Clostridium difficile in relation to enteric bacterial pathogens

The high prevalence of Clostridioides difficile among nursing home elders associates with a dysbiotic microbiome

Clostridioides difficile disproportionally affects the elderly living in nursing homes (NHs). Our objective was to explore the prevalence of C. difficile in NH elders, over time and to determine whether the microbiome or other clinical factors are associated with C. difficile colonization.We collected serial stool samples from NH residents. C. difficile prevalence was determined by quantitative polymerase-chain reaction detection of Toxin genes tcdA and tcdB; microbiome composition was determined by shotgun metagenomic sequencing. We used mixed-effect random forest modeling machine to determine bacterial taxa whose abundance is associated with C. difficile prevalence while controlling for clinical covariates including demographics, medications, and past medical history.We enrolled 167 NH elders who contributed 506 stool samples. Of the 123 elders providing multiple samples, 30 (24.4%) elders yielded multiple samples in which C. difficile was detected and 78 (46.7%) had at least one C. difficile positive sample. Elders with C. difficile positive samples were characterized by increased abundances of pathogenic or inflammatory-associated bacterial taxa and by lower abundances of taxa with anti-inflammatory or symbiotic properties. Proton pump inhibitor (PPI) use is associated with lower prevalence of C. difficile (Odds Ratio 0.46; 95%CI, 0.22-0.99) and the abundance of bacterial species with known beneficial effects was higher in PPI users and markedly lower in elders with high C. difficile prevalence.C. difficile is prevalent among NH elders and a dysbiotic gut microbiome associates with C. difficile colonization status. Manipulating the gut microbiome may prove to be a key strategy in the reduction of C. difficile in the NH.

Mixed Viral-Bacterial Infections and Their Effects on Gut Microbiota and Clinical Illnesses in Children

Acute gastroenteritis remains a major cause of morbidity and mortality among young children worldwide. It accounts for approximately 1.34 million deaths annually in children younger than five years. Infection can be caused by viral, bacterial and/or parasitic microorganisms. Dysbiosis due to such infections could dramatically affect disease prognosis as well as development of chronic illness. The aim of this study was to analyze gut microbiome and clinical outcomes in young children suffering from viral or mixed viral-bacterial infection. We evaluated gut microbiota composition in children suffering from viral or mixed viral-bacterial infection with two major viruses rotavirus (RV) and norovirus (NoV) and two pathogenic bacteria [Enteroaggregative E. coli (EAEC), and Enteropathogenic E. coli (EPEC)]. We sequenced 16S ribosomal RNA (V4 region) genes using Illumina MiSeq in 70 hospitalized children suffering from gastroenteric infections plus nine healthy controls. The study summarized Operational Taxonomic Unit (OTU) abundances with the Bray-Curtis index and performed a non-metric multidimensional scaling analysis to visualize microbiome similarities. We used a permutational multivariate analyses of variance to test the significance of group differences. We also analyzed the correlation between microbiome changes and clinical outcomes. Our data demonstrated a significant increase in the severity score in children with viral-bacterial mixed infections compared to those with virus infections alone. Statistical analysis by overall relative abundance denoted lesser proportions of Bacteroides in the infected children, whereas Bifidobacteriaceae richness was more prominent in the bacterial-viral mixed infections. Pairwise differences of gut microbiota were significantly higher in RV + EAEC (P = 0.009) and NoV + EAEC (P = 0.009) co-infections, compared to EPEC mixed infection with both, RV (P = 0.045) and NoV (P = 0.188). Shannon diversity index showed considerable more variation in microbiome diversity in children infected with RV cohort compared to NoV cohort. Our results highlight that richness of Bifidobacteriaceae, which acts as probiotics, increased with the severity of the viral-bacterial mixed infections. As expected, significant reduction of relative numbers of Bacteroides was characterized in both RV and NoV infections, with more reduction observed in co-infection pathogenic E. coli. Although mixed infection with EAEC resulted in significant microbiota differences compared to viral infection only or mixed infection with EPEC, the clinical condition of the children were worsened with both pathogenic E.coli co-infections. Further, in comparison with RV cohort, augmented number of differential abundant pathogenic OTUs were peculiarly noticed only with NoV mixed infection.

Clostridium difficile infection: a comprehensive review

Clostridium difficile is one of the most important causes of healthcare acquired diarrhea. The disease spectrum caused by C. difficile infection ranges from mild, self-limited, illness to a severe, life-threatening colitis. The incidence of C. difficile associated disease has risen dramatically over the last decade, leading to increased research interest aiming at the discovery of new virulence factors and the development of new treatment and prevention regimens. This review summarizes the pathogenesis and changing epidemiology of C. difficile associated disease, the clinical spectrum and laboratory methods to diagnose C. difficile infection, and current treatment strategies.

Clostridium difficile ribotype 027-associated disease in children with norovirus infection

Two previously healthy children developed Clostridium difficile ribotype 027-associated disease concomitantly with norovirus infection. Viral gastroenteritis may contribute to epithelial homeostasis of the intestine and exacerbate the effects of toxins produced by C. difficile ribotype 027.

Evaluation of C. diff.-CUBE test for detection of Clostridium difficile-associated diarrhea

The toxin B assay was used to evaluate C. diff.-CUBE, a new dot-immunobinding assay (DIA) for the laboratory diagnosis of Clostridium difficile-associated diarrhea. The widely used latex agglutination test was also included for comparison. Stools from 100 patients suspected of having C. difficile-associated diarrhea were tested. The toxin B assay, latex agglutination, and DIA tests were positive for 12%, 9%, and 22% of the specimens, respectively. The sensitivity, specificity, and positive and negative predictive values of the DIA test were 67%, 84%, 36%, and 95%, respectively, compared with the toxin B assay. The specificity (98%) and positive predictive value (78%) for the latex agglutination test were significantly higher than those of the DIA test. Of 13 specimens solely positive by the DIA test, 11 were cultured and none were positive. Clinical assessment supported only two of the 13 positive DIA results. When clinical assessment was included in the analysis, the DIA positive predictive value rose to 45%. Although the sensitivity and negative predictive values of the DIA test are comparable to the latex agglutination test, the low specificity and positive predictive values of the DIA test make it an inappropriate method to use for screening in a population with a low prevalence of true positives.

Diarrheal disease due to Clostridium difficile in general practice

A total of 288 stool samples from patients attending their general practitioners was examined for the presence of Clostridium difficile. C. difficile or its cytotoxin was found in 16 patients (5.5%) and was the most common enteric pathogen detected. Most patients had only mild to moderate diarrhea but in the majority of patients the diarrhea was protracted. Eleven of the 16 patients had received antimicrobial agents in the 3 mths preceding onset of diarrhea and there was good circumstantial evidence that 2 other patients had also been exposed. None of the patients had a history of any inflammatory bowel disease or possible occupational exposure. The prescribing habits of general practitioners with regard to antimicrobial agents were monitored for a 1 yr period. Tetracyclines and amoxycillin accounted for approximately 25% each of all prescriptions dispensed. Ten of the 16 patients were treated with antimicrobials (mainly metronidazole) and in most cases the diarrhea resolved. We conclude that C. difficile may be a significant cause of community-acquired diarrhea.

Cytotoxic effects of children's faeces: relation to diarrhoea due to Clostridium difficile and other enteric pathogens

Cytotoxicity of faecal extracts was demonstrated in 47 of 88 children (54%) referred for microbiological investigation of stools. Cytotoxic Clostridium difficile and vertotoxigenic Escherichia coli (VTEC) were the pathogens identified most commonly but cytotoxicity was also found in association with Campylobacter jejuni, Salmonella spp, Shigella sonnei, Giardia lamblia, rotavirus, adenovirus and poliovirus type 1 which had been acquired by oral immunization. In two patients, one of whom had cystic fibrosis, cytotoxicity of faecal extracts was associated with isolation of Pseudomonas aeruginosa. In five of 13 patients with diarrhoea and cytotoxic C. difficile, other pathogens were also present, in agreement with the view that C. difficile are more readily recovered when the intestinal flora have been altered by colonization with other micro-organisms. There was no correlation between previous treatment with antibiotics and isolation of C. difficile. Cytotoxicity neutralized by antitoxin, usually to C. sordellii, is used to detect cytotoxic C. difficile. We suggest that cytotoxicity not neutralized in this way should be an indication for further investigation of stools for the presence of other pathogens such as VTEC or viruses.

Enterotoxins from Clostridium difficile; diarrhoeogenic potency and morphological effects in the rat intestine

The action of toxins A, B, and C from Clostridium difficile was studied in the small intestine and colon of rats. All three caused fluid accumulation in the small intestine, maximal secretion being induced by 1 micrograms of toxin A, 20 micrograms of B, and 15 micrograms of C. Both toxins A and C caused shedding of epithelial cells from the villi without visible damage to crypt cells; toxin A caused further extensive necrosis and bleeding. Toxin B caused secretion without visible damage to the epithelial cells, though this activity was unstable and decreased significantly after one week of storage. In the colon, toxin A caused secretion and shedding of surface epithelial cells without damage to crypt cells, toxin C caused only a weak secretion, and toxin B had no effect at all. In terms of immunohistochemistry, it was found that toxin A bound to the enterocytes at the tips of the villi but not to goblet and crypt cells. The complex expression or interaction of the toxins produced by Cl difficile may explain the broad spectrum of disease (diarrhoea, colitis, and pseudomembranous colitis) associated with this micro-organism.

[Occurrence of Clostridium difficile in the feces of children of Rio de Janeiro, RJ, Brazil]

A ocorrência de Clostridium difficile foi analisada em amostras de fezes de 175 crianças com idade variando de 1 a 35 meses. Para o isolamento primário do microrganismo foi empregado o meio de cultura seletivo diferencial "CCFA" (cicloserina-cefoxitina-frutose-agar). Num grupo de 67 crianças sem distúrbios gastrintestinais e que não estavam sob uso de agentes antimicrobianos a ocorrência do C. difficile foi de 22,4%, enquanto que num outro grupo de 28 crianças nas mesmas condições, porém, sob tratamento com antimicrobianos a ocorrência do microrganismo foi de 50%. Num terceiro grupo de 58 crianças com diarréia e sob antibiótico-terapia a ocorrência de C. difficile atingiu 13,8%. Este mesmo percentual foi encontrado num quarto grupo de 22 crianças com diarréia, porém, sem tratamento com agentes antimicrobianos. De um modo geral, os maiores índices de ocorrência de C. difficile foram encontrados em crianças com idade variando entre 1 a 12 meses (28,1%). Índices inferiores foram verificados entre crianças com idade superior a 1 ano. Outrossim, os resultados evidenciam que crianças com distúrbios gastrintestinais apresentam menor incidência deste microrganismo nas fezes. Por outro lado. não houve diferença estatísticamente significativa entre os grupos de crianças com e sem terapia antimicrobiana.

Laboratory diagnosis of Clostridium difficile-associated diarrhoea

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

Pediatric gastroenteritis in primary care and in hospitalized patients

One-hundred and fifty-seven consecutive children below seven years of age (primary care n = 48, hospitalized patients n = 109) with acute gastroenteritis of assumed infectious origin were studied. Rotavirus was demonstrated by electron microscopy of faeces in 44% of all patients. The occurrence of rotavirus among patients in primary care, 15%, was significantly lower than among hospitalized patients, 57% (p less than 0.01). Adenovirus was isolated in six per cent and enterovirus in two per cent of the patients with no differences between the two groups. Yersinia enterocolitica and Campylobacter jejuni were demonstrated in each three per cent. Salmonella and Shigella spp. or Giardia lamblia were not found in any cases. Thus the cause of gastroenteritis was established in 58% of the patients. This figure was lower among patients in primary care (27%) than among hospitalized patients (72%), a difference mainly due to the high occurrence of rotavirus in the latter group. Clostridium difficile was recovered in 20 cases (12%), eight of which harboured one more enteropathogenic agent. Cultures from the nose and throat revealed Streptococcus pneumoniae, Haemophilus influenzae, Branhamella catarrhalis or group A, C and G streptococci in 58% of the patients with no differences regarding the occurrence of rotavirus in faeces. Neither Clostridium difficile nor respiratory tract pathogens were found to play a role in causation of gastroenteritis in the children investigated.

Cell surface binding site for Clostridium difficile enterotoxin: evidence for a glycoconjugate containing the sequence Gal alpha 1-3Gal beta 1-4GlcNAc

This study was undertaken to determine whether a binding site for Clostridium difficile enterotoxin (toxin A) exists in the brush border membranes (BBMs) of the hamster, an animal known to be extremely sensitive to the action of the toxin. Toxin A was the only antigen adsorbed by the BBMs from the culture filtrate of C. difficile. The finding that binding activity could not be destroyed by heat indicated that a carbohydrate moiety might be involved. We therefore examined erythrocytes from various animal species for binding activity since erythrocytes provide a variety of carbohydrate sequences on their cell surfaces. Only rabbit erythrocytes bound the toxin, and the cells agglutinated. A binding assay based on an enzyme-linked immunosorbent assay method for quantifying C. difficile toxin A was used to compare binding of the toxin to hamster BBMs, rabbit erythrocytes, and BBMs from rats, which are less susceptible to the action of C. difficile toxin A than hamsters. Results of this comparison indicated the following order of toxin-binding frequency: rabbit erythrocytes greater than hamster BBMs greater than rat BBMs. Binding of toxin A to hamster BBMs at 37 degrees C was comparable to what has been observed with cholera toxin, but binding was enhanced at 4 degrees C. A similar binding phenomenon was observed with rabbit erythrocytes. Examination of the cell surfaces of hamster BBMs and rabbit erythrocytes with lectins and specific glycosidases revealed a high concentration of terminal alpha-linked galactose. Treatment of both membrane types with alpha-galactosidase destroyed the binding activity. The glycoprotein, calf thyroglobulin, also bound the toxin and inhibited toxin binding to cells. Toxin A did not bind to human erythrocytes from blood group A, B, or O donors. However, after fucosidase treatment of human erythrocytes, only blood group B erythrocytes, which possess the blood group B structure Gal alpha 1-3[Fuc alpha 1-2]Gal beta 1-4GlcNAc-R, bound the toxin. This indicated that toxin A was likely binding to Gal alpha 1-3Gal beta 1-4GlcNAc, a carbohydrate sequence also found on calf thyroglobulin and rabbit erythrocytes. All of the results indicate that hamster BBMs contain a carbohydrate-binding site for toxin A that has at least a Gal alpha 1-3Gal beta 1-4GlcNAc nonreducing terminal sequence.

Clostridium difficile in general practice and community health

The isolation rate for Clostridium difficile in diarrhoeal stools was investigated in patients from general practice and community health centres over a 14-month period. C. difficile or its cytotoxin was detected in specimens from 89 (4.7%) of 1882 patients studied and accounted for 30.3% of all enteropathogenic micro-organisms isolated. Overall C. difficile was second only to Giardia lamblia in frequency. Recovery rates in the different groups of patients surveyed varied from 3.6 to 27.5%. The relationship between stool culture results and stool cytotoxin assay also varied considerably between groups of patients studied. Coincident infections with a variety of enteropathogenic bacteria and intestinal parasites were diagnosed in 14 of the 89 patients. It was concluded that laboratories servicing this type of practice should be aware that C. difficile may be a cause of diarrhoea. An adequate clinical history should facilitate proper processing of the specimen.

Diagnosis of Clostridium difficile-associated intestinal disease

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

Routine culturing for Clostridium difficile?

In order to determine whether routine culturing for Clostridium difficile was warranted or whether culturing a selected group of patients was adequate, we conducted a prospective trial of culturing all stool specimens for C. difficile. A total of 408 specimens from 297 patients was studied. Two hundred and eighteen stool specimens from 169 patients were selected on the basis of fulfilling one or more of the following criteria; (i) the stools were loose or watery; (ii) leukocytes and/or red cells were seen on direct microscopic examination; (iii) there was a history of antibiotic therapy; (iv) there was a diagnosis or history of inflammatory bowel disease. Fifty-three stools from 33 (19.5%) of these patients either yielded C. difficile by culture or had C. difficile cytotoxin demonstrable in fecal extracts. C. difficile was cultured in only one of 190 stools from the remaining 128 patients. Hence routine culturing of all stool specimens does not appear warranted provided that an accurate clinical history can be obtained and a careful macroscopic and microscopic examination is carried out.

Clostridium difficile-associated diarrhoea

During the course of 1 year, Clostridium difficile was isolated from 145 (4 per cent) of 3591 faecal specimens submitted to a hospital routine bacteriology laboratory. These C. difficile positive specimens came from 95 patients or 10.99 per cent of 864 patients investigated for suspected gastroenteritis. In a control population of 318 persons C. difficile was isolated from only 10 of them or 3.1 per cent; this difference was statistically significant. We conclude that as this increase in the isolation of C. difficile from patients with diarrhoea is significant and is about as frequent as that of Campylobacter spp., faecal specimens submitted for routine bacteriology should also be cultured for C. difficile . As with diarrhoea caused by other enteric pathogens, most C. difficile -associated episodes of diarrhoea are mild and spontaneously reversible but approximately 20 per cent of patients have prolonged diarrhoea and may benefit from treatment.

Toxin A of Clostridium difficile: production, purification and effect in mouse intestine

Clostridium difficile produces one diarrhoeogenic toxin designed A, and one cytopathogenic toxin designed B. Toxin A was purified in a four-step-fractionation procedure. In the last purification step the toxin was separated by elution with galactose from an agarose gel. The purified toxin A induced a clear and watery hypersecretion in intestinal loops of mouse, while mixtures of toxin A and B induced a haemorrhagic secretion. At an ED50 value for the purified toxin A of 0.5 microgram there was a brief, optimal hypersecretion after four hours. Like the fluid secretion induced by cholera toxin, that induced by toxin A could be inhibited by chlorpromazine or by depletion of intestinal bile. In contrast to cholera toxin, however, toxin A did not activate intestinal adenylate cyclase--at least not permanently. Antisera which neutralized cholera toxin did not neutralize toxin A, and vice versa.

Intestinal colonization of infant hamsters with Clostridium difficile

Infant hamsters of different ages were examined for their susceptibility to enteric Clostridium difficile colonization. Intragastric administration of C. difficile to infant hamsters resulted in multiplication of the organism in the intestinal tracts of animals 4 to 12 days old; hamsters younger or older were resistant to C. difficile intestinal colonization. Toxicity to the colonized animals could not be demonstrated despite cytotoxin titers in some infant hamsters comparable to titers found in the intestinal tracts of adult hamsters with C. difficile-associated intestinal disease. When introduced into 4-day-old hamsters, C. difficile colonized the intestinal tract and remained at high levels until the animals were 13 days old, at which time the presence of intestinal C. difficile could no longer be demonstrated. The number of C. difficile required to colonize the intestinal tracts of 50% of 7-day-old hamsters was 18 viable cells. On the other hand, 10(8) viable cells of C. difficile failed to colonize the intestinal tracts of healthy, non-antibiotic-treated adult hamsters.

Clostridium difficile toxin associated with chronic diarrhea and failure to gain weight

Two young children are described in whom chronic diarrhea associated with the presence of Clostridium difficile toxin responded to treatment with oral vancomycin. C. difficile infection should be considered in the evaluation of young children with diarrhea who fail to gain weight, even in the absence of prior antibiotic treatment.

Diarrhoea associated with Clostridium difficile in a hospital population

The incidence of disease associated with Clostridium difficile was investigated in a general hospital population over a period of six months. In 26 (14.5%) of 179 patients studied, C. difficile was either isolated or faecal cytotoxin was detected. The incidence of other enteropathogenic bacteria, except Aeromonas hydrophila, was low. Faecal cytotoxin was not detected in nine patients (35%), and non-cytotoxigenic strains of C. difficile were isolated from these patients. In seven patients, a selective broth was required to isolate C. difficile, suggesting their presence in low numbers. Although some C. difficile diarrhoeal disease which was not associated with antibiotic therapy was recorded, prior exposure to antibiotic agents still appears to be the major predisposing factor in this population. Faecal cytotoxin detection, sigmoidoscopy, and rectal biopsy were not reliable investigations for disease associated with C. difficile; hence, we advocate increased emphasis on isolation of the causative organism. Routine culturing for C. difficile in a hospital population appears to be warranted.

Isolation of Clostridium difficile from hospitalized patients without antibiotic-associated diarrhea or colitis

Stool samples from 100 hospitalized patients and 21 healthy adults, obtained between March and June 1980, were cultured on a special selective medium containing cefoxitin and cycloserine to detect Clostridium difficile. This organism was isolated from 13 of the hospitalized patients and from 1 healthy subject. None of the patients with positive cultures had received antimicrobial therapy in the 3 preceding months. The observed rate of C. difficile isolation from adults not suffering from antibiotic-associated diarrhea or colitis is higher than previously reported. C. difficile culture is not recommended as a substitute for toxin assay in the evaluation of patients with intestinal disorders after antimicrobial chemotherapy.

Clostridium difficile and cytotoxin in routine faecal specimens

Over a five-month period 1239 unselected, routine faecal specimens from 856 patients were examined for Clostridium difficile. One hundred specimens representing 69 patients were culture-positive. Toxin was detected in the stool of ten. During the study period, there were 41 Salmonella, 12 Campylobacter and 9 Shigella infections. C difficile was isolated together with Salmonella from 12 patients. No patient required specific treatment for C difficile infection. The significance of these findings is discussed.

Intestinal occurrence of Campylobacter fetus subspecies jejuni and Clostridium difficile in children in Sweden

Stool samples were cultured from 356 children in different states of health and in different age groups between birth and six years of age in order to investigate the occurrence of Campylobacter jejuni and Clostridium difficile. Campylobacter jejuni was isolated from two of 56 children with diarrhoea but was not isolated from any of 300 healthy children or children recently treated with antibiotics. Campylobacter jejuni does not seem to be a common cause of diarrhoea in children in Sweden and is definitely not a member of the normal fecal flora. Clostridium difficile was isolated from 17 of 100 healthy children one week to one year old, and from one of 100 perinatal children. About the same isolation frequency was found in children with diarrhoea and in children recently treated with antibiotics. A total of 34 isolates of Clostridium difficile were obtained, 29 of which were from children less than one year old. The isolation of Clostridium difficile in stools of children should in most cases be considered a normal finding.

Clostridium difficile in association with sporadic diarrhoea

A total of 154 patients admitted to an infectious diseases unit were included in a year's prospective survey of sporadic diarrhoeal disease. Stools from 19 of them yielded Clostridium difficile, generally on more than one occasion. Twelve of these patients were assessed as having a severe or moderately severe gastrointestinal illness: Cl difficile was the only pathogen isolated from 10 of them, and two had an associated salmonella infection. Seven had had a recent course of antibiotics, but five had not taken antibiotics. Faeces from seven patients with moderate or mild gastrointestinal illness yielded Cl difficile, and two of these patients also had an associated salmonella infection. Two patients in this group had no antibiotic history. From these findings, the occurrence of C difficile in faeces could not be described as antibiotic-associated. Faecal Cl difficile cytotoxin was detected in only six patients, and generally at low levels. In such patients a more relevant pathogenic index might take account of the numbers of Cl difficile present and of their toxigenic potential.

Bacillus pumilus in the induction of clindamycin-associated enterocolitis in guinea pigs

Antibiotic-associated enterocolitis was induced in guinea pigs by the intraperitoneal injection of clindamycin. The colonic and cecal mucosa and feces of acutely ill animals were cultured under aerobic and anaerobic conditions on 5% sheep blood agar plates and on a selective and differential medium for Clostridium difficile. All morphologically distinct colony types were isolated in pure culture and identified. A sterile cell-free filtrate of each isolate was tested for ability to induce morphological changes in cultured monolayers of mouse adrenal cells. The filtrate of a predominant isolate, Bacillus pumilus, induced an alteration of cellular morphology; the sterile filtrate of other isolates were unreactive. Toxin contained in cell-free filtrates of B. pumilus caused a syndrome identical to clindamycin-associated enterocolitis when injected intracecally into guinea pigs. The toxin had a molecular weight of 6,500 daltons as determined by molecular sieve chromatography and was inactivated with pronase, lipase, and trypsin. The minimal inhibitory concentrations of clindamycin and vancomycin for B. pumilus were 50 micrograms/ml and less than or equal to 0.4 micrograms/ml, respectively.

Occurrence of toxin-producing Clostridium difficile in antibiotic-associated diarrhea in Sweden

From 1324 patients with antibiotic-associated diarrhea (AAD) 1643 stool samples were analyzed by a cell test for Clostridium difficile toxin in stool filtrates and cultivation for occurrence of C. difficile strains. In patients with no detectable toxin in their stool strains of C. difficile were isolated in 2.2% whereas when toxin was detectable, the isolation rate varied from 17% to 36%. Furthermore, there was a correlation between toxin titre in stool filtrate and production of cytotoxin in vitro by the corresponding C. difficile strains. Five clostridial strains, not belonging to the species C. difficile, were found to produce typical cytotoxin in vitro. However, five strains identified as C. difficile by biochemical reactions and gas liquid chromatography, did not produce an extracellular cytotoxin. The antibiotic susceptibility patterns of the Clostridium strains were investigated. No correlation was recognized between antibiotic resistance of isolated Clostridium strains and the AAD-inducing antibiotic penicillins and linco/clindamycin. Neither did cases of relapse of diarrheal disease after vancomycin treatment harbour C. difficile strains with increased resistance to vancomycin. It is concluded that the pathogenesis of antibiotic-associated enterocolitis is more complex than a mere intestinal overgrowth of resistant strains of C. difficile.