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Mani J, Levy S, Angelova A, Hazrati S, Fassnacht R, Subramanian P, Richards T, Niederhuber JE, Maxwell GL, Hourigan SK. Epidemiological and microbiome associations of Clostridioides difficile carriage in infancy and early childhood. Gut Microbes 2023; 15:2203969. [PMID: 37096914 PMCID: PMC10132246 DOI: 10.1080/19490976.2023.2203969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/12/2023] [Indexed: 04/26/2023] Open
Abstract
There has been an increase in the prevalence of Clostridioides difficile (C. diff) causing significant economic impact on the health care system. Although toxigenic C. diff carriage is recognized in infancy, there is limited data regarding its longitudinal trends, associated epidemiolocal risk factors and intestinal microbiome characteristics. The objectives of our longitudinal cohort study were to investigate temporal changes in the prevalence of toxigenic C.diff colonization in children up to 2 years, associated epidemiological and intestinal microbiome characteristics. Pregnant mothers were enrolled prenatally, and serial stool samples were collected from their children for 2 years. 2608 serial stool samples were collected from 817 children. 411/817 (50%) were males, and 738/817 (90%) were born full term. Toxigenic C.diff was detected in 7/569 (1%) of meconium samples, 116/624 (19%) of 2 m (month), 221/606 (37%) of 6 m, 227/574 (40%) of 12 m and 18/235 (8%) of 24 m samples. Infants receiving any breast milk at 6 m were less likely to be carriers at 2 m, 6 m and 12 m than those not receiving it. (p = 0.002 at 2 m, p < 0.0001 at 6 m, p = 0.022 at 12 m). There were no robust differences in the underlying alpha or beta diversity between those with and without toxigenic C. diff carriage at any timepoint, although small differences in the relative abundance of certain taxa were found. In this largest longitudinal cohort study to date, a high prevalence of toxigenic C. diff carrier state was noted. Toxigenic C. diff carrier state in children is most likely a transient component of the dynamic infant microbiome.
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Affiliation(s)
- Jyoti Mani
- Department of Pediatrics, Children’s National Medical Center, Washington, DC, USA
| | - Shira Levy
- National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD, USA
| | - Angelina Angelova
- National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD, USA
| | - Sahel Hazrati
- Women’s Service Line, Inova Health System, Falls Church, VA, USA
| | - Ryan Fassnacht
- Inova Children’s Hospital, Inova Health System, Falls Church, VA, USA
| | - Poorani Subramanian
- National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD, USA
- Inova Children’s Hospital, Inova Health System, Falls Church, VA, USA
| | - Tiana Richards
- Inova Children’s Hospital, Inova Health System, Falls Church, VA, USA
| | - John E. Niederhuber
- Inova Children’s Hospital, Inova Health System, Falls Church, VA, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Suchitra K. Hourigan
- National Institute of Allergy and Infectious Diseases, National Institute of Health, Bethesda, MD, USA
- Inova Children’s Hospital, Inova Health System, Falls Church, VA, USA
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2
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Vasilescu IM, Chifiriuc MC, Pircalabioru GG, Filip R, Bolocan A, Lazăr V, Diţu LM, Bleotu C. Gut Dysbiosis and Clostridioides difficile Infection in Neonates and Adults. Front Microbiol 2022; 12:651081. [PMID: 35126320 PMCID: PMC8810811 DOI: 10.3389/fmicb.2021.651081] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 12/15/2021] [Indexed: 12/11/2022] Open
Abstract
In this review, we focus on gut microbiota profiles in infants and adults colonized (CDC) or infected (CDI) with Clostridioides difficile. After a short update on CDI epidemiology and pathology, we present the gut dysbiosis profiles associated with CDI in adults and infants, as well as the role of dysbiosis in C. difficile spores germination and multiplication. Both molecular and culturomic studies agree on a significant decrease of gut microbiota diversity and resilience in CDI, depletion of Firmicutes, Bacteroidetes, and Actinobacteria phyla and a high abundance of Proteobacteria, associated with low butyrogenic and high lactic acid-bacteria levels. In symptomatic cases, microbiota deviations are associated with high levels of inflammatory markers, such as calprotectin. In infants, colonization with Bifidobacteria that trigger a local anti-inflammatory response and abundance of Ruminococcus, together with lack of receptors for clostridial toxins and immunological factors (e.g., C. difficile toxins neutralizing antibodies) might explain the lack of clinical symptoms. Gut dysbiosis amelioration through administration of “biotics” or non-toxigenic C. difficile preparations and fecal microbiota transplantation proved to be very useful for the management of CDI.
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Affiliation(s)
- Iulia-Magdalena Vasilescu
- Department of Microbiology, Faculty of Biology, University of Bucharest, Bucharest, Romania
- INBI “Prof. Dr. Matei Balş” – National Institute for Infectious Diseases, Bucharest, Romania
| | - Mariana-Carmen Chifiriuc
- Department of Microbiology, Faculty of Biology, University of Bucharest, Bucharest, Romania
- Research Institute of the University of Bucharest, Bucharest, Romania
- Academy of Romanian Scientists, Bucharest, Romania
- The Romanian Academy, Bucharest, Romania
- *Correspondence: Mariana-Carmen Chifiriuc,
| | | | - Roxana Filip
- Faculty of Medicine and Biological Sciences, Stefan cel Mare University of Suceava, Suceava, Romania
- Regional County Emergency Hospital, Suceava, Romania
| | - Alexandra Bolocan
- Department of General Surgery, University Emergency Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Veronica Lazăr
- Department of Microbiology, Faculty of Biology, University of Bucharest, Bucharest, Romania
| | - Lia-Mara Diţu
- Department of Microbiology, Faculty of Biology, University of Bucharest, Bucharest, Romania
| | - Coralia Bleotu
- Department of Microbiology, Faculty of Biology, University of Bucharest, Bucharest, Romania
- Research Institute of the University of Bucharest, Bucharest, Romania
- Ştefan S. Nicolau Institute of Virology, Romanian Academy, Bucharest, Romania
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3
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Dutta D, Jafri F, Stuhr D, Knoll BM, Lim SH. A contemporary review of Clostridioides difficile infections in patients with haematologic diseases. J Intern Med 2021; 289:293-308. [PMID: 32910532 DOI: 10.1111/joim.13173] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/18/2020] [Indexed: 12/14/2022]
Abstract
Clostridioides (Clostridium) difficile (C. difficile) infection is one of the most common causes of increased morbidity and mortality. Approximately 500 000 C. difficile infections (CDIs) occur each year in the United States, and they result in more than 29 000 deaths. Patients with haematologic diseases are at a higher risk for this infection due to frequent hospitalization and exposure to treatment-associated risk factors. Whilst several currently available antimicrobial agents offer resolution, recurrence of infection remains a major concern. Recent advancement in deciphering C. difficile virulence mechanisms and identification of its allies in contributing to the infection has led to the development of alternative treatment strategies. Here, we will provide a contemporary discussion of how major risk factors in haematologic diseases, such as immunosuppression, chemoradiation, use of antibiotic, proton pump inhibitor and opioid, and deficiency in butyrate and antimicrobial peptides contribute to C. difficile infection. Next, we will highlight different approaches to control and mitigate this infection such as antibiotic stewardship and faecal microbiota transplantation. Finally, we will explore several emerging treatments such as use of pre- and probiotics, immunotherapy and microbiome-sparing agents.
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Affiliation(s)
- D Dutta
- From the, Division of Hematology and Oncology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA.,Division of Hematology and Oncology, New York Medical College, Valhalla, NY, USA
| | - F Jafri
- Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - D Stuhr
- Division of Hematology and Oncology, New York Medical College, Valhalla, NY, USA.,Lake Erie College of Osteopathic Medicine, Bradenton, FL, USA
| | - B M Knoll
- Department of Medicine, New York Medical College, Valhalla, NY, USA.,Division of Infectious Diseases, New York Medical College, Valhalla, NY, USA
| | - S H Lim
- From the, Division of Hematology and Oncology, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA.,Division of Hematology and Oncology, New York Medical College, Valhalla, NY, USA
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4
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Boarini-Ferroni L, Cardozo MV, Casagrande MF, Nascimento KA, Almeida HMDS, Mechler-Dreibi ML, de Oliveira LG, Schocken-Iturrino RP. Experimental inoculation and nose-to-nose transmission of Clostridioides difficile between weaned piglets. Vet Microbiol 2020; 247:108754. [PMID: 32768208 DOI: 10.1016/j.vetmic.2020.108754] [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: 03/03/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/29/2022]
Abstract
In piglets, Clostridioides (C.) difficile infection presents mostly subclinical manifestation. As this agent became important in veterinary medicine due to a hypothesis of zoonosis, the objective of this study was to evaluate the transmission of C. difficile by nose-to-nose contact in young piglets. Six 20-day-old piglets were separated into three groups (infected, sentinel and control), and distributed in different isolation cabinets which allowed nose-to-nose contact only between infected and sentinel groups. The challenged group received an inoculum 106 CFU/mL of C. difficile 096 by oropharyngeal route. Rectal swab samples were daily collected for microbiological and molecular analysis. Euthanasia of all piglets was performed 18 days after challenge to evaluate anatomical, histological and microbiological lesions of the organs of these animals. The challenged and sentinel groups showed clinical signs of infection and genes encoding TcdB were detected by conventional PCR in both groups, confirming the transmission of the pathogen from the challenged to the sentinel piglets. At necropsy, tonsil, liver, spleen, mesenteric lymph nodes, ileocolic lymph nodes, jejunum, ileum, proximal colon, distal colon and cecum were collected for microbiological analysis; lesions were observed varying in degree and intensity. This study demonstrated a novel route of transmission of C. difficile between young piglets, which was proven to occur by nose-to-nose contact.
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Affiliation(s)
- Livia Boarini-Ferroni
- Sao Paulo State University, School of Agricultural and Veterinarian Sciences, Campus Jaboticabal, Brazil
| | - Marita Vedovelli Cardozo
- Sao Paulo State University, School of Agricultural and Veterinarian Sciences, Campus Jaboticabal, Brazil
| | - Mariana Froner Casagrande
- Sao Paulo State University, School of Agricultural and Veterinarian Sciences, Campus Jaboticabal, Brazil
| | - Karla Alvarenga Nascimento
- Sao Paulo State University, School of Agricultural and Veterinarian Sciences, Campus Jaboticabal, Brazil
| | | | | | - Luís Guilherme de Oliveira
- Sao Paulo State University, School of Agricultural and Veterinarian Sciences, Campus Jaboticabal, Brazil.
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5
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Engevik MA, Danhof HA, Chang-Graham AL, Spinler JK, Engevik KA, Herrmann B, Endres BT, Garey KW, Hyser JM, Britton RA, Versalovic J. Human intestinal enteroids as a model of Clostridioides difficile-induced enteritis. Am J Physiol Gastrointest Liver Physiol 2020; 318:G870-G888. [PMID: 32223302 PMCID: PMC7272722 DOI: 10.1152/ajpgi.00045.2020] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Clostridioides difficile is an important nosocomial pathogen that produces toxins to cause life-threatening diarrhea and colitis. Toxins bind to epithelial receptors and promote the collapse of the actin cytoskeleton. C. difficile toxin activity is commonly studied in cancer-derived and immortalized cell lines. However, the biological relevance of these models is limited. Moreover, no model is available for examining C. difficile-induced enteritis, an understudied health problem. We hypothesized that human intestinal enteroids (HIEs) express toxin receptors and provide a new model to dissect C. difficile cytotoxicity in the small intestine. We generated biopsy-derived jejunal HIE and Vero cells, which stably express LifeAct-Ruby, a fluorescent label of F-actin, to monitor actin cytoskeleton rearrangement by live-cell microscopy. Imaging analysis revealed that toxins from pathogenic C. difficile strains elicited cell rounding in a strain-dependent manner, and HIEs were tenfold more sensitive to toxin A (TcdA) than toxin B (TcdB). By quantitative PCR, we paradoxically found that HIEs expressed greater quantities of toxin receptor mRNA and yet exhibited decreased sensitivity to toxins when compared with traditionally used cell lines. We reasoned that these differences may be explained by components, such as mucins, that are present in HIEs cultures, that are absent in immortalized cell lines. Addition of human-derived mucin 2 (MUC2) to Vero cells delayed cell rounding, indicating that mucus serves as a barrier to toxin-receptor binding. This work highlights that investigation of C. difficile infection in that HIEs can provide important insights into the intricate interactions between toxins and the human intestinal epithelium.NEW & NOTEWORTHY In this article, we developed a novel model of Clostridioides difficile-induced enteritis using jejunal-derived human intestinal enteroids (HIEs) transduced with fluorescently tagged F-actin. Using live-imaging, we identified that jejunal HIEs express high levels of TcdA and CDT receptors, are more sensitive to TcdA than TcdB, and secrete mucus, which delays toxin-epithelial interactions. This work also optimizes optically clear C. difficile-conditioned media suitable for live-cell imaging.
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Affiliation(s)
- Melinda A. Engevik
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Heather A. Danhof
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | | | - Jennifer K. Spinler
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Kristen A. Engevik
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - Beatrice Herrmann
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Bradley T. Endres
- 5Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Kevin W. Garey
- 5Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas
| | - Joseph M. Hyser
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
| | - Robert A. Britton
- 3Alkek Center for Metagenomic and Microbiome Research, Baylor College of Medicine, Houston, Texas,4Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | - James Versalovic
- 1Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas,2Department of Pathology, Texas Children’s Hospital, Houston, Texas
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6
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Usui M. One Health approach to Clostridioides difficile in Japan. J Infect Chemother 2020; 26:643-650. [PMID: 32334949 DOI: 10.1016/j.jiac.2020.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/22/2020] [Indexed: 12/19/2022]
Abstract
Clostridioides difficile infections (CDIs) are predominantly a healthcare-associated illness in developed countries, with the majority of cases being elderly and hospitalize patients who used antibiotic therapy. Recently, the incidence of community-associated CDIs (CA-CDIs) in younger patients without a previous history of hospitalization or antibiotic treatment has been increasing globally. C. difficile is sometimes found in the intestine of many animals, such as pigs, calves, and dogs. Food products such as retail meat products and vegetables sometimes contain C. difficile. C. difficile has also been isolated from several environments such as compost manure, rivers, and soils. Yet, direct transmission of C. difficile from animals, food products, and environments to humans has not been proven, although these strains have similar molecular characteristics. Therefore, it has been suggested that there is a relationship between CA-CDIs and C. difficile from animals, food products, and the environment. To clarify the importance of the presence of C. difficile in several sources, characterization of C. difficile in these sources is required. However, the epidemiology of C. difficile in animals, food products, and the environment is not well studied in Japan. This review summarizes recent trends of CDIs and compares the molecular characteristics of C. difficile in Japanese animals, food products, and the environment. The prevalence trends of C. difficile in Japan are similar to those in the rest of the world. Therefore, I recommend using a One Health approach to CDI surveillance, monitoring, and control.
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Affiliation(s)
- Masaru Usui
- Laboratory of Food Microbiology and Food Safety, Department of Health and Environmental Sciences, School of Veterinary Medicine, Rakuno Gakuen University, 582 Midorimachi, Bunkyodai, Ebetsu, Hokkaido, 069-8501, Japan.
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7
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Clostridioides (Clostridium) Difficile in Food-Producing Animals, Horses and Household Pets: A Comprehensive Review. Microorganisms 2019; 7:microorganisms7120667. [PMID: 31835413 PMCID: PMC6955671 DOI: 10.3390/microorganisms7120667] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 02/06/2023] Open
Abstract
Clostridioides (Clostridium) difficile is ubiquitous in the environment and is also considered as a bacterium of great importance in diarrhea-associated disease for humans and different animal species. Food animals and household pets are frequently found positive for toxigenic C. difficile without exposing clinical signs of infection. Humans and animals share common C. difficile ribotypes (RTs) suggesting potential zoonotic transmission. However, the role of animals for the development of human infection due to C. difficile remains unclear. One major public health issue is the existence of asymptomatic animals that carry and shed the bacterium to the environment, and infect individuals or populations, directly or through the food chain. C. difficile ribotype 078 is frequently isolated from food animals and household pets as well as from their environment. Nevertheless, direct evidence for the transmission of this particular ribotype from animals to humans has never been established. This review will summarize the current available data on epidemiology, clinical presentations, risk factors and laboratory diagnosis of C. difficile infection in food animals and household pets, outline potential prevention and control strategies, and also describe the current evidence towards a zoonotic potential of C. difficile infection.
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8
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Andino-Molina M, Barquero-Calvo E, Seyboldt C, Schmoock G, Neubauer H, Tzoc E, Rodríguez C, Quesada-Gómez C. Multidrug-resistant Clostridium difficile ribotypes 078 and 014/5-FLI01 in piglets from Costa Rica. Anaerobe 2018; 55:78-82. [PMID: 30414919 DOI: 10.1016/j.anaerobe.2018.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 11/04/2018] [Accepted: 11/07/2018] [Indexed: 12/18/2022]
Abstract
Though an overlap of Clostridium difficile PCR ribotypes (RT) in humans and animals has been noted -particularly in piglets-information regarding C. difficile isolates from swine is scarce in Latin America. A characterization of 10 C. difficile isolates obtained from this origin in Costa Rica revealed the presence of the RT078 (n = 4) and RT014/5-FLI01 (n = 6) ribotypes. Unlike two previous reports from the region, all isolates were multidrug resistant (MDR). According to a minimum spanning tree (MST) analysis, our RT078 isolates formed a clonal complex with some German RT078 isolates and the already noted overlap of RT078 strains in humans and animals. This unanticipated high level of genetic relatedness confirms the transcontinental spread and geographically unlimited clustering of RT078.
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Affiliation(s)
- Mauricio Andino-Molina
- Escuela de Medicina Veterinaria, Universidad Nacional, Heredia, Costa Rica; Escuela de Microbiología, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras; Centro de Investigación en Enfermedades Tropicales, Universidad de Costa Rica, San José, Costa Rica; Laboratorio de Investigación en Bacteriología Anaerobia, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Elías Barquero-Calvo
- Escuela de Medicina Veterinaria, Universidad Nacional, Heredia, Costa Rica; Centro de Investigación en Enfermedades Tropicales, Universidad de Costa Rica, San José, Costa Rica
| | - Christian Seyboldt
- Institute of Bacterial Infections and Zoonoses, Federal Research Institute for Animal Health (Friedrich-Loeffler-Institut), Jena, Germany
| | - Gernot Schmoock
- Institute of Bacterial Infections and Zoonoses, Federal Research Institute for Animal Health (Friedrich-Loeffler-Institut), Jena, Germany
| | - Heinrich Neubauer
- Institute of Bacterial Infections and Zoonoses, Federal Research Institute for Animal Health (Friedrich-Loeffler-Institut), Jena, Germany
| | - Edgardo Tzoc
- Escuela de Microbiología, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras
| | - César Rodríguez
- Centro de Investigación en Enfermedades Tropicales, Universidad de Costa Rica, San José, Costa Rica; Laboratorio de Investigación en Bacteriología Anaerobia, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica
| | - Carlos Quesada-Gómez
- Centro de Investigación en Enfermedades Tropicales, Universidad de Costa Rica, San José, Costa Rica; Laboratorio de Investigación en Bacteriología Anaerobia, Facultad de Microbiología, Universidad de Costa Rica, San José, Costa Rica.
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9
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Thornton CS, Rubin JE, Greninger AL, Peirano G, Chiu CY, Pillai DR. Epidemiological and genomic characterization of community-acquired Clostridium difficile infections. BMC Infect Dis 2018; 18:443. [PMID: 30170546 PMCID: PMC6119286 DOI: 10.1186/s12879-018-3337-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/16/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a major cause of morbidity and mortality in North America and Europe. The aim of this study was to identify epidemiologically-confirmed cases of community-acquired (CA)-CDI in a large North American urban center and analyze isolates using multiple genetic and phenotypic methods. METHODS Seventy-eight patients testing positive for C. difficile from outpatient clinics were further investigated by telephone questionnaire. CA-CDI isolates were characterized by antibiotic susceptibility, pulsed-field gel electrophoresis and whole genome sequencing. CA-CDI was defined as testing positive greater than 12 weeks following discharge or no previous hospital admission in conjunction with positive toxin stool testing. RESULTS 51.3% (40/78) of the patients in this study were found to have bona fide CA-CDI. The majority of patients were female (71.8% vs. 28.2%) with 50-59 years of age being most common (21.8%). Common co-morbidities included ulcerative colitis (1/40; 2.5%), Crohn's disease (3/40; 7.5%), celiac disease (2/40; 5.0%) and irritable bowel syndrome (8/40; 20.0%). However, of 40 patients with CA-CDI, 9 (29.0%) had been hospitalized between 3 and 6 months prior and 31 (77.5%) between 6 and 12 months prior. The hypervirulent North American Pulostype (NAP) 1-like (9/40; 22.5%) strain was the most commonly identified pulsotype. Whole genome sequencing of CA-CDI isolates confirmed that NAP 1-like pulsotypes are commonplace in CA-CDI. From a therapeutic perspective, there was universal susceptibility to metronidazole and vancomycin. CONCLUSIONS All CA-CDI cases had some history of hospitalization if the definition were modified to health care facility exposure in the last 12 months and is supported by the genomic analysis. This raises the possibility that even CA-CDI may have nosocomial origins.
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Affiliation(s)
- Christina S Thornton
- Department of Microbiology and Infectious Diseases, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Joseph E Rubin
- Calgary Laboratory Services, Calgary, AB, Canada.,Department of Veterinary Microbiology, University of Saskatchewan, Regina, Canada
| | - Alexander L Greninger
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | | | - Charles Y Chiu
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA.,Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
| | - Dylan R Pillai
- Department of Microbiology and Infectious Diseases, University of Calgary, Calgary, AB, Canada. .,Department of Medicine, University of Calgary, Calgary, AB, Canada. .,Calgary Laboratory Services, Calgary, AB, Canada. .,Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada. .,Diagnostic and Scientific Center, Room 1W-416, 9-3535 Research Road NW, Calgary, AB, T2L 2K8, Canada.
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10
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Grześkowiak Ł, Riedmüller J, de Thomasson H, Bordessoule S, Seyboldt C, Zentek J, Vahjen W. Porcine and bovine Clostridium difficile ribotype 078 isolates demonstrate similar growth and toxigenic properties. Int Microbiol 2018; 21:215-221. [PMID: 30810901 DOI: 10.1007/s10123-018-0018-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/28/2018] [Accepted: 06/29/2018] [Indexed: 02/08/2023]
Abstract
Clostridioides (C.) difficile are found in cows, pigs and poultry suggesting that this pathogen is present and more importantly animals could act as a reservoir, via food or environment, of human C. difficile infection. Molecular methods together with phenotypical characterisation bring integrated and important tools to describe diversity and nature of bacteria including C. difficile. Moreover, similar or identical C. difficile types are found in different farm animals. This study aimed to phenotypically characterise C. difficile isolates belonging to ribotype 078 and to identify differences such as growth and toxicity between porcine and bovine isolates. C. difficile isolates were assessed for the growth behaviour (turbidimetry), metabolic potential (Biolog AN) and toxin production (ELISA method) in vitro. The concentration of released either toxin A (TcdA) or toxin B (TcdB) varied greatly between the isolates tested; however, it did not differ between the porcine and bovine ribotypes. Also, the TcdA/TcdB ratio of the isolates did not show a difference either. The most common metabolised substrates were pyruvic acid followed by α-ketobutyric acid. The results show that both porcine and bovine C. difficile RT 078 share similar phenotypical characteristics including growth and production of toxins. The findings may help understand the virulence of C. difficile RT 078 in porcine and bovine species.
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Affiliation(s)
- Łukasz Grześkowiak
- Freie Universität Berlin, Institute of Animal Nutrition, Königin-Luise-Str. 49, 14195, Berlin, Germany.
| | - Jonathan Riedmüller
- Freie Universität Berlin, Institute of Animal Nutrition, Königin-Luise-Str. 49, 14195, Berlin, Germany
| | | | - Solenne Bordessoule
- Ecole de Biologie Industrielle, 49 Avenue des Genottes, 95800, Cergy, France
| | - Christian Seyboldt
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler-Institut, Naumburger Straße 96a, 07743, Jena, Germany
| | - Jürgen Zentek
- Freie Universität Berlin, Institute of Animal Nutrition, Königin-Luise-Str. 49, 14195, Berlin, Germany
| | - Wilfried Vahjen
- Freie Universität Berlin, Institute of Animal Nutrition, Königin-Luise-Str. 49, 14195, Berlin, Germany
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11
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Oka K, Osaki T, Hanawa T, Kurata S, Sugiyama E, Takahashi M, Tanaka M, Taguchi H, Kamiya S. Establishment of an Endogenous Clostridium difficile Rat Infection Model and Evaluation of the Effects of Clostridium butyricum MIYAIRI 588 Probiotic Strain. Front Microbiol 2018; 9:1264. [PMID: 29967595 PMCID: PMC6015907 DOI: 10.3389/fmicb.2018.01264] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 05/24/2018] [Indexed: 12/21/2022] Open
Abstract
Clostridium difficile is well known as an agent responsible for pseudomembranous colitis and antibiotic-associated diarrhea. The hamster model utilizing an oral route for infection of C. difficile has been considered to be the standard model for analysis of C. difficile infection (CDI) but this model exhibits differences to human CDI, most notably as most hamsters die without exhibiting diarrhea. Therefore, we attempted to develop a new non-lethal and diarrheal rat CDI model caused by endogenous C. difficile using metronidazole (MNZ) and egg white. In addition, the effects of probiotic strain Clostridium butyricum MIYAIRI 588 (CBM) on CDI were examined using this model. Syrian Golden hamsters received clindamycin phosphate orally at 30 mg/kg on 5 days before challenge with either C. difficile VPI10463 (hypertoxigenic strain) or KY34 (low toxigenic clinical isolate). Mortality and the presence of diarrhea were observed twice a day for the duration of the experiment. Wistar rats received 10% egg white dissolved in drinking water for 1 week ad libitum following intramuscular administration of 200 mg/kg MNZ twice a day for 3 days. Diarrhea score was determined for each day and fecal water content, biotin concentration, and cytotoxin titer in feces were examined. More than 70% of hamsters orally infected with C. difficile died without exhibiting diarrhea regardless of toxigenicity of strain. The rats receiving egg white after MNZ administration developed diarrhea due to overgrowth of endogenous C. difficile. This CDI model is non-lethal and diarrheal, and some rats in this model were spontaneously cured. The incidence of diarrhea was significantly decreased in C. butyricum treated rats. These results indicate that the CDI model using egg white and MNZ has potentially better similarity to human CDI, and implies that treatment with C. butyricum may reduce the risk of CDI.
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Affiliation(s)
- Kentaro Oka
- Tokyo R&D Center, Miyarisan Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Takako Osaki
- Department of Infectious Diseases, Kyorin University School of Medicine, Tokyo, Japan
| | - Tomoko Hanawa
- Department of Infectious Diseases, Kyorin University School of Medicine, Tokyo, Japan
| | - Satoshi Kurata
- Department of Infectious Diseases, Kyorin University School of Medicine, Tokyo, Japan
| | - Emi Sugiyama
- Research Laboratory, Miyarisan Pharmaceutical Co., Ltd., Nagano, Japan
| | - Motomichi Takahashi
- Tokyo R&D Center, Miyarisan Pharmaceutical Co., Ltd., Tokyo, Japan.,Department of Infectious Diseases, Kyorin University School of Medicine, Tokyo, Japan
| | - Mamoru Tanaka
- Research Laboratory, Miyarisan Pharmaceutical Co., Ltd., Nagano, Japan
| | - Haruhiko Taguchi
- Department of Immunology, Kyorin University Faculty of Health Sciences, Tokyo, Japan
| | - Shigeru Kamiya
- Department of Infectious Diseases, Kyorin University School of Medicine, Tokyo, Japan
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12
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Zhang Y, Li S, Yang Z, Shi L, Yu H, Salerno-Goncalves R, Saint Fleur A, Feng H. Cysteine Protease-Mediated Autocleavage of Clostridium difficile Toxins Regulates Their Proinflammatory Activity. Cell Mol Gastroenterol Hepatol 2018; 5:611-625. [PMID: 29930981 PMCID: PMC6009800 DOI: 10.1016/j.jcmgh.2018.01.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/30/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND & AIMS Clostridium difficile toxin A (TcdA) and C difficile toxin toxin B (TcdB), the major virulence factors of the bacterium, cause intestinal tissue damage and inflammation. Although the 2 toxins are homologous and share a similar domain structure, TcdA is generally more inflammatory whereas TcdB is more cytotoxic. The functional domain of the toxins that govern the proinflammatory activities of the 2 toxins is unknown. METHODS Here, we investigated toxin domain functions that regulate the proinflammatory activity of C difficile toxins. By using a mouse ilea loop model, human tissues, and immune cells, we examined the inflammatory responses to a series of chimeric toxins or toxin mutants deficient in specific domain functions. RESULTS Blocking autoprocessing of TcdB by mutagenesis or chemical inhibition, while reducing cytotoxicity of the toxin, significantly enhanced its proinflammatory activities in the animal model. Furthermore, a noncleavable mutant TcdB was significantly more potent than the wild-type toxin in the induction of proinflammatory cytokines in human colonic tissues and immune cells. CONCLUSIONS In this study, we identified a novel mechanism of regulating the biological activities of C difficile toxins in that cysteine protease-mediated autoprocessing regulates toxins' proinflammatory activities. Our findings provide new insight into the pathogenesis of C difficile infection and the design of therapeutics against the disease.
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Key Words
- 3D, 3-dimensional
- ACPD, CPD domain of TcdA
- Autoprocessing
- Bgt, GTD of TcdB
- Br, RBD of TcdB
- C difficile
- CDI, Clostridium difficile infection
- CPD, cysteine protease domain
- Cysteine Protease
- GT, glucosyltransferase
- GTD, glucosyltransferase domain
- IL, interleukin
- Inflammation
- InsP6, inositol hexakisphosphate
- MPO, myeloperoxidase
- PBMC, peripheral blood mononuclear cell
- PBS, phosphate-buffered saline
- PCR, polymerase chain reaction
- RBD, receptor binding domain
- TER, transepithelial electrical resistance
- TcdA, Clostridium difficile toxin A
- TcdB, Clostridium difficile toxin B
- Toxins
- aTcdA, GTD deficient TcdA
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Affiliation(s)
- Yongrong Zhang
- Department of Microbial Pathogenesis, School of Dentistry, University of Maryland, Baltimore, Maryland
| | - Shan Li
- Department of Microbial Pathogenesis, School of Dentistry, University of Maryland, Baltimore, Maryland
| | - Zhiyong Yang
- Department of Microbial Pathogenesis, School of Dentistry, University of Maryland, Baltimore, Maryland
| | - Lianfa Shi
- Department of Microbial Pathogenesis, School of Dentistry, University of Maryland, Baltimore, Maryland
| | - Hua Yu
- Department of Microbial Pathogenesis, School of Dentistry, University of Maryland, Baltimore, Maryland
| | - Rosangela Salerno-Goncalves
- Department of Pediatrics and Center for Vaccine Development, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Ashley Saint Fleur
- Department of Microbial Pathogenesis, School of Dentistry, University of Maryland, Baltimore, Maryland
| | - Hanping Feng
- Department of Microbial Pathogenesis, School of Dentistry, University of Maryland, Baltimore, Maryland,Correspondence Address correspondence to: Hanping Feng, PhD, 650 W Baltimore Street, Room 7211, Baltimore, Maryland 21201. fax: (410) 706-6511.
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13
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Kuiper GA, van Prehn J, Ang W, Kneepkens F, van der Schoor S, de Meij T. Clostridium difficile infections in young infants: Case presentations and literature review. IDCases 2017; 10:7-11. [PMID: 28791215 PMCID: PMC5536825 DOI: 10.1016/j.idcr.2017.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/17/2017] [Accepted: 07/17/2017] [Indexed: 12/17/2022] Open
Abstract
It has been assumed that symptomatic Clostridium difficile infections do not occur in young infants, as this specific group would lack specific C. difficile toxin receptors. As a consequence, it is often current practice not to test for C. difficile in neonates and young infants up to 2 years of age presenting with (bloody) diarrhea. The evidence to support this is, however, weak and largely based on small, poorly designed animal studies. We present two young infants with recurrent bloody diarrhea following antimicrobial therapy, positive testing for toxigenic C. difficile and successfully treated with metronidazole and vancomycin, and provide an overview of the literature on C. difficile infections in children under two years of age. Both our case histories and the literature search provide evidence for C. difficile infection as a potential cause of bloody diarrhea in neonates and young infants, in particular after previous treatment with antimicrobials.
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Affiliation(s)
- Gé-Ann Kuiper
- Department of Pediatrics, Onze Lieve Vrouwe Gasthuis locatie Oost, Amsterdam, The Netherlands
| | - Joffrey van Prehn
- Department of Medical Microbiology and Infection Control, VU Medical Center, Amsterdam, The Netherlands
| | - Wim Ang
- Department of Medical Microbiology and Infection Control, VU Medical Center, Amsterdam, The Netherlands
| | - Frank Kneepkens
- Department of Pediatric Gastroenterology, VU Medical Center, Amsterdam, The Netherlands
| | - Sophie van der Schoor
- Department of Pediatrics, Onze Lieve Vrouwe Gasthuis locatie Oost, Amsterdam, The Netherlands
| | - Tim de Meij
- Department of Pediatric Gastroenterology, VU Medical Center, Amsterdam, The Netherlands
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14
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Diseases of the Alimentary Tract. Vet Med (Auckl) 2017. [PMCID: PMC7167529 DOI: 10.1016/b978-0-7020-5246-0.00007-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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15
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Thai H, Guerron AD, Bencsath KP, Liu X, Loor M. Fulminant Clostridium difficile enteritis causing abdominal compartment syndrome. Surg Infect (Larchmt) 2015; 15:821-5. [PMID: 24824419 DOI: 10.1089/sur.2013.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Clostridium difficile infection of the small bowel, or C. difficile enteritis (CDE), is an uncommon condition. Cases reported previously have been described in patients with inflammatory bowel disease (IBD), compromised immune systems, or a history of colectomy or small bowel surgery. CASE DESCRIPTION We present a case of fulminant CDE causing abdominal compartment syndrome following a routine outpatient inguinal hernia repair. This patient developed multiple organ failure dysfunction syndrome requiring surgical abdominal decompression and a small bowel resection. This case highlights the challenges in the diagnosis of CDE, particularly in patients with intact colons and unusual presentations. DISCUSSION A high index of suspicion is required, as early recognition of CDE is essential in reducing morbidity and mortality. This case report is followed by a review of the current literature on CDE, with a focus on the complexities inherent in the identification of this problem and the decision-making process for surgical intervention.
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Affiliation(s)
- Hue Thai
- 1 Department of General Surgery, Cleveland Clinic , Cleveland, Ohio
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16
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Santiago B, Guerra L, García-Morín M, González E, Gonzálvez A, Izquierdo G, Martos A, Santos M, Navarro M, Hernández-Sampelayo M, Saavedra-Lozano J. Aislamiento de Clostridium difficile en niños hospitalizados con diarrea. An Pediatr (Barc) 2015; 82:417-25. [DOI: 10.1016/j.anpedi.2014.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 06/02/2014] [Accepted: 07/15/2014] [Indexed: 12/13/2022] Open
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17
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Santiago B, Guerra L, García-Morín M, González E, Gonzálvez A, Izquierdo G, Martos A, Santos M, Navarro M, Hernández-Sampelayo M, Saavedra-Lozano J. Clostridium difficile isolation in children hospitalized with diarrhoea. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2015.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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18
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Shkoporov AN, Khokhlova EV, Savochkin KA, Kafarskaia LI, Efimov BA. Production of biologically active scFv and VHH antibody fragments in Bifidobacterium longum. FEMS Microbiol Lett 2015; 362:fnv083. [PMID: 25994292 DOI: 10.1093/femsle/fnv083] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2015] [Indexed: 01/01/2023] Open
Abstract
Bifidobacteria constitute a significant part of healthy intestinal microbiota in adults and infants and present a promising platform for construction of genetically modified probiotic agents for treatment of gastrointestinal disorders. In this study, three strains of Bifidobacterium longum were constructed that express and secrete biologically active single-chain antibodies against human TNF-α and Clostridium difficile exotoxin A. Anti-TNF-α scFv antibody D2E7 was produced at the level of 25 μg L(-1) in broth culture and was mostly retained in the cytoplasm, while VHH-type antibodies A20.1 and A26.8 against C. difficile exotoxin A were produced at the levels of 0.3-1 mg L(-1) and secreted very efficiently. The biological activity of both antibody types was demonstrated in the mammalian cell-based assays. Expression of A20.1 and A26.8 was also observed in vivo after intragastric administration of transformed B. longum strains to (C57/BL6 × DBA/2)F1 mice. The obtained B. longum strains may serve as prototypes for construction of novel probiotic medications against inflammatory bowel disease and C. difficile-associated disease.
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Affiliation(s)
- A N Shkoporov
- Department of Microbiology and Virology, Pirogov Russian National Research Medical University, Ostrovitjanova str. 1, Moscow 117997, Russia Pharmbacter LLC, Skladochnaya ul., 1 - 1, Moscow 127018, Russia
| | - E V Khokhlova
- Department of Microbiology and Virology, Pirogov Russian National Research Medical University, Ostrovitjanova str. 1, Moscow 117997, Russia
| | - K A Savochkin
- Pharmbacter LLC, Skladochnaya ul., 1 - 1, Moscow 127018, Russia
| | - L I Kafarskaia
- Department of Microbiology and Virology, Pirogov Russian National Research Medical University, Ostrovitjanova str. 1, Moscow 117997, Russia
| | - B A Efimov
- Department of Microbiology and Virology, Pirogov Russian National Research Medical University, Ostrovitjanova str. 1, Moscow 117997, Russia
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19
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D'Auria KM, Bloom MJ, Reyes Y, Gray MC, van Opstal EJ, Papin JA, Hewlett EL. High temporal resolution of glucosyltransferase dependent and independent effects of Clostridium difficile toxins across multiple cell types. BMC Microbiol 2015; 15:7. [PMID: 25648517 PMCID: PMC4323251 DOI: 10.1186/s12866-015-0361-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 01/22/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Clostridium difficile toxins A and B (TcdA and TcdB), considered to be essential for C. difficile infection, affect the morphology of several cell types with different potencies and timing. However, morphological changes over various time scales are poorly characterized. The toxins' glucosyltransferase domains are critical to their deleterious effects, and cell responses to glucosyltransferase-independent activities are incompletely understood. By tracking morphological changes of multiple cell types to C. difficile toxins with high temporal resolution, cellular responses to TcdA, TcdB, and a glucosyltransferase-deficient TcdB (gdTcdB) are elucidated. RESULTS Human umbilical vein endothelial cells, J774 macrophage-like cells, and four epithelial cell lines (HCT8, T84, CHO, and immortalized mouse cecal epithelial cells) were treated with TcdA, TcdB, gdTcdB. Impedance across cell cultures was measured to track changes in cell morphology. Metrics from impedance data, developed to quantify rapid and long-lasting responses, produced standard curves with wide dynamic ranges that defined cell line sensitivities. Except for T84 cells, all cell lines were most sensitive to TcdB. J774 macrophages stretched and increased in size in response to TcdA and TcdB but not gdTcdB. High concentrations of TcdB and gdTcdB (>10 ng/ml) greatly reduced macrophage viability. In HCT8 cells, gdTcdB did not induce a rapid cytopathic effect, yet it delayed TcdA and TcdB's rapid effects. gdTcdB did not clearly delay TcdA or TcdB's toxin-induced effects on macrophages. CONCLUSIONS Epithelial and endothelial cells have similar responses to toxins yet differ in timing and degree. Relative potencies of TcdA and TcdB in mouse epithelial cells in vitro do not correlate with potencies in vivo. TcdB requires glucosyltransferase activity to cause macrophages to spread, but cell death from high TcdB concentrations is glucosyltransferase-independent. Competition experiments with gdTcdB in epithelial cells confirm common TcdA and TcdB mechanisms, yet different responses of macrophages to TcdA and TcdB suggest different, additional mechanisms or targets in these cells. This first-time, precise quantification of the response of multiple cell lines to TcdA and TcdB provides a comparative framework for delineating the roles of different cell types and toxin-host interactions.
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Affiliation(s)
- Kevin M D'Auria
- Department of Biomedical Engineering, University of Virginia, PO Box 800759, Charlottesville, VA, 22908, USA.
| | - Meghan J Bloom
- Department of Biomedical Engineering, University of Virginia, PO Box 800759, Charlottesville, VA, 22908, USA. .,Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, PO Box 801340, Charlottesville, VA, 22908, USA.
| | - Yesenia Reyes
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, PO Box 801340, Charlottesville, VA, 22908, USA.
| | - Mary C Gray
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, PO Box 801340, Charlottesville, VA, 22908, USA.
| | - Edward J van Opstal
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, PO Box 801340, Charlottesville, VA, 22908, USA. .,Current address: Vanderbilt University School of Medicine, 340 Light Hall, Nashville, TN, 27232, USA.
| | - Jason A Papin
- Department of Biomedical Engineering, University of Virginia, PO Box 800759, Charlottesville, VA, 22908, USA.
| | - Erik L Hewlett
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, PO Box 801340, Charlottesville, VA, 22908, USA.
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20
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Controversies Surrounding Clostridium difficile Infection in Infants and Young Children. CHILDREN-BASEL 2014; 1:40-7. [PMID: 27417466 PMCID: PMC4939517 DOI: 10.3390/children1010040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 05/26/2014] [Indexed: 01/05/2023]
Abstract
Clostridium difficile is a frequent cause of antibiotic-associated diarrhea in adults and older children. However, as many as 80% of infants can be asymptomatically colonized. The reasons for this have not been well established but are believed to be due to differences in toxin receptors or toxin internalization. Determining which children who test positive for C. difficile warrant treatment is exceedingly difficult, especially in the setting of increased rates of detection and the rising risk of disease in children lacking classic risk factors for C. difficile.
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21
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Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infect Drug Resist 2014; 7:63-72. [PMID: 24669194 PMCID: PMC3962320 DOI: 10.2147/idr.s46780] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
There has been a startling shift in the epidemiology of Clostridium difficile infection over the last decade worldwide, and it is now increasingly recognized as a cause of diarrhea in the community. Classically considered a hospital-acquired infection, it has now emerged in populations previously considered to be low-risk and lacking the traditional risk factors for C. difficile infection, such as increased age, hospitalization, and antibiotic exposure. Recent studies have demonstrated great genetic diversity for C. difficile, pointing toward diverse sources and a fluid genome. Environmental sources like food, water, and animals may play an important role in these infections, apart from the role symptomatic patients and asymptomatic carriers play in spore dispersal. Prospective strain typing using highly discriminatory techniques is a possible way to explore the suspected diverse sources of C. difficile infection in the community. Patients with community-acquired C. difficile infection do not necessarily have a good outcome and clinicians should be aware of factors that predict worse outcomes in order to prevent them. This article summarizes the emerging epidemiology, risk factors, and outcomes for community-acquired C. difficile infection.
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Affiliation(s)
- Arjun Gupta
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Killeen S, Martin ST, Hyland J, O' Connell PR, Winter DC. Clostridium difficile enteritis: a new role for an old foe. Surgeon 2014; 12:256-62. [PMID: 24618362 DOI: 10.1016/j.surge.2014.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/16/2014] [Accepted: 01/16/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Small bowel involvement of Clostridium difficile is increasingly encountered. Data on many management aspects are lacking. AIM To synthesis existing reports and assess the frequency, pathophysiology, outcomes, risk factors, diagnosis and management of C. difficle enteritis. METHODS A systematic review of the literature was conducted to evaluate evidence regarding frequency, pathophysiology, risk factors, optimal diagnosis, management and outcomes for C. difficle enteritis. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included original articles reporting C. difficle enteritis from January 1950 to December 2012. RESULTS C. difficle enteritis is rare but increasingly encountered. Presentation is variable and distinct predisposing factors include emergency surgery, white race and increased age. Diagnosis generally involves a sensitive but often non specific screening test for C. difficile antigens. Oral metronidazole represents first line therapy and surgery may be required for complications. Outcomes are inconsistent but may be improving. CONCLUSIONS A high index of clinical suspicion, early diagnosis and treatment are vital. Further prospective studies are needed to determine the significance of asymptomatic small bowel C. difficile infections.
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Affiliation(s)
- S Killeen
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland.
| | - S T Martin
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland
| | - J Hyland
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland
| | - P R O' Connell
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland
| | - D C Winter
- St. Vincent's University Hospital, Department of Colorectal Surgery, Dublin 4, Ireland
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Norén T, Johansson K, Unemo M. Clostridium difficile PCR ribotype 046 is common among neonatal pigs and humans in Sweden. Clin Microbiol Infect 2014; 20:O2-6. [DOI: 10.1111/1469-0691.12296] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 06/07/2013] [Accepted: 06/08/2013] [Indexed: 11/29/2022]
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Gerhard R, Frenzel E, Goy S, Olling A. Cellular uptake of Clostridium difficile TcdA and truncated TcdA lacking the receptor binding domain. J Med Microbiol 2013; 62:1414-1422. [DOI: 10.1099/jmm.0.057828-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The combined repetitive oligopeptides (CROPs) of Clostridium difficile toxins A (TcdA) and B (TcdB) induce clathrin-mediated endocytosis of the toxins. Inconsistently, CROP-truncated TcdA1–1874 is also capable of entering host cells and displaying full cytotoxic properties although with less potency. Pre-incubation of cells with isolated CROPs, however, reconstitutes the reduced uptake of TcdA1–1874 to the level of the full-length toxin. We believe that TcdA exhibits an additional binding motif beyond the C-terminally located CROP domain, which might interact with cellular receptor structures that are associated with alternative internalization pathways. This study therefore evaluated endocytosis routes of CROP-dependent cellular uptake for TcdA and CROP-independent cellular uptake for TcdA1–1874. Clathrin knockdown or inhibition with chlorpromazine affected subsequent internalization of TcdA and TcdA1–1874, although only to some extent, arguing for alternative, clathrin-independent endocytosis routes. Inhibition of dynamin, a GTPase essentially involved in clathrin-mediated endocytosis as well as in various clathrin-independent uptake mechanisms, affected uptake of TcdA to the same extent as clathrin inhibition. In contrast, uptake of TcdA1–1874 was almost completely eliminated in dynamin-inhibited cells. Thus, clathrin-independent uptake of TcdA1–1874 presumably depends on dynamin. These findings demonstrate that the toxins are endocytosed via complex pathways involving clathrin and dynamin, putatively enabling them to adapt to mechanisms of various cell types. With regard to the emergence of C. difficile strains producing C-terminally truncated toxins, this study emphasizes the relevance of elucidating toxin uptake as a prerequisite for the development of toxin intervention strategies.
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Affiliation(s)
- Ralf Gerhard
- Institut für Toxikologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Eileen Frenzel
- Institut für Toxikologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Sebastian Goy
- Institut für Toxikologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Alexandra Olling
- Institut für Toxikologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Arruda PH, Madson DM, Ramirez A, Rowe E, Lizer JT, Songer JG. Effect of age, dose and antibiotic therapy on the development of Clostridium difficile infection in neonatal piglets. Anaerobe 2013; 22:104-10. [DOI: 10.1016/j.anaerobe.2013.04.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/10/2013] [Accepted: 04/14/2013] [Indexed: 01/05/2023]
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Clostridium difficile in foods and animals: history and measures to reduce exposure. Anim Health Res Rev 2013; 14:11-29. [PMID: 23324529 DOI: 10.1017/s1466252312000229] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Many articles have summarized the changing epidemiology of Clostridium difficile infections (CDI) in humans, but the emerging presence of C. difficile in foods and animals and possible measures to reduce human exposure to this important pathogen have been infrequently addressed. CDIs have traditionally been assumed to be restricted to health-care settings. However, recent molecular studies indicate that this is no longer the case; animals and foods might be involved in the changing epidemiology of CDIs in humans; and genome sequencing is disproving person-to-person transmission in hospitals. Although zoonotic and foodborne transmission have not been confirmed, it is evident that susceptible people can be inadvertently exposed to C. difficile from foods, animals, or their environment. Strains of epidemic clones present in humans are common in companion and food animals, raw meats, poultry products, vegetables, and ready-to-eat foods, including salads. In order to develop science-based prevention strategies, it is critical to understand how C. difficile reaches foods and humans. This review contextualizes the current understanding of CDIs in humans, animals, and foods. Based on available information, we propose a list of educational measures that could reduce the exposure of susceptible people to C. difficile. Enhanced educational efforts and behavior change targeting medical and non-medical personnel are needed.
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Steele J, Mukherjee J, Parry N, Tzipori S. Antibody against TcdB, but not TcdA, prevents development of gastrointestinal and systemic Clostridium difficile disease. J Infect Dis 2012; 207:323-30. [PMID: 23125448 DOI: 10.1093/infdis/jis669] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND A dramatic increase in morbidity and mortality from Clostridium difficile infection (CDI) due to the recent emergence of virulent, antibiotic-resistant strains has led to a search for alternatives to antibiotics, including vaccines and immune-based therapy that target the 2 key toxins-TcdA and TcdB. METHODS We investigated the efficacy of specific human monoclonal antibodies (HuMab) and alpaca polyclonal antibodies against each toxin separately and in combination in the gnotobiotic piglet model of CDI. Additionally, the HuMab and polyclonal antibodies were exploited to investigate the precise contribution of each toxin to systemic and/or gastrointestinal (GI) tract disease. RESULTS Our results indicate that TcdB is an important virulence factor associated with GI and systemic pathology. Administration of anti-TcdB antibody alone or with anti-TcdA protected 100% of piglets from development of systemic CDI and minimized GI lesions. Conversely, 100% of piglets administered only anti-TcdA developed severe GI and systemic disease, with 67%-83% fatality, faring worse than placebo-treated control animals. CONCLUSIONS These results highlight the importance of TcdB in the pathogenesis of CDI and the effectiveness of TcdB-specific antibody in treating CDI. However, the results raise new questions regarding the nature of TcdA interaction with therapeutic antibodies.
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Affiliation(s)
- Jennifer Steele
- Tufts Cummings School of Veterinary Medicine, Department of Biomedical Sciences, Division of Infectious Diseases, North Grafton, MA 01536, USA
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Tamma PD, Sandora TJ. Clostridium difficile Infection in Children: Current State and Unanswered Questions. J Pediatric Infect Dis Soc 2012; 1:230-43. [PMID: 23687578 PMCID: PMC3656539 DOI: 10.1093/jpids/pis071] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 06/14/2012] [Indexed: 01/22/2023]
Abstract
The incidence of Clostridium difficile infection (CDI) in children has increased over the past decade. In recent years, new and intriguing data on pediatric CDI have emerged. Community-onset infections are increasingly recognized, even in children who have not previously received antibiotics. A hypervirulent strain is responsible for up to 20% of pediatric CDI cases. Unique risk factors for CDI in children have been identified. Advances in diagnostic testing strategies, including the use of nucleic acid amplification tests, have raised new questions about the optimal approach to diagnosing CDI in children. Novel therapeutic options are available for adult patients with CDI, raising questions about the use of these agents in children. Updated recommendations about infection prevention and control measures are now available. We summarize these recent developments in pediatric CDI in this review and also highlight remaining knowledge gaps that should be addressed in future research efforts.
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Affiliation(s)
- Pranita D. Tamma
- Johns Hopkins Medical Institutions, Division of Pediatric Infectious Diseases, Department of Pediatrics, Baltimore, Maryland;
| | - Thomas J. Sandora
- Boston Children's Hospital, Division of Infectious Diseases, Departments of Medicine and Laboratory Medicine, Massachusetts
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Antimicrobial resistance, toxinotype, and genotypic profiling of Clostridium difficile isolates of swine origin. J Clin Microbiol 2012; 50:2366-72. [PMID: 22518873 DOI: 10.1128/jcm.06581-11] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The occurrence of Clostridium difficile infections in patients that do not fulfill the classical risk factors prompted us to investigate new risk factors of disease. The goal of this study was to characterize strains and associated antimicrobial resistance determinants of C. difficile isolated from swine raised in Ohio and North Carolina. Genotypic approaches used include PCR detection, toxinotyping, DNA sequencing, and pulsed-field gel electrophoresis (PFGE) DNA fingerprinting. Thirty-one percent (37/119) of isolates carried both tetM and tetW genes. The ermB gene was found in 91% of isolates that were resistant to erythromycin (68/75). Eighty-five percent (521/609) of isolates were toxin gene tcdB and tcdA positive. A total of 81% (494/609) of isolates were positive for cdtB and carry a tcdC gene (a toxin gene negative regulator) with a 39-bp deletion. Overall, 88% (196/223) of pigs carry a single C. difficile strain, while 12% (27/223) of pigs carried multiple strains. To the best of our knowledge, this is the first report of individual pigs found to carry more than one strain type of C. difficile. A significant difference in toxinotype profiles in the two geographic locations was noted, with a significantly (P < 0.001) higher prevalence of toxinotype V found in North Carolina (84%; 189/224) than in Ohio (55%; 99/181). Overall, the study findings indicate that significant proportions of C. difficile in swine are toxigenic and often are associated with antimicrobial resistance genes, although they are not resistant to drugs that are used to treat C. difficile infections.
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Squire MM, Riley TV. Clostridium difficile infection in humans and piglets: a 'One Health' opportunity. Curr Top Microbiol Immunol 2012; 365:299-314. [PMID: 22695920 DOI: 10.1007/82_2012_237] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Clostridium difficile causes infectious diarrhoea in humans and animals. It has been found in both diarrhoeal and non-diarrhoeal pigs, horses and cattle, suggesting a potential reservoir for human insection, and in 20-40 % of meat products in Canada and the USA, suggesting the possibility, albeit not proven, of food-borne transmission. Although it is not yet completely clear, it is likely that excessive antimicrobial exposure is driving the establishment of C. difficile in animals, in a manner analogous to human infection, rather than the organism just being normal flora of the animal gastrointestinal tract. PCR ribotype 078 is the most common ribotype of C. difficile found in pigs (83 % in one study in the USA) and cattle (up to 100 %) and this ribotype is now the third most common ribotype of C. difficile found in human infection in Europe. Human and pig strains of C. difficile are genetically identical in Europe confirming that a zoonosis exists. Rates of community-acquired C. difficile infection (CDI) are increasing world wide, a fact that sits well with the notion that animals are a reservoir for human infection. Thus, there are three problems that require resolution: a human health issue, an animal health issue and the factor common to both these problems, environmental contamination. To successfully deal with these recent changes in the epidemiology of CDI will require a 'one health' approach involving human health physicians, veterinarians and environmental scientists.
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Affiliation(s)
- Michele M Squire
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western Australia, Perth, Australia,
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Hussack G, Arbabi-Ghahroudi M, Mackenzie CR, Tanha J. Isolation and characterization of Clostridium difficile toxin-specific single-domain antibodies. Methods Mol Biol 2012; 911:211-39. [PMID: 22886255 DOI: 10.1007/978-1-61779-968-6_14] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Camelidae single-domain antibodies (VHHs) are a unique class of small binding proteins that are promising inhibitors of targets relevant to infection and immunity. With VHH selection from hyperimmunized phage display libraries now routine and the fact that VHHs possess long, extended complementarity-determining region (CDR3) loop structures that can access traditionally immunosilent epitopes, VHH-based inhibition of targets such as bacterial toxins are being explored. Toxin A and toxin B are high molecular weight exotoxins (308 kDa and 269 kDa, respectively) secreted by Clostridium difficile that are the causative agents of C. difficile-associated diseases in humans and in animals. Here, we provide protocols for the rapid generation of C. difficile toxin A- and toxin B-specific VHHs by llama immunization and recombinant antibody/phage display technology approaches and for further characterization of the VHHs with respect to toxin-binding affinity and specificity and the conformational nature of their epitopes.
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Affiliation(s)
- Greg Hussack
- Institute for Biological Sciences, National Research Council Canada, Ottawa, ON, Canada
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32
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Clostridium difficile Infection in Humans and Piglets: A ‘One Health’ Opportunity. Curr Top Microbiol Immunol 2012. [DOI: 10.1007/978-3-662-45792-4_237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Keessen E, Gaastra W, Lipman L. Clostridium difficile infection in humans and animals, differences and similarities. Vet Microbiol 2011; 153:205-17. [DOI: 10.1016/j.vetmic.2011.03.020] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 03/07/2011] [Accepted: 03/17/2011] [Indexed: 01/05/2023]
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McNamara SE, Abdujamilova N, Somsel P, Gordoncillo MJ, DeDecker JM, Bartlett PC. Carriage of Clostridium difficile and other enteric pathogens among a 4-H avocational cohort. Zoonoses Public Health 2011; 58:192-9. [PMID: 20529211 DOI: 10.1111/j.1863-2378.2010.01338.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Clostridium difficile (CD), Salmonella, Campylobacter and enterohemorrhagic Escherichia coli (EHEC) are major causes of morbidity in a variety of enteric diseases in humans and animals, but subclinical carriage in both is probably more common than are clinical cases. Little is known regarding the prevalence of these pathogens in animals raised for exhibit at Michigan county fairs or the frequency with which Michigan citizens raising these animals may have been subclinically colonized. To address these issues, 361 fecal specimens from 158 humans and 203 of their farm animals were cultured for CD, Salmonella and Campylobacter. Additionally, 50 people and their cattle were tested for EHEC. No EHEC, Salmonella or Campylobacter were detected. However, 16 specimens (4.4%) were positive for CD: 13 humans, two horses and one pig. None of the farm animal specimens submitted by any of the 13 CD-positive humans were positive for CD. Strain characterization [toxinotype, pulsed-field gel electrophoresis (PFGE)] demonstrated that the human CD isolates were similar to what has been reported previously in the general US population. We conclude that horses and farm animals (cattle, sheep, goats and swine) at 1-2 months before market weight showed no evidence of wide-spread carriage of the common enteric pathogens, including the recently reported CD toxinotype V. These results provide no support to the hypothesis that 4-H members or others visiting county fair animal husbandry projects in these counties may be at increased risk for acquisition of CD, Salmonella, Campylobacter or EHEC from animals.
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Affiliation(s)
- S E McNamara
- Infectious Diseases Division, Bureau of Laboratories, Michigan Department of Community Health, Lansing, MI, USA
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Kaslow DC, Shiver JW. Clostridium difficileand Methicillin-ResistantStaphylococcus aureus:Emerging Concepts in Vaccine Development. Annu Rev Med 2011; 62:201-15. [DOI: 10.1146/annurev-med-051109-101544] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- David C. Kaslow
- Merck Research Laboratories, Merck & Co. Inc., North Wales, Pennsylvania 19454; ,
| | - John W. Shiver
- Merck Research Laboratories, Merck & Co. Inc., North Wales, Pennsylvania 19454; ,
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Kim JH, Muder RR. Clostridium difficile enteritis: a review and pooled analysis of the cases. Anaerobe 2011; 17:52-5. [PMID: 21334446 DOI: 10.1016/j.anaerobe.2011.02.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 02/09/2011] [Accepted: 02/12/2011] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Clostridium difficile is the most common cause of healthcare-associated infection diarrhea and usually restricted to infection of the colon. However, small bowel involvement of C. difficile infection has been reported. We performed a literature review and pooled analysis of the reported cases of C. difficile enteritis METHOD A Pubmed literature database search and pooled analysis of the reported cases of C. difficile enteritis. RESULTS 56 cases of C. difficile enteritis have been reported from 1980 to 2010; 48 cases were published since 2001. Median age was 55 years. 27 patients (48.2%) were female. 29 patients (51.8%) had inflammatory bowel disease (IBD) - Crohn's disease or ulcerative colitis and 20 patients (35.7%) had predisposing medical condition(s) that might lead to an immunoincompetent state. 33 patients (58.9%) had colectomy with ileostomy and 13 patients (23.2%) had other small and/or large bowel surgery. Thirty four patients (60.7%) received ICU management and 18 patients (32.1%) died. We categorized the patients into two groups, 38 survivors (67.9%) 18 non-survivors (32.1%). Significantly older age was noted in non-survivors. Median age was 48 years and 66 years, respectively for survivors and non-survivors, P < 0.001. There were more patients with predisposing medical condition(s) among non-survivors, (13/18, 72.2%) than among survivors (7/38, 18.4%), P < 0.001. CONCLUSIONS C. difficile enteritis is still rare, however it seems to be increasingly reported in recent years. Surgically altered intestinal anatomies, advanced age, predisposing medical condition(s) that might lead to immunoincompetence appear to be at risk for developing C. difficile enteritis. Recognition of C. difficile infection not only in the colon but also in the small bowel may lead to improved outcomes.
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Affiliation(s)
- J H Kim
- Division of Infectious Diseases, University of Pittsburgh Medical Center, PA 15213, USA
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37
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Hussack G, Arbabi-Ghahroudi M, van Faassen H, Songer JG, Ng KKS, MacKenzie R, Tanha J. Neutralization of Clostridium difficile toxin A with single-domain antibodies targeting the cell receptor binding domain. J Biol Chem 2011; 286:8961-76. [PMID: 21216961 DOI: 10.1074/jbc.m110.198754] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile is a leading cause of nosocomial infection in North America and a considerable challenge to healthcare professionals in hospitals and nursing homes. The gram-positive bacterium produces two high molecular weight exotoxins, toxin A (TcdA) and toxin B (TcdB), which are the major virulence factors responsible for C. difficile-associated disease and are targets for C. difficile-associated disease therapy. Here, recombinant single-domain antibody fragments (V(H)Hs), which specifically target the cell receptor binding domains of TcdA or TcdB, were isolated from an immune llama phage display library and characterized. Four V(H)Hs (A4.2, A5.1, A20.1, and A26.8), all shown to recognize conformational epitopes, were potent neutralizers of the cytopathic effects of toxin A on fibroblast cells in an in vitro assay. The neutralizing potency was further enhanced when V(H)Hs were administered in paired or triplet combinations at the same overall V(H)H concentration, suggesting recognition of nonoverlapping TcdA epitopes. Biacore epitope mapping experiments revealed that some synergistic combinations consisted of V(H)Hs recognizing overlapping epitopes, an indication that factors other than mere epitope blocking are responsible for the increased neutralization. Further binding assays revealed TcdA-specific V(H)Hs neutralized toxin A by binding to sites other than the carbohydrate binding pocket of the toxin. With favorable characteristics such as high production yield, potent toxin neutralization, and intrinsic stability, these V(H)Hs are attractive systemic therapeutics but are more so as oral therapeutics in the destabilizing environment of the gastrointestinal tract.
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Affiliation(s)
- Greg Hussack
- Institute for Biological Sciences, National Research Council Canada, Ottawa, Ontario K1A 0R6, Canada
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38
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Keel MK, Songer JG. The Attachment, Internalization, and Time-Dependent, Intracellular Distribution of Clostridium difficile Toxin A in Porcine Intestinal Explants. Vet Pathol 2010; 48:369-80. [DOI: 10.1177/0300985810380395] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Toxin A (TcdA), secreted by toxigenic strains of Clostridium difficile, produces lesions typical of C. difficile–associated disease (CDAD) in susceptible mammal species. Porcine colon explants maintained for 2 hours with TcdA developed severe lesions characterized by cell swelling, swelling of mitochondria and other organelles, distension of cytoplasmic vesicles, expansion of paracellular spaces, apoptosis, and necrosis. Severity of lesions was proportional to the dosage of toxin. No lesions were present in uninoculated control tissues after 2 hours. Receptor-mediated endocytosis is the keystone event in the pathogenesis of the toxin, and susceptibility of a given species is thought to depend on the presence of receptors in intestinal epithelial cells. The fate of TcdA applied to viable colon explants was determined by transmission electron microscopy in an anti-toxin-labeled gold assay. At 5 minutes postinoculation, the presence of TcdA was indicated at the membrane of microvilli or in the cytoplasm of epithelial cells. TcdA was also indirectly observed within endosomes or attached at their margin. A 30-minute inoculation period was associated with many more gold particles labeling structures inside the cell, although some were still attached to microvilli. Within the cell, most TcdA was associated with mitochondria of epithelial cells, but some gold particles decorated the nuclei. Endothelial cells of the lamina propria had evidence of TcdA at both their lumenal and basal aspects, as well as in the cytoplasm and, occasionally, nuclei. Gold particles also labeled the lumen of such vessels as well as leucocytes in blood vessels and the lamina propria.
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Affiliation(s)
- M. K. Keel
- Southeastern Cooperative Wildlife Disease Study, College of Veterinary Medicine, The University of Georgia, Athens, GA, USA
- Department of Veterinary Microbiology and Preventive Medicine, College of Veterinary Medicine, Iowa State University, Ames, IA, USA
| | - J. G. Songer
- Southeastern Cooperative Wildlife Disease Study, College of Veterinary Medicine, The University of Georgia, Athens, GA, USA
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Khanna S, Pardi DS. The growing incidence and severity of Clostridium difficile infection in inpatient and outpatient settings. Expert Rev Gastroenterol Hepatol 2010; 4:409-16. [PMID: 20678014 DOI: 10.1586/egh.10.48] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Clostridium difficile infection (CDI) is a leading cause of nosocomial infections, with disease severity ranging from mild diarrhea to fulminant colitis. The incidence and severity of CDI has been on the rise over the last 10-20 years, with CDI being increasingly described outside healthcare settings and in populations previously thought to be at low risk. There has also been an increase in the morbidity, mortality and economic burden associated with CDI in the last several years. This increasing incidence and severity is thought to be at least partially due to frequent antibiotic use and the emergence of a hypervirulent C. difficile strain.
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Affiliation(s)
- Sahil Khanna
- Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Bakri MM, Sutherland AD, Brown DJ, Vesely P, Crossan C, Scobie L. Assessment of the potential risk of infection associated withClostridium difficilefrom porcine xenografts. Xenotransplantation 2009; 16:472-6. [DOI: 10.1111/j.1399-3089.2009.00538.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lavallée C, Laufer B, Pépin J, Mitchell A, Dubé S, Labbé AC. Fatal Clostridium difficile enteritis caused by the BI/NAP1/027 strain: a case series of ileal C. difficile infections. Clin Microbiol Infect 2009; 15:1093-9. [PMID: 19681954 DOI: 10.1111/j.1469-0691.2009.03004.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Clostridium difficile generally causes diarrhoea and colitis. Small-bowel infections are considered to be rare. Twelve cases of ileal C. difficile infections are presented, including the first reported case proven to be caused by the hypervirulent BI/NAP1/027 strain. This case series suggests that small bowel involvement in C. difficile infections may be more frequent than previously thought.
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Affiliation(s)
- C Lavallée
- Département de Microbiologie, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada
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Sun X, He X, Tzipori S, Gerhard R, Feng H. Essential role of the glucosyltransferase activity in Clostridium difficile toxin-induced secretion of TNF-alpha by macrophages. Microb Pathog 2009; 46:298-305. [PMID: 19324080 DOI: 10.1016/j.micpath.2009.03.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 03/11/2009] [Accepted: 03/12/2009] [Indexed: 01/30/2023]
Abstract
Clostridium difficile causes serious and potentially fatal inflammatory diseases of the colon. Two large protein toxins, TcdA and TcdB, have been clearly implicated in pathogenesis. The goal of this study was to determine whether the glucosyltransferase activity of the toxins is critical for the induction of tumor necrosis factor-alpha (TNF-alpha), an important cytokine mediating both local and systematic inflammatory response. A dose-dependent TNF-alpha secretion was demonstrated in murine macrophage cell line RAW 264.7 after exposure to TcdA or TcdB. TNF-alpha production was blocked by anti-toxin antibodies, indicating that the cytokine-driven response is mediated by the toxins. Both toxins disrupted the cytoskeleton of host cells, while cytoskeleton disruptions using Cytochalasin-D and latrunculin B did not affect TNF-alpha production. The TNF-alpha synthesis was inhibited by reagents that target clathrin-dependent endocytosis or prevent endosomal acidification, suggesting that the endocytosis pathway is necessary for the induction of TNF-alpha. Furthermore, knockout of the enzymatic activity by mutating two key amino acids in the catalytic domain of TcdA abolished its cytokine-inducing activity. Our studies demonstrated a crucial role of the glucosyltransferase activity of C. difficile toxins in the induction of TNF-alpha in macrophages.
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Affiliation(s)
- Xingmin Sun
- Division of Infectious Diseases, Department of Biomedical Sciences, Tufts University, Cummings School of Veterinary Medicine, North Grafton, MA 01536, USA
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Yang G, Zhou B, Wang J, He X, Sun X, Nie W, Tzipori S, Feng H. Expression of recombinant Clostridium difficile toxin A and B in Bacillus megaterium. BMC Microbiol 2008; 8:192. [PMID: 18990232 PMCID: PMC2586027 DOI: 10.1186/1471-2180-8-192] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Accepted: 11/06/2008] [Indexed: 12/18/2022] Open
Abstract
Background Major Clostridium difficile virulence factors are the exotoxins TcdA and TcdB. Due to the large size and poor stability of the proteins, the active recombinant TcdA and TcdB have been difficult to produce. Results The toxin genes tcdA and tcdB were amplified by PCR using chromosomal DNA from a toxigenic strain as a template, and cloned into a shuttle vector pHis1522. The sequences of both tcdA and tcdB genes in the vector have been verified by DNA sequencing. The constructs were transformed into B. megaterium protoplasts and the protein expression was controlled under a xylose promoter. The recombinant toxins (rTcdA and rTcdB) were purified from bacterial crude extracts. Approximately 5 – 10 mg of highly purified recombinant toxins were obtained from one liter of bacterial culture. The resulting rTcdA and rTcdB had similar molecular masses to the native toxins, and their biological activities were found to be similar to their native counterparts after an extensive examination. Conclusion We have generated the full length and active recombinant TcdA and TcdB in Bacillus megaterium.
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Affiliation(s)
- Guilin Yang
- Division of Infectious Diseases, Department of Biomedical Sciences, Tufts University Cummings School of Veterinary Medicine, North Grafton, Massachusetts 01536, USA.
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