like quorum sensing system have been identified in a C. difficile prophage, suggesting that it could possibly participate in cell-cell communication. Yet, other C. difficile prophages contain riboswitches predicted to recognize the secondary messenger molecule c-di-GMP involved in bacterial multicellular behaviors. Altogether, recent findings on clostridial phages underline the diversity of mechanisms and intricate relationship linking phages with their host. Here, milestone discoveries linking phages and virulence of some of the most pathogenic clostridial species will be retraced, with a focus on C. botulinum, C. novyi, C. difficile, and Clostridium perfringens phages, for which evidences are mostly available.
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Update on Antimicrobial Resistance in Clostridium difficile: Resistance Mechanisms and Antimicrobial Susceptibility Testing. J Clin Microbiol 2017; 55:1998-2008. [PMID: 28404671 DOI: 10.1128/jcm.02250-16] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Oral antibiotics such as metronidazole, vancomycin and fidaxomicin are therapies of choice for Clostridium difficile infection. Several important mechanisms for C. difficile antibiotic resistance have been described, including the acquisition of antibiotic resistance genes via the transfer of mobile genetic elements, selective pressure in vivo resulting in gene mutations, altered expression of redox-active proteins, iron metabolism, and DNA repair, as well as via biofilm formation. This update summarizes new information published since 2010 on phenotypic and genotypic resistance mechanisms in C. difficile and addresses susceptibility test methods and other strategies to counter antibiotic resistance of C. difficile.
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The efficacy of fidaxomicin in the treatment of Clostridium difficile infection in a real-world clinical setting: a Spanish multi-centre retrospective cohort. Eur J Clin Microbiol Infect Dis 2016; 36:295-303. [PMID: 27718071 DOI: 10.1007/s10096-016-2802-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/23/2016] [Indexed: 01/01/2023]
Abstract
The objective of this study was to evaluate the efficacy and safety of fidaxomicin in the real-life clinical setting. This was a retrospective cohort of patients with Clostridium difficile infection (CDI) treated with fidaxomicin in 20 Spanish hospitals between July 2013 and July 2014. Clinical cure, 30-day recurrence, 30-day mortality, sustained cure, and factors associated with the failure to achieve sustained cure were analyzed. Of the 72 patients in the cohort 41 (56.9 %) had a fatal underlying disease. There were 44 (61.1 %) recurrent episodes and 26 cases (36.1 %) with a history of multiple recurrences. Most episodes were severe (26, 36 %) or severe-complicated (14, 19.4 %). Clinical cure rate was 90.3 %, recurrence rate was 16.7 % and three patients (4.2 %) died during the follow-up period. Sustained cure was achieved in 52 cases (72.2 %). Adverse events were reported in five cases (6.9 %). Factors associated with the lack of sustained cure were cardiovascular comorbidity (OR 11.4; 95 %CI 1.9-67.8), acute kidney failure (OR 7.4; 95 %CI 1.3-43.1), concomitant systemic antibiotic treatment (OR 6.2; 95 %CI 1.1-36.8), and C-reactive protein value at diagnosis (OR 1.2 for each 1 mg/dl increase; 95 %CI 1.03-1.3). Fidaxomicin is an effective and well tolerable treatment for severe CDI and for cases with elevated recurrence risk.
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Differences in the Molecular Epidemiology and Antibiotic Susceptibility of Clostridium difficile Isolates in Pediatric and Adult Patients. Antimicrob Agents Chemother 2016; 60:4896-900. [PMID: 27270275 DOI: 10.1128/aac.00714-16] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/27/2016] [Indexed: 01/11/2023] Open
Abstract
The rising incidence of Clostridium difficile infections (CDIs) in adults is partly related to the global spread of fluoroquinolone-resistant strains, namely, BI/NAP1/027. Although CDIs are also increasingly diagnosed in children, BI/NAP1/027 is relatively uncommon in children. Little is known about the antibiotic susceptibility of pediatric CDI isolates. C. difficile was cultured from tcdB-positive stools collected from children diagnosed with CDI between December 2012 and December 2013 at an academic children's hospital. CDI isolates were grouped by restriction endonuclease analysis (REA). MICs were measured by agar dilution method for 7 antibiotics. Susceptibility breakpoints were based on guidelines from CLSI and/or the European Committee on Antimicrobial Susceptibility Testing (EUCAST). MICs and REA groupings of C. difficile isolates from 74 adult patients (29 isolates underwent REA) from a temporally and geographically similar adult cohort were compared to those of pediatric isolates. Among 122 pediatric and 74 adult isolates, respectively, the rates of resistance were as follows: metronidazole, 0% and 0%; vancomycin, 0% and 8% (P = 0.003); rifaximin, 1.6% and 6.7% (P = 0.11); clindamycin, 18.9% and 25.3% (P = 0.29); and moxifloxacin, 2.5% and 36% (P = <0.0001). Only 1 of 122 (0.8%) BI/NAP1/027 isolates was identified among the children, compared to 9 of 29 (31%) isolates identified among the adults (P = <0.0001). The 3 moxifloxacin-resistant pediatric isolates were of REA groups BI and CF and a nonspecific group. The 2 rifaximin-resistant pediatric isolates were of REA groups DH and Y. The 21 clindamycin-resistant pediatric isolates were distributed among 9 REA groups (groups A, CF, DH, G, L, M, and Y and 2 unique nonspecific REA groups). These data suggest that a diverse array of relatively antibiotic-susceptible C. difficile strains predominate in a cohort of children with CDI compared to adults.
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CdtR Regulates TcdA and TcdB Production in Clostridium difficile. PLoS Pathog 2016; 12:e1005758. [PMID: 27414650 PMCID: PMC4944984 DOI: 10.1371/journal.ppat.1005758] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 06/18/2016] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile is a global health burden and the leading cause of antibiotic-associated diarrhoea worldwide, causing severe gastrointestinal disease and death. Three well characterised toxins are encoded by this bacterium in two genetic loci, specifically, TcdB (toxin B) and TcdA (toxin A) in the Pathogenicity Locus (PaLoc) and binary toxin (CDT) in the genomically distinct CDT locus (CdtLoc). Toxin production is controlled by regulators specific to each locus. The orphan response regulator, CdtR, encoded within the CdtLoc, up-regulates CDT production. Until now there has been no suggestion that CdtR influences TcdA and TcdB production since it is not carried by all PaLoc-containing strains and CdtLoc is not linked genetically to PaLoc. Here we show that, in addition to CDT, CdtR regulates TcdA and TcdB production but that this effect is strain dependent. Of clinical relevance, CdtR increased the production of TcdA, TcdB and CDT in two epidemic ribotype 027 human strains, modulating their virulence in a mouse infection model. Strains traditionally from animal lineages, notably ribotype 078 strains, are increasingly being isolated from humans and their genetic and phenotypic analysis is critical for future studies on this important pathogen. Here we show that CdtR-mediated toxin regulation did not occur in other strain backgrounds, including a ribotype 078 animal strain. The finding that toxin gene regulation is strain dependent highlights the regulatory diversity between C. difficile isolates and the importance of studying virulence regulation in diverse lineages and clinically relevant strains. Our work provides the first evidence that TcdA, TcdB and CDT production is linked by a common regulatory mechanism and that CdtR may act as a global regulator of virulence in epidemic 027 strains. Clostridium difficile is the leading cause of antibiotic-associated diarrhoea. The TcdB, TcdA and binary toxins produced by C. difficile are encoded in two genomically distinct loci: TcdB and TcdA in the Pathogenicity Locus (PaLoc) and binary toxin (CDT) in the CDT locus (CdtLoc). Toxin production is primarily controlled by regulators specific to each locus. Because the presence of these loci varies amongst different strains of C. difficile, no rational link for their co-regulation has ever been proposed. Here we have shown that the regulator of CDT production, CdtR, also regulates production of TcdA and TcdB in a strain dependent manner. These results represent the first evidence that TcdA and TcdB production is linked to the production of CDT by a common regulatory mechanism. Collectively, our results establish CdtR as an important virulence regulator in two clinically important, epidemic strains of C. difficile, and further highlights the need to investigate regulatory mechanisms of important virulence factors in diverse strain backgrounds.
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Wetmore JB, Gilbertson DT, Liu J, Collins AJ. Improving Outcomes in Patients Receiving Dialysis: The Peer Kidney Care Initiative. Clin J Am Soc Nephrol 2016; 11:1297-1304. [PMID: 27006497 PMCID: PMC4934850 DOI: 10.2215/cjn.12981215] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The past decade has witnessed a marked reduction in mortality rates among patients receiving maintenance dialysis. However, the reasons for this welcome development are uncertain, and greater understanding is needed to translate advances in care into additional survival gains. To fill important knowledge gaps and to enable dialysis provider organizations to learn from one another, with the aim of advancing patient care, the Peer Kidney Care Initiative (Peer) was created in 2014 by the chief medical officers of 14 United States dialysis provider organizations and the Chronic Disease Research Group. Areas of particular clinical importance were targeted to help shape the public health agenda in CKD and ESRD. Peer focuses on the effect of geographic variation on outcomes, the implications of seasonality for morbidity and mortality, the clinical significance of understudied disorders affecting dialysis patients, and the debate about how best to monitor and evaluate progress in care. In the realm of geovariation, Peer has provided key observations on regional variation in the rates of ESRD incidence, hospitalization, and pre-ESRD care. Regarding seasonality, Peer has reported on variation in both infection-related and non-infection-related hospitalizations, suggesting that ambient environmental conditions may affect a range of health outcomes in dialysis patients. Specific medical conditions that Peer highlights include Clostridium difficile infection, which has become strikingly more common in patients in the year after dialysis initiation, and chronic obstructive pulmonary disease, the treatments for which have the potential to contribute to sudden cardiac death. Finally, Peer challenges the nephrology community to consider alternatives to standardized mortality ratios in assessing progress in care, positing that close scrutiny of trends over time may be the most effective way to drive improvements in patient care.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota; and
| | - David T. Gilbertson
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Jiannong Liu
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Allan J. Collins
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Spinler JK, Ross CL, Savidge TC. Probiotics as adjunctive therapy for preventing Clostridium difficile infection - What are we waiting for? Anaerobe 2016; 41:51-57. [PMID: 27180657 DOI: 10.1016/j.anaerobe.2016.05.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 12/14/2022]
Abstract
With the end of the golden era of antibiotic discovery, the emergence of a new post-antibiotic age threatens to thrust global health and modern medicine back to the pre-antibiotic era. Antibiotic overuse has resulted in the natural evolution and selection of multi-drug resistant bacteria. One major public health threat, Clostridium difficile, is now the single leading cause of hospital-acquired bacterial infections and is by far the most deadly enteric pathogen for the U.S. POPULATION Due to the high morbidity and mortality and increasing incidence that coincides with antibiotic use, non-traditional therapeutics are ideal alternatives to current treatment methods and also provide an avenue towards prevention. Despite the need for alternative therapies to antibiotics and the safety of most probiotics on the market, researchers are inundated with regulatory issues that hinder the translational science required to push these therapies forward. This review discusses the regulatory challenges of probiotic research, expert opinion regarding the application of probiotics to C. difficile infection and the efficacy of probiotics in preventing this disease.
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Affiliation(s)
- Jennifer K Spinler
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA.
| | - Caná L Ross
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
| | - Tor C Savidge
- Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, 1102 Bates Ave., Houston, TX, USA; Department of Pathology & Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA
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