1
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Marlow C, Clayton JA, Minich N, Golonka G, Maruskin L, Jencson AL, Hailes JM, Choi H, Chatterjee P, Hwang M, Jinadatha C, Cadnum JL, Donskey CJ, Toltzis P. Molecular Epidemiology of Clostridioides difficile Colonization in Families With Infants. Open Forum Infect Dis 2024; 11:ofae299. [PMID: 38911950 PMCID: PMC11192056 DOI: 10.1093/ofid/ofae299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Indexed: 06/25/2024] Open
Abstract
Background Community-associated Clostridioides difficile infection is a major public health hazard to adults and older children. Infants frequently excrete toxigenic C difficile asymptomatically in their stool, but their importance as a community reservoir of C difficile is uncertain. Methods Families of healthy infants were recruited at the baby's 4-month well child visit and were followed longitudinally until the baby was approximately 9 months old. Babies and mothers submitted stool or rectal swabs every 2 weeks that were cultivated for C difficile; fathers' participation was encouraged but not required. Clostridioides difficile isolates were strain-typed by fluorescent polymerase chain reaction ribotyping and by core genome multilocus sequence typing, and the number of families in whom the same strain was cultivated from >1 family member ("strain sharing") was assessed. Results Thirty families were enrolled, including 33 infants (3 sets of twins) and 30 mothers; 19 fathers also participated. Clostridioides difficile was identified in 28 of these 30 families over the course of the study, and strain sharing was identified in 17 of these 28. In 3 families, 2 separate strains were shared. The infant was involved in 17 of 20 instances of strain sharing, and in 13 of these, the baby was identified first, with or without a concomitantly excreting adult. Excretion of shared strains usually was persistent. Conclusions Clostridioides difficile strain sharing was frequent in healthy families caring for an infant, increasing the likelihood that asymptomatically excreting babies and their families represent a reservoir of the organism in the community.
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Affiliation(s)
- Christine Marlow
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Jason A Clayton
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Nori Minich
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | | | | | - Annette L Jencson
- Infectious Diseases Section (CJD) and Research Service (ALJ, JMH, JLC), Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Jennifer M Hailes
- Infectious Diseases Section (CJD) and Research Service (ALJ, JMH, JLC), Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Hosoon Choi
- Department of Medicine (CJ) and Department of Research (HC, PC, MH), Central Texas Veterans Healthcare System, Temple, Texas, USA
| | - Piyali Chatterjee
- Department of Medicine (CJ) and Department of Research (HC, PC, MH), Central Texas Veterans Healthcare System, Temple, Texas, USA
| | - Munok Hwang
- Department of Medicine (CJ) and Department of Research (HC, PC, MH), Central Texas Veterans Healthcare System, Temple, Texas, USA
| | - Chetan Jinadatha
- Department of Medicine (CJ) and Department of Research (HC, PC, MH), Central Texas Veterans Healthcare System, Temple, Texas, USA
| | - Jennifer L Cadnum
- Infectious Diseases Section (CJD) and Research Service (ALJ, JMH, JLC), Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Curtis J Donskey
- Infectious Diseases Section (CJD) and Research Service (ALJ, JMH, JLC), Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Philip Toltzis
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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Bassères E, Eubank TA, Begum K, Alam MJ, Jo J, Le TM, Lancaster CK, Gonzales-Luna AJ, Garey KW. Antibacterial activity of ibezapolstat against antimicrobial-resistant clinical strains of Clostridioides difficile. Antimicrob Agents Chemother 2024; 68:e0162123. [PMID: 38364016 PMCID: PMC10916401 DOI: 10.1128/aac.01621-23] [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: 12/08/2023] [Accepted: 01/25/2024] [Indexed: 02/18/2024] Open
Abstract
Antimicrobial resistance is emerging in clinical strains of Clostridioides difficile. Ibezapolstat (IBZ) is a DNA polymerase IIIC inhibitor that has completed phase II clinical trials. IBZ has potent in vitro activity against wild-type, susceptible strains but its effect on C. difficile strains with reduced susceptibility to metronidazole (MTZ), vancomycin (VAN), or fidaxomicin (FDX) has not been tested. The primary objective of this study was to test the antibacterial properties of IBZ against multidrug-resistant C. difficile strains. The in vitro activity, bactericidal, and time-kill activity of IBZ versus comparators were evaluated against 100 clinical strains of which 59 had reduced susceptibility to other C. difficile antibiotics. Morphologic changes against a multidrug resistance strain were visualized by light and scanning electron microscopy. The overall IBZ MIC50/90 values (µg/mL) for evaluated C. difficile strains were 4/8, compared with 2/4 for VAN, 0.5/1 for FDX, and 0.25/4 for MTZ. IBZ MIC50/90 values did not differ based on non-susceptibility to antibiotic class or number of classes to which strains were non-susceptible. IBZ bactericidal activity was similar to the minimum inhibitory concentration (MIC) and maintained in wild-type and non-susceptible strains. Time-kill assays against two laboratory wild-type and two clinical non-susceptible strains demonstrated sustained IBZ activity despite reduced killing by comparator antibiotics for IBZ and VAN non-susceptible strains. Microscopy visualized increased cell lengthening and cellular damage in multidrug-resistant strains exposed to IBZ sub-MIC concentrations. This study demonstrated the potent antibacterial activity of IBZ against a large collection of C. difficile strains including multidrug-resistant strains. This study highlights the therapeutic potential of IBZ against multidrug-resistant strains of C. difficile.
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Affiliation(s)
- Eugénie Bassères
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Taryn A. Eubank
- 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
| | - Jinhee Jo
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Thanh M. Le
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Chris K. Lancaster
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Anne J. Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, 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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3
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Abdrabou AMM, Sy I, Bischoff M, Arroyo MJ, Becker SL, Mellmann A, von Müller L, Gärtner B, Berger FK. Discrimination between hypervirulent and non-hypervirulent ribotypes of Clostridioides difficile by MALDI-TOF mass spectrometry and machine learning. Eur J Clin Microbiol Infect Dis 2023; 42:1373-1381. [PMID: 37721704 PMCID: PMC10587247 DOI: 10.1007/s10096-023-04665-y] [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: 02/20/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023]
Abstract
Hypervirulent ribotypes (HVRTs) of Clostridioides difficile such as ribotype (RT) 027 are epidemiologically important. This study evaluated whether MALDI-TOF can distinguish between strains of HVRTs and non-HVRTs commonly found in Europe. Obtained spectra of clinical C. difficile isolates (training set, 157 isolates) covering epidemiologically relevant HVRTs and non-HVRTs found in Europe were used as an input for different machine learning (ML) models. Another 83 isolates were used as a validation set. Direct comparison of MALDI-TOF spectra obtained from HVRTs and non-HVRTs did not allow to discriminate between these two groups, while using these spectra with certain ML models could differentiate HVRTs from non-HVRTs with an accuracy >95% and allowed for a sub-clustering of three HVRT subgroups (RT027/RT176, RT023, RT045/078/126/127). MALDI-TOF combined with ML represents a reliable tool for rapid identification of major European HVRTs.
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Affiliation(s)
- Ahmed Mohamed Mostafa Abdrabou
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Straße 100, Building 43, D-66421, Homburg, Saar, Germany.
- Medical Microbiology and Immunology Department, Faculty of Medicine, Mansoura University, El Gomhouria Street, Mansoura, 35516, Egypt.
- National Reference Center for Clostridioides (Clostridium) difficile, Homburg-Münster-Coesfeld, Germany.
| | - Issa Sy
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Straße 100, Building 43, D-66421, Homburg, Saar, Germany
| | - Markus Bischoff
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Straße 100, Building 43, D-66421, Homburg, Saar, Germany
- National Reference Center for Clostridioides (Clostridium) difficile, Homburg-Münster-Coesfeld, Germany
| | - Manuel J Arroyo
- Clover Bioanalytical Software, Av. del Conocimiento, 41, 18016, Granada, Spain
| | - Sören L Becker
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Straße 100, Building 43, D-66421, Homburg, Saar, Germany
| | - Alexander Mellmann
- National Reference Center for Clostridioides (Clostridium) difficile, Homburg-Münster-Coesfeld, Germany
- Institute of Hygiene, University of Münster, Robert-Koch-Straße 41, 48149, Münster, Germany
| | - Lutz von Müller
- National Reference Center for Clostridioides (Clostridium) difficile, Homburg-Münster-Coesfeld, Germany
- Christophorus Kliniken Coesfeld, Coesfeld, Germany
| | - Barbara Gärtner
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Straße 100, Building 43, D-66421, Homburg, Saar, Germany
- National Reference Center for Clostridioides (Clostridium) difficile, Homburg-Münster-Coesfeld, Germany
| | - Fabian K Berger
- Institute of Medical Microbiology and Hygiene, Saarland University, Kirrberger Straße 100, Building 43, D-66421, Homburg, Saar, Germany
- National Reference Center for Clostridioides (Clostridium) difficile, Homburg-Münster-Coesfeld, Germany
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4
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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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5
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Alonso CD, Pollock NR, Garey KW, Gonzales-Luna AJ, Williams DN, Daugherty K, Cuddemi C, Villafuerte-Gálvez J, White NC, Chen X, Xu H, Sprague R, Barrett C, Miller M, Foussadier A, Lantz A, Banz A, Kelly CP. Higher In Vivo Fecal Concentrations of Clostridioides difficile Toxins A and B in Patients With North American Pulsed-Field Gel Electrophoresis Type 1/Ribotype 027 Strain Infection. Clin Infect Dis 2022; 75:2019-2022. [PMID: 35607815 DOI: 10.1093/cid/ciac406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Indexed: 01/17/2023] Open
Abstract
Ultrasensitive, quantitative Clostridioides difficile stool toxin measurement demonstrated significantly higher concentrations of toxins A and B in patients infected with the North American pulsed-field gel electrophoresis type 1/ribotype 027 (NAP-1/027) strain compared with other strains, providing in vivo confirmation of the in vitro association between NAP-1/027 and elevated toxin production.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nira R Pollock
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - David N Williams
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine Cuddemi
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Javier Villafuerte-Gálvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nicole C White
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rebecca Sprague
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Caitlin Barrett
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | | | | | - Ciarán P Kelly
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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6
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Tsai BY, Chien CC, Huang SH, Zheng JY, Hsu CY, Tsai YS, Hung YP, Ko WC, Tsai PJ. The emergence of Clostridioides difficile PCR ribotype 127 at a hospital in northeastern Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:896-909. [PMID: 35042668 DOI: 10.1016/j.jmii.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 10/27/2021] [Accepted: 12/25/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Several studies have highlighted the incidence of Clostridioides difficile infections (CDIs) in Taiwan and certain ribotypes have been related to severe clinical diseases. A study was conducted to investigate the polymerase chain reaction (PCR) ribotypes and genetic relatedness of clinical C. difficile strains collected from January 2009 to December 2015 at a hospital in northeastern Taiwan. MATERIAL AND METHODS A modified two-step typing algorithm for C. difficile was used by combining a modified 8-plex and 3'-truncated tcdA screening PCR. In addition, MLVA typing was adopted for investigation of bacterial clonality and transmission. RESULTS Among a total of 86 strains, 24 (28%) were nontoxigenic and 62 (72%) had both tcdA and tcdB (A + B+). No tcdA-negative and tcdB-positive (A-B+) strains were identified. Binary toxin (CDT)-producing (cdtA+/cdtB+) strains were started to be identified in 2013. The 21 (34%) A+B+ clinical strains with binary toxin and tcdC deletion were identified as RT127 strains, which contained both RT078-lineage markers and fluoroquinolone (FQ)-resistant mutations (Thr82Ile in gyrA). Multiple loci variable-number tandem repeat analysis (MLVA) for phylogenetic relatedness of RT127 strains indicated that 20 of 21 strains belonged to a clonal complex that was identical to a clinical strain collected from southern Taiwan in 2011, suggestive of a clonal expansion in Taiwan. CONCLUSION A two-step typing method could rapidly confirm species identification and define the toxin gene profile of C. difficile isolates. The clonal expansion of RT127 strains in Taiwan indicates monitoring and surveillance of toxigenic C. difficile isolates from human, animal, and environment are critical to develop One Health prevention strategies.
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Affiliation(s)
- Bo-Yang Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Chun-Chih Chien
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan.
| | - Shu-Huan Huang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Kee-Lung, Keelung, Taiwan.
| | - Jun-Yuan Zheng
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Kee-Lung, Kee-Lung, Taiwan.
| | - Chih-Yu Hsu
- Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan.
| | - Yau-Sheng Tsai
- Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Yuan-Pin Hung
- Departments of Internal Medicine, Tainan Hospital, Ministry of Health & Welfare, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Pei-Jane Tsai
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medical Laboratory Science and Biotechnology, National Cheng Kung University, Tainan, Taiwan; Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan, Taiwan; Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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7
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Schroeder CP, Hengel RL, Nathan RV, Ritter TE, Obi EN, Lancaster C, Van Anglen LJ, Garey KW. Appropriate cleaning reduces potential risk of spore transmission from patients with Clostridioides difficile infection treated in outpatient infusion centers. Anaerobe 2022; 77:102617. [DOI: 10.1016/j.anaerobe.2022.102617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/28/2022] [Accepted: 07/21/2022] [Indexed: 11/01/2022]
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8
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Jo J, Gonzales-Luna AJ, Lancaster CK, McPherson JK, Begum K, Jahangir Alam M, Garey KW. Multi-country surveillance of Clostridioides difficile demonstrates high prevalence of spores in non-healthcare environmental settings. Anaerobe 2022; 75:102543. [DOI: 10.1016/j.anaerobe.2022.102543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/27/2022] [Accepted: 02/23/2022] [Indexed: 01/05/2023]
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9
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Ressler A, Wang J, Rao K. Defining the black box: a narrative review of factors associated with adverse outcomes from severe Clostridioides difficile infection. Therap Adv Gastroenterol 2021; 14:17562848211048127. [PMID: 34646358 PMCID: PMC8504270 DOI: 10.1177/17562848211048127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/31/2021] [Indexed: 02/04/2023] Open
Abstract
In the United States, Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated infection, affecting nearly half a million people and resulting in more than 20,000 in-hospital deaths every year. It is therefore imperative to better characterize the intricate interplay between C. difficile microbial factors, host immunologic signatures, and clinical features that are associated with adverse outcomes of severe CDI. In this narrative review, we discuss the implications of C. difficile genetics and virulence factors in the molecular epidemiology of CDI, and the utility of early biomarkers in predicting the clinical trajectory of patients at risk of developing severe CDI. Furthermore, we identify associations between host immune factors and CDI outcomes in both animal models and human studies. Next, we highlight clinical factors including renal dysfunction, aging, blood biomarkers, level of care, and chronic illnesses that can affect severe CDI diagnosis and outcome. Finally, we present our perspectives on two specific treatments pertinent to patient outcomes: metronidazole administration and surgery. Together, this review explores the various venues of CDI research and highlights the importance of integrating microbial, host, and clinical data to help clinicians make optimal treatment decisions based on accurate prediction of disease progression.
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Affiliation(s)
- Adam Ressler
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Joyce Wang
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
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10
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Almutairi MS, Gonzales-Luna AJ, Alnezary FS, Fallatah SB, Alam MJ, Begum K, Garey KW. Comparative clinical outcomes evaluation of hospitalized patients infected with Clostridioides difficile ribotype 106 vs. other toxigenic strains. Anaerobe 2021; 72:102440. [PMID: 34461273 DOI: 10.1016/j.anaerobe.2021.102440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although Clostridioides difficile surveillance often identifies emerging strains, clinical outcome evaluations are rarely performed. Ribotype (RT) 106 is a commonly isolated C. difficile strain worldwide; however, studies investigating RT 106 clinical outcomes are limited. The purpose of this study was to investigate clinical outcomes of RT 106 infections compared with two other endemic strains of varying virulence. METHODS This multicenter study evaluated adults hospitalized with C. difficile infection (CDI). C. difficile samples underwent PCR ribotyping and patients infected with RT 106 were compared to patients infected with a known hypervirulent strain (RT 027) and a strain associated with less virulence (RT 014-020). Electronic medical records were reviewed by blinded investigators to assess the primary outcome of poor clinical outcome (composite of initial clinical failure, discharge to a higher level of care, 90-day CDI recurrence, and CDI-contributable mortality). RESULTS A total of 396 patients with CDI were identified (RT 106, 32.3%; RT 027, 29.3%; RT 014-020, 38.3%). Patients infected with RT 014-020 less often experienced a poor clinical outcome (40%) compared with RT 106 (56%) and RT 027 (65%) infection (P < 0.0001). After controlling for covariates and using RT 014-020 as a comparator, patients infected with RT 106 (OR, 2.25; 95% CI, 1.36-3.73) or RT 027 (OR, 2.56; 95% CI, 1.52-4.31) had higher odds of poor clinical outcome. Using RT 027 as the comparator, only RT 014-020 was associated with lower odds of poor clinical outcome (OR, 0.42; 95% CI, 0.27-0.65). CONCLUSION This study demonstrated that the emergent C. difficile RT 106 was associated with increased rates of poor clinical outcomes compared to RT 014-020 and comparable poor clinical outcomes to RT 027. These findings can help to better understand the clinical significance of this and future emerging ribotypes.
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Affiliation(s)
- Masaad Saeed Almutairi
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA; Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA.
| | - Faris S Alnezary
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA; Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Medina, Saudi Arabia
| | - Saad B Fallatah
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA; Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Medina, Saudi Arabia
| | - M Jahangir Alam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Khurshida Begum
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA.
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11
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Miles-Jay A, Young VB, Pamer EG, Savidge TC, Kamboj M, Garey KW, Snitkin ES. A multisite genomic epidemiology study of Clostridioides difficile infections in the USA supports differential roles of healthcare versus community spread for two common strains. Microb Genom 2021; 7. [PMID: 34180789 PMCID: PMC8461479 DOI: 10.1099/mgen.0.000590] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Clostridioides difficile is the leading cause of healthcare-associated infectious diarrhoea. However, it is increasingly appreciated that healthcare-associated infections derive from both community and healthcare environments, and that the primary sites of C. difficile transmission may be strain-dependent. We conducted a multisite genomic epidemiology study to assess differential genomic evidence of healthcare vs community spread for two of the most common C. difficile strains in the USA: sequence type (ST) 1 (associated with ribotype 027) and ST2 (associated with ribotype 014/020). We performed whole-genome sequencing and phylogenetic analyses on 382 ST1 and ST2 C. difficile isolates recovered from stool specimens collected during standard clinical care at 3 geographically distinct US medical centres between 2010 and 2017. ST1 and ST2 isolates both displayed some evidence of phylogenetic clustering by study site, but clustering was stronger and more apparent in ST1, consistent with our healthcare-based study more comprehensively sampling local transmission of ST1 compared to ST2 strains. Analyses of pairwise single-nucleotide variant (SNV) distance distributions were also consistent with more evidence of healthcare transmission of ST1 compared to ST2, with 44 % of ST1 isolates being within two SNVs of another isolate from the same geographical collection site compared to 5.5 % of ST2 isolates (P-value=<0.001). Conversely, ST2 isolates were more likely to have close genetic neighbours across disparate geographical sites compared to ST1 isolates, further supporting non-healthcare routes of spread for ST2 and highlighting the potential for misattributing genomic similarity among ST2 isolates to recent healthcare transmission. Finally, we estimated a lower evolutionary rate for the ST2 lineage compared to the ST1 lineage using Bayesian timed phylogenomic analyses, and hypothesize that this may contribute to observed differences in geographical concordance among closely related isolates. Together, these findings suggest that ST1 and ST2, while both common causes of C. difficile infection in hospitals, show differential reliance on community and hospital spread. This conclusion supports the need for strain-specific criteria for interpreting genomic linkages and emphasizes the importance of considering differences in the epidemiology of circulating strains when devising interventions to reduce the burden of C. difficile infections.
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Affiliation(s)
| | | | - Eric G Pamer
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,The University of Chicago, Chicago, IL, USA
| | | | - Mini Kamboj
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, TX, USA
| | - Evan S Snitkin
- University of Michigan Medical School, Ann Arbor, MI, USA
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12
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Gilbert J, Leslie J, Putler R, Weiner S, Standke A, Penkevich A, Keidan M, Young VB, Rao K. Anti-toxin antibody is not associated with recurrent Clostridium difficile infection. Anaerobe 2021; 67:102299. [PMID: 33227427 PMCID: PMC8094835 DOI: 10.1016/j.anaerobe.2020.102299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/23/2020] [Accepted: 11/16/2020] [Indexed: 02/08/2023]
Abstract
Clostridium difficile infection (CDI) recurs in ∼20% of patients. Prior studies indicated that antibody responses directed against the C. difficile toxins A and B were potentially associated with lower risk of recurrent CDI. Here we tested the hypothesis that circulating anti-toxin IgG antibody levels associate with reduced risk of recurrent CDI. A cohort study with prospective enrollment and retrospective data abstraction examined antibody levels in 275 adult patients at the University of Michigan with CDI. We developed an enzyme linked immunosorbent assay to detect IgG antibodies against toxin A and toxin B in sera obtained at the time of diagnosis. Logistic regression examined the relationship between antibody levels and recurrence, and sensitivity tests evaluated for follow-up and survivor biases, history of CDI, and PCR ribotype. Follow-up data were available for 174 subjects, of whom 36 (20.7%) had recurrence. Comparing antibody levels vs. recurrence and CDI history, anti-toxin A levels were similar, while anti-toxin B levels had a greater range of values. In unadjusted analysis, detection of anti-toxin A antibodies, but not anti-toxin B antibodies, associated with an increased risk of recurrence (OR 2.71 [1.06, 8.37], P = .053). Adjusting for confounders weakened this association. The results were the same in sensitivity analyses. We observed a borderline increased risk of recurrence in patients positive for anti-toxin A antibodies, and sensitivity analyses showed this was not simply a reflection of prior exposure status. Future studies are needed to assess how neutralizing antibody or levels after treatment associate with recurrence.
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Affiliation(s)
| | | | - Rose Putler
- Department of Microbiology and Immunology, USA
| | - Shayna Weiner
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Alexandra Standke
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Aline Penkevich
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Micah Keidan
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Vincent B Young
- Department of Microbiology and Immunology, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Krishna Rao
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.
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13
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Lin Q, Pollock NR, Banz A, Lantz A, Xu H, Gu L, Gerding DN, Garey KW, Gonzales-Luna AJ, Zhao M, Song L, Duffy DC, Kelly CP, Chen X. Toxin A-Predominant Pathogenic Clostridioides difficile: A Novel Clinical Phenotype. Clin Infect Dis 2021; 70:2628-2633. [PMID: 31400280 DOI: 10.1093/cid/ciz727] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Most Clostridioides difficile toxinogenic strains produce both toxins A and B (A+B+), but toxin A-negative, toxin B-positive (A-B+) variants also cause disease. We report the identification of a series of pathogenic clinical C. difficile isolates that produce high amounts of toxin A with low or nondetectable toxin B. METHODS An ultrasensitive, quantitative immunoassay was used to measure toxins A and B in stool samples from 187 C. difficile infection (CDI) patients and 44 carriers. Isolates were cultured and assessed for in vitro toxin production and in vivo phenotypes (mouse CDI model). RESULTS There were 7 CDI patients and 6 carriers who had stools with detectable toxin A (TcdA, range 23-17 422 pg/mL; 5.6% of samples overall) but toxin B (TcdB) below the clinical detection limit (<20 pg/mL; median TcdA:B ratio 17.93). Concentrations of toxin A far exceeded B in in vitro cultures of all 12 recovered isolates (median TcdA:B ratio 26). Of 8 toxin A>>B isolates tested in mice, 4 caused diarrhea, and 3 of those 4 caused lethal disease. Ribotyping demonstrated strain diversity. TcdA-predominant samples were also identified at 2 other centers, with similar frequencies (7.5% and 6.8%). CONCLUSIONS We report the discovery of clinical pathogenic C. difficile strains that produce high levels of toxin A but minimal or no toxin B. This pattern of toxin production is not rare (>5% of isolates) and is consistently observed in vitro and in vivo in humans and mice. Our study highlights the significance of toxin A in human CDI pathogenesis and has important implications for CDI diagnosis, treatment, and vaccine development.
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Affiliation(s)
- Qianyun Lin
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Divisions of Gastroenterology, Massachusetts
| | - Nira R Pollock
- Infectious Diseases, Beth Israel Deaconess Medical Center, Massachusetts.,Department of Laboratory Medicine, Boston Children's Hospital, Massachusetts
| | | | | | - Hua Xu
- Divisions of Gastroenterology, Massachusetts
| | - Limei Gu
- Divisions of Gastroenterology, Massachusetts
| | - Dale N Gerding
- Department of Veterans Affairs, Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Texas
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Texas
| | | | | | | | | | - Xinhua Chen
- Divisions of Gastroenterology, Massachusetts
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14
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Thanissery R, McLaren MR, Rivera A, Reed AD, Betrapally NS, Burdette T, Winston JA, Jacob M, Callahan BJ, Theriot CM. Clostridioides difficile carriage in animals and the associated changes in the host fecal microbiota. Anaerobe 2020; 66:102279. [PMID: 33022384 PMCID: PMC10760528 DOI: 10.1016/j.anaerobe.2020.102279] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 08/31/2020] [Accepted: 09/27/2020] [Indexed: 02/08/2023]
Abstract
The relationship between the gut microbiota and Clostridioides difficile, and its role in the severity of C. difficile infection in humans is an area of active research. Intestinal carriage of toxigenic and non-toxigenic C. difficile strains, with and without clinical signs, is reported in animals, however few studies have looked at the risk factors associated with C. difficile carriage and the role of the host gut microbiota. Here, we isolated and characterized C. difficile strains from different animal species (predominantly canines (dogs), felines (cats), and equines (horses)) that were brought in for tertiary care at North Carolina State University Veterinary Hospital. C. difficile strains were characterized by toxin gene profiling, fluorescent PCR ribotyping, and antimicrobial susceptibility testing. 16S rRNA gene sequencing was done on animal feces to investigate the relationship between the presence of C. difficile and the gut microbiota in different hosts. Here, we show that C. difficile was recovered from 20.9% of samples (42/201), which included 33 canines, 2 felines, and 7 equines. Over 69% (29/42) of the isolates were toxigenic and belonged to 14 different ribotypes including ones known to cause CDI in humans. The presence of C. difficile results in a shift in the fecal microbial community structure in both canines and equines. Commensal Clostridium hiranonis was negatively associated with C. difficile in canines. Further experimentation showed a clear antagonistic relationship between the two strains in vitro, suggesting that commensal Clostridia might play a role in colonization resistance against C. difficile in different hosts.
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Affiliation(s)
- R Thanissery
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA
| | - M R McLaren
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA
| | - A Rivera
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA
| | - A D Reed
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA
| | - N S Betrapally
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA
| | - T Burdette
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA
| | - J A Winston
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA
| | - M Jacob
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA
| | - B J Callahan
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA
| | - C M Theriot
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, 1060 William Moore Drive, Raleigh, NC, 27607, USA.
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15
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Degree of concordance of Clostridioides difficile strains in adults with community-associated C. difficile infection and infants with C. difficile colonization. Infect Control Hosp Epidemiol 2020; 42:731-736. [PMID: 33208213 DOI: 10.1017/ice.2020.1290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Infants asymptomatically excrete Clostridioides difficile during their first year of life, suggesting that they may represent a source of infection for adults who acquire community-associated C. difficile infection (CA-CDI). The genetic relationship of C. difficile strains from asymptomatic infants and adults with CA-CDI is not well defined. METHODS In this study, 50 infants were recruited at birth, and stool samples were collected at routine well-child visits. Adult stool samples collected during the same period and geographical area from patients who were diagnosed with CA-CDI were selected for comparison. C. difficile was cultivated and probed by PCR for toxin genes and were typed by PCR fluorescent ribotyping. Isolates from adults and infants with shared ribotypes were subjected to whole-genome sequencing (WGS). RESULTS Of these 50 infants, 36 were positive for C. difficile at least once in their first year of life, with a peak incidence at 6 months. Among 180 infant stool samples, 48 were positive. Of 48 isolates from positive stools, 29 were toxigenic by polymerase chain reaction (PCR) and 8 of 48 stool samples were positive for toxin by enzyme immunoassays (EIAs). Ribotypes F106 and F014-020 were present in both colonized infants and adults with CA-CDI. WGS identified 1 adult-infant pair that differed by 5 single-nucleotide polymorphisms (SNPs). Also, 4 additional adult-infant clusters differed by ≤16 SNPs. CONCLUSIONS Infants that are colonized with C. difficile share ribotypes with adults from the same geographical region with CA-CDI. Selected isolates in the 2 populations show a genetic relationship by WGS.
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16
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Maslanka JR, Gu CH, Zarin I, Denny JE, Broadaway S, Fett B, Mattei LM, Walk ST, Abt MC. Detection and elimination of a novel non-toxigenic Clostridioides difficile strain from the microbiota of a mouse colony. Gut Microbes 2020; 12:1-15. [PMID: 33305657 PMCID: PMC7734020 DOI: 10.1080/19490976.2020.1851999] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Clostridioides difficile is an enteric bacterial pathogen that can a cause nosocomial infection leading to debilitating colitis. The development of a murine model of C. difficile infection has led to fundamental discoveries in disease pathogenesis and the host immune response to infection. Recently, C. difficile endogenously present in the microbiota of mice has been reported and was found to complicate interpretation of mouse studies. Here, we report a novel C. difficile strain, named NTCD-035, isolated from the microbiota of our mouse colony. The presence of NTCD-035 in mice prior to challenge with a highly pathogenic C. difficile strain (VPI10463) led to significantly reduced disease severity. Phylogenetic characterization derived from whole genome sequencing and PCR ribotyping identified the isolate as a novel clade 1, ribotype 035 strain that lacks the pathogenicity locus required to produce toxins. Deficiency in toxin production along with sporulation capacity and secondary bile acid sensitivity was confirmed using in vitro assays. Inoculation of germ-free mice with NTCD-035 did not cause morbidity despite the strain readily colonizing the large intestine. Implementation of a culture-based screening procedure enabled the identification of mice harboring C. difficile in their microbiota, the establishment of a C. difficile-free mouse colony, and a monitoring system to prevent future contamination. Taken together, these data provide a framework for screening mice for endogenously harbored C. difficile and support clinical findings that demonstrate the therapeutic potential of non-toxigenic strains in preventing C. difficile associated disease. Abbreviations: PaLoc - Pathogenicity locus, CFUs - Colony forming units, TcdA - toxin-A, TcdB - toxin-B, CdtA - binary toxin A, CdtB - binary toxin B, CdtR - binary toxin R, NTCD - non-toxigenic C. difficile.
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Affiliation(s)
- Jeffrey R. Maslanka
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher H. Gu
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Isma Zarin
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua E. Denny
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan Broadaway
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT, USA
| | - Bryton Fett
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa M. Mattei
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Seth T. Walk
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT, USA
| | - Michael C. Abt
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,CONTACT Michael C Abt Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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17
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Bassères E, Begum K, Lancaster C, Gonzales-Luna AJ, Carlson TJ, Miranda J, Rashid T, Alam MJ, Eyre DW, Wilcox MH, Garey KW. In vitro activity of eravacycline against common ribotypes of Clostridioides difficile. J Antimicrob Chemother 2020; 75:2879-2884. [PMID: 32719870 PMCID: PMC7678891 DOI: 10.1093/jac/dkaa289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023] Open
Abstract
Background Eravacycline is a novel synthetic fluorocycline antibacterial approved for complicated intra-abdominal infections. Objectives The purpose of this study was to assess the in vitro activities of eravacycline and comparator antibiotics against contemporary clinical isolates of Clostridioides difficile representing common ribotypes, including isolates with decreased susceptibility to metronidazole and vancomycin. Methods Clinical C. difficile strains from six common or emerging ribotypes were used to test the in vitro activities of eravacycline and comparator antibiotics (fidaxomicin, vancomycin and metronidazole) by broth microdilution. In addition, MBC experiments, time–kill kinetic studies and WGS experiments were performed. Results A total of 234 isolates were tested, including ribotypes RT001 (n = 37), RT002 (n = 41), RT014-020 (n = 39), RT027 (n = 42), RT106 (n = 38) and RT255 (n = 37). MIC50/90 values were lowest for eravacycline (≤0.0078/0.016 mg/L), followed by fidaxomicin (0.016/0.063 mg/L), metronidazole (0.25/1.0 mg/L) and vancomycin (2.0/4.0 mg/L). MBCs were lower for eravacycline compared with vancomycin for all ribotypes tested. Both vancomycin and eravacycline demonstrated bactericidal killing, including for epidemic RT027. The presence of the tetM or tetW resistance genes did not affect the MIC of eravacycline. Conclusions This study demonstrated potent in vitro activity of eravacycline against a large collection of clinical C. difficile strains that was not affected by ribotype, susceptibility to vancomycin or the presence of certain tet resistance genes. Further development of eravacycline as an antibiotic to be used in patients with Clostridioides difficile infection is warranted.
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Affiliation(s)
| | | | | | | | - Travis J Carlson
- Fred Wilson School of Pharmacy, High Point University, High Point, NC, USA
| | - Julie Miranda
- University of Houston College of Pharmacy, Houston, TX, USA
| | - Tasnuva Rashid
- University of Houston College of Pharmacy, Houston, TX, USA
| | | | - David W Eyre
- Big Data Institute, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Mark H Wilcox
- Healthcare Associated Infections Research Group, Leeds Institute for Medical Research, University of Leeds, Old Medical School, Leeds General Infirmary, Leeds LS1 3EX, UK.,Microbiology, Leeds Teaching Hospitals NHS Trust, Old Medical School, Leeds General Infirmary, Leeds LS1 3EX, UK
| | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, TX, USA
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18
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Menon A, Perry DA, Motyka J, Weiner S, Standke A, Penkevich A, Keidan M, Young VB, Rao K. Changes in the Association between Diagnostic Testing Method, PCR Ribotype, and Clinical Outcomes from Clostridioides difficile Infection: One Institution's Experience. Clin Infect Dis 2020; 73:e2883-e2889. [PMID: 32930705 DOI: 10.1093/cid/ciaa1395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In patients with Clostridioides difficile infection (CDI), the relationship between clinical, microbial, and temporal/epidemiological trends relate and disease severity and adverse outcomes is incompletely understood. Here, in a follow-up to our study conducted in 2010-2013, we evaluate stool toxin levels and C. difficile PCR ribotypes. We hypothesized that elevated stool toxins and infection with ribotype 027 associate with severe disease and adverse outcomes. METHODS In a cohort of 565 subjects at the University of Michigan with CDI diagnosed by positive testing for toxins A/B by EIA or PCR for the tcdB gene, we quantified stool toxin levels via a modified cell cytotoxicity assay, isolated C. difficile by anaerobic culture, and performed PCR ribotyping. Severe CDI was defined by IDSA criteria, and primary outcomes were all-cause 30-day mortality and a composite of colectomy, ICU admission, and/or death attributable to CDI within 30 days. Analyses included bivariable tests and adjusted logistic regression. RESULTS 199 samples were diagnosed by EIA and 447 were diagnosed by PCR. Toxin positivity associated with IDSA severity, but not primary outcomes. In 2016, compared to 2010-2013, ribotype 106 newly emerged, accounting for 10.6% of strains, ribotype 027 fell from 16.5% to 9.3%, and ribotype 014-027 remained stable at 18.9%. Ribotype 014-020 associated with IDSA severity and 30-day mortality (P=.001). CONCLUSION Toxin positivity by EIA and CCA associated with IDSA severity, but not with subsequent adverse outcomes. The molecular epidemiology of C. difficile has shifted, and this may have implications for the optimal diagnostic strategy for and clinical severity of CDI.
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Affiliation(s)
- Anitha Menon
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - D Alex Perry
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jonathan Motyka
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Shayna Weiner
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alexandra Standke
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Aline Penkevich
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Micah Keidan
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vincent B Young
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Krishna Rao
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
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19
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In Vitro Activity of Omadacycline, a New Tetracycline Analog, and Comparators against Clostridioides difficile. Antimicrob Agents Chemother 2020; 64:AAC.00522-20. [PMID: 32513796 PMCID: PMC7526832 DOI: 10.1128/aac.00522-20] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/31/2020] [Indexed: 02/06/2023] Open
Abstract
Omadacycline is a potent aminomethylcycline with in vitro activity against Gram-positive, Gram-negative, and anaerobic bacteria. Preliminary data demonstrated that omadacycline has in vitro activity against Clostridioides difficile; however, large-scale in vitro studies have not been done. The purpose of this study was to assess the in vitro susceptibility of omadacycline and comparators on a large biobank of clinical C. difficile isolates. Omadacycline is a potent aminomethylcycline with in vitro activity against Gram-positive, Gram-negative, and anaerobic bacteria. Preliminary data demonstrated that omadacycline has in vitro activity against Clostridioides difficile; however, large-scale in vitro studies have not been done. The purpose of this study was to assess the in vitro susceptibility of omadacycline and comparators on a large biobank of clinical C. difficile isolates. In vitroC. difficile susceptibility to omadacycline and comparators (fidaxomicin, metronidazole, and vancomycin) was assessed using the broth microdilution method. Minimum bactericidal concentrations (MBCs) and time-kill assays were assessed for pharmacodynamics analysis, and whole-genome sequencing was performed in a subset of isolates to assess distribution of MICs and resistance determinants. Two hundred fifty clinical C. difficile isolates collected between 2015 and 2018 were tested for in vitro susceptibility of omadacycline and comparators. Ribotypes included F001 (n = 5), F002 (n = 56), F014-020 (n = 66), F017 (n = 8), F027 (n = 53), F106 (n = 45), and F255 (n = 17). Omadacycline demonstrated potent in vitro activity with an MIC range of 0.016 to 0.13 μg/ml, an MIC50 of 0.031 μg/ml, and an MIC90 of 0.031 μg/ml. No difference was observed for omadacycline MIC50 and MIC90 values stratified by ribotype, disease severity, or vancomycin susceptibility. Bactericidal activity was confirmed in time-kill studies. No difference was observed in MIC based on C. difficile phylogeny. Further development of omadacycline as an intravenous and oral antibiotic directed toward C. difficile infection is warranted.
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20
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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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Saund K, Rao K, Young VB, Snitkin ES. Genetic Determinants of Trehalose Utilization Are Not Associated With Severe Clostridium difficile Infection Outcome. Open Forum Infect Dis 2020; 7:ofz548. [PMID: 31976356 PMCID: PMC6966243 DOI: 10.1093/ofid/ofz548] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/31/2019] [Indexed: 11/20/2022] Open
Abstract
In a case–control study of patients with Clostridium difficile infection, we found no statistically significant association between the presence of trehalose utilization variants in infecting C. difficile strains and development of severe infection outcome. These results do not support trehalose utilization conferring enhanced virulence in the context of human C. difficile infections.
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Affiliation(s)
- Katie Saund
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Krishna Rao
- Department of Internal Medicine/Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Vincent B Young
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine/Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Evan S Snitkin
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Internal Medicine/Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan, USA
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22
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Berger FK, Mellmann A, von Müller L, Bischoff M, Gärtner BC. Quality assurance for genotyping and resistance testing of Clostridium (Clostridioides) difficile isolates - Experiences from the first inter-laboratory ring trial in four German speaking countries. Anaerobe 2019; 61:102093. [PMID: 31494260 DOI: 10.1016/j.anaerobe.2019.102093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 01/05/2023]
Abstract
Clostridium (Clostridioides) difficile is a major cause of nosocomial diarrhoea. A first inter-laboratory ring trial was performed in four European countries to evaluate the genotyping and antibiotic susceptibility testing (AST) accuracy. Six C. difficile isolates representing the epidemiologic important ribotypes (RT), RT001, RT002, RT010, RT014, RT027, and RT078 were blinded and send to 21 participating laboratories. Participants tested the samples with their genotyping and AST methods in use for concordance with reference. A total of 21 genotyping- and 14 antimicrobial susceptibility data sets were obtained. Ribotyping (11 participants) correctly identified most RTs (median 91% concordance rate) except for RT002, which was misidentified in 4/11 reports. However, this isolate was correctly asserted to RT002 after an update of a publicly available ribotyping database. Multilocus sequence typing, surface layer sequence typing, DNA microarray based genotyping, and whole genome sequencing, which were used by 1-3 participants, identified all six isolates correctly. AST was done by epsilometry by the participants and compared to agar dilution data determined by the coordinating reference centre. Susceptibilities against metronidazole, moxifloxacin, and vancomycin were correctly identified in 235 of 237 cases and in accordance to agar dilution as the gold standard. Genotyping of the C. difficile test strains revealed a remarkable high concordance on the level of ribotypes with a wide variety of methods. Epsilometry appears to be a reliable method for AST of C. difficile isolates in routine clinical microbiology laboratories.
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Affiliation(s)
- Fabian K Berger
- German National Reference Center for Clostridioides (Clostridium) difficile, Germany; Institute of Medical Microbiology and Hygiene, University of Saarland, Kirrberger Straße, Building 43, 66424, Homburg/Saar, Germany.
| | - Alexander Mellmann
- German National Reference Center for Clostridioides (Clostridium) difficile, Germany; Institute of Hygiene, University Hospital Münster, Robert-Koch-Straße 41, 48149, Münster, Germany
| | - Lutz von Müller
- German National Reference Center for Clostridioides (Clostridium) difficile, Germany; Institute of Medical Microbiology and Hygiene, University of Saarland, Kirrberger Straße, Building 43, 66424, Homburg/Saar, Germany; Institute for Laboratory Medicine, Microbiology and Hygiene, Christophorus Kliniken, Südwall 22, 48653, Coesfeld, Germany
| | - Markus Bischoff
- German National Reference Center for Clostridioides (Clostridium) difficile, Germany; Institute of Medical Microbiology and Hygiene, University of Saarland, Kirrberger Straße, Building 43, 66424, Homburg/Saar, Germany
| | - Barbara C Gärtner
- German National Reference Center for Clostridioides (Clostridium) difficile, Germany; Institute of Medical Microbiology and Hygiene, University of Saarland, Kirrberger Straße, Building 43, 66424, Homburg/Saar, Germany
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23
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Alam MJ, McPherson J, Miranda J, Thrall A, Ngo V, Kessinger R, Begum K, Marin M, Garey KW. Molecular epidemiology of Clostridioides difficile in domestic dogs and zoo animals. Anaerobe 2019; 59:107-111. [PMID: 31207298 DOI: 10.1016/j.anaerobe.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/31/2019] [Accepted: 06/14/2019] [Indexed: 02/08/2023]
Abstract
Animals such as domestic dogs and zoo animals reside in close proximity to humans and could contribute to the dissemination of Clostridioides difficile spores which are common in the community environment. The purpose of this study was to assess C. difficile colonization in domestic dogs attending a day boarding facility and zoo animals receiving systemic antibiotics. Stool samples and paw swabs were collected from dogs who attended a day boarding facility. Stool samples were also collected from zoo animals starting systemic antibiotics. Finally, environmental samples were collected from nearby public parks. Stool samples and swabs were incubated anaerobically in enrichment broth for C. difficile growth, PCR was done to confirm presence of toxin genes, and PCR ribotyping was performed for strain characterization. During the study period, 136 dog stool samples were obtained, the paws of 16 dogs were swabbed, and 250 environmental swabs from surrounding public parks were obtained. Twenty-three of 136 dog stool samples (17%) and 9 of 16 dog paws sampled (56%) grew toxigenic C. difficile. One hundred and four stool samples from 49 zoo animals were collected of which 19 (18%) grew toxigenic C. difficile. Rates of toxigenic C. difficile colonization increased significantly during antibiotic therapy (33%) and then returned to baseline during the follow-up (11%) period (p = 0.019). Fifty-five of 250 environmental swabs from public parks (22%) grew toxigenic C. difficile. Ribotypes associated with human disease including 106 and 014-020 were isolated from all sources. This study demonstrated a high rate of toxigenic C. difficile colonization in domestic dogs and zoo animals with ribotypes similar to those causing human disease. These results demonstrate the relationship between humans, animals, and the environment in the dissemination of spores.
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Affiliation(s)
| | | | - Julie Miranda
- University of Houston College of Pharmacy, Houston, TX, USA
| | - Allyson Thrall
- University of Houston College of Pharmacy, Houston, TX, USA
| | - Van Ngo
- University of Houston College of Pharmacy, Houston, TX, USA
| | | | | | | | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, TX, USA.
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Gonzalez-Orta M, Saldana C, Ng-Wong Y, Cadnum J, Jencson A, Jinadatha C, Donskey CJ. Are Many Patients Diagnosed With Healthcare-associated Clostridioides difficile Infections Colonized With the Infecting Strain on Admission? Clin Infect Dis 2019; 69:1801-1804. [DOI: 10.1093/cid/ciz189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/28/2019] [Indexed: 02/04/2023] Open
Abstract
Abstract
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.
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Affiliation(s)
- Melany Gonzalez-Orta
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
- Department of Medicine, Cleveland Clinic Foundation, Ohio
| | - Carlos Saldana
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
- Department of Medicine, Cleveland Clinic Foundation, Ohio
| | - Yilen Ng-Wong
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
| | - Jennifer Cadnum
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
| | - Annette Jencson
- Research Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland Clinic Foundation, Ohio
| | - Chetan Jinadatha
- Department of Medicine, Central Texas Veterans Health Care System, Temple, Texas A&M University, Bryan
- College of Medicine, Texas A&M University, Bryan
| | - Curtis J Donskey
- Geriatric Research, Education, and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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25
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Clostridioides difficile ribotypes isolated from domestic environment and from patients in Bangladesh. Anaerobe 2019; 56:88-90. [PMID: 30794875 DOI: 10.1016/j.anaerobe.2019.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 02/10/2019] [Accepted: 02/12/2019] [Indexed: 01/03/2023]
Abstract
Clostridioides difficile infection (CDI) is an emerging but often understudied infectious disease in developing countries. This study was aimed to isolate and characterize C. difficile from shoe sole swabs and diarrheal patient's stool samples in Bangladesh. We collected 94 shoe sole swabs samples from urban communities in Dhaka and 208 diarrheal stool samples from hospitalized patients over a period of 4 months. Samples were incubated anaerobically for C. difficile growth, confirmed toxigenic, and PCR-ribotyped. Eleven of 94 (11.7%) shoe sole swabs and 4 of 208 (1.9%) stool samples were culture positive of which 9 shoe sole isolates were toxigenic. Six PCR ribotypes from the 9 toxigenic isolates were identified with ribotype F014-020 being the most common (n = 4; 44%). The recently identified ribotype 106 strain was also identified. To the best of our knowledge, this is the first report of C. difficile culture, isolation and characterization from environmental sources in Bangladesh.
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Environmental transmission of Clostridioides difficile ribotype 027 at a long-term care facility; an outbreak investigation guided by whole genome sequencing. Infect Control Hosp Epidemiol 2018; 39:1322-1329. [PMID: 30253813 DOI: 10.1017/ice.2018.230] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This article describes a CDI outbreak in a long-term care (LTC) facility that used molecular typing techniques and whole-genome sequencing to identify widespread dissemination of the clonal strain in the environment which was successfully removed after terminal cleaning. SETTING This study was conducted in a long-term care facility in Texas. METHODS A recently hospitalized LTC patient was diagnosed with CDI followed shortly thereafter by 7 subsequent CDI cases. A stool specimen was obtained from each patient for culturing and typing. An environmental point-prevalence study of the facility was conducted before and after terminal cleaning of the facility to assess environmental contamination. Cultured isolates were typed using ribotyping, multilocus variant analysis, and whole-genome sequencing. RESULTS Stool samples were available for 5 of 8 patients; of these specimens, 4 grew toxigenic C. difficile ribotype 027. Of 50 environmental swab samples collected throughout the facility prior to the facility-wide terminal cleaning, 19 (38%) grew toxigenic C. difficile (most commonly ribotype 027, 79%). The terminal cleaning was effective at reducing C. difficile spores in the environment and at eradicating the ribotype 027 strain (P<.001). Using multilocus variance analysis and whole-genome sequencing, clinical and environmental strains were highly related and, in some cases, were identical. CONCLUSION Using molecular typing techniques, we demonstrated reduced environmental contamination with toxigenic C. difficile and the eradication of a ribotype 027 clone. These techniques may help direct infection control efforts and decrease the burden of CDI in the healthcare system.
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Snydman DR, McDermott LA, Thorpe CM, Chang J, Wick J, Walk ST, Vickers RJ. Antimicrobial susceptibility and ribotypes of Clostridium difficile isolates from a Phase 2 clinical trial of ridinilazole (SMT19969) and vancomycin. J Antimicrob Chemother 2018; 73:2078-2084. [PMID: 29718329 PMCID: PMC6054158 DOI: 10.1093/jac/dky135] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/22/2018] [Accepted: 03/20/2018] [Indexed: 12/18/2022] Open
Abstract
Objectives We evaluated the antimicrobial susceptibility and ribotypes of Clostridium difficile isolates from participants in a Phase 2 study of ridinilazole, a novel targeted-spectrum agent for treatment of C. difficile infection. Methods Participants received ridinilazole (200 mg twice daily) or vancomycin (125 mg four times daily) for 10 days (ClinicalTrials.gov: NCT02092935). The MICs of ridinilazole and comparators for C. difficile isolates from stool samples were determined by agar dilution. Toxin gene profiling was performed by multiplex PCR and ribotype identification by capillary electrophoresis. Results Eighty-nine isolates were recovered from 88/100 participants (one participant had two strains at baseline). The median colony count (cfu/g stool) was 1.9 × 104 (range: 2.5 × 102-7.0 × 106). Twelve participants (three received ridinilazole and nine received vancomycin) experienced recurrence, confirmed by immunoassays for free toxin in stool samples. The ribotype of eight out of nine isolates obtained at recurrence matched those of the initial isolates. All isolates, including those obtained at recurrence, were susceptible to ridinilazole within the expected range [median (range) MIC: 0.12 (0.06-0.5) mg/L]. The median (range) vancomycin MIC was 1 (0.5-4.0) mg/L. At baseline, 13.6% and 13.3% of samples in the ridinilazole and vancomycin groups were positive for VRE, increasing to 23.7% and 29.7% by day 40, respectively. Common ribotypes included 014-20 (14 isolates), 027 (13), 106 (7), 002 (7), 078-126 (4), 001 (4), 087 (3) and 198 (3). Toxin gene profiling of nearly all baseline isolates (98.9%) revealed a binary toxin gene (cdtA/cdtB) prevalence of 35%. Conclusions Ridinilazole potently inhibited recovered C. difficile isolates. Recurrence was not associated with altered susceptibility.
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Affiliation(s)
- David R Snydman
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Laura A McDermott
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Cheleste M Thorpe
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Justin Chang
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Jenna Wick
- Division of Geographic Medicine and Infectious Diseases and Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Seth T Walk
- Department of Microbiology and Immunology, Montana State University, Bozeman, MT, USA
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Cost-effectiveness analysis of ribotype-guided fecal microbiota transplantation in Chinese patients with severe Clostridium difficile infection. PLoS One 2018; 13:e0201539. [PMID: 30048534 PMCID: PMC6062131 DOI: 10.1371/journal.pone.0201539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 06/20/2018] [Indexed: 12/14/2022] Open
Abstract
Background Clostridium difficile infection (CDI) caused by ribotype 002 strain is associated with poor outcomes in Chinese patients. Fecal microbiota transplantation (FMT) is an effective but costly treatment for CDI. We aimed to examine potential cost-effectiveness of ribotype-guided FMT in Chinese patients with severe CDI. Methods A decision-analytic model was designed to simulate outcomes of ribotype 002-guided FMT versus vancomycin treatment in Chinese patients with severe CDI in the hospital setting. Outcome measures included mortality rate; direct medical cost; and quality-adjusted life year (QALY) loss for CDI. Sensitivity analysis was performed to examine robustness of base-case results. Results Comparing to vancomycin treatment, ribotype-guided FMT group reduced mortality (11.6% versus 17.1%), cost (USD8,807 versus USD9,790), and saved 0.472 QALYs in base-case analysis. One-way sensitivity analysis found the ribotype-guided FMT group to remain cost-effective when patient acceptance rate of FMT was >0.6% and ribotype 002 prevalence was >0.07%. In probabilistic sensitivity analysis, ribotype-guided FMT gained higher QALYs at 100% of simulations with mean QALY gain of 0.405 QALYs (95%CI: 0.400–0.410; p<0.001). The ribotype-guided group was less costly in 97.9% of time, and mean cost-saving was USA679 (95%CI: 670–688; p<0.001). Conclusions In the present model, ribotype-guided FMT appears to be a potential option to save QALYs and cost when comparing with vancomycin. The cost-effectiveness of ribotype-guided FMT is subject to the patient acceptance to FMT and prevalence of ribotype 002.
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Characterization of Flagellum and Toxin Phase Variation in Clostridioides difficile Ribotype 012 Isolates. J Bacteriol 2018; 200:JB.00056-18. [PMID: 29735765 DOI: 10.1128/jb.00056-18] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/02/2018] [Indexed: 12/21/2022] Open
Abstract
Clostridioides difficile causes diarrheal diseases mediated in part by the secreted toxins TcdA and TcdB. C. difficile produces flagella that also contribute to motility and bacterial adherence to intestinal cells during infection. Flagellum expression and toxin gene expression are linked via the flagellar alternative sigma factor, SigD. Recently, we identified a flagellar switch upstream of the early flagellar biosynthesis operon that mediates phase variation of both flagellum and toxin production in C. difficile strain R20291. However, we were unable to detect flagellar switch inversion in C. difficile strain 630, a ribotype 012 strain commonly used in research labs, suggesting that the strain is phase locked. To determine whether a phase-locked flagellar switch is limited to 630 or present more broadly in ribotype 012 strains, we assessed the frequency and phenotypic outcomes of flagellar switch inversion in multiple C. difficile ribotype 012 isolates. The laboratory-adapted strain JIR8094, a derivative of strain 630, and six clinical and environmental isolates were all found to be phase-off, nonmotile, and attenuated for toxin production. We isolated low-frequency motile derivatives of JIR8094 with partial recovery of motility and toxin production and found that additional changes in JIR8094 impact these processes. The clinical and environmental isolates varied considerably in the frequency by which flagellar phase-on derivatives arose, and these derivatives showed fully restored motility and toxin production. Taken together, these results demonstrate heterogeneity in flagellar and toxin phase variation among C. difficile ribotype 012 strains and perhaps other ribotypes, which could impact disease progression and diagnosis.IMPORTANCEC. difficile produces flagella that enhance bacterial motility and secretes toxins that promote diarrheal disease symptoms. Previously, we found that production of flagella and toxins is coregulated via a flippable DNA element termed the flagellar switch, which mediates the phase-variable production of these factors. Here, we evaluate multiple isolates of C. difficile ribotype 012 strains and find them to be primarily flagellar phase off (flg-off state). Some, but not all, of these isolates showed the ability to switch between flg-on and -off states. These findings suggest heterogeneity in the ability of C. difficile ribotype 012 strains to phase-vary flagellum and toxin production, which may broadly apply to pathogenic C. difficile.
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Seekatz AM, Wolfrum E, DeWald CM, Putler RKB, Vendrov KC, Rao K, Young VB. Presence of multiple Clostridium difficile strains at primary infection is associated with development of recurrent disease. Anaerobe 2018; 53:74-81. [PMID: 29859301 DOI: 10.1016/j.anaerobe.2018.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 02/07/2023]
Abstract
Recurrence of Clostridium difficile infection (CDI) places a major burden on the healthcare system. Previous studies have suggested that specific C. difficile strains, or ribotypes, are associated with severe disease and/or recurrence. However, in some patients a new strain is detected in subsequent infections, complicating longitudinal studies focused on strain differences that may contribute to disease outcome. We examined ribotype composition over time in patients who did or did not develop recurrence to examine infection with multiple C. difficile ribotypes (mixed infection), during the course of infection. Using a retrospective patient cohort, we isolated and ribotyped a median of 36 C. difficile colonies from 61 patients (105 total samples) at initial infection, recurrence (a second case of CDI within 15-56 days of initial infection), and reinfection (a second case of CDI after 56 days of initial infection). We observed mixed infection in 78.6% of samples at initial infection in patients who went on to develop recurrence compared to 18.1% of patients who did not, and mixed infection remained associated with subsequent recurrence after adjusting for gender and prior antibiotic exposure (OR 3.5, 95% CI 1.3-9.4, P = .015). In patients who were sampled longitudinally (44 consecutive events in 32 patients), the dominant ribotype changed in 31.8% of consecutive samples and the newly dominant ribotype was not detected in prior samples from that patient. Our results suggest that mixed C. difficile infection is more prevalent than previously demonstrated and potentially a marker of susceptibility to recurrence.
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Affiliation(s)
- Anna M Seekatz
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Emily Wolfrum
- School of Public Health, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Rosemary K B Putler
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kimberly C Vendrov
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Krishna Rao
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vincent B Young
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA.
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An Observational Cohort Study of Clostridium difficile Ribotype 027 and Recurrent Infection. mSphere 2018; 3:3/3/e00033-18. [PMID: 29794054 PMCID: PMC5967198 DOI: 10.1128/msphere.00033-18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 05/02/2018] [Indexed: 12/18/2022] Open
Abstract
CDI is a major public health issue, with over 400,000 cases per year in the United States alone. Recurrent CDI is common, occurring in approximately one in five individuals after a primary episode. Although interventions exist that could reduce the risk of recurrence, deployment in all patients is limited by cost, invasiveness, and/or an undetermined long-term safety profile. Thus, clinicians need risk stratification tools to properly allocate treatments. Because prior research on clinical predictors has failed to yield a reliable, reproducible, and effective predictive model to assist treatment decisions, accurate biomarkers of recurrence would be of great value. This study tested whether PCR ribotype independently predicted rCDI, and the data build upon prior research in showing that ribotype 027 is associated with rCDI. Recurrent Clostridium difficile infection (rCDI) frequently complicates recovery from CDI. Accurately predicting rCDI would allow judicious allocation of limited resources, but published models have met with limited success. Thus, biomarkers predictive of recurrence have been sought. This study tested whether PCR ribotype independently predicted rCDI. Stool samples from nonpregnant inpatients ≥18 years of age with diarrhea were included from October 2010 to January 2013 after the patients tested positive for C. difficile in the clinical microbiology laboratory. Per guidelines, the rCDI was defined as a positive test for C. difficile at >2 weeks but ≤8 weeks from the index episode. For each sample, a single colony of C. difficile was isolated by anaerobic culture, confirmed to be toxigenic by PCR, and ribotyped. Simple logistic regression and multiple logistic regression were used to model the primary outcome of rCDI, incorporating a wide range of clinical parameters. In total, 927 patients with 968 index episodes of CDI were included, with 110 (11.4%) developing rCDI. Age and use of proton pump inhibitors or concurrent antibiotics did not increase the risk of rCDI. Low serum bilirubin levels and ribotype 027 were associated with increased risk of rCDI on unadjusted analysis, with health care-associated CDI being inversely associated. In the final multivariable model, ribotype 027 was the strongest independent predictor of rCDI (odds ratio, 2.17; 95% confidence interval, 1.33 to 3.56; P = 0.002). Ribotype 027 is an independent predictor of rCDI. IMPORTANCE CDI is a major public health issue, with over 400,000 cases per year in the United States alone. Recurrent CDI is common, occurring in approximately one in five individuals after a primary episode. Although interventions exist that could reduce the risk of recurrence, deployment in all patients is limited by cost, invasiveness, and/or an undetermined long-term safety profile. Thus, clinicians need risk stratification tools to properly allocate treatments. Because prior research on clinical predictors has failed to yield a reliable, reproducible, and effective predictive model to assist treatment decisions, accurate biomarkers of recurrence would be of great value. This study tested whether PCR ribotype independently predicted rCDI, and the data build upon prior research in showing that ribotype 027 is associated with rCDI.
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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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Ulrich RJ, Santhosh K, Mogle JA, Young VB, Rao K. Is Clostridium difficile infection a risk factor for subsequent bloodstream infection? Anaerobe 2017; 48:27-33. [PMID: 28669864 PMCID: PMC5711547 DOI: 10.1016/j.anaerobe.2017.06.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 06/22/2017] [Accepted: 06/29/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a common nosocomial diarrheal illness increasingly associated with mortality in United States. The underlying factors and mechanisms behind the recent increases in morbidity from CDI have not been fully elucidated. Murine models suggest a mucosal barrier breakdown leads to bacterial translocation and subsequent bloodstream infection (BSI). This study tests the hypothesis that CDI is associated with subsequent BSI in humans. METHODS We conducted a retrospective cohort study on 1132 inpatients hospitalized >72 h with available stool test results for toxigenic C. difficile. The primary outcome was BSI following CDI. Secondary outcomes included 30-day mortality, colectomy, readmission, and ICU admission. Unadjusted and adjusted logistic regression models were developed. RESULTS CDI occurred in 570 of 1132 patients (50.4%). BSI occurred in 86 (7.6%) patients. Enterococcus (14%) and Klebsiella (14%) species were the most common organisms. Patients with BSI had higher comorbidity scores and were more likely to be male, on immunosuppression, critically ill, and have a central venous catheter in place. Of the patients with BSI, 36 (42%) had CDI. CDI was not associated with subsequent BSI (OR 0.69; 95% CI 0.44-1.08; P = 0.103) in unadjusted analysis. In multivariable modeling, CDI appeared protective against subsequent BSI (OR 0.57; 95% CI 0.34-0.96; P = 0.036). Interaction modeling suggests a complicated relationship among CDI, BSI, antibiotic exposure, and central venous catheter use. CONCLUSIONS In this cohort of inpatients that underwent testing for CDI, CDI was not a risk factor for developing subsequent BSI.
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Affiliation(s)
- Robert J Ulrich
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA.
| | - Kavitha Santhosh
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA; Division of Infectious Diseases, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Jill A Mogle
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA; Division of Infectious Diseases, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Vincent B Young
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA; Division of Infectious Diseases, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA; Department of Microbiology and Immunology, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Krishna Rao
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA; Division of Infectious Diseases, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA.
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Acquisition of Clostridium difficile Colonization and Infection After Transfer From a Veterans Affairs Hospital to an Affiliated Long-Term Care Facility. Infect Control Hosp Epidemiol 2017; 38:1070-1076. [DOI: 10.1017/ice.2017.140] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUNDClostridium difficile infection (CDI) and asymptomatic carriage of toxigenic C. difficile are common in long-term care facilities (LTCFs). However, whether C. difficile is frequently acquired in the LTCF versus during acute-care admissions remains unknown.OBJECTIVETo test the hypothesis that LTCF residents often acquire C. difficile colonization and infection in the LTCFDESIGNThis 5-month cohort study was conducted to determine the incidence of acquisition of C. difficile colonization and infection in asymptomatic patients transferred from a Veterans Affairs hospital to an affiliated LTCF.METHODSRectal swabs were cultured for toxigenic C. difficile at the time of transfer to the LTCF and weekly for up to 6 weeks. We calculated the proportion of LTCF-onset CDI cases within 1 month of transfer that occurred in residents colonized on admission versus those with new acquisition in the LTCF.RESULTSOf 110 patients transferred to the LTCF, 12 (11%) were asymptomatically colonized with toxigenic C. difficile upon admission, and 4 of these 12 patients (33%) developed CDI within 1 month, including 3 recurrent and 1 initial CDI episode. Of 82 patients with negative cultures on transfer and at least 1 follow-up culture, 22 (27%) acquired toxigenic C. difficile colonization, and 4 developed CDI within 1 month, including 1 recurrent and 3 initial CDI episodes.CONCLUSIONLTCF residents frequently acquired colonization with toxigenic C. difficile after transfer from the hospital, and 3 of 4 initial CDI cases with onset within 1 month of transfer occurred in residents who acquired colonization in the LTCF.Infect Control Hosp Epidemiol 2017;38:1070–1076
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Alam MJ, Walk ST, Endres BT, Basseres E, Khaleduzzaman M, Amadio J, Musick WL, Christensen JL, Kuo J, Atmar RL, Garey KW. Community Environmental Contamination of Toxigenic Clostridium difficile. Open Forum Infect Dis 2017; 4:ofx018. [PMID: 28480289 PMCID: PMC5414050 DOI: 10.1093/ofid/ofx018] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/27/2017] [Indexed: 12/18/2022] Open
Abstract
Background Clostridium difficile infection is often considered to result from recent acquisition of a C difficile isolate in a healthcare setting. However, C difficile spores can persist for long periods of time, suggesting a potentially large community environmental reservoir. The objectives of this study were to assess community environmental contamination of toxigenic C difficile and to assess strain distribution in environmental versus clinical isolates. Methods From 2013 to 2015, we collected community environmental swabs from homes and public areas in Houston, Texas to assess C difficile contamination. All positive isolates were tested for C difficile toxins A and B, ribotyped, and compared with clinical C difficile isolates obtained from hospitalized patients in Houston healthcare settings. Results A total of 2538 environmental samples were collected over the study period. These included samples obtained from homes (n = 1079), parks (n = 491), chain stores (n = 225), fast food restaurants (n = 123), other commercial stores (n = 172), and hospitals (n = 448). Overall, 418 environmental isolates grew toxigenic C difficile (16.5%; P < .001) most commonly from parks (24.6%), followed by homes (17.1%), hospitals (16.5%), commercial stores (8.1%), chain stores (7.6%), and fast food restaurants (6.5%). A similar distribution of ribotypes was observed between clinical and environmental isolates with the exception that ribotype 027 was more common in clinical isolates compared with environmental isolates (P < .001). Conclusions We identified a high prevalence of toxigenic C difficile from community environs that were similar ribotypes to clinical isolates. These findings suggest that interventions beyond isolation of symptomatic patients should be targeted for prevention of C difficile infection.
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Affiliation(s)
- M Jahangir Alam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Texas
| | - Seth T Walk
- Department of Immunology and Infectious Diseases, Montana State University, Bozeman
| | - Bradley T Endres
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Texas
| | - Eugenie Basseres
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Texas
| | - Mohammed Khaleduzzaman
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Texas
| | - Jonathan Amadio
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Texas
| | | | - Jennifer L Christensen
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Julie Kuo
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Texas
| | - Robert L Atmar
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Texas
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Thabit AK, Alam MJ, Burnham CAD, Nicolau DP. Clinical use comparison of a semiautomated PCR with fluorescent ribotyping for typing of Clostridium difficile. Arch Microbiol 2016; 199:317-323. [PMID: 27730251 DOI: 10.1007/s00203-016-1305-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/11/2016] [Accepted: 10/05/2016] [Indexed: 11/25/2022]
Abstract
Molecular typing of Clostridium difficile is performed to assess strain relatedness or place strains within an epidemiological context. Different C. difficile ribotyping systems are available. However, a common strain library does not exist. We aimed to compare ribotyping results of 29 clinical C. difficile isolates by two methods: semiautomated PCR-ribotyping and fluorescent PCR-ribotyping. For certain ribotypes (n = 16/29; 55.2 %), the inter-laboratory reproducibility was consistent among multiple samples from individual subjects, while 54.8 % (n = 14/29) were discordant. Additionally, 11/29 ribotypes (38 %) and 12/29 ribotypes (41 %) did not match with known reference strains in the semiautomated PCR-fluorescent ribotyping systems' libraries, respectively. The identification of 027 ribotype by both systems was consistent for 75 % of the isolates. Discriminatory indices for the semiautomated PCR-ribotyping and fluorescent PCR-ribotyping systems are 0.906 and 0.886, respectively. Although ribotyping provides important epidemiologic insights, the lack of a common strain library makes interpretation of results using different ribotyping protocols difficult.
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Affiliation(s)
- Abrar K Thabit
- Center for Anti-infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA
- Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - David P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
- Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA.
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Kullin B, Wojno J, Abratt V, Reid SJ. Toxin A-negative toxin B-positive ribotype 017 Clostridium difficile is the dominant strain type in patients with diarrhoea attending tuberculosis hospitals in Cape Town, South Africa. Eur J Clin Microbiol Infect Dis 2016; 36:163-175. [DOI: 10.1007/s10096-016-2790-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/13/2016] [Indexed: 12/12/2022]
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Thabit AK, Nicolau DP. An exploratory study to evaluate Clostridium difficile polymerase chain reaction ribotypes and infection outcomes. Infect Drug Resist 2016; 9:143-8. [PMID: 27390531 PMCID: PMC4930231 DOI: 10.2147/idr.s108325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Clostridium difficile infection ranges from mild to severe prolonged diarrhea with systemic symptoms. Previous studies have assessed the correlation of some disease severity parameters to C. difficile ribotypes. However, certain clinical parameters of interest have not yet been evaluated. AIM We conducted an exploratory study to evaluate the correlation of C. difficile ribotypes to parameters not assessed previously, notably days to diarrhea resolution (in terms of days to formed stools and days to less than three stools per day), length of hospital stay, 30-day recurrence rates, and 30-day readmission rates. Additional severity parameters evaluated include leukocytosis, serum creatinine, fever, and nausea/vomiting. METHODS Polymerase chain reaction ribotyping was performed on C. difficile isolates from baseline stool samples of 29 patients. A retrospective chart review was conducted to assess the parameters of interest. RESULTS The most common ribotypes were 027 (38%), 014/020 (21%), and 106/174 (21%). Numerically, 027 ribotype patients required more days to less than three stools per day versus 014/020 and 106/174 ribotype patients (P=0.2). The three ribotypes were similar regarding time to formed stools, duration of hospitalization, and 30-day readmission rate (P=0.2, 0.6, and 0.8, respectively). Recurrence within 30 days occurred in two patients with 027 and two patients with 014/020 (P=0.6). Leukocytosis and fever were more prominent with 027 than with 014/020 and 106/174 (P=0.04 for both parameters), although the degree of nausea/vomiting did not differ between the three groups (P=0.3). A serum creatinine level ≥1.5 times the premorbid level was seen in only three patients, each infected with a different ribotype. CONCLUSION Although these data provide a baseline assessment of outcomes to aid in the design of future studies, the diversity of C. difficile ribotypes within the population must be considered, and additional work with other ribotypes may further explain the association with these outcomes.
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Affiliation(s)
- Abrar K Thabit
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA; Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA; Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
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Rao K, Santhosh K, Mogle JA, Higgins PDR, Young VB. Elevated fecal calprotectin associates with adverse outcomes from Clostridium difficile infection in older adults. Infect Dis (Lond) 2016; 48:663-9. [PMID: 27206404 DOI: 10.1080/23744235.2016.1186832] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) causes a mild to moderate colitis in most patients, but some, especially older adults, develop severe, adverse outcomes. Biomarkers predicting outcomes are needed to optimize treatments. This study tested whether fecal calprotectin associated with a composite primary outcome of complicated CDI (intensive care unit admission, colectomy, or death due to CDI within 30 days of diagnosis) and/or 8-week recurrence. METHODS Stool was collected in Cary-Blair media at the time of diagnosis from inpatients of age >60 years that tested positive for C. difficile (enzyme immunoassay [EIA] for toxin A/B or polymerase chain reaction for the tcdB gene). Fecal calprotectin was measured and normalized to solid stool weight. Analysis was performed using logistic regression. Variables were selected for the final model using likelihood ratio tests. RESULTS Fifty patients were included with a mean age 72.8 (± 7.5), and 13 (26%) developed the primary outcome. Clinical variables such as age, gender, and comorbid disease did not associate with complicated CDI/recurrence, nor did traditional biomarkers such as serum albumin or white blood cell count. A high normalized fecal calprotectin (>2000 μg/g) associated with the primary outcome in the final model after adjustment for gender and detectable fecal toxin(s) by EIA (OR 24.9, 95% CI 2.4-257.9, p = 0.007) with a specificity of 91.9%. CONCLUSION This study provides evidence that fecal calprotectin level associates with complications from CDI in older adults. Further studies are required to validate these findings in larger cohorts and incorporate them into clinical prediction algorithms.
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Affiliation(s)
- Krishna Rao
- a Divisions of Infectious Diseases , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,c Division of Infectious Diseases , Veterans Affairs Ann Arbor Healthcare System , Ann Arbor , MI , USA
| | - Kavitha Santhosh
- a Divisions of Infectious Diseases , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA
| | - Jill A Mogle
- a Divisions of Infectious Diseases , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA
| | - Peter D R Higgins
- b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,d Department of Gastroenterology , University of Michigan School of Medicine , Ann Arbor , MI , USA
| | - Vincent B Young
- a Divisions of Infectious Diseases , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,b Department of Internal Medicine , University of Michigan School of Medicine , Ann Arbor , MI , USA ;,e Department of Microbiology and Immunology , University of Michigan School of Medicine , Ann Arbor , MI , USA
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Seekatz AM, Rao K, Santhosh K, Young VB. Dynamics of the fecal microbiome in patients with recurrent and nonrecurrent Clostridium difficile infection. Genome Med 2016; 8:47. [PMID: 27121861 PMCID: PMC4847246 DOI: 10.1186/s13073-016-0298-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/08/2016] [Indexed: 02/07/2023] Open
Abstract
Background Recurrent Clostridium difficile infection (CDI) remains problematic, with up to 30 % of individuals diagnosed with primary CDI experiencing at least one episode of recurrence. The success of microbial-based therapeutics, such as fecal microbiota transplantation, for the treatment of recurrent CDI underscores the importance of restoring the microbiota. However, few studies have looked at the microbial factors that contribute to the development of recurrent disease. Here we compare microbial changes over time in patients with or without recurrence to identify microbial signatures associated with the development of recurrence. Methods We used 16S rRNA-encoding gene sequence analysis to compare the fecal microbiota of 93 patients with recurrent and nonrecurrent CDI, sampled longitudinally. Cross-group and intra-individual differences in microbial community diversity and similarity were compared prior to the development of recurrent disease and over time. Results Samples from these patient groups exhibited variable community profiles, clustering into four distinct community groups. Cross-group comparison of the index sample collected from patients that did or did not develop recurrence revealed differences in diversity and community structure (analysis of molecular variance, p < 0.05). Intra-individual comparisons of the microbiota were more informative and samples from recurrent patients were less likely to recover in diversity (Chi-square test, p < 0.005), exhibiting less community similarity overall (Kruskal–Wallis test, p < 0.05). Interestingly, patients with severe disease harbored a significantly less diverse community, a trend that was observed across both nonrecurrent and recurrent patient groups (Wilcoxon test, p < 0.05). Conclusions To date, this study represents one of the largest studies focused on the relationship between predictive signals from the gut microbiota and the development of recurrent CDI. Our data demonstrate that specific microbiota-derived characteristics associate with disease severity and recurrence and that future studies could incorporate these characteristics into predictive models. Electronic supplementary material The online version of this article (doi:10.1186/s13073-016-0298-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Maria Seekatz
- Department of Internal Medicine/Division of Infectious Disease, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Krishna Rao
- Department of Internal Medicine/Division of Infectious Disease, University of Michigan Medical School, Ann Arbor, MI, USA.,Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, MI, USA
| | - Kavitha Santhosh
- Department of Internal Medicine/Division of Infectious Disease, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vincent Bensan Young
- Department of Internal Medicine/Division of Infectious Disease, University of Michigan Medical School, Ann Arbor, MI, USA. .,Department of Microbiology & Immunology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA.
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In the Endemic Setting, Clostridium difficile Ribotype 027 Is Virulent But Not Hypervirulent. Infect Control Hosp Epidemiol 2015; 36:1318-23. [PMID: 26288985 DOI: 10.1017/ice.2015.187] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Conflicting reports have been published on the association between Clostridium difficile ribotypes and severe disease outcomes in patients with C. difficile infection (CDI); several so-called hypervirulent ribotypes have been described. We performed a multicenter study to assess severe disease presentation and severe outcomes among CDI patients infected with different ribotypes. METHODS Stool samples that tested positive for C. difficile toxin were collected and cultured from patients who presented to any of 7 different hospitals in Houston, Texas (2011-2013). C. difficile was characterized using a fluorescent PCR ribotyping method. Medical records were reviewed to determine clinical characteristics and ribotype association with severe CDI presentation (ie, leukocytosis and/or hypoalbuminemia) and severe CDI outcomes (ie, ICU admission, ileus, toxic megacolon, colectomy, and/or in-hospital death). RESULTS Our study included 715 patients aged 61±18 years (female: 63%; median Charlson comorbidity index: 2.5±2.4; hospital-onset CDI: 45%; severe CDI: 36.7%; severe CDI outcomes: 12.3%). The most common ribotypes were 027, 014-020, FP311, 002, 078-126, and 001. Ribotype 027 was a significant independent predictor of severe disease (adjusted odds ratio [aOR], 2.24; 95% confidence interval [CI], 1.53-3.29; P<.001) and severe CDI outcomes (aOR, 1.71; 95% CI, 1.02-2.85; P=.041) compared with all other ribotypes in aggregate. However, in an analysis using all common ribotypes as individual variables, ribotype 027 was not associated with severe CDI outcomes more often than other ribotypes. CONCLUSION Ribotype 027 showed virulence equal to that of other ribotypes identified in this endemic setting. Clinical severity markers of CDI may be more predictive of severe CDI outcomes than a particular ribotype.
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Rao K, Micic D, Natarajan M, Winters S, Kiel MJ, Walk ST, Santhosh K, Mogle JA, Galecki AT, LeBar W, Higgins PDR, Young VB, Aronoff DM. Clostridium difficile ribotype 027: relationship to age, detectability of toxins A or B in stool with rapid testing, severe infection, and mortality. Clin Infect Dis 2015; 61:233-41. [PMID: 25828993 DOI: 10.1093/cid/civ254] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 02/18/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) can cause severe disease and death, especially in older adults. A better understanding of risk factors for adverse outcomes is needed. This study tests the hypotheses that infection with specific ribotypes and presence of stool toxins independently associate with severity and constructs predictive models of adverse outcomes. METHODS Cases of non-recurrent CDI were prospectively included after positive stool tests for toxins A and/or B by enzyme immunoassay (EIA) or tcdB by polymerase chain reaction. Outcomes included severe CDI (intensive care unit admission, colectomy, or death attributable to CDI within 30 days of diagnosis) and 30-day all-cause mortality. Adjusted models were developed to test hypotheses and predict outcomes. RESULTS In total, 1144 cases were included. The toxin EIA was positive in 37.2% and 35.6% of patients were of age >65 years. One of the 137 unique ribotypes was ribotype 027 (16.2%). Detectable stool toxin did not associate with outcomes. Adjusting for covariates, including age, Ribotype 027 was a significant predictor of severe CDI (90 cases; odds ratio [OR], 1.73; 95% confidence interval [CI], 1.03-2.89; P = .037) and mortality (89 cases; OR, 2.02; 95% CI, 1.19-3.43; P = .009). Concurrent antibiotic use associated with both outcomes. Both multivariable predictive models had excellent performance (area under the curve >0.8). CONCLUSIONS Detection of stool toxin A and/or B by EIA does not predict severe CDI or mortality. Infection with ribotype 027 independently predicts severe CDI and mortality. Use of concurrent antibiotics is a potentially modifiable risk factor for severe CDI.
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Affiliation(s)
- Krishna Rao
- Division of Infectious Diseases Department of Internal Medicine Division of Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, Michigan
| | - Dejan Micic
- Department of Internal Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Illinois
| | | | | | | | - Seth T Walk
- Department of Microbiology and Immunology, Montana State University, Bozeman
| | | | - Jill A Mogle
- Division of Infectious Diseases Department of Internal Medicine
| | - Andrzej T Galecki
- Division of Geriatric Medicine Department of Biostatistics, University of Michigan School of Medicine, Ann Arbor
| | | | | | - Vincent B Young
- Division of Infectious Diseases Department of Internal Medicine Department of Microbiology and Immunology
| | - David M Aronoff
- Division of Infectious Diseases Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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