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Kunishima H, Ichiki K, Ohge H, Sakamoto F, Sato Y, Suzuki H, Nakamura A, Fujimura S, Matsumoto K, Mikamo H, Mizutani T, Morinaga Y, Mori M, Yamagishi Y, Yoshizawa S. Japanese Society for infection prevention and control guide to Clostridioides difficile infection prevention and control. J Infect Chemother 2024; 30:673-715. [PMID: 38714273 DOI: 10.1016/j.jiac.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Affiliation(s)
- Hiroyuki Kunishima
- Department of Infectious Diseases. St. Marianna University School of Medicine, Japan.
| | - Kaoru Ichiki
- Department of Infection Control and Prevention, Hyogo Medical University Hospital, Japan
| | - Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Fumie Sakamoto
- Quality Improvement and Safety Center, Itabashi Chuo Medical Center, Japan
| | - Yuka Sato
- Department of Infection Control and Nursing, Graduate School of Nursing, Aichi Medical University, Japan
| | - Hiromichi Suzuki
- Department of Infectious Diseases, University of Tsukuba School of Medicine and Health Sciences, Japan
| | - Atsushi Nakamura
- Department of Infection Prevention and Control, Graduate School of Medical Sciences, Nagoya City University, Japan
| | - Shigeru Fujimura
- Division of Clinical Infectious Diseases and Chemotherapy, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Japan
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Faculty of Pharmacy, Keio University, Japan
| | - Hiroshige Mikamo
- Department of Clinical Infectious Diseases, Aichi Medical University, Japan
| | | | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Minako Mori
- Department of Infection Control, Hiroshima University Hospital, Japan
| | - Yuka Yamagishi
- Department of Clinical Infectious Diseases, Kochi Medical School, Kochi University, Japan
| | - Sadako Yoshizawa
- Department of Laboratory Medicine/Department of Microbiology and Infectious Diseases, Faculty of Medicine, Toho University, Japan
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O’Grady K, Hong S, Putsathit P, George N, Hemphill C, Huntington PG, Korman TM, Kotsanas D, Lahra M, McDougall R, McGlinchey A, Levy A, Moore CV, Nimmo G, Prendergast L, Robson J, Speers DJ, Waring L, Wehrhahn MC, Weldhagen GF, Wilson RM, Riley TV, Knight DR. Defining the phylogenetics and resistome of the major Clostridioides difficile ribotypes circulating in Australia. Microb Genom 2024; 10:001232. [PMID: 38717815 PMCID: PMC11165652 DOI: 10.1099/mgen.0.001232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/27/2024] [Indexed: 06/13/2024] Open
Abstract
Clostridioides difficile infection (CDI) remains a significant public health threat globally. New interventions to treat CDI rely on an understanding of the evolution and epidemiology of circulating strains. Here we provide longitudinal genomic data on strain diversity, transmission dynamics and antimicrobial resistance (AMR) of C. difficile ribotypes (RTs) 014/020 (n=169), 002 (n=77) and 056 (n=36), the three most prominent C. difficile strains causing CDI in Australia. Genome scrutiny showed that AMR was uncommon in these lineages, with resistance-conferring alleles present in only 15/169 RT014/020 strains (8.9 %), 1/36 RT056 strains (2.78 %) and none of 77 RT002 strains. Notably, ~90 % of strains were resistant to MLSB agents in vitro, but only ~5.9 % harboured known resistance alleles, highlighting an incongruence between AMR genotype and phenotype. Core genome analyses revealed all three RTs contained genetically heterogeneous strain populations with limited evidence of clonal transmission between CDI cases. The average number of pairwise core genome SNP (cgSNP) differences within each RT group ranged from 23.3 (RT056, ST34, n=36) to 115.6 (RT002, ST8, n=77) and 315.9 (RT014/020, STs 2, 13, 14, 49, n=169). Just 19 clonal groups (encompassing 40 isolates), defined as isolates differing by ≤2 cgSNPs, were identified across all three RTs (RT014/020, n=14; RT002, n=3; RT056, n=2). Of these clonal groups, 63 % (12/19) comprised isolates from the same Australian State and 37 % (7/19) comprised isolates from different States. The low number of plausible transmission events found for these major RTs (and previously documented populations in animal and environmental sources/reservoirs) points to widespread and persistent community sources of diverse C. difficile strains as opposed to ongoing nationwide healthcare outbreaks dominated by a single clone. Together, these data provide new insights into the evolution of major lineages causing CDI in Australia and highlight the urgent need for enhanced surveillance, and for public health interventions to move beyond the healthcare setting and into a One Health paradigm to effectively combat this complex pathogen.
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Affiliation(s)
- Keeley O’Grady
- Centre for Biosecurity and One Health, Harry Butler Institute, Murdoch University, Murdoch, Western Australia, Australia
| | - Stacey Hong
- Communicable Disease Control Directorate, WA Department of Health, East Perth, Western Australia, Australia
| | - Papanin Putsathit
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Narelle George
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
| | | | - Peter G. Huntington
- Department of Microbiology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Tony M. Korman
- Monash University, Monash Health, Clayton, Victoria, Australia
| | - Despina Kotsanas
- Monash Infectious Diseases, Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Monica Lahra
- Department of Microbiology, The Prince of Wales Hospital, Randwick, New South Wales, Australia
| | | | | | - Avram Levy
- Department of Microbiology, PathWest Laboratory Medicine WA, Nedlands, Western Australia, Australia
| | - Casey V. Moore
- Microbiology and Infectious Diseases Laboratories, SA Pathology, Adelaide, South Australia, Australia
| | - Graeme Nimmo
- Pathology Queensland, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
| | | | - Jennifer Robson
- Sullivan Nicolaides Pathology, Taringa, Queensland, Australia
| | - David J. Speers
- Department of Microbiology, PathWest Laboratory Medicine WA, Nedlands, Western Australia, Australia
- School of Medicine, The University of Western Australia, Nedlands, Western Australia, Australia
| | | | | | - Gerhard F. Weldhagen
- Microbiology and Infectious Diseases Laboratories, SA Pathology, Adelaide, South Australia, Australia
| | - Richard M. Wilson
- Australian Clinical Labs, Microbiology Department, Wayville, South Australia, Australia
| | - Thomas V. Riley
- Centre for Biosecurity and One Health, Harry Butler Institute, Murdoch University, Murdoch, Western Australia, Australia
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
- Department of Microbiology, PathWest Laboratory Medicine WA, Nedlands, Western Australia, Australia
- School of Biomedical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Daniel R. Knight
- Department of Microbiology, PathWest Laboratory Medicine WA, Nedlands, Western Australia, Australia
- School of Biomedical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia
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Liu A, Chan E, Madigan V, Leung V, Dosvaldo L, Sherry N, Howden B, Bond K, Marshall C. Using whole genome sequencing to characterize Clostridioides difficile isolates at a tertiary center in Melbourne, Australia. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e7. [PMID: 38234420 PMCID: PMC10789990 DOI: 10.1017/ash.2023.529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 01/19/2024]
Abstract
Objective Clostridioides difficile infection (CDI) is the commonest cause of healthcare-associated diarrhea and undergoes standardized surveillance and mandatory reporting in most Australian states and territories. Historically attributed to nosocomial spread, local and international whole genome sequencing (WGS) data suggest varied sources of acquisition. This study describes C. difficile genotypes isolated at a tertiary center in Melbourne, Australia, their likely source of acquisition, and common risk factors. Design Retrospective observational study. Setting The Royal Melbourne Hospital (RMH), a 570-bed tertiary center in Victoria, Australia. Methods Short-read whole genome sequencing was performed on 75 out of 137 C. difficile isolates obtained from 1/5/2021 to 28/2/2022 and compared to previous data from 8/11/2015 to 1/11/2016. Existing data from infection control surveillance and electronic medical records were used for epidemiological and risk factor analysis. Results Eighty-five (62.1%) of the 137 cases were defined as healthcare-associated from epidemiological data. On genome sequencing, 33 different multi-locus sequence type (MLST) subtypes were identified, with changes in population structure compared to the 2015-16 period. Risk factors for CDI were present in 130 (94.9%) cases, including 108 (78.8%) on antibiotics, 86 (62.8%) on acid suppression therapy, and 25 (18.2) on chemotherapy. Conclusion In both study periods, most C. difficile isolates were not closely related, suggesting varied sources of acquisition and that spread of C. difficile within the hospital was unlikely. Current infection control precautions may therefore warrant review. Underlying risk factors for CDI were common and may contribute to the proportion of healthcare-associated infections in the absence of proven hospital transmission.
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Affiliation(s)
- Alice Liu
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Eddie Chan
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Victoria Madigan
- Infectious Diseases Department, The Northern Hospital, Melbourne, Victoria, Australia
| | - Vivian Leung
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Infection Prevention and Surveillance Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Lucille Dosvaldo
- Infection Prevention and Surveillance Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Norelle Sherry
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne, Victoria, Australia
| | - Benjamin Howden
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Microbiological Diagnostic Unit Public Health Laboratory, Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne, Victoria, Australia
| | - Katherine Bond
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Caroline Marshall
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Infection Prevention and Surveillance Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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Tan C, Zhu F, Xiao Y, Wu Y, Meng X, Liu S, Liu T, Chen S, Zhou J, Li C, Wu A. Immunoinformatics Approach Toward the Introduction of a Novel Multi-Epitope Vaccine Against Clostridium difficile. Front Immunol 2022; 13:887061. [PMID: 35720363 PMCID: PMC9204425 DOI: 10.3389/fimmu.2022.887061] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Clostridium difficile (C.difficile) is an exclusively anaerobic, spore-forming, and Gram-positive pathogen that is the most common cause of nosocomial diarrhea and is becoming increasingly prevalent in the community. Because C. difficile is strictly anaerobic, spores that can survive for months in the external environment contribute to the persistence and diffusion of C. difficile within the healthcare environment and community. Antimicrobial therapy disrupts the natural intestinal flora, allowing spores to develop into propagules that colonize the colon and produce toxins, thus leading to antibiotic-associated diarrhea and pseudomembranous enteritis. However, there is no licensed vaccine to prevent Clostridium difficile infection (CDI). In this study, a multi-epitope vaccine was designed using modern computer methods. Two target proteins, CdeC, affecting spore germination, and fliD, affecting propagule colonization, were chosen to construct the vaccine so that it could simultaneously induce the immune response against two different forms (spore and propagule) of C. difficile. We obtained the protein sequences from the National Center for Biotechnology Information (NCBI) database. After the layers of filtration, 5 cytotoxic T-cell lymphocyte (CTL) epitopes, 5 helper T lymphocyte (HTL) epitopes, and 7 B-cell linear epitopes were finally selected for vaccine construction. Then, to enhance the immunogenicity of the designed vaccine, an adjuvant was added to construct the vaccine. The Prabi and RaptorX servers were used to predict the vaccine's two- and three-dimensional (3D) structures, respectively. Additionally, we refined and validated the structures of the vaccine construct. Molecular docking and molecular dynamics (MD) simulation were performed to check the interaction model of the vaccine-Toll-like receptor (TLR) complexes, vaccine-major histocompatibility complex (MHC) complexes, and vaccine-B-cell receptor (BCR) complex. Furthermore, immune stimulation, population coverage, and in silico molecular cloning were also conducted. The foregoing findings suggest that the final formulated vaccine is promising against the pathogen, but more researchers are needed to verify it.
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Affiliation(s)
- Caixia Tan
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Fei Zhu
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Yuanyuan Xiao
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Yuqi Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Xiujuan Meng
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Sidi Liu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Ting Liu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Siyao Chen
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Juan Zhou
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Chunhui Li
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders (XiangYa Hospital), Changsha, China
| | - Anhua Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders (XiangYa Hospital), Changsha, China
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Martínez-Meléndez A, Cruz-López F, Morfin-Otero R, Maldonado-Garza HJ, Garza-González E. An Update on Clostridioides difficile Binary Toxin. Toxins (Basel) 2022; 14:toxins14050305. [PMID: 35622552 PMCID: PMC9146464 DOI: 10.3390/toxins14050305] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 01/01/2023] Open
Abstract
Infection with Clostridioides difficile (CDI), a common healthcare-associated infection, includes symptoms ranging from mild diarrhea to severe cases of pseudomembranous colitis. Toxin A (TcdA) and toxin B (TcdB) cause cytotoxicity and cellular detachment from intestinal epithelium and are responsible for CDI symptomatology. Approximately 20% of C. difficile strains produce a binary toxin (CDT) encoded by the tcdA and tcdB genes, which is thought to enhance TcdA and TcdB toxicity; however, the role of CDT in CDI remains controversial. Here, we focused on describing the main features of CDT and its impact on the host, clinical relevance, epidemiology, and potential therapeutic approaches.
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Affiliation(s)
- Adrián Martínez-Meléndez
- Subdirección Académica de Químico Farmacéutico Biólogo, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Pedro de Alba S/N, Cd Universitaria, San Nicolás de los Garza 66450, Nuevo Leon, Mexico; (A.M.-M.); (F.C.-L.)
| | - Flora Cruz-López
- Subdirección Académica de Químico Farmacéutico Biólogo, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Pedro de Alba S/N, Cd Universitaria, San Nicolás de los Garza 66450, Nuevo Leon, Mexico; (A.M.-M.); (F.C.-L.)
| | - Rayo Morfin-Otero
- Instituto de Patología Infecciosa y Experimental “Dr. Francisco Ruiz Sánchez”, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Calle Hospital 308, Colonia el Retiro, Guadalajara 44280, Jalisco, Mexico;
| | - Héctor J. Maldonado-Garza
- Servicio de Gastroenterología, Facultad de Medicina/Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero Pte. S/N y Av. José E. González, Col. Mitras Centro, Monterrey 64460, Nuevo Leon, Mexico;
| | - Elvira Garza-González
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina y Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero Pte. S/N y Av. José E. González, Col. Mitras Centro, Monterrey 64460, Nuevo Leon, Mexico
- Correspondence:
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6
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Linkage study of surveillance and hospital admission data to investigate Clostridium difficile infection in hospital patients in Perth, Western Australia. Anaerobe 2022; 74:102528. [PMID: 35104667 DOI: 10.1016/j.anaerobe.2022.102528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Increasing incidence rates of Clostridium difficile infection (CDI) and outbreaks of emerging strains have highlighted the need for continuous monitoring and surveillance of CDI in Australia. Active surveillance captures all hospital-identified CDI cases in Western Australia (WA), where all C. difficile isolates recovered are routinely PCR ribotyped. The aim of this study was to determine incidence rates and descriptive and molecular epidemiology of CDI among patients in Perth, WA using linkage of surveillance and hospital administrative records. METHODS All CDI cases (confirmed by tcdB PCR) from July 2012 to June 2014 captured in the Hospital Infection Surveillance WA dataset for three hospitals were linked with hospital admission records from the Patient Administration System and ribotyping data to calculate incidence rates of CDI and the distribution of various ribotypes (RTs). RESULTS There were 381 individual cases of CDI identified among 354 hospital patients (including outpatients and ED) who experienced ≥1 CDI episode during the study period. CDI was hospital-associated in 62.7% of cases and community-associated (CA)-CDI in 31.2%. The overall incidence rate was 4.40/10,000 patient days (PD, 95% CI 3.98-4.86), females across all age groups experienced higher incidence (risk ratio 1.29, p < 0.05). The risk ratio for CA-CDI was highest (7.76, p < 0.01) for females vs males aged 15-29 years. Overall, 10.8% of cases were admitted to ICU, 15.2% had a recurrent infection and the mortality rate was 7.2%. C. difficile RT 014/020 predominated (34.9%) among 339 isolates of 71 different RTs. CONCLUSIONS The incidence of CDI in WA is high and RT 014/020 continues to be the dominant molecular type in an otherwise diverse array of strains. High strain diversity suggests CDI cases arise from exposure to many different reservoirs.
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7
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Knight DR, Imwattana K, Kullin B, Guerrero-Araya E, Paredes-Sabja D, Didelot X, Dingle KE, Eyre DW, Rodríguez C, Riley TV. Major genetic discontinuity and novel toxigenic species in Clostridioides difficile taxonomy. eLife 2021; 10:64325. [PMID: 34114561 PMCID: PMC8241443 DOI: 10.7554/elife.64325] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 06/08/2021] [Indexed: 12/17/2022] Open
Abstract
Clostridioides difficile infection (CDI) remains an urgent global One Health threat. The genetic heterogeneity seen across C. difficile underscores its wide ecological versatility and has driven the significant changes in CDI epidemiology seen in the last 20 years. We analysed an international collection of over 12,000 C. difficile genomes spanning the eight currently defined phylogenetic clades. Through whole-genome average nucleotide identity, and pangenomic and Bayesian analyses, we identified major taxonomic incoherence with clear species boundaries for each of the recently described cryptic clades CI–III. The emergence of these three novel genomospecies predates clades C1–5 by millions of years, rewriting the global population structure of C. difficile specifically and taxonomy of the Peptostreptococcaceae in general. These genomospecies all show unique and highly divergent toxin gene architecture, advancing our understanding of the evolution of C. difficile and close relatives. Beyond the taxonomic ramifications, this work may impact the diagnosis of CDI.
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Affiliation(s)
- Daniel R Knight
- Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, Australia.,School of Biomedical Sciences, the University of Western Australia, Nedlands, Australia
| | - Korakrit Imwattana
- School of Biomedical Sciences, the University of Western Australia, Nedlands, Australia.,Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Brian Kullin
- Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Enzo Guerrero-Araya
- Microbiota-Host Interactions and Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile.,Millenium Nucleus in the Biology of Intestinal Microbiota, Santiago, Chile
| | - Daniel Paredes-Sabja
- Microbiota-Host Interactions and Clostridia Research Group, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile.,Millenium Nucleus in the Biology of Intestinal Microbiota, Santiago, Chile.,Department of Biology, Texas A&M University, College Station, United States
| | - Xavier Didelot
- School of Life Sciences and Department of Statistics, University of Warwick, Coventry, United Kingdom
| | - Kate E Dingle
- Nuffield Department of Clinical Medicine, University of Oxford, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - David W Eyre
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom
| | - César Rodríguez
- Facultad de Microbiología & Centro de Investigación en Enfermedades Tropicales (CIET), Universidad de Costa Rica, San José, Costa Rica
| | - Thomas V Riley
- Medical, Molecular and Forensic Sciences, Murdoch University, Murdoch, Australia.,School of Biomedical Sciences, the University of Western Australia, Nedlands, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia
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8
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High Prevalence of Clostridium difficile in Home Gardens in Western Australia. Appl Environ Microbiol 2020; 87:AEM.01572-20. [PMID: 33097511 DOI: 10.1128/aem.01572-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/14/2020] [Indexed: 01/05/2023] Open
Abstract
In recent years, community-associated Clostridium difficile infection (CA-CDI) has emerged as a significant health problem, accounting for ∼50% of all CDI cases. We hypothesized that the home garden environment could contribute to the dissemination of C. difficile spores in the community and investigated 23 homes in 22 suburbs of Perth, Western Australia. We identified a high prevalence of toxigenic C. difficile in this environment. In total, 97 samples consisting of soil (n = 48), compost (n = 15), manure (n = 12), and shoe sole swabs (n = 22) were collected. All samples were cultured anaerobically on C. difficile ChromID agar and enriched in brain heart infusion broth, and isolates were characterized by toxin gene PCR and PCR ribotyping. Two-thirds (67%; 95% confidence interval [CI], 57 to 76%) of home garden samples, including 79% (95% CI, 68 to 91%) of soil, 67% (95% CI, 43 to 90%) of compost, 83% (95% CI, 62% to 100%) of manure, and 32% (95% CI, 12 to 51%) of shoe sole samples, contained C. difficile Of 87 isolates, 38% (95% CI, 28 to 48%) were toxigenic, and 26 PCR ribotypes (RTs), 5 of which were novel, were identified. The toxigenic C. difficile strain RT014/020 was the most prevalent RT. Interestingly, 19 esculin hydrolysis-negative strains giving white colonies were identified on C. difficile ChromID agar, 5 of which were novel toxigenic RTs that produced only toxin A. Clearly, there is the potential for transmission of C. difficile in the community due to the contamination of home gardens. Our findings highlight the importance of a "One Health" approach to dealing with CDI.IMPORTANCE Recently, community-associated Clostridium difficile infection (CA-CDI) has emerged as a significant problem, accounting for ∼50% of all CDI cases and reported to affect a younger population without traditional risk factors. Possible sources of CA-CDI are soil, food, and water contaminated by animal feces, and recent reports show overlapping ribotypes of C. difficile in animals, humans, and the environment; however, the epidemiology of CA-CDI and related risk factors need to be better understood. Our research aimed to determine the prevalence of C. difficile in home gardens and on the shoe soles of homeowners in Perth, Western Australia. There were high rates of contamination with C. difficile in gardens, and some of the ribotypes identified had been isolated from human cases of CDI in Western Australia. This study shows that home gardens and shoes may be a source of C. difficile in CA-CDI.
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9
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Laboratory-Based Surveillance of Clostridium difficile Infection in Australian Health Care and Community Settings, 2013 to 2018. J Clin Microbiol 2020; 58:JCM.01552-20. [PMID: 32848038 DOI: 10.1128/jcm.01552-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/22/2020] [Indexed: 11/20/2022] Open
Abstract
In the early 2000s, a binary toxin (CDT)-producing strain of Clostridium difficile, ribotype 027 (RT027), caused extensive outbreaks of diarrheal disease in North America and Europe. This strain has not become established in Australia, and there is a markedly different repertoire of circulating strains there compared to other regions of the world. The C. difficile Antimicrobial Resistance Surveillance (CDARS) study is a nationwide longitudinal surveillance study of C. difficile infection (CDI) in Australia. Here, we describe the molecular epidemiology of CDI in Australian health care and community settings over the first 5 years of the study, 2013 to 2018. Between 2013 and 2018, 10 diagnostic microbiology laboratories from five states in Australia participated in the CDARS study. From each of five states, one private (representing community) and one public (representing hospitals) laboratory submitted isolates of C. difficile or PCR-positive stool samples during two collection periods per year, February-March (summer/autumn) and August-September (winter/spring). C. difficile was characterized by toxin gene profiling and ribotyping. A total of 1,523 isolates of C. difficile were studied. PCR ribotyping yielded 203 different RTs, the most prevalent being RT014/020 (n = 449; 29.5%). The epidemic CDT+ RT027 (n = 2) and RT078 (n = 6), and the recently described RT251 (n = 10) and RT244 (n = 6) were not common, while RT126 (n = 17) was the most prevalent CDT+ type. A heterogeneous C. difficile population was identified. C. difficile RT014/020 was the most prevalent type found in humans with CDI. Continued surveillance of CDI in Australia remains critical for the detection of emerging strain lineages.
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Martínez-Meléndez A, Morfin-Otero R, Villarreal-Treviño L, Baines SD, Camacho-Ortíz A, Garza-González E. Molecular epidemiology of predominant and emerging Clostridioides difficile ribotypes. J Microbiol Methods 2020; 175:105974. [PMID: 32531232 DOI: 10.1016/j.mimet.2020.105974] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/05/2020] [Accepted: 06/05/2020] [Indexed: 12/18/2022]
Abstract
There has been an increase in the incidence and severity of Clostridioides difficile infection (CDI) worldwide, and strategies to control, monitor, and diminish the associated morbidity and mortality have been developed. Several typing methods have been used for typing of isolates and studying the epidemiology of CDI; serotyping was the first typing method, but then was replaced by pulsed-field gel electrophoresis (PFGE). PCR ribotyping is now the gold standard method; however, multi locus sequence typing (MLST) schemes have been developed. New sequencing technologies have allowed comparing whole bacterial genomes to address genetic relatedness with a high level of resolution and discriminatory power to distinguish between closely related strains. Here, we review the most frequent C. difficile ribotypes reported worldwide, with a focus on their epidemiology and genetic characteristics.
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Affiliation(s)
- Adrián Martínez-Meléndez
- Universidad Autónoma de Nuevo León, Facultad de Ciencias Químicas, Pedro de Alba S/N, Ciudad Universitaria, CP 66450 San Nicolás de los Garza, Nuevo Leon, Mexico
| | - Rayo Morfin-Otero
- Hospital Civil de Guadalajara "Fray Antonio Alcalde" e Instituto de Patología Infecciosa y Experimental, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara. Sierra Mojada 950, Col. Independencia, CP 44350 Guadalajara, Jalisco, Mexico
| | - Licet Villarreal-Treviño
- Universidad Autónoma de Nuevo León, Facultad de Ciencias Biológicas, Departamento de Microbiología e Inmunología, Pedro de Alba S/N, Ciudad Universitaria, CP 66450 San Nicolás de los Garza, Nuevo Leon, Mexico
| | - Simon D Baines
- University of Hertfordshire, School of Life and Medical Sciences, Department of Biological and Environmental Sciences, Hatfield AL10 9AB, UK
| | - Adrián Camacho-Ortíz
- Universidad Autónoma de Nuevo León, Hospital Universitario "Dr. José Eleuterio González", Servicio de Infectología. Av. Francisco I. Madero Pte. S/N y Av. José E. González. Col. Mitras Centro, CP 64460 Monterrey, Nuevo Leon, Mexico
| | - Elvira Garza-González
- Universidad Autónoma de Nuevo León, Hospital Universitario "Dr. José Eleuterio González", Servicio de Infectología. Av. Francisco I. Madero Pte. S/N y Av. José E. González. Col. Mitras Centro, CP 64460 Monterrey, Nuevo Leon, Mexico.
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11
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Abstract
PURPOSE OF REVIEW The epidemiology of Clostridioides difficile infection (CDI) is changing, with increasing rates of community-acquired infections. In light of recent advances in understanding C. difficile transmission networks with whole-genome sequencing, new routes of spread outside the hospital need to be considered. This review examines the evidence behind food as a driver of C. difficile dissemination. RECENT FINDINGS Recently published studies adding to the existing body of literature supporting C. difficile as a foodborne pathogen are discussed. Specifically, new evidence on the presence of C. difficile in root vegetables is reviewed. Whole genome sequencing studies delineating local and global transmission networks, in which the food chain may play a large role, are presented. Additional research implicating trehalose in the food industry and C. difficile is examined. SUMMARY Genomic studies show that a new approach to studying C. difficile transmission is needed. Further research on C. difficile epidemiology should shift from a primarily nosocomial setting to include the community and environment at large, and attention given to implications of the food chain in the spread of this pathogen.
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12
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Lal A, Swaminathan A, Holani T. Spatial clusters of Clostridium difficile infection and an association with neighbourhood socio-economic disadvantage in the Australian Capital Territory, 2004-2014. Infect Dis Health 2019; 25:3-10. [PMID: 31680021 DOI: 10.1016/j.idh.2019.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND In Australia, rates of Clostridium difficile infection (CDI) in all States and Territories have increased significantly since mid-2011, with rates of infection increasing faster in the community setting than within hospitals. Knowledge about the risk factors for CDI is essential to determine the risk of community outbreaks of CDI and to design interventions that reduce those risks. METHODS We examine the role of neighbourhood socio-economic disadvantage, demography and testing practices on spatial patterns in CDI incidence in the Australian Capital Territory (ACT). Data on all tests conducted for CDI, including postcode of residence, were obtained from January 2004-December 2014. Distribution of age groups and the neighbourhood Index of Relative Socio-economic Advantage Disadvantage (IRSAD) were obtained from the Australian Bureau of Statistics 2011 National Census data. A Bayesian spatial conditional autoregressive model was fitted at the postcode level to quantify the relationship between CDI and socio-demographic factors. To identify CDI hotspots, exceedance probabilities were set at a threshold of twice the estimated relative risk. RESULTS After controlling for spatial patterns in testing practices, area-level socio-economic advantage (IRSAD) (RR = 0.74, 95% CI 0.57, 0.94) was inversely associated with CDI. Three postcodes had a high probability (0.8-1.0) of excess risk of diagnosed CDI. CONCLUSION We demonstrate geographic variations in CDI in the ACT with a positive association of CDI with neighbourhood socioeconomic disadvantage and identify areas with a high probability of elevated risk compared with surrounding communities. These findings provide further evidence to inform a targeted response to reduce CDI risk.
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Affiliation(s)
- Aparna Lal
- Research School of Population Health, Australian National University, Acton, Australia.
| | - Ashwin Swaminathan
- General Medicine & Infectious Diseases Physician, Canberra Hospital, Garran, Australia
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13
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Martin JSH, Eyre DW, Fawley WN, Griffiths D, Davies K, Mawer DPC, Peto TEA, Crook DW, Walker AS, Wilcox MH. Patient and Strain Characteristics Associated With Clostridium difficile Transmission and Adverse Outcomes. Clin Infect Dis 2019; 67:1379-1387. [PMID: 29659753 PMCID: PMC6186849 DOI: 10.1093/cid/ciy302] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 05/23/2018] [Indexed: 01/05/2023] Open
Abstract
Background No study has used whole-genome sequencing (WGS) to investigate risk factors for Clostridium difficile (CD) transmission between cases, or assessed the impact of recent acquisition on patient outcome. Methods This 20 month retrospective cohort study included consecutive cytotoxin-positive diarrheal samples, which underwent culture, ribotyping, and WGS (Illumina). Sequenced isolates were compared using single nucleotide variants (SNVs). Independent predictors of acquisition from another case, onward transmission, 120-day recurrence, and 30-day mortality were identified using logistic regression with backwards elimination. Results Of 660 CD cases, 640 (97%) were sequenced, of which 567 (89%) shared a ribotype with a prior case, but only 227 (35%) were ≤2 SNVs from a prior case, supporting recent acquisition. Plausible (<2 SNVs) recent ward-based acquisition from a symptomatic case was more frequent in certain ribotypes; 64% (67/105) for ribotype-027 cases, compared with 11% (6/57) for ribotype-078. Independent risk factors (adjusted P < .05) for CD acquisition included older age, longer inpatient duration, and ribotype; these factors, and male sex, increased onward transmission. Patients with a plausible donor had a greater risk of recurrence (adjusted P = .001) and trended towards greater 30-day mortality (adjusted P = .06). Ribotype had no additional mortality or recurrence impact after adjusting for acquisition (P > .1). Conclusions Greater transmission of certain lineages suggests CD may have different reservoirs and modes of transmission. Acquiring CD from a recent case is associated with poorer clinical outcomes. Clinical characteristics associated with increased healthcare-associated CD transmission could be used to target preventative interventions.
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Affiliation(s)
| | - David W Eyre
- Nuffield Department of Medicine, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, United Kingdom
| | - Warren N Fawley
- Public Health England-Leeds Regional Laboratory, United Kingdom
| | - David Griffiths
- Nuffield Department of Medicine, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, United Kingdom
| | - Kerrie Davies
- Leeds Teaching Hospitals & University of Leeds, United Kingdom
| | | | - Timothy E A Peto
- Nuffield Department of Medicine, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, United Kingdom
| | - Derrick W Crook
- Nuffield Department of Medicine, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, United Kingdom.,Public Health England, Colindale, United Kingdom
| | - A Sarah Walker
- Nuffield Department of Medicine, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, United Kingdom
| | - Mark H Wilcox
- Leeds Teaching Hospitals & University of Leeds, United Kingdom
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14
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Imwattana K, Knight DR, Kullin B, Collins DA, Putsathit P, Kiratisin P, Riley TV. Clostridium difficile ribotype 017 - characterization, evolution and epidemiology of the dominant strain in Asia. Emerg Microbes Infect 2019; 8:796-807. [PMID: 31138041 PMCID: PMC6542179 DOI: 10.1080/22221751.2019.1621670] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Clostridium difficile ribotype (RT) 017 is an important toxigenic C. difficile RT which, due to a deletion in the repetitive region of the tcdA gene, only produces functional toxin B. Strains belonging to this RT were initially dismissed as nonpathogenic and circulated largely undetected for almost two decades until they rose to prominence following a series of outbreaks in the early 2000s. Despite lacking a functional toxin A, C. difficile RT 017 strains have been shown subsequently to be capable of causing disease as severe as that caused by strains producing both toxins A and B. While C. difficile RT 017 strains can be found in almost every continent today, epidemiological studies suggest that the RT is endemic in Asia and that the global spread of this MLST clade 4 lineage member is a relatively recent event. C. difficile RT 017 transmission appears to be mostly from human to human with only a handful of reports of isolations from animals. An important feature of C. difficile RT 017 strains is their resistance to several antimicrobials and this has been documented as a possible factor driving multiple outbreaks in different parts of the world. This review summarizes what is currently known regarding the emergence and evolution of strains belonging to C. difficile RT 017 as well as features that have allowed it to become an RT of global importance.
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Affiliation(s)
- Korakrit Imwattana
- a School of Biomedical Sciences , The University of Western Australia , Crawley, Australia.,b Department of Microbiology, Faculty of Medicine Siriraj Hospital , Mahidol University , Bangkok, Thailand
| | - Daniel R Knight
- c School of Veterinary and Life Sciences , Murdoch University , Murdoch, Australia
| | - Brian Kullin
- d Department of Molecular and Cell Biology , University of Cape Town , Cape Town , South Africa
| | - Deirdre A Collins
- e School of Medical and Health Sciences , Edith Cowan University , Joondalup, Australia
| | - Papanin Putsathit
- e School of Medical and Health Sciences , Edith Cowan University , Joondalup, Australia
| | - Pattarachai Kiratisin
- b Department of Microbiology, Faculty of Medicine Siriraj Hospital , Mahidol University , Bangkok, Thailand
| | - Thomas V Riley
- a School of Biomedical Sciences , The University of Western Australia , Crawley, Australia.,c School of Veterinary and Life Sciences , Murdoch University , Murdoch, Australia.,e School of Medical and Health Sciences , Edith Cowan University , Joondalup, Australia.,f PathWest Laboratory Medicine , Queen Elizabeth II Medical Centre , Nedlands , Australia
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15
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Cao H, Wong SCY, Yam WC, Liu MCJ, Chow KH, Wu AKL, Ho PL. Genomic investigation of a sequence type 67 Clostridium difficile causing community-acquired fulminant colitis in Hong Kong. Int J Med Microbiol 2019; 309:270-273. [DOI: 10.1016/j.ijmm.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/24/2019] [Accepted: 05/10/2019] [Indexed: 12/20/2022] Open
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16
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Hong S, Knight DR, Chang B, Carman RJ, Riley TV. Phenotypic characterisation of Clostridium difficile PCR ribotype 251, an emerging multi-locus sequence type clade 2 strain in Australia. Anaerobe 2019; 60:102066. [PMID: 31260740 DOI: 10.1016/j.anaerobe.2019.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/18/2019] [Accepted: 06/27/2019] [Indexed: 02/07/2023]
Abstract
The global emergence of epidemic Clostridium difficile PCR ribotype (RT) 027 prompted enhanced surveillance of emerging strains. Recently, there have been reports of severe C. difficile infection in Australia caused by an unusual strain of C. difficile not seen previously. Identified as PCR RT251, this strain produces toxins A (TcdA) and B (TcdB), as well as binary toxin (CDT), and shares a common phylogenetic lineage with RT027. In this study, C. difficile RT251 strains were sourced from various geographical locations and potential virulence factors were evaluated and compared to that of control strains, CD630, VPI10463 and R20291 invitro. C. difficile RT251 strains were motile, germinated and sporulated efficiently, despite producing significantly less TcdA and TcdB compared to all control strains. Genomic analyses revealed three multi-locus sequence types (MLSTs 188, 231 and 365) with four to five loci variants compared to RT027 (ST1) all MLST clade 2. C. difficile RT251 strains were susceptible to metronidazole, vancomycin and moxifloxacin, a fluoroquinolone antimicrobial to which RT027 strains are often resistant. Further studies using whole-genome sequencing are required to determine additional virulence factors that may contribute to the pathogenicity of C. difficile RT251 strains.
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Affiliation(s)
- Stacey Hong
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, The University of Western Australia, Queen Elizabeth II Medical Centre, Nedlands, 6009, Western Australia, Australia
| | - Daniel R Knight
- Medical, Molecular and Forensic Sciences, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, 6105, Western Australia, Australia
| | - Barbara Chang
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, The University of Western Australia, Queen Elizabeth II Medical Centre, Nedlands, 6009, Western Australia, Australia
| | - Robert J Carman
- TechLab Inc., 2001 Kraft Drive, Blacksburg, VA, 24060-6359, USA
| | - Thomas V Riley
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, The University of Western Australia, Queen Elizabeth II Medical Centre, Nedlands, 6009, Western Australia, Australia; Medical, Molecular and Forensic Sciences, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, 6105, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Joondalup, 6027, Western Australia, Australia; PathWest Laboratory Medicine, Department of Microbiology, Queen Elizabeth II Medical Centre, Nedlands, 6009, Western Australia, Australia.
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17
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Knight DR, Riley TV. Genomic Delineation of Zoonotic Origins of Clostridium difficile. Front Public Health 2019; 7:164. [PMID: 31281807 PMCID: PMC6595230 DOI: 10.3389/fpubh.2019.00164] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/03/2019] [Indexed: 01/27/2023] Open
Abstract
Clostridium difficile is toxin-producing antimicrobial resistant (AMR) enteropathogen historically associated with diarrhea and pseudomembranous colitis in hospitalized patients. In recent years, there have been dramatic increases in the incidence and severity of C. difficile infection (CDI), and associated morbidity and mortality, in both healthcare and community settings. C. difficile is an ancient and diverse species that displays a sympatric lifestyle, establishing itself in a range of ecological niches external to the healthcare system. These sources/reservoirs include food, water, soil, and over a dozen animal species, in particular, livestock such as pigs and cattle. In a manner analogous to human infection, excessive antimicrobial exposure, particularly to cephalosporins, is driving the expansion of C. difficile in livestock populations worldwide. Subsequent spore contamination of meat, vegetables grown in soil containing animal feces, agricultural by-products such as compost and manure, and the environment in general (households, lawns, and public spaces) is contributing to a persistent community source/reservoir of C. difficile and the insidious rise of CDI in the community. The whole-genome sequencing era continues to redefine our view of this complex pathogen. The application of high-resolution microbial genomics in a One Health framework (encompassing clinical, veterinary, and environment derived datasets) is the optimal paradigm for advancing our understanding of CDI in humans and animals. This approach has begun to yield critical insights into the genetic diversity, evolution, AMR, and zoonotic potential of C. difficile. In Europe, North America, and Australia, microevolutionary analysis of the C. difficile core genome shows strains common to humans and animals (livestock or companion animals) do not form distinct populations but share a recent evolutionary history. Moreover, for C. difficile sequence type 11 and PCR ribotypes 078 and 014, major lineages of One Health importance, this approach has substantiated inter-species clonal transmission between animals and humans. These findings indicate either a zoonosis or anthroponosis. Moreover, they challenge the existing paradigm and the long-held misconception that CDI is primarily a healthcare-associated infection. In this article, evolutionary, and zoonotic aspects of CDI are discussed, including the anthropomorphic factors that contribute to the spread of C. difficile from the farm to the community.
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Affiliation(s)
- Daniel R Knight
- Medical, Molecular, and Forensic Sciences, Murdoch University, Perth, WA, Australia
| | - Thomas V Riley
- Medical, Molecular, and Forensic Sciences, Murdoch University, Perth, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia.,School of Biomedical Sciences, The University of Western Australia, Nedlands, WA, Australia.,PathWest Laboratory Medicine, Department of Microbiology, Nedlands, WA, Australia
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18
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Eyre DW, Didelot X, Buckley AM, Freeman J, Moura IB, Crook DW, Peto TEA, Walker AS, Wilcox MH, Dingle KE. Clostridium difficile trehalose metabolism variants are common and not associated with adverse patient outcomes when variably present in the same lineage. EBioMedicine 2019; 43:347-355. [PMID: 31036529 PMCID: PMC6558026 DOI: 10.1016/j.ebiom.2019.04.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/18/2019] [Accepted: 04/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridium difficile ribotype-027, ribotype-078, and ribotype-017 are virulent and epidemic lineages. Trehalose metabolism variants in these ribotypes, combined with increased human trehalose consumption, have been hypothesised to have contributed to their emergence and virulence. METHODS 5232 previously whole-genome sequenced C. difficile isolates were analysed. Clinical isolates were used to investigate the impact of trehalose metabolism variants on mortality. Import data were used to estimate changes in dietary trehalose. Ribotype-027 virulence was investigated in a clinically reflective gut model. FINDINGS Trehalose metabolism variants found in ribotype-027 and ribotype-017 were widely distributed throughout C. difficile clade-2 and clade-4 in 24/29 (83%) and 10/11 (91%) of sequence types (STs), respectively. The four-gene trehalose metabolism cluster described in ribotype-078 was common in genomes from all five clinically-important C. difficile clades (40/167 [24%] STs). The four-gene cluster was variably present in 208 ribotype-015 infections (98 [47%]); 27/208 (13%) of these patients died within 30-days of diagnosis. Adjusting for age, sex, and infecting ST, there was no association between 30-day all-cause mortality and the four-gene cluster (OR 0.36 [95%CI 0.09-1.34, p = 0.13]). Synthetic trehalose imports in the USA, UK, Germany and the EU were < 1 g/capita/year during 2000-2006, and < 9 g/capita/year 2007-2012, compared with dietary trehalose from natural sources of ~100 g/capita/year. Trehalose supplementation did not increase ribotype-027 virulence in a clinically-validated gut model. INTERPRETATION Trehalose metabolism variants are common in C. difficile. Increases in total dietary trehalose during the early-mid 2000s C. difficile epidemic were likely relatively minimal. Alternative explanations are required to explain why ribotype-027, ribotype-078 and ribotype-017 have been successful. FUNDING National Institute for Health Research. Gut model experiments only: Hayashibara Co. Ltd.
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Affiliation(s)
- David W Eyre
- Big Data Institute, University of Oxford, UK; Nuffield Department of Medicine, University of Oxford, UK.
| | - Xavier Didelot
- School of Life Sciences, Department of Statistics, University of Warwick, UK
| | - Anthony M Buckley
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
| | - Jane Freeman
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
| | - Ines B Moura
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
| | - Derrick W Crook
- Nuffield Department of Medicine, University of Oxford, UK; National Institutes of Health Research Health Protection Unit on Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, UK; National Institutes of Health Research Biomedical Research Centre, University of Oxford, UK
| | - Tim E A Peto
- Nuffield Department of Medicine, University of Oxford, UK; National Institutes of Health Research Health Protection Unit on Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, UK; National Institutes of Health Research Biomedical Research Centre, University of Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, UK; National Institutes of Health Research Health Protection Unit on Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, UK; National Institutes of Health Research Biomedical Research Centre, University of Oxford, UK
| | - Mark H Wilcox
- Healthcare Associated Infections Research Group, University of Leeds, Leeds, UK
| | - Kate E Dingle
- Nuffield Department of Medicine, University of Oxford, UK
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19
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High Clostridium difficile contamination rates of domestic and imported potatoes compared to some other vegetables in Slovenia. Food Microbiol 2019; 78:194-200. [DOI: 10.1016/j.fm.2018.10.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 09/06/2018] [Accepted: 10/29/2018] [Indexed: 01/04/2023]
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20
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Status of vaccine research and development for Clostridium difficile. Vaccine 2019; 37:7300-7306. [PMID: 30902484 DOI: 10.1016/j.vaccine.2019.02.052] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/21/2019] [Indexed: 12/15/2022]
Abstract
Clostridium difficile associated disease is fundamentally associated with dysbiosis of the gut microbiome as a consequence of antibiotic use. This is because this sporulating, obligate anaerobe germinates and proliferates rapidly in the dysbiotic gut, which is an indirect consequence of their use. During its growth, C. difficile produces two toxins, toxin A (TcdA) and toxin B (TcdB), which are responsible for the majority of clinical symptoms associated with the disease. Three parenterally delivered vaccines, based on detoxified or recombinant forms of these toxins, have undergone or are undergoing clinical trials. Each offers the opportunity to generate high titres of toxin neutralising antibodies. Whilst these data suggest these vaccines may reduce primary symptomatic disease, they do not in their current form reduce the capacity of the organism to persist and shed from the vaccinated host. The current progress of vaccine development is considered with advantages and limitations of each highlighted. In addition, several alternative approaches are described that seek to limit C. difficile germination, colonisation and persistence. It may yet prove that the most effective treatments to limit infection, disease and spread of the organism will require a combination of therapeutic approaches. The potential use and efficacy of these vaccines in low and middle income countries will be depend on the development of a cost effective vaccine and greater understanding of the distribution and extent of disease in these countries.
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21
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Clostridium difficile in Asia: Opportunities for One Health Management. Trop Med Infect Dis 2018; 4:tropicalmed4010007. [PMID: 30597880 PMCID: PMC6473466 DOI: 10.3390/tropicalmed4010007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 12/22/2018] [Accepted: 12/23/2018] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile is a ubiquitous spore-forming bacterium which causes toxin-mediated diarrhoea and colitis in people whose gut microflora has been depleted by antimicrobial use, so it is a predominantly healthcare-associated disease. However, there are many One Health implications to C. difficile, given high colonisation rates in food production animals, contamination of outdoor environments by use of contaminated animal manure, increasing incidence of community-associated C. difficile infection (CDI), and demonstration of clonal groups of C. difficile shared between human clinical cases and food animals. In Asia, the epidemiology of CDI is not well understood given poor testing practices in many countries. The growing middle-class populations of Asia are presenting increasing demands for meat, thus production farming, particularly of pigs, chicken and cattle, is rapidly expanding in Asian countries. Few reports on C. difficile colonisation among production animals in Asia exist, but those that do show high prevalence rates, and possible importation of European strains of C. difficile like ribotype 078. This review summarises our current understanding of the One Health aspects of the epidemiology of CDI in Asia.
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Wehrhahn MC, Keighley C, Kurtovic J, Knight DR, Hong S, Hutton ML, Lyras D, Wang Q, Leong R, Borody T, Edye M, Riley TV. A series of three cases of severe Clostridium difficile infection in Australia associated with a binary toxin producing clade 2 ribotype 251 strain. Anaerobe 2018; 55:117-123. [PMID: 30500477 DOI: 10.1016/j.anaerobe.2018.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 11/13/2018] [Accepted: 11/26/2018] [Indexed: 02/08/2023]
Abstract
Three patients with severe Clostridium difficile infection (CDI) caused by an unusual strain of C. difficile, PCR ribotype (RT) 251, were identified in New South Wales, Australia. All cases presented with severe diarrhoea, two had multiple recurrences and one died following a colectomy. C. difficile RT251 strains were isolated by toxigenic culture. Genetic characterisation was performed using techniques including toxin gene profiling, PCR ribotyping, whole genome sequencing (WGS), in-silico multi-locus-sequence-typing (MLST) and core-genome single nucleotide variant (SNV) analyses. Antimicrobial susceptibility was determined using an agar incorporation method. In vitro toxin production was confirmed by Vero cell cytotoxicity assay and pathogenicity was assessed in a murine model of CDI. All RT251 isolates contained toxin A (tcdA), toxin B (tcdB) and binary toxin (cdtA and cdtB) genes. Core-genome analyses revealed the RT251 strains were clonal, with 0-5 SNVs between isolates. WGS and MLST clustered RT251 in the same evolutionary clade (clade 2) as RT027. Despite comparatively lower levels of in vitro toxin production, in the murine model RT251 infection resembled RT027 infection. Mice showed marked weight loss, severe disease within 48 h post-infection and death. All isolates were susceptible to metronidazole and vancomycin. Our observations suggest C. difficile RT251 causes severe disease and emphasise the importance of ongoing surveillance for new and emerging strains of C. difficile with enhanced virulence.
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Affiliation(s)
- Michael C Wehrhahn
- Microbiology Department, Douglass Hanly Moir Pathology, Macquarie Park, NSW, Australia.
| | - Caitlin Keighley
- Centre for Infectious Diseases and Microbiology Laboratory Services, Westmead, NSW, Australia
| | - Jelica Kurtovic
- Gastrointestinal and Liver Unit, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Daniel R Knight
- School of Veterinary & Life Sciences, Murdoch University, Murdoch, WA, Australia
| | - Stacey Hong
- School of Biomedical Sciences, The University of Western Australia, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia
| | - Melanie L Hutton
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Qinning Wang
- Centre for Infectious Diseases and Microbiology Laboratory Services, Westmead, NSW, Australia
| | - Rupert Leong
- Macquarie GI, Macquarie University Hospital, NSW, Australia
| | - Tom Borody
- Centre for Digestive Diseases, Five Dock, NSW, Australia
| | - Michael Edye
- Blacktown Mount Druitt Clinical School, Western Sydney University, NSW, Australia
| | - Thomas V Riley
- School of Veterinary & Life Sciences, Murdoch University, Murdoch, WA, Australia; School of Biomedical Sciences, The University of Western Australia, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia; Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia; School of Medical & Health Sciences, Edith Cowan University, Joondalup, WA, Australia
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Brown AWW, Wilson RB. Clostridium difficile colitis and zoonotic origins-a narrative review. Gastroenterol Rep (Oxf) 2018; 6:157-166. [PMID: 30151199 PMCID: PMC6101521 DOI: 10.1093/gastro/goy016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/26/2018] [Accepted: 04/24/2018] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile is a major cause of hospital-associated diarrhoea, and in severe cases leads to pseudomembranous colitis and toxic megacolon. The frequency of C. difficile infection (CDI) has increased in recent decades, with 453 000 cases identified in 2011 in the USA. This is related to antibiotic-selection pressure, disruption of normal host intestinal microbiota and emergence of antibiotic-resistant C. difficile strains. The burden of community-acquired CDI has been increasingly appreciated, with disease identified in patients previously considered low-risk, such as young women or patients with no prior antibiotic exposure. C. difficile has been identified in livestock animals, meat products, seafood and salads. It has been postulated that the pool of C. difficile in the agricultural industry may contribute to human CDI. There is widespread environmental dispersal of C. difficile spores. Domestic households, turf lawns and public spaces are extensively contaminated, providing a potential reservoir for community-acquired CDI. In Australia, this is particularly associated with porcine-derived C. difficile UK PCR ribotype 014/020. In this article, the epidemiological differences between hospital- and community-acquired CDI are discussed, including some emerging evidence for community-acquired CDI being a possible zoonosis.
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Affiliation(s)
- Alexander W W Brown
- General Surgery Department, Liverpool Hospital, Elizabeth St, Liverpool, NSW, Australia
| | - Robert B Wilson
- General Surgery Department, Liverpool Hospital, Elizabeth St, Liverpool, NSW, Australia
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24
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Clostridium difficile Exposures, Colonization, and the Microbiome: Implications for Prevention. Infect Control Hosp Epidemiol 2018; 39:596-602. [PMID: 29553000 DOI: 10.1017/ice.2018.36] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
New studies have been published regarding the epidemiology of Clostridium difficile in topics such as asymptomatic C. difficile colonization, community-associated C. difficile infection, environmental contamination outside healthcare settings, animal colonization, and the interactions between C. difficile and the gut microbiome. In addition to summarizing these findings, this review offers a perspective on the potential impact of high-throughput sequencing and other potential techniques on the prevention of C. difficile.Infect Control Hosp Epidemiol 2018;39:596-602.
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Lim S, Foster N, Elliott B, Riley T. High prevalence ofClostridium difficileon retail root vegetables, Western Australia. J Appl Microbiol 2018; 124:585-590. [DOI: 10.1111/jam.13653] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 10/30/2017] [Accepted: 11/03/2017] [Indexed: 01/28/2023]
Affiliation(s)
- S.C. Lim
- The University of Western Australia; Nedlands WA Australia
| | - N.F. Foster
- PathWest Laboratory Medicine; Nedlands WA Australia
| | - B. Elliott
- Edith Cowan University; Joondalup WA Australia
| | - T.V. Riley
- The University of Western Australia; Nedlands WA Australia
- PathWest Laboratory Medicine; Nedlands WA Australia
- Edith Cowan University; Joondalup WA Australia
- Murdoch University; Murdoch WA Australia
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26
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Collins J, Robinson C, Danhof H, Knetsch C, van Leeuwen H, Lawley T, Auchtung J, Britton. R. Dietary trehalose enhances virulence of epidemic Clostridium difficile. Nature 2018; 553:291-294. [PMID: 29310122 PMCID: PMC5984069 DOI: 10.1038/nature25178] [Citation(s) in RCA: 242] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 11/28/2017] [Indexed: 12/24/2022]
Abstract
Clostridium difficile disease has recently increased to become a dominant nosocomial pathogen in North America and Europe, although little is known about what has driven this emergence. Here we show that two epidemic ribotypes (RT027 and RT078) have acquired unique mechanisms to metabolize low concentrations of the disaccharide trehalose. RT027 strains contain a single point mutation in the trehalose repressor that increases the sensitivity of this ribotype to trehalose by more than 500-fold. Furthermore, dietary trehalose increases the virulence of a RT027 strain in a mouse model of infection. RT078 strains acquired a cluster of four genes involved in trehalose metabolism, including a PTS permease that is both necessary and sufficient for growth on low concentrations of trehalose. We propose that the implementation of trehalose as a food additive into the human diet, shortly before the emergence of these two epidemic lineages, helped select for their emergence and contributed to hypervirulence.
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Affiliation(s)
- J. Collins
- Baylor College of Medicine, Department of Molecular Virology and
Microbiology
| | - C. Robinson
- University of Oregon, Institute for Molecular Biology
| | - H. Danhof
- Baylor College of Medicine, Department of Molecular Virology and
Microbiology
| | - C.W. Knetsch
- Leiden University Medical Centre, Department of Medical
Microbiology, The Netherlands
| | - H.C. van Leeuwen
- Leiden University Medical Centre, Department of Medical
Microbiology, The Netherlands
| | - T.D. Lawley
- Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus,
United Kingdom
| | - J.M. Auchtung
- Baylor College of Medicine, Department of Molecular Virology and
Microbiology
| | - R.A. Britton.
- Baylor College of Medicine, Department of Molecular Virology and
Microbiology
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27
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Abstract
PCR-ribotyping, a method based on heterogeneity of ribosomal intergenic spacer region, is the preferred method for genotyping of Clostridium difficile. Standardly used procedure for PCR-ribotyping is culturing of C. difficile from fecal samples and subsequent typing. In this chapter, we describe a modified PCR-ribotyping method for direct detection of PCR-ribotypes directly in total stool DNA extract, without prior need to isolate C. difficile.
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Affiliation(s)
- Sandra Janezic
- National Laboratory for Health, Environment and Food (NLZOH), Prvomajska 1, 2000, Maribor, Slovenia. .,Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000, Maribor, Slovenia.
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28
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Quainoo S, Coolen JPM, van Hijum SAFT, Huynen MA, Melchers WJG, van Schaik W, Wertheim HFL. Whole-Genome Sequencing of Bacterial Pathogens: the Future of Nosocomial Outbreak Analysis. Clin Microbiol Rev 2017; 30:1015-1063. [PMID: 28855266 PMCID: PMC5608882 DOI: 10.1128/cmr.00016-17] [Citation(s) in RCA: 228] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Outbreaks of multidrug-resistant bacteria present a frequent threat to vulnerable patient populations in hospitals around the world. Intensive care unit (ICU) patients are particularly susceptible to nosocomial infections due to indwelling devices such as intravascular catheters, drains, and intratracheal tubes for mechanical ventilation. The increased vulnerability of infected ICU patients demonstrates the importance of effective outbreak management protocols to be in place. Understanding the transmission of pathogens via genotyping methods is an important tool for outbreak management. Recently, whole-genome sequencing (WGS) of pathogens has become more accessible and affordable as a tool for genotyping. Analysis of the entire pathogen genome via WGS could provide unprecedented resolution in discriminating even highly related lineages of bacteria and revolutionize outbreak analysis in hospitals. Nevertheless, clinicians have long been hesitant to implement WGS in outbreak analyses due to the expensive and cumbersome nature of early sequencing platforms. Recent improvements in sequencing technologies and analysis tools have rapidly increased the output and analysis speed as well as reduced the overall costs of WGS. In this review, we assess the feasibility of WGS technologies and bioinformatics analysis tools for nosocomial outbreak analyses and provide a comparison to conventional outbreak analysis workflows. Moreover, we review advantages and limitations of sequencing technologies and analysis tools and present a real-world example of the implementation of WGS for antimicrobial resistance analysis. We aimed to provide health care professionals with a guide to WGS outbreak analysis that highlights its benefits for hospitals and assists in the transition from conventional to WGS-based outbreak analysis.
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Affiliation(s)
- Scott Quainoo
- Department of Microbiology, Radboud University, Nijmegen, The Netherlands
| | - Jordy P M Coolen
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Sacha A F T van Hijum
- Centre for Molecular and Biomolecular Informatics, Radboud University Medical Centre, Nijmegen, The Netherlands
- NIZO, Ede, The Netherlands
| | - Martijn A Huynen
- Centre for Molecular and Biomolecular Informatics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Willem J G Melchers
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Willem van Schaik
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, United Kingdom
| | - Heiman F L Wertheim
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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29
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Collins DA, Selvey LA, Celenza A, Riley TV. Community-associated Clostridium difficile infection in emergency department patients in Western Australia. Anaerobe 2017; 48:121-125. [PMID: 28807622 DOI: 10.1016/j.anaerobe.2017.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/02/2017] [Accepted: 08/08/2017] [Indexed: 02/03/2023]
Abstract
Clostridium difficile infection (CDI) is primarily associated with hospitalised patients, however, community-associated CDI (CA-CDI) has increased in Australia. We aimed to investigate the epidemiology and outcomes of CA-CDI cases presenting to hospital emergency departments in Western Australia (WA). A retrospective case-control study of CA-CDI cases presenting at six emergency departments in WA from July 2013 to June 2014 was performed. Clinical signs, recent medication, hospitalisations and potential risk factors for CA-CDI were investigated for cases (n = 34) and unmatched controls (n = 62) who were infected with another gastrointestinal pathogen, including Campylobacter spp., Salmonella spp., Aeromonas spp., Shigella sonnei and Escherichia coli O157. Elevated white cell count (31.3% vs 8.2%, p < 0.01), female gender (67.6% vs 41.9%, p < 0.05), age ≥65 years (41.2% vs 21.0%, p < 0.05) and antimicrobial use in the previous month (41.2% vs 11.3%, p < 0.01) were significantly more frequent among cases compared to controls. After multivariable analysis, antibiotic use (odds ratio 8.49, 95% confidence interval 2.75-26.21) and age ≥65 years (3.03, 1.05-8.75) were significantly associated with CA-CDI. Ribotype (RT) 014/020 was most common (40.7%) among 27 C. difficile isolates followed by RTs 002 (14.8%), 001, 056 and 244 (all 7.4%). CA-CDI was associated with advanced age and recent antibiotic use compared to those infected with other gastrointestinal pathogens. RT 014 has also recently been found at high prevalence in public lawn spaces, and previously RT 014 strains from humans and pigs in Australia were closely genetically related, suggesting CA-CDI may be linked with these community reservoirs.
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Affiliation(s)
- Deirdre A Collins
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia.
| | - Linda A Selvey
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Antonio Celenza
- Division of Emergency Medicine, School of Medicine, University of Western Australia, Australia
| | - Thomas V Riley
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia; Department of Microbiology, PathWest Laboratory Medicine (WA), Perth, Australia
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Nyc O, Tejkalova R, Kriz Z, Ruzicka F, Kubicek L, Matejkova J, Kuijper E, Krutova M. Two Clusters of Fluoroquinolone and Clindamycin-ResistantClostridium difficilePCR Ribotype 001 Strain Recognized by Capillary Electrophoresis Ribotyping and Multilocus Variable Tandem Repeat Analysis. Microb Drug Resist 2017; 23:609-615. [DOI: 10.1089/mdr.2016.0159] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Otakar Nyc
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
| | - Renata Tejkalova
- Department of Medical Microbiology, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdenek Kriz
- 2nd Department of Surgery, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Filip Ruzicka
- Department of Medical Microbiology, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lubos Kubicek
- 2nd Department of Surgery, St. Anne's University Hospital, and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jana Matejkova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
| | - Ed Kuijper
- Leiden University Medical Centre, Leiden, the Netherlands
| | - Marcela Krutova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
- DNA Laboratory, Department of Pediatric Neurology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
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31
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Cassir N, Fahsi N, Durand G, Lagier JC, Raoult D, Fournier PE. Emergence of Clostridium difficile tcdC variant 078 in Marseille, France. Eur J Clin Microbiol Infect Dis 2017; 36:1971-1974. [PMID: 28573471 DOI: 10.1007/s10096-017-3022-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/22/2017] [Indexed: 12/18/2022]
Abstract
The purpose of this investigation was to evaluate the epidemiology of hypervirulent Clostridium difficile ribotypes from January 2013 to February 2017 in the Marseille area of southern France. By using the Xpert Clostridium difficile Epi polymerase chain reaction (PCR) assay and sequencing the tcdC gene, we characterised C. difficile isolates from symptomatic patients diagnosed with C. difficile infection (CDI) in Marseille university hospitals. We first tested retrospectively 278 C. difficile samples isolated from January 2013 to December 2014 and observed a high prevalence of isolates with tcdC mutations and deletions previously described in both hypervirulent ribotypes RT027 and RT078 (16.4% and 10.7%, respectively). We highlighted the co-circulation of these two hypervirulent C. difficile tcdC variants (tV) with distinct epidemiological characteristics. While an RT027 outbreak occurred mainly as healthcare-associated infection in the elderly, CDI caused by tV078 occurred mainly in a younger population as community-associated infection. From January 2016, a systematic survey of these two hypervirulent C. difficile ribotypes revealed the emergence of CDI caused by tV078, currently being more prevalent than RT027 in the Marseille area. The present study is the first report of the emergence of CDI caused by tV078 in southern France. We showed the simultaneous circulation and sequential spread of hypervirulent ribotypes, such as RT027 and tV078. This emphasises the need for an efficient surveillance system for CDI with ribotyping and an optimised management of CDI caused by hypervirulent strains.
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Affiliation(s)
- N Cassir
- Unité de Recherche sur les Maladies Infectieuses Tropicales et Emergentes (URMITE), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, Institut Hospitalier Universitaire (IHU)-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseillle Cedex 05, France.
| | - N Fahsi
- Unité de Recherche sur les Maladies Infectieuses Tropicales et Emergentes (URMITE), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, Institut Hospitalier Universitaire (IHU)-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseillle Cedex 05, France
| | - G Durand
- Unité de Recherche sur les Maladies Infectieuses Tropicales et Emergentes (URMITE), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, Institut Hospitalier Universitaire (IHU)-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseillle Cedex 05, France
| | - J-C Lagier
- Unité de Recherche sur les Maladies Infectieuses Tropicales et Emergentes (URMITE), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, Institut Hospitalier Universitaire (IHU)-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseillle Cedex 05, France
| | - D Raoult
- Unité de Recherche sur les Maladies Infectieuses Tropicales et Emergentes (URMITE), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, Institut Hospitalier Universitaire (IHU)-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseillle Cedex 05, France
| | - P-E Fournier
- Unité de Recherche sur les Maladies Infectieuses Tropicales et Emergentes (URMITE), Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, Institut Hospitalier Universitaire (IHU)-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseillle Cedex 05, France.
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32
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Krutova M, Nyc O, Matejkova J, Kuijper EJ, Jalava J, Mentula S. The recognition and characterisation of Finnish Clostridium difficile isolates resembling PCR-ribotype 027. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 51:344-351. [PMID: 28583353 DOI: 10.1016/j.jmii.2017.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 01/03/2017] [Accepted: 02/06/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE To characterise and compare twenty-eight Finnish Clostridium difficile RT027-like isolates, selected based on the presence of 18 bp deletion in the tcdC gene and toxin gene profile (A, B, binary), with eleven RT027 isolates from different Finnish geographical areas and time periods. METHODS Twenty-eight C. difficile RT027-like isolates and 11 RT027 comparative strains were characterised by capillary-electrophoresis (CE) ribotyping, multi-locus variable tandem-repeats analysis (MLVA), multi-locus sequence typing (MLST), and sequencing of tcdC and gyrA gene fragments. Susceptibility to moxifloxacin was determined by E-test. RESULTS Of 28 RT027-like isolates, seven RTs (016, 034, 075, 080, 153, 176 and 328), three WEBRIBO types (411, 475, AI-78) and three new profiles (F1-F3) were identified. MLVA revealed six clonal complexes (RTs 016, 027, 176 and F3). MLST showed eleven sequence types (1, 41, 47, 67, 95, 191,192, 223, 229, 264 and new ST). Twenty-two isolates (RTs 016, 080, 176, 328, F1, F2, F3 and WRTAI-78) carried Δ117 in the tcdC gene. Isolates of RTs 016, 027 and 176 were moxifloxacin resistant and harboured Thr82Ile in the GyrA. CONCLUSION Our results show a high diversity within 28 Finnish RT027-like C. difficile isolates, with twelve CE-ribotyping profiles and eleven STs. MLVA revealed the regional spread of RTs 016, 027, 176 and F3. The presence of Δ117 in the tcdC gene in eight non-027 RTs highlights the importance of careful interpretation of the results from molecular systems targeting this site in the genome of C. difficile and the need of strain typing for epidemiological purposes.
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Affiliation(s)
- Marcela Krutova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic; DNA Laboratory, Department of Paediatric Neurology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic.
| | - Otakar Nyc
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic
| | - Jana Matejkova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Czech Republic
| | - Ed J Kuijper
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Jari Jalava
- Bacterial Infections Unit, Department of Infectious Diseases, National Institute for Health and Welfare, Helsinki, Finland
| | - Silja Mentula
- Bacterial Infections Unit, Department of Infectious Diseases, National Institute for Health and Welfare, Helsinki, Finland
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33
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Elliott B, Androga GO, Knight DR, Riley TV. Clostridium difficile infection: Evolution, phylogeny and molecular epidemiology. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2017; 49:1-11. [PMID: 28012982 DOI: 10.1016/j.meegid.2016.12.018] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 12/19/2016] [Accepted: 12/19/2016] [Indexed: 02/07/2023]
Abstract
Over the recent decades, Clostridium difficile infection (CDI) has emerged as a global public health threat. Despite growing attention, C. difficile remains a poorly understood pathogen, however, the exquisite sensitivity offered by next generation sequencing (NGS) technology has enabled analysis of the genome of C. difficile, giving us access to massive genomic data on factors such as virulence, evolution, and genetic relatedness within C. difficile groups. NGS has also demonstrated excellence in investigations of outbreaks and disease transmission, in both small and large-scale applications. This review summarizes the molecular epidemiology, evolution, and phylogeny of C. difficile, one of the most important pathogens worldwide in the current antibiotic resistance era.
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Affiliation(s)
- Briony Elliott
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia
| | - Grace O Androga
- School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Australia
| | - Daniel R Knight
- School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Australia
| | - Thomas V Riley
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, Australia; School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Australia; School of Veterinary and Life Sciences, Murdoch University, Murdoch, Australia; Department of Microbiology, PathWest Laboratory Medicine, Perth, Australia.
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34
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Laboratory-based surveillance of Clostridium difficile strains circulating in the Australian healthcare setting in 2012. Pathology 2017; 49:309-313. [PMID: 28237369 DOI: 10.1016/j.pathol.2016.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/04/2016] [Accepted: 10/12/2016] [Indexed: 11/24/2022]
Abstract
Clostridium difficile infection (CDI) has risen in prominence in Australia recently. We conducted laboratory-based surveillance of CDI to examine C. difficile circulating in Australia in October/November 2012. We collected 542 isolates from all States and Territories of Australia except the Northern Territory. The most common ribotypes (RTs) were RTs 014/020 (25.5%), 002 (10.5%), 056 (5.9%) and 070 (4.2%). The survey results were compared with results from a similar Australian survey conducted in 2010. Proportions of RTs 014/020 and 002 remained similar, while RTs 056 (5.9%), 015 (4.1%), 017 (3.3%) and 244 (2.4%) increased in prevalence. Basic clinical and demographic data were available for 338 cases. The majority were healthcare facility-associated (HCFA-CDI, 51.5%) while 17.5% were community-associated (CA-CDI). While no RTs were associated with CA-CDI, RTs 056 and 126 were recently found in Australian production animals, indicating a possible community health threat in Australia.
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35
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High prevalence of toxigenic Clostridium difficile in public space lawns in Western Australia. Sci Rep 2017; 7:41196. [PMID: 28145453 PMCID: PMC5286503 DOI: 10.1038/srep41196] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 12/15/2016] [Indexed: 01/05/2023] Open
Abstract
Clostridium difficile is a well-established hospital pathogen. Recently, it has been detected increasingly in patients without hospital contact. Given this rise in community associated infections with C. difficile, we hypothesized that the environment could play an important role in transmission of spores outside the hospital. Lawn samples (311) collected in public spaces in the metropolitan area of Perth, Western Australia, from February to June 2016 were cultured for C. difficile. C. difficile was isolated from the samples by direct and enrichment culture, and characterized by standard molecular methods using toxin gene PCR and ribotyping. The overall prevalence of C. difficile was 59%, new lawn (≤4 months old) was twice as likely as old lawn (>4 months old) to test positive (OR = 2.3; 95%CI 1.16-4.57, p = 0.015) and 35 C. difficile ribotypes were identified with toxigenic ribotype 014/020 (39%) predominating. The highest viable count from lawn soil samples was 1200 CFU/g. These results show that lawns in Perth, Western Australia, harbor toxigenic C. difficile, an important finding. The source of lawn contamination is likely related to modern practice of producing "roll-out" lawn. Further work should focus on identifying specific management practices that lead to C. difficile contamination of lawn to inform prevention and control measures.
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36
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Baro E, Galperine T, Denies F, Lannoy D, Lenne X, Odou P, Guery B, Dervaux B. Cost-Effectiveness Analysis of Five Competing Strategies for the Management of Multiple Recurrent Community-Onset Clostridium difficile Infection in France. PLoS One 2017; 12:e0170258. [PMID: 28103289 PMCID: PMC5245822 DOI: 10.1371/journal.pone.0170258] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/31/2016] [Indexed: 12/17/2022] Open
Abstract
Background Clostridium difficile infection (CDI) is characterized by high rates of recurrence, resulting in substantial health care costs. The aim of this study was to analyze the cost-effectiveness of treatments for the management of second recurrence of community-onset CDI in France. Methods We developed a decision-analytic simulation model to compare 5 treatments for the management of second recurrence of community-onset CDI: pulsed-tapered vancomycin, fidaxomicin, fecal microbiota transplantation (FMT) via colonoscopy, FMT via duodenal infusion, and FMT via enema. The model outcome was the incremental cost-effectiveness ratio (ICER), expressed as cost per quality-adjusted life year (QALY) among the 5 treatments. ICERs were interpreted using a willingness-to-pay threshold of €32,000/QALY. Uncertainty was evaluated through deterministic and probabilistic sensitivity analyses. Results Three strategies were on the efficiency frontier: pulsed-tapered vancomycin, FMT via enema, and FMT via colonoscopy, in order of increasing effectiveness. FMT via duodenal infusion and fidaxomicin were dominated (i.e. less effective and costlier) by FMT via colonoscopy and FMT via enema. FMT via enema compared with pulsed-tapered vancomycin had an ICER of €18,092/QALY. The ICER for FMT via colonoscopy versus FMT via enema was €73,653/QALY. Probabilistic sensitivity analysis with 10,000 Monte Carlo simulations showed that FMT via enema was the most cost-effective strategy in 58% of simulations and FMT via colonoscopy was favored in 19% at a willingness-to-pay threshold of €32,000/QALY. Conclusions FMT via enema is the most cost-effective initial strategy for the management of second recurrence of community-onset CDI at a willingness-to-pay threshold of €32,000/QALY.
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Affiliation(s)
- Emilie Baro
- Univ. Lille, CHU Lille, EA 2694 - Santé Publique: Epidémiologie et Qualité des Soins, Lille, France
- * E-mail:
| | - Tatiana Galperine
- CHU Lille, Maladies Infectieuses, French Group of Faecal Microbiota Transplantation (GFTF), Lille, France
| | - Fanette Denies
- CHU Lille, Direction de la Recherche en Santé, Lille, France
| | - Damien Lannoy
- Univ. Lille, CHU Lille, EA 7365 - GRITA - Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Xavier Lenne
- CHU Lille, Département d’Information Médicale, Lille, France
| | - Pascal Odou
- Univ. Lille, CHU Lille, EA 7365 - GRITA - Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Benoit Guery
- CHU Lille, Maladies Infectieuses, French Group of Faecal Microbiota Transplantation (GFTF), Lille, France
- Univ. Lille, CHU Lille, EA 7366 - Recherche Translationnelle: Relations Hôte-Pathogènes, Lille, France
| | - Benoit Dervaux
- Univ. Lille, CHU Lille, EA 2694 - Santé Publique: Epidémiologie et Qualité des Soins, Lille, France
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Knight DR, Squire MM, Collins DA, Riley TV. Genome Analysis of Clostridium difficile PCR Ribotype 014 Lineage in Australian Pigs and Humans Reveals a Diverse Genetic Repertoire and Signatures of Long-Range Interspecies Transmission. Front Microbiol 2017; 7:2138. [PMID: 28123380 PMCID: PMC5225093 DOI: 10.3389/fmicb.2016.02138] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 12/19/2016] [Indexed: 12/19/2022] Open
Abstract
Clostridium difficile PCR ribotype (RT) 014 is well-established in both human and porcine populations in Australia, raising the possibility that C. difficile infection (CDI) may have a zoonotic or foodborne etiology. Here, whole genome sequencing and high-resolution core genome phylogenetics were performed on a contemporaneous collection of 40 Australian RT014 isolates of human and porcine origin. Phylogenies based on MLST (7 loci, STs 2, 13, and 49) and core orthologous genes (1260 loci) showed clustering of human and porcine strains indicative of very recent shared ancestry. Core genome single nucleotide variant (SNV) analysis found 42% of human strains showed a clonal relationship (separated by ≤2 SNVs in their core genome) with one or more porcine strains, consistent with recent inter-host transmission. Clones were spread over a vast geographic area with 50% of the human cases occurring without recent healthcare exposure. These findings suggest a persistent community reservoir with long-range dissemination, potentially due to agricultural recycling of piggery effluent. We also provide the first pan-genome analysis for this lineage, characterizing its resistome, prophage content, and in silico virulence potential. The RT014 is defined by a large "open" pan-genome (7587 genes) comprising a core genome of 2296 genes (30.3% of the total gene repertoire) and an accessory genome of 5291 genes. Antimicrobial resistance genotypes and phenotypes varied across host populations and ST lineages and were characterized by resistance to tetracycline [tetM, tetA(P), tetB(P) and tetW], clindamycin/erythromycin (ermB), and aminoglycosides (aph3-III-Sat4A-ant6-Ia). Resistance was mediated by clinically important mobile genetic elements, most notably Tn6194 (harboring ermB) and a novel variant of Tn5397 (harboring tetM). Numerous clinically important prophages (Siphoviridae and Myoviridae) were identified as well as an uncommon accessory gene regulator locus (agr3). Conservation in the pathogenicity locus and S-layer correlated with ST affiliation, further extending the concept of clonal C. difficile lineages. This study provides novel insights on the genetic variability and strain relatedness of C. difficile RT014, a lineage of emerging One Health importance. Ongoing molecular and genomic surveillance of strains in humans, animals, food, and the environment is imperative to identify opportunities to reduce the overall CDI burden.
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Affiliation(s)
- Daniel R. Knight
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western AustraliaNedlands, WA, Australia
| | - Michele M. Squire
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western AustraliaNedlands, WA, Australia
| | - Deirdre A. Collins
- Microbiology and Immunology, School of Pathology and Laboratory Medicine, The University of Western AustraliaNedlands, WA, Australia
- Department of Population Health, School of Medical and Health Sciences, Edith Cowan UniversityJoondalup, WA, Australia
| | - Thomas V. Riley
- Department of Population Health, School of Medical and Health Sciences, Edith Cowan UniversityJoondalup, WA, Australia
- PathWest Laboratory Medicine, Department of Microbiology, Queen Elizabeth II Medical CentreNedlands, WA, Australia
- Department of Medical and Molecular Sciences, School of Veterinary and Life Sciences, Murdoch UniversityMurdoch, WA, Australia
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A population-based longitudinal study of Clostridium difficile infection-related hospitalization in mid-age and older Australians. Epidemiol Infect 2016; 145:575-582. [DOI: 10.1017/s0950268816002260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
SUMMARYClostridium difficile is the principal cause of infectious diarrhoea in hospitalized patients. We investigated the incidence and risk factors for hospitalization due to C. difficile infection (CDI) in older Australians. We linked data from a population-based prospective cohort study (the 45 and Up Study) of 266 922 adults aged ⩾45 years recruited in New South Wales, Australia to hospitalization and death records for 2006–2012. We estimated the incidence of CDI hospitalization and calculated days in hospital and costs per hospitalization. We also estimated hazard ratios (HR) for CDI hospitalization using Cox regression with age as the underlying time variable. Over a total follow-up of 1 126 708 person-years, 187 adults had an incident CDI hospitalization. The crude incidence of CDI hospitalization was 16·6/100 000 person-years, with a median hospital stay of 6 days, and a median cost of AUD 6102 per admission. Incidence increased with age and year of follow-up, with a threefold increase for 2009–2012. After adjustment, CDI hospitalization rates were significantly lower in males than females (adjusted HR 0·6, 95% confidence interval 0·4–0·7). CDI hospitalization rates increased significantly over 2009–2012. There is a need to better understand the increasing risk of CDI hospitalization in women.
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Park L, Mone A, Price JC, Tzimas D, Hirsh J, Poles MA, Malter L, Chen LA. Perceptions of fecal microbiota transplantation for Clostridium difficile infection: factors that predict acceptance. Ann Gastroenterol 2016; 30:83-88. [PMID: 28042242 PMCID: PMC5198252 DOI: 10.20524/aog.2016.0098] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 09/16/2016] [Indexed: 12/21/2022] Open
Abstract
Background Despite the effectiveness of fecal microbiota transplantation (FMT) for treating recurrent Clostridium difficile (C. difficile) infection, some patients are reluctant to accept this therapy. Our study examined attitudes towards FMT and factors that contribute to patients’ acceptance of this treatment. Methods We distributed patient surveys at a Veterans Affairs hospital, a public hospital, and an academic faculty practice. Multivariable logistic regression was performed, adjusting for factors associated with FMT acceptance on univariate analysis and prior experience with C. difficile infection. Results Of 267 patients, only 12% knew of FMT prior to the survey, but 77% would undergo the procedure if medically indicated. On multivariable analysis, those with children and with college degrees or higher were more likely to agree to FMT (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.02-4.35; OR 2.27, 95% CI 1.11-4.60 respectively). Sixty-five respondents (71%) chose colonoscopy as the preferred vehicle for FMT, while nasogastric tube was least preferred. Disease transmission was the most common concern (30%, n=242), and FMT success rate was the least selected concern (9.1%). Conclusions Most patients in a diverse sample of gastroenterology clinics had no prior knowledge of FMT, but were receptive to the procedure. Having children and higher education levels were predictors for FMT acceptance. Our findings suggest that barriers to FMT utilization may be overcome with counseling about safety concerns. More data on the risk of transmitting diseases or clinical characteristics, such as obesity, through FMT are needed and will be important for the acceptance of this procedure.
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Affiliation(s)
- Leslie Park
- Division of Gastroenterology, NYU Langone Medical Center, New York City, NY (Leslie Park, Anjali Mone, Demetrios Tzimas, Jacqueline Hirsh, Michael A. Poles, Lisa Malter, Lea Ann Chen)
| | - Anjali Mone
- Division of Gastroenterology, NYU Langone Medical Center, New York City, NY (Leslie Park, Anjali Mone, Demetrios Tzimas, Jacqueline Hirsh, Michael A. Poles, Lisa Malter, Lea Ann Chen)
| | - Jennifer C Price
- Division of Gastroenterology, University of California San Francisco, San Francisco, California (Jennifer C. Price), USA
| | - Demetrios Tzimas
- Division of Gastroenterology, NYU Langone Medical Center, New York City, NY (Leslie Park, Anjali Mone, Demetrios Tzimas, Jacqueline Hirsh, Michael A. Poles, Lisa Malter, Lea Ann Chen)
| | - Jacqueline Hirsh
- Division of Gastroenterology, NYU Langone Medical Center, New York City, NY (Leslie Park, Anjali Mone, Demetrios Tzimas, Jacqueline Hirsh, Michael A. Poles, Lisa Malter, Lea Ann Chen)
| | - Michael A Poles
- Division of Gastroenterology, NYU Langone Medical Center, New York City, NY (Leslie Park, Anjali Mone, Demetrios Tzimas, Jacqueline Hirsh, Michael A. Poles, Lisa Malter, Lea Ann Chen)
| | - Lisa Malter
- Division of Gastroenterology, NYU Langone Medical Center, New York City, NY (Leslie Park, Anjali Mone, Demetrios Tzimas, Jacqueline Hirsh, Michael A. Poles, Lisa Malter, Lea Ann Chen)
| | - Lea Ann Chen
- Division of Gastroenterology, NYU Langone Medical Center, New York City, NY (Leslie Park, Anjali Mone, Demetrios Tzimas, Jacqueline Hirsh, Michael A. Poles, Lisa Malter, Lea Ann Chen)
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Advances in the Microbiome: Applications to Clostridium difficile Infection. J Clin Med 2016; 5:jcm5090083. [PMID: 27657145 PMCID: PMC5039486 DOI: 10.3390/jcm5090083] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 09/02/2016] [Accepted: 09/13/2016] [Indexed: 12/14/2022] Open
Abstract
Clostridium difficile is a major cause of morbidity and mortality worldwide, causing over 400,000 infections and approximately 29,000 deaths in the United States alone each year. C. difficile is the most common cause of nosocomial diarrhoea in the developed world, and, in recent years, the emergence of hyper-virulent (mainly ribotypes 027 and 078, sometimes characterised by increased toxin production), epidemic strains and an increase in the number of community-acquired infections has caused further concern. Antibiotic therapy with metronidazole, vancomycin or fidaxomicin is the primary treatment for C. difficile infection (CDI). However, CDI is unique, in that, antibiotic use is also a major risk factor for acquiring CDI or recurrent CDI due to disruption of the normal gut microbiota. Therefore, there is an urgent need for alternative, non-antibiotic therapeutics to treat or prevent CDI. Here, we review a number of such potential treatments which have emerged from advances in the field of microbiome research.
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Furuya-Kanamori L, Clements ACA, Foster NF, Huber CA, Hong S, Harris-Brown T, Yakob L, Paterson DL, Riley TV. Asymptomatic Clostridium difficile colonization in two Australian tertiary hospitals, 2012-2014: prospective, repeated cross-sectional study. Clin Microbiol Infect 2016; 23:48.e1-48.e7. [PMID: 27615716 DOI: 10.1016/j.cmi.2016.08.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/28/2016] [Accepted: 08/31/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the prevalence and risk factors for asymptomatic toxigenic (TCD) and nontoxigenic Clostridium difficile (NTCD) colonization in a broad cross section of the general hospital population over a 3-year period. METHODS Patients without diarrhoea admitted to two Australian tertiary hospitals were randomly selected through six repeated cross-sectional surveys conducted between 2012 and 2014. Stool specimens were cultured under anaerobic conditions, and C. difficile isolates were tested for the presence of toxin genes and ribotyped. Patients were then grouped into noncolonized, TCD colonized or NTCD colonized for identifying risk factors using multinomial logistic regression models. RESULTS A total of 1380 asymptomatic patients were enrolled; 76 patients (5.5%) were TCD colonized and 28 (2.0%) were NTCD colonized. There was a decreasing annual trend in TCD colonization, and asymptomatic colonization was more prevalent during the summer than winter months. TCD colonization was associated with gastro-oesophageal reflux disease (relative risk ratio (RRR) = 2.20; 95% confidence interval (CI) 1.17-4.14), higher number of admissions in the previous year (RRR = 1.24; 95% CI 1.10-1.39) and antimicrobial exposure during the current admission (RRR = 2.78; 95% CI 1.23-6.28). NTCD colonization was associated with chronic obstructive pulmonary disease (RRR = 3.88; 95% CI 1.66-9.07) and chronic kidney failure (RRR = 5.78; 95% CI 2.29-14.59). Forty-eight different ribotypes were identified, with 014/020 (n = 23), 018 (n = 10) and 056 (n = 6) being the most commonly isolated. CONCLUSIONS Risk factors differ between patients with asymptomatic colonization by toxigenic and nontoxigenic strains. Given that morbidity is largely driven by toxigenic strains, this novel finding has important implications for disease control and prevention.
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Affiliation(s)
- L Furuya-Kanamori
- Research School of Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - A C A Clements
- Research School of Population Health, The Australian National University, Canberra, Australian Capital Territory, Australia.
| | - N F Foster
- Microbiology & Immunology, School of Pathology & Laboratory Medicine, The University of Western Australia, Australia; Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia
| | - C A Huber
- UQ Centre for Clinical Research, The University of Queensland, Herston, Queensland, Australia
| | - S Hong
- Microbiology & Immunology, School of Pathology & Laboratory Medicine, The University of Western Australia, Australia
| | - T Harris-Brown
- UQ Centre for Clinical Research, The University of Queensland, Herston, Queensland, Australia
| | - L Yakob
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - D L Paterson
- UQ Centre for Clinical Research, The University of Queensland, Herston, Queensland, Australia
| | - T V Riley
- Microbiology & Immunology, School of Pathology & Laboratory Medicine, The University of Western Australia, Australia; Department of Microbiology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, WA, Australia
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Vickers RJ, Tillotson G, Goldstein EJC, Citron DM, Garey KW, Wilcox MH. Ridinilazole: a novel therapy for Clostridium difficile infection. Int J Antimicrob Agents 2016; 48:137-43. [PMID: 27283730 DOI: 10.1016/j.ijantimicag.2016.04.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/22/2016] [Accepted: 04/23/2016] [Indexed: 12/15/2022]
Abstract
Clostridium difficile infection (CDI) is the leading cause of infectious healthcare-associated diarrhoea. Recurrent CDI increases disease morbidity and mortality, posing a high burden to patients and a growing economic burden to the healthcare system. Thus, there exists a significant unmet and increasing medical need for new therapies for CDI. This review aims to provide a concise summary of CDI in general and a specific update on ridinilazole (formerly SMT19969), a novel antibacterial currently under development for the treatment of CDI. Owing to its highly targeted spectrum of activity and ability to spare the normal gut microbiota, ridinilazole provides significant advantages over metronidazole and vancomycin, the mainstay antibiotics for CDI. Ridinilazole is bactericidal against C. difficile and exhibits a prolonged post-antibiotic effect. Furthermore, treatment with ridinilazole results in decreased toxin production. A phase 1 trial demonstrated that oral ridinilazole is well tolerated and specifically targets clostridia whilst sparing other faecal bacteria. Phase 2 and 3 trials will hopefully further our understanding of the clinical utility of ridinilazole for the treatment of CDI.
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Affiliation(s)
- Richard J Vickers
- Summit Therapeutics plc, 85b Park Drive, Milton Park, Abingdon, Oxford OX14 4RY, UK.
| | | | - Ellie J C Goldstein
- R.M. Alden Research Laboratory, Culver City, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, TX, USA
| | - Mark H Wilcox
- Microbiology, Leeds Teaching Hospitals and University of Leeds, Old Medical School, Leeds General Infirmary, Leeds, UK
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Fawley WN, Davies KA, Morris T, Parnell P, Howe R, Wilcox MH. Enhanced surveillance of Clostridium difficile infection occurring outside hospital, England, 2011 to 2013. Euro Surveill 2016; 21:30295. [DOI: 10.2807/1560-7917.es.2016.21.29.30295] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/18/2016] [Indexed: 12/20/2022] Open
Abstract
There are limited national epidemiological data for community-associated (CA)-Clostridium difficile infections (CDIs). Between March 2011 and March 2013, laboratories in England submitted to the Clostridium difficile Ribotyping Network (CDRN) up to 10 diarrhoeal faecal samples from successive patients with CA-CDI, defined here as C. difficile toxin-positive diarrhoea commencing outside hospital (or less than 48 hours after hospital admission), including those cases associated with community-based residential care, with no discharge from hospital within the previous 12 weeks. Patient demographics and C. difficile PCR ribotypes were compared for CA-CDIs in our study and presumed healthcare-associated (HA) CDIs via CDRN. Ribotype diversity indices, ranking and relative prevalences were very similar in CA- vs HA-CDIs, although ribotypes 002 (p ≤ 0.0001),020 (p = 0.009) and 056 (p < 0.0001) predominated in CA-CDIs; ribotype 027 (p = 0.01) predominated in HA-CDIs. Epidemic ribotypes 027 and 078 predominated in institutional residents with CDI (including care/nursing homes) compared with people with CDI living at home. Ribotype diversity decreased with increasing age in HA-CDIs, but not in CA-CDIs. Ribotype 078 CA-CDIs were significantly more common in elderly people (3.4% (6/174) vs 8.7% (45/519) in those aged < 65 and ≥ 65 years, respectively; p = 0.019). No antibiotics were prescribed in the previous four weeks in about twofold more CA-CDI vs HAs (38.6% (129/334) vs 20.3% (1,226/6,028); p < 0.0001). We found very similar ribotype distributions in CA- and HA-CDIs, although a few ribotypes significantly predominated in one setting. These national data emphasise the close interplay between, and likely common reservoirs for, CDIs, particularly when epidemic strains are not dominant.
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Affiliation(s)
- Warren N Fawley
- Public Health Laboratory Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Kerrie A Davies
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Trefor Morris
- UK Anaerobe Reference Unit (UKARU), Public Health Wales, Cardiff, United Kingdom
| | - Peter Parnell
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Robin Howe
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
| | - Mark H Wilcox
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Public Health Laboratory Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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Shin JH, Chaves-Olarte E, Warren CA. Clostridium difficile Infection. Microbiol Spectr 2016; 4:10.1128/microbiolspec.EI10-0007-2015. [PMID: 27337475 PMCID: PMC8118380 DOI: 10.1128/microbiolspec.ei10-0007-2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Indexed: 02/07/2023] Open
Abstract
Clostridium difficile is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus that has long been recognized to be the most common etiologic pathogen of antibiotic-associated diarrhea. C. difficile infection (CDI) is now the most common cause of health care-associated infections in the United States and accounts for 12% of these infections (Magill SS et al., N Engl J Med370:1198-1208, 2014). Among emerging pathogens of public health importance in the United States, CDI has the highest population-based incidence, estimated at 147 per 100,000 (Lessa FC et al., N Engl J Med372:825-834, 2015). In a report on antimicrobial resistance, C. difficile has been categorized by the Centers for Disease Control and Prevention as one of three "urgent" threats (http://www.cdc.gov/drugresistance/threat-report-2013/). Although C. difficile was first described in the late 1970s, the past decade has seen the emergence of hypertoxigenic strains that have caused increased morbidity and mortality worldwide. Pathogenic strains, host susceptibility, and other regional factors vary and may influence the clinical manifestation and approach to intervention. In this article, we describe the global epidemiology of CDI featuring the different strains in circulation outside of North America and Europe where strain NAP1/027/BI/III had originally gained prominence. The elderly population in health care settings has been disproportionately affected, but emergence of CDI in children and healthy young adults in community settings has, likewise, been reported. New approaches in management, including fecal microbiota transplantation, are discussed.
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Affiliation(s)
- Jae Hyun Shin
- Department of Medicine, Division of Infectious Disease and International Health, University of Virginia, Charlottesville, VA 22908
| | - Esteban Chaves-Olarte
- Centro de Investigación en Enfermedades Tropicales, Facultad de Microbiología, Universidad de Costa Rica, Costa Rica
| | - Cirle A Warren
- Department of Medicine, Division of Infectious Disease and International Health, University of Virginia, Charlottesville, VA 22908
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Abstract
Infection of the colon with the Gram-positive bacterium Clostridium difficile is potentially life threatening, especially in elderly people and in patients who have dysbiosis of the gut microbiota following antimicrobial drug exposure. C. difficile is the leading cause of health-care-associated infective diarrhoea. The life cycle of C. difficile is influenced by antimicrobial agents, the host immune system, and the host microbiota and its associated metabolites. The primary mediators of inflammation in C. difficile infection (CDI) are large clostridial toxins, toxin A (TcdA) and toxin B (TcdB), and, in some bacterial strains, the binary toxin CDT. The toxins trigger a complex cascade of host cellular responses to cause diarrhoea, inflammation and tissue necrosis - the major symptoms of CDI. The factors responsible for the epidemic of some C. difficile strains are poorly understood. Recurrent infections are common and can be debilitating. Toxin detection for diagnosis is important for accurate epidemiological study, and for optimal management and prevention strategies. Infections are commonly treated with specific antimicrobial agents, but faecal microbiota transplants have shown promise for recurrent infections. Future biotherapies for C. difficile infections are likely to involve defined combinations of key gut microbiota.
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Affiliation(s)
- Wiep Klaas Smits
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Dena Lyras
- Infection and Immunity Program, Monash Biomedicine Discovery Institute, and Department of Microbiology, Monash University, Victoria, Australia
| | - D. Borden Lacy
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, and The Veterans Affairs Tennessee Valley Healthcare System, Nashville Tennessee, USA
| | - Mark H. Wilcox
- Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Ed J. Kuijper
- Section Experimental Bacteriology, Department of Medical Microbiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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Clostridium difficile infection: epidemiology, diagnosis and understanding transmission. Nat Rev Gastroenterol Hepatol 2016; 13:206-16. [PMID: 26956066 DOI: 10.1038/nrgastro.2016.25] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Clostridium difficile infection (CDI) continues to affect patients in hospitals and communities worldwide. The spectrum of clinical disease ranges from mild diarrhoea to toxic megacolon, colonic perforation and death. However, this bacterium might also be carried asymptomatically in the gut, potentially leading to 'silent' onward transmission. Modern technologies, such as whole-genome sequencing and multi-locus variable-number tandem-repeat analysis, are helping to track C. difficile transmission across health-care facilities, countries and continents, offering the potential to illuminate previously under-recognized sources of infection. These typing strategies have also demonstrated heterogeneity in terms of CDI incidence and strain types reflecting different stages of epidemic spread. However, comparison of CDI epidemiology, particularly between countries, is challenging due to wide-ranging approaches to sampling and testing. Diagnostic strategies for C. difficile are complicated both by the wide range of bacterial targets and tests available and the need to differentiate between toxin-producing and non-toxigenic strains. Multistep diagnostic algorithms have been recommended to improve sensitivity and specificity. In this Review, we describe the latest advances in the understanding of C. difficile epidemiology, transmission and diagnosis, and discuss the effect of these developments on the clinical management of CDI.
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Worth LJ, Spelman T, Bull AL, Brett JA, Richards MJ. Epidemiology of Clostridium difficile infections in Australia: enhanced surveillance to evaluate time trends and severity of illness in Victoria, 2010-2014. J Hosp Infect 2016; 93:280-5. [PMID: 27107622 DOI: 10.1016/j.jhin.2016.03.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 03/08/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND With epidemic strains of Clostridium difficile posing a substantial healthcare burden internationally, there is a need for longitudinal evaluation of Clostridium difficile infection (CDI) events in Australia. AIM To evaluate time trends and severity of illness for CDI events in Australian healthcare facilities. METHODS All CDI events in patients admitted to Victorian public hospitals between 1(st) October 2010 and 31(st) December 2014 were reported to the Victorian Healthcare Associated Infection Surveillance System. CDI was defined as the isolation of a toxin-producing C. difficile organism in a diarrhoeal specimen, and classified as community-associated (CA-CDI) or healthcare-associated (HA-CDI). Severe disease was defined as admission to an intensive care unit, requirement for surgery and/or death due to infection. Time trends were examined using a mixed-effects Poisson regression model, and the Walter and Edward test of seasonality was applied to evaluate potential cyclical patterns. FINDINGS In total, 6736 CDI events were reported across 89 healthcare facilities. Of these, 4826 (71.6%) were HA-CDI, corresponding to a rate of 2.49/10,000 occupied bed days (OBDs). The incidence of HA-CDI was highest in the fifth quarter of surveillance (3.6/10,000 OBDs), followed by a reduction. Severe disease was reported in 1.66% of events, with the proportion being significantly higher for CA-CDI compared with HA-CDI (2.21 vs 1.45%, P = 0.03). The highest and lowest incidence of HA-CDI occurred in March and October, respectively. CONCLUSIONS A low incidence of HA-CDI was reported in Victoria compared with US/European surveillance reports. Seasonality was evident, together with diminishing HA-CDI rates in 2012-2014. Severe infections were more common in CA-CDI, supporting future enhanced surveillance in community settings.
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Affiliation(s)
- L J Worth
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia; Department of Medicine, University of Melbourne, Victoria, Australia.
| | - T Spelman
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia
| | - A L Bull
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia
| | - J A Brett
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia
| | - M J Richards
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia; Department of Medicine, University of Melbourne, Victoria, Australia
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Cheng AC, Collins DA, Elliott B, Ferguson JK, Paterson DL, Thean S, Riley TV. Laboratory-based surveillance of Clostridium difficile circulating in Australia, September - November 2010. Pathology 2016; 48:257-60. [PMID: 27020502 DOI: 10.1016/j.pathol.2016.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/05/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Abstract
Clostridium difficile rose in prominence in the early 2000s with large-scale outbreaks of a particular binary toxin-positive strain, ribotype 027, in North America and Europe. In Australia outbreaks of the same scale had not and have not been seen. A survey of C. difficile across Australia was performed for 1 month in 2010. A collection of 330 C. difficile isolates from all States and Territories except Victoria and the Northern Territory was amassed. PCR ribotyping revealed a diverse array of strains. Ribotypes 014/020 (30.0%) and 002 (11.8%) were most common, followed by 054 (4.2%), 056 (3.9%), 070 (3.6%) and 005 (3.3%). The collection also contained few binary toxin positive strains, namely 027 (0.9%), 078 (0.3%), 244 (0.3%), 251 (0.3%) and 127 (0.3%). The survey highlights the need for vigilance for emerging strains in Australia, and gives an overview of the molecular epidemiology of C. difficile in Australia prior to an increase in incidence noted from mid-2011.
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Affiliation(s)
- Allen C Cheng
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Infectious Diseases Unit, Alfred Hospital, Melbourne, Vic, Australia
| | - Deirdre A Collins
- School of Pathology and Laboratory Medicine, University of Western Australia, WA, Australia
| | - Briony Elliott
- School of Pathology and Laboratory Medicine, University of Western Australia, WA, Australia
| | - John K Ferguson
- Infection Prevention Service, Hunter New England Health, Newcastle, NSW, Australia; Hunter New England Health and University of Newcastle, John Hunter Hospital, Newcastle, NSW, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Sara Thean
- Department of Microbiology, PathWest Laboratory Medicine (WA), Perth, WA, Australia
| | - Thomas V Riley
- School of Pathology and Laboratory Medicine, University of Western Australia, WA, Australia; Department of Microbiology, PathWest Laboratory Medicine (WA), Perth, WA, Australia.
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49
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Collins DA, Riley TV. Routine detection of Clostridium difficile in Western Australia. Anaerobe 2016; 37:34-7. [DOI: 10.1016/j.anaerobe.2015.11.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 11/06/2015] [Accepted: 11/18/2015] [Indexed: 01/05/2023]
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Abstract
Clostridium difficile infection (CDI) is the leading cause of antimicrobial and health care-associated diarrhea in humans, presenting a significant burden to global health care systems. In the last 2 decades, PCR- and sequence-based techniques, particularly whole-genome sequencing (WGS), have significantly furthered our knowledge of the genetic diversity, evolution, epidemiology, and pathogenicity of this once enigmatic pathogen. C. difficile is taxonomically distinct from many other well-known clostridia, with a diverse population structure comprising hundreds of strain types spread across at least 6 phylogenetic clades. The C. difficile species is defined by a large diverse pangenome with extreme levels of evolutionary plasticity that has been shaped over long time periods by gene flux and recombination, often between divergent lineages. These evolutionary events are in response to environmental and anthropogenic activities and have led to the rapid emergence and worldwide dissemination of virulent clonal lineages. Moreover, genome analysis of large clinically relevant data sets has improved our understanding of CDI outbreaks, transmission, and recurrence. The epidemiology of CDI has changed dramatically over the last 15 years, and CDI may have a foodborne or zoonotic etiology. The WGS era promises to continue to redefine our view of this significant pathogen.
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