Sensitive and selective culture medium for detection of environmental Clostridium difficile isolates without requirement for anaerobic culture conditions

Sensitive detection of viable salmonella bacteria based on tertiary cascade signal amplification via splintR ligase ligation-PCR amplification-CRISPR/Cas12a cleavage

Several viable Salmonella bacteria are capable of causing severe human diseases and huge economic losses. In this regard, viable Salmonella bacteria detection techniques that can identify small numbers of microbial cells are highly valuable. Here, we present a detection method (referred to as SPC) based on the amplification of tertiary signals using splintR ligase ligation, PCR amplification and CRISPR/Cas12a cleavage. The detection limit of the SPC assay was 6 copies (HilA RNA) and 10 CFU (cell). Based on Intracellular HilA RNA detection, this assay can be used to distinguish between viable and dead Salmonella. In addition, it is able to detect multiple serotypes of Salmonella and has been successfully used to detect Salmonella in milk or isolated from farms. Overall, this assay is a promising test for viable pathogens detection and biosafety control.

Duplex detection of foodborne pathogens using a SERS optofluidic sensor coupled with immunoassay

Herein, we developed a surface-enhanced Raman spectroscopy (SERS) optofluidic sensor coupled with immunoprobes to simultaneously separate and detect the foodborne pathogens, Escherichia coli O157:H7, and Salmonella in lettuce and packed salad. The method consists of three steps of (i) enrichment to enhance detection sensitivity, (ii) selective separation and labelling of target bacteria by their specific antibody-bearing SERS-nanotags and (iii) detection of tagged bacterial cells using SERS within a hydrodynamic flow-focusing SERS optofluidic device, where even low counts of bacterial cells were detectable in the very thin-film-like sample stream. SERS-nanotags consisted of different Raman reporter molecules, representing each species, i.e., the detection of Raman reporter confirms the presence of the target pathogen. The anti-E. coli antibody used in this study functions against all strains of E. coli O157:H7 and the anti-Salmonella antibody used in this work acts on a wide range of Salmonella enterica strains. Bacterial counts of 1000, 100, and 10 CFU/ 200 g sample were successfully detected after only 15 min enrichment. Our method showed a very low detection limit value of 10 CFU/ 200 g sample for the bacterial mixture in both lettuce and packed salad, proving the efficiency and high sensitivity of our method to detect multiple pathogens in the food samples. The total analysis time, including sample preparation for simultaneous detection of multiple bacteria, was estimated to be 2 h, which is much less than the time required in conventional methods. Hence, our proposed protocol is considered a promising rapid and efficient approach for pathogen screening of food samples.

Toxigenic Clostridium difficile-mediated Diarrhoea in Hematopoietic Stem Cell Transplantation In-Patients: Rapid Diagnosis and Efficient Treatment

Allogenic hematopoietic stem cell transplant (HSCT) recipients are susceptible to any kind of infectious agents including Clostridium difficile. We studied 86 allogenic-HSCT patients who faced diarrhoea while receiving antibiotics. DNA from stool samples were explored for the presence of C. difficile toxin genes (tcdA; tcdB) by multiplex real-time PCR. Results showed nine toxigenic C. difficile amongst which seven were positive for both toxins and two were positive for tcdB. Six of toxigenic C. difficile organisms harbouring both toxin genes were also isolated by toxigenic culture. Clostridium difficile infection was controlled successfully with oral Metronidazole and Vancomycin in the confirmed infected patients.

Simple and portable on-site system for nucleic acid-based detection of Clostridium difficile in stool samples using two columns containing microbeads and loop-mediated isothermal amplification

It is challenging to employ nucleic acid-based diagnostics for the in situ detection of Clostridium difficile from complex fecal samples because essential sample preparation and amplification procedures require various experimental resources. In this study, a simple and effective on-site nucleic acid-based detection system was used to detect C. difficile in stool samples. Two columns containing different microbeads, namely, glass and functionalized graphene oxide-coated microbeads, were designed to remove relatively large impurities by filtration and concentrate bacteria, including C. difficile, from stool samples by adsorption. The bacterial nucleic acids were effectively extracted using a small bead beater. The effectiveness of enzyme inhibitors remaining in the sample was efficiently reduced by the direct buffer developed in this study. This sample preparation kit consisting of two simple columns showed better performance in real-time polymerase chain reaction (PCR) and equivalent performance in loop-mediated isothermal amplification (LAMP) than other sample preparation kits, despite 90% simplification of the process. The amplification-ready samples were introduced into two microtubes containing LAMP pre-mixtures (one each for E. coli as an external positive control and C. difficile) by a simple sample loader, which was operated using a syringe. LAMP, which indicates amplification based on color change, was performed at 65 °C in a small water bath. The limit of detection (L.O.D) and analytical sensitivity/specificity of our simple and effective kit were compared with those of a commercial kit. C. difficile in stool samples could be detected within 1 h with 10³ cfu/10 mg using LAMP combined simple on-site detection kit.

Diagnostic deficiencies of C. difficile infection among patients in a tertiary hospital in Saudi Arabia: A laboratory-based case series

Clostridioides difficile infection (CDI) has become a threatening public health problem in the developed world. In the kingdom of Saudi Arabia, prevalence of CDI is still unknown due to limited surveillance protocols and diagnostic resources. We used a two-step procedure to study and confirm C. difficile cases. We also studied toxin profiles of these isolates. Stool samples were collected from symptomatic patients and clinically suspected of CDI for almost 12 months. Isolates were confirmed by culture method followed by 16S rRNA sequencing. Multiplex PCR was performed for the identification of toxin A, toxin B and binary toxin genes and compared to Gene Expert results. Out of the 47 collected samples, 27 were successfully grown on culture media. 18 samples were confirmed as C. difficile by both culture and 16S rRNA sequencing. Interestingly, the rest of the isolates (9 species) belonged to different genera. Our results showed 95% of samples were positive for both toxin A and B (tcdA, tcdB) and all samples exhibited the toxin gene regulator tcdC. All samples were confirmed negative for the binary toxin gene ctdB and 11% of the isolates were positive for ctdA gene. Interestingly, one isolate harbored the binary toxin gene (cdtA ⁺) and tested negative for both toxins A and B. We believe that combining the standard culture method with molecular techniques can make the detection of C. difficile more accurate.

Microbial bioburden of inpatient and outpatient areas beyond patient hospital rooms

OBJECTIVE

To investigate the frequency of environmental contamination in hospital areas outside patient rooms and in outpatient healthcare facilities.

DESIGN

Culture survey.

SETTING

This study was conducted across 4 hospitals, 4 outpatient clinics, and 1 surgery center.

METHODS

We conducted 3 point-prevalence culture surveys for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridioides difficile, Candida spp, and gram-negative bacilli including Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter baumanii, and Stenotrophomonas maltophilia in each facility. In hospitals, high-touch surfaces were sampled from radiology, physical therapy, and mobile equipment and in emergency departments, waiting rooms, clinics, and endoscopy facilities. In outpatient facilities, surfaces were sampled in exam rooms including patient and provider areas, patient bathrooms, and waiting rooms and from portable equipment. Fluorescent markers were placed on high-touch surfaces and removal was assessed 1 day later.

RESULTS

In the hospitals, 110 (9.4%) of 1,195 sites were positive for 1 or more bacterial pathogens (range, 5.3%-13.7% for the 4 hospitals) and 70 (5.9%) were positive for Candida spp (range, 3.7%-5.9%). In outpatient facilities, 31 of 485 (6.4%) sites were positive for 1 or more bacterial pathogens (range, 2% to 14.4% for the 5 outpatient facilities) and 50 (10.3%) were positive for Candida spp (range, 3.9%-23.3%). Fluorescent markers had been removed from 33% of sites in hospitals (range, 28.4%-39.7%) and 46.3% of sites in outpatient clinics (range, 7.4%-82.8%).

CONCLUSIONS

Surfaces in hospitals outside patient rooms and in outpatient facilities are frequently contaminated with healthcare-associated pathogens. Improvements in cleaning and disinfection practices are needed to reduce contamination.

Systematic Evaluation of Parameters Important for Production of Native Toxin A and Toxin B from Clostridioides difficile

In the attempt to improve the purification yield of native toxin A (TcdA) and toxin B (TcdB) from Clostridioides difficile (C. difficile), we systematically evaluated culture parameters for their influence on toxin production. In this study, we showed that culturing C. difficile in a tryptone-yeast extract medium buffered in PBS (pH 7.5) that contained 5 mM ZnCl₂ and 10 mM glucose supported the highest TcdB production, measured by the sandwich ELISA. These culture conditions were scalable into 5 L and 15 L dialysis tube cultures, and we were able to reach a TcdB concentration of 29.5 µg/mL of culture. Furthermore, we established a purification protocol for TcdA and TcdB using FPLC column chromatography, reaching purities of >99% for both toxins with a yield around 25% relative to the starting material. Finally, by screening the melting temperatures of TcdA and TcdB in various buffer conditions using differential scanning fluorimetry, we found optimal conditions for improving the protein stability during storage. The results of this study present a complete protocol for obtaining high amounts of highly purified native TcdA and TcdB from C. difficile.

Clostridium difficile Infection Reservoirs Within an Acute Rehabilitation Environment

OBJECTIVE

Clostridium difficile infection is a common hospital-associated infection spread via patient contact or contaminated environments. The risk for spread of C difficile may be greater in inpatient rehabilitation units than in some hospital units as patients are not confined to their rooms and often share equipment. Environmental disinfection is challenging in shared medical equipment, especially in equipment with complex designs. The study aimed to examine the presence of C difficile spores within an acute rehabilitation environment and to evaluate disinfection effectiveness.

DESIGN

Cultures were performed on 28 rehabilitation rooms, 28 rehabilitation floor surfaces, and 80 shared devices and equipment. Two disinfection interventions were implemented, and environmental cultures then were repeated postintervention.

RESULTS

Environmental cultures positive for CD spores were rehabilitation rooms (1/28), rehabilitation floors (13/28), and wheelchairs (3/20). After the implementation of new disinfection methods, repeat cultures were obtained and produced negative results.

CONCLUSIONS

Nonsporicidal disinfectant was not effective on hospital floors. Sporicidal disinfection of the floor is important when rates of C difficile infection are increased. Wheelchairs are complex devices and difficult to properly clean. The hospital purchased an ultraviolent device for wheelchair cleaning with a subsequent reduction in spores on repeat cultures.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Recognize the impact of Clostridium difficile infections on the healthcare system; (2) Describe potential reservoirs of Clostridium difficile in the inpatient rehabilitation environment; and (3) Discuss interventions that may be implemented to reduce the reservoirs of Clostridium difficile on the rehabilitation unit.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Direct Clostridioides difficile ribotyping from stool using capillary electrophoresis

Clostridioides difficile(C. difficile) genotyping is essential for surveillance of emerging strains, transmissions, and outbreak investigations, but culture is lengthy and may not be routinely performed, which necessitates culture-independent genotyping methods. We aimed to develop a direct from stool C. difficile PCR ribotyping algorithm using capillary electrophoresis. Ribotypes were generated directly from 66.8% of stools with 33.2% requiring broth enrichment. 16S and tcdB cycle thresholds (Ct) were significantly lower (P< 0.001) in directly ribotyped stools compared to enriched stools, and Ct correlated with direct ribotyping (area under the curve: 0.97 and 0.96, respectively). Direct and isolate ribotypes were 94.7% concordant. Mixed C. difficile ribotypes were presumptively identified in 14 (7.5%) samples with 12 (6.4%) mixtures confirmed. We have developed a rapid PCR ribotyping algorithm allowing for direct C. difficile genotyping from stool using capillary electrophoresis with occasional detection of mixed C. difficile populations in stool, which is a limitation of conventional isolate genotyping.

High levels of toxigenic Clostridioides difficile contamination of hospital environments: a hidden threat in hospital-acquired infections in Kenya

Introduction

The contribution of Clostridioides difficile (formerly Clostridium difficile) to the burden of hospital-associated infections (HAIs) remains undetermined in many African countries.

Aim

This study aimed to identify a sensitive and readily adaptable C. difficile detection assay and to evaluate the C. difficile HAI risk in Kenya.

Methodology

Sterile swabs in neutralizing buffer were used to sample equipment or surfaces that patients and clinical staff touched frequently. These swabs were either plated directly on chromogenic agar or cultured in an enrichment broth before plating. The swab suspensions, enrichment broth and plate cultures were screened by quantitative PCR (qPCR) to determine the most efficient detection method. The HAI risk was evaluated by testing the C. difficile-positive samples by qPCR for the A, B and binary toxins.

Results

C. difficile was detected on 4/57 (7.0 %) equipment and surfaces by direct culture. The additional enrichment step increased the detection rate 10-fold to 43/57 (75.4 %). In total, 51/57 (89.5 %) environmental samples were positive for C. difficile detected through either culture or qPCR. The genes encoding the primary toxins, tcdA and tcdB, were detected on six surfaces, while the genes encoding the binary toxins, cdtA and cdtB, were detected on 2/57 (3.5 %) and 3/57 (5.3 %) surfaces, respectively. Different C. difficile toxin gene profiles were detected: the tcdA+/tcdB− gene profile on 4/10 (40 %) high-touch surfaces, tcdA−/tcdB+ on 3/10 (30 %) surfaces, tcdA+/tcdB+/cdtA+/cdtB+ on 2/10 (20 %) surfaces and tcdA−/tcdB+/cdtB+ on one high-touch surface.

Conclusion

The widespread contamination of hospital environments by toxigenic C. difficile gives a strong indication of the high risk of C. difficile infections (CDIs). The two-step culture process described can easily be adapted for monitoring hospital environment contamination by C. difficile.

Longitudinal study on the detection of Clostridioides difficile at the Fargo Veteran Affairs Community Living Center

Our study used C Diff Banana Broth to evaluate the occurrence of positive Clostridioides difficile spores in new and preexisting hospital rooms. C difficile incidence was 5.5%. Analysis using multiple linear regression found that rooms with contact precautions in place were significant predictors of a positive sample (P ≤ .001). Room occupancy was not a significant predictor (P = .544). Thus it could be interpreted that the environment can be a significant carrier for C difficile.

A Two-Step Approach for Diagnosing Glutamate Dehydrogenase Genes by Conventional Polymerase Chain Reaction from Clostridium difficile Isolates

BACKGROUND

Clostridium difficile is the major causative agent of nosocomial antibiotic-associated colitis. The gold standard for C. difficile detection is stool culture followed by cytotoxic assay, although it is laborious and time-consuming. We developed a screening test based on a two-step conventional polymerase chain reaction (PCR) approach to detect gluD, the glutamate dehydrogenase (GDH) enzyme gene, which is a marker for screening of C. difficile. Targeting gluD comparing to the conserved stable genetic element of pathogenicity locus (PaLoc), with an accessory gene of Cdd3, was an effective method for the detection of this pathogen from patients with enterocolitis.

METHODS

Fresh fecal samples of the patients who were clinically suspicious for antibiotic-associated colitis were collected. Stool specimens were cultured on the cycloserine-cefoxitin fructose agar (CCFA) in an anaerobic condition, following alcohol shock treatment and enrichment in Clostridium difficile Brucella broth (CDBB). On confirmed colonies, PCR was carried out for detection of PaLoc subsidiary gene, Cdd3, and toxicogenic genes, tcdA and tcdB. The gluD that is GDH gene detection was performed by conventional PCR on the extracted DNA from 578 fresh stool samples.

RESULTS

57 (9.8%) strains of C. difficile were approved by conventional PCR for gluD and Cdd3 genes, in which 37 (6.4%) colonies had tcdA+/tcdB+ genotype, 2 (0.3%) tcdA+/tcdB-, 4 (0.7%) tcdA-/ tcdB+ and the remaining 14 (2.4%) colonies were tcdA and tcdB negative.

CONCLUSION

These results demonstrate that targeting gluD by PCR is quite promising for rapid detection of C. difficile from fresh fecal samples. Furthermore, the multiple-gene analysis for tcdA and tcdB assay proved a reliable approach for diagnosing of toxigenic strains among clinical samples.

Hospital-associated Clostridium difficile infection and reservoirs within the hospital environment

BACKGROUND

Clostridium difficile infection (CDI) is a leading cause of hospital-associated infections. Antibiotic stewardship, environmental disinfection, and reduction of transmission via health care workers are the major modes of CDI prevention within hospitals.

METHODS

The aim of this study was to evaluate the role of the environment in the spread of CDI within hospital rooms. Bed tracing of positive-CDI inpatients was performed to detect the strength of association to specific rooms. Environmental cultures were conducted to identify adequacy of environmental C difficile (CD) spores. Whole-genome sequencing was performed to evaluate the degree of CD relatedness.

RESULTS

Bed tracing performed for 211 CDI patients showed a limited list of high-burden rooms. Environmental cultures for surfaces disinfected with a sporicidal agent were almost entirely negative, whereas the floors were positive for CDI in 15% of the studied patient rooms. Whole-genome sequencing did not detect any close genetic relatedness.

CONCLUSIONS

Unlike in an outbreak setting, bed tracing did not yield conclusive results of room reservoirs. The C diff Banana Broth culture was inexpensive, sensitive, and easy to incubate under aerobic conditions. Sporicidal disinfectants were effective in eliminating CD from the environment. CD spores were found on floors and hard-to-clean surfaces.

Impact of routine use of a spray formulation of bleach on Clostridium difficile spore contamination in non-C difficile infection rooms

The frequency of recovery of Clostridium difficile spores from surfaces after postdischarge cleaning of non-C difficile infection rooms was significantly reduced from 24%-5% after a commercial spray formulation of bleach was substituted for a quaternary ammonium disinfectant. These results suggest that routine use of a sporicidal disinfectant in all postdischarge rooms could potentially be beneficial in reducing the risk for C difficile transmission from contaminated surfaces.

Are Many Patients Diagnosed With Healthcare-associated Clostridioides difficile Infections Colonized With the Infecting Strain on Admission?

In a cohort of 480 patients admitted to an acute care hospital, 68 (14%) had positive perirectal cultures for toxigenic Clostridioides difficile on admission. Of the 11 patients (2%) diagnosed with healthcare-associated C. difficile infections, 3 (27%) had genetically related admission and infection isolates, based on whole-genome sequencing.

Evaluation of growth and sporulation of a non-toxigenic strain of Clostridioides difficile (Z31) and its shelf viability

The oral administration of non-toxigenic strains of Clostridioides difficile (NTCD) is currently showing promising results for the prevention of Clostridioides difficile infection (CDI) in humans and animals, and is being considered as a possible commercial product to be used in the near future. The aim of this work was to evaluate five culture media for the growth and sporulation of one NTCD (Z31) and evaluate the viability of a lyophilized spore solution of NTCD Z31 stored at 4 °C or at 25 °C for 2 years. Reinforced clostridial medium (RCM) and brain heart infusion broth (BHI) provided the highest production of NTCD Z31 spores. In the first 6 months of the storage of the lyophilized solution, a reduction in spore count of approximately 0.3 Log₁₀ CFU/mL was observed; however, no further significant reduction in spore count was observed up to 24 months. No difference in spore concentration was found between the two storage temperatures from 6 to 24 months of storage. The present work showed BHI and RCM to be the best choices for the growth and sporulation of NTCD Z31 and suggested that the spores of NTCD Z31 are stable for up to 2 years under both temperature conditions.

A microbiological study to investigate the carriage and transmission-potential of Clostridium difficile spores on single-use and reusable sharps containers

BACKGROUND

A 2015 study matching use of disposable and reusable sharps containers (DSCs, RSCs) with Clostridium difficile infection (CDI) incidence found a decreased incidence with DSCs. We conducted microbiologic samplings and examined the literature and disease-transmission principles to evaluate the scientific feasibility of such an association.

METHODS

(i) 197 RSCs were sampled for C. difficile at processing facilities; (ii) RSCs were challenged with high C. difficile densities to evaluate efficacy of automated decontamination; and (iii) 50 RSCs and 50 DSCs were sampled in CDI patient rooms in 7 hospitals. Results were coupled with epidemiologic studies, clinical requirements, and chain-of-infection principles, and tests of evidence of disease transmission were applied.

RESULTS

C. difficile spores were found on 9 of 197 (4.6%) RSCs prior to processing. Processing completely removed C. difficile. In CDI patient rooms, 4 of 50 RSCs (8.0%) and 8 of 50 DSCs (16.0%) had sub-infective counts of C. difficile (P = .27). DSCs were in permanent wall cabinets; RSCs were removed and decontaminated frequently.

CONCLUSION

With C. difficile bioburden being sub-infective on both DSCs and RSCs, sharps containers being no-touch, and glove removal required after sharps disposal, we found 2 links in the chain of infection to be broken and 5 of 7 tests of evidence to be unmet. We conclude that sharps containers pose no risk of C. difficile transmission.

Association of gingivitis with dental calculus thickness or dental calculus coverage and subgingival bacteria in feline leukemia virus- and feline immunodeficiency virus-negative cats

Periodontal disease is the most common oral disease in cats. The objectives of this study were to determine the relationships between gingivitis and dental calculus thickness (DCT), or dental calculus coverage (DCC); determine the association of gingivitis scores and types of oral bacteria; and to evaluate bacterial co-infection in cats with periodontal disease. Twelve cats that were not infected with feline leukemia or feline immunodeficiency viruses were enrolled in the study. Gingivitis, DCT, and DCC were scored and recorded. A Kruskal-Wallis test was used to compare scores among canine, 2nd premolar, 3rd premolar, 4th premolar, and 1st molar teeth. The relationship between gingivitis and DCT or DCC scores was determined using the Spearman rank sum test (ρ). Subgingival bacteria were cultured and the association between bacterial species and gingivitis score was evaluated using a Fisher's exact test. The average gingivitis, DCT, and DCC scores for the caudal maxillary teeth were higher for the caudal mandibular teeth and more severe for the 3rd premolar, 4th premolar, and 1st molar teeth than for the canine teeth. A strong relationship between average DCT or DCC score and average gingivitis score was found (ρ = 0.96 and 1, respectively). Aerobic and anaerobic bacterial infections were identified in a large number of cats with periodontal disease (71.1% and 28.9%, respectively). In conclusion, severe gingivitis scores were associated with anaerobic bacterial infection. The caudal teeth are affected with more severe gingivitis, DCT, and DCC than the other teeth. Antibiotic prophylaxis should be prescribed in cats with periodontal disease.

Multiplex detection and genotyping of pathogenic bacteria on paper-based biosensor with a novel universal primer mediated asymmetric PCR

Traditionary multiplex asymmetric polymerase chain reaction (PCR) can be applied to detect multiplex target organisms simultaneously, but complex optimizations of primer concentrations and staggered additions of primers are required to achieve equal amplification of multiplex genes. To overcome this shortcoming, we propose a novel method based on multiplex asymmetric PCR and paper-based nucleic acid diagnostics (PBNAD). In the asymmetric PCR, a universal primer was introduced to break the bottlenecks of low sensitivity and self-inhibition among different sets of primers. Amplification using the novel multiplex asymmetric PCR boosted the quantity of single-stranded amplicons, and the amplified products contained the same sequence at the 5' end. Therefore, only one gold nanoparticle-based signal probe was needed for the simultaneous detection of three genes using the PBNAD platform, and the detection signals could be observed with the naked eye. With this highly efficient, novel multiplex asymmetric PCR, as little as 1 pg/μL genomic DNA can be detected. This method can also be applied to genotyping for reliable epidemiological investigations. This proof-of-concept study highlights the potential of the PBNAD platform for cost- and labor-effective applications in the detection of pathogenic bacteria.

A possible route for foodborne transmission of Clostridium difficile?

Spores of toxigenic Clostridium difficile and spores of food-poisoning strains of Clostridium perfringens show a similar prevalence in meats. Spores of both species are heat resistant and can survive cooking of foods. C. perfringens is a major cause of foodborne illness; studies are needed to determine whether C. difficile transmission by a similar route is a cause of infection.