The Comparative Pathology of Clostridium difficile-associated Disease

Clostridium difficile is a confirmed pathogen in a wide variety of mammals, but the incidence of disease varies greatly in relation to host species, age, environmental density of spores, administration of antibiotics, and possibly, other factors. Lesions vary as well, in severity and distribution within individuals, and in some instances, age groups, of a given species. The cecum and colon are principally affected in most species, but foals and rabbits develop severe jejunal lesions. Explanations for variable susceptibility of species, and age groups within a species, are largely speculative. Differences in colonization rates and toxin-receptor densities have been proposed. Clostridium difficile-associated disease is most commonly diagnosed in Syrian hamsters, horses, and neonatal pigs, but it is reported sporadically in many other species. The essential virulence factors of C. difficile are large exotoxins, toxin A (TcdA) and toxin B (TcdB). Receptor-mediated endocytosis of the toxins is followed by endosomal acidification, a necessary step for conversion of the toxin to its active form in the cytosol. Cell-surface receptors have been characterized for TcdA, but remain to be identified for TcdB. Both TcdA and TcdB disrupt the actin cytoskeleton by disrupting Rho-subtype, intracellular signaling molecules. Disruption of the actin cytoskeleton is catastrophic for cellular function, but inflammation and neurogenic stimuli are also involved in the pathogenesis of the disease.

Evaluation of Five Enzyme Immunoassays Compared with the Cytotoxicity Assay for Diagnosis of Clostridium Difficile-Associated Diarrhea in Dogs

Clostridium difficile-associated-diarrhea (CDAD) is a nosocomial infection in dogs. Diagnosis of this infection is dependent on clinical signs of disease supported by laboratory detection of C. difficile toxins A or B, or both, in fecal specimens via enzyme-linked immunosorbent assay (ELISA). Unfortunately, to the authors' knowledge, commercially available ELISAs have not been validated in dogs to date. We evaluated 5 ELISAs done on 143 canine fecal specimens (100 diarrheic and 43 nondiarrheic dogs) and on 29 C. difficile isolates. The results of each ELISA were compared with the cytotoxin B tissue culture assay (CTA). Clostridium difficile was isolated from 23% of the fecal specimens. Eighteen of the 143 fecal specimens were toxin positive (15 diarrheic and 3 nondiarrheic dogs). On the basis of multiplex polymerase chain reaction (PCR) analysis for toxin-A and -B genes, 72% of the isolates were toxigenic. The carriage rate of toxigenic isolates in diarrheic dogs was higher than that in the nondiarrheic dogs; however, these differences were not statistically significant. A good correlation was found between CTA, PCR, and culture results. The ELISAs done on fecal specimens collected from diarrheic dogs had low sensitivity (7–33%). In contrast, ELISA for toxin A or B, or both, performed on toxigenic isolates had high sensitivity (93%). These results suggest that commercially available human ELISAs are inadequate for the diagnosis of canine C. difficile-associated diarrhea when tested on fecal specimens. In contrast, the Premier ToxinA/B and Techlab ToxinA/B ELISAs may be useful for the diagnosis of canine CDAD when used on toxigenic isolates.

A Prospective, Case Control Study Evaluating the Association between Clostridium Difficile Toxins in the Colon of Neonatal Swine and Gross and Microscopic Lesions

Clostridium difficile infection in swine has most often been described in suckling pigs, where it has been associated with mesocolonic edema and typhlocolitis. This prospective study was designed to assess the correlation between the presence of C. difficile toxins (TCd) in the colon contents of neonatal pigs and a number of parameters, including gross evidence of diarrhea, mesocoloninc edema, typhlitis, and colitis. C. difficile was isolated from 51% (66/129) of large intestines and TCd was detected in the colon contents of 50% (65/129) of the piglets. Fifty-eight percent (38/65) of TCd-positive piglets had normal to pelleted colon and rectal contents, whereas 75% (48/64) of TCd-negative pigs had gross evidence of diarrhea. Clostridium difficile toxin-positive animals were significantly more likely to have normal to pelleted feces. Edema of the mesocolon was observed in 38/65 (59%) of TCd-positive piglets. Because a high number of TCd-positive piglets (41%) lacked edema of the mesocolon and a high number of TCd-negative pigs had mesocolonic edema (51%), a statistically significant association between TCd and mesocolonic edema was not identified. Seventy-five percent (49/65) of TCd-positive piglets had colitis and 47/65 (72%) had typhlitis. The association between TCd and both colitis and typhlitis was statistically significant. Apparently healthy piglets were obtained from 5 separate sites. Because TCd was detected in the colon contents of 23/29 (79%) apparently healthy piglets obtained from 5 separate sites, and 70% of TCd-positive control pigs had colitis, C. difficile may represent an important subclinical issue in neonatal swine.

Postoperative Clostridium difficile infection with PCR ribotype 078 strain identified at necropsy in five Thoroughbred racehorses

Clostridium difficile is an important cause of acute enterocolitis in horses. We describe five cases of C difficile infection occurring postoperatively in Thoroughbred racehorses. Following diarrhoea or colic accompanied by a marked increase in packed cell volume (to ≥60 per cent) and leucopenia (≤4000 cells/μl) within two to four days after surgery in all five horses, four of them died or were euthanased because of colitis or severe diarrhoea. In these four horses, necrotising entero-typhlo-colitis was revealed by postmortem examination, and C difficile was recovered from the contents of the small and/or large intestine. The remaining horse was euthanased because of marked decline in general condition and the presence of a lung abscess, from which C difficile was isolated. The horse had had severe postoperative diarrhoea before the onset of respiratory disorder; laboratory tests for C difficile were not performed on the faeces. All C difficile isolates were toxin-A-positive, toxin-B-positive and actin-specific ADP-ribosyltransferase (CDT)-positive. The isolates were indistinguishable by pulsed field gel electrophoresis analysis, PCR ribotyping, and slpA sequence typing, and the slpA sequences and PCR ribotype patterns were identical to those of known PCR type 078. This case sequence might have been healthcare-associated infection, although there was about a four-month interval between each disease onset.

Prevalence of Clostridium difficile in horses

Fecal samples were collected to establish the apparent prevalence of Clostridium difficile shedding in Standardbred and Thoroughbred racehorses housed at 4 racetracks and 2 breeding facilities, and in horses admitted to a referral large animal clinic. Forty-one (7.59%) of 540 racetrack horses, seven (5.83%) of 120 breeding farm horses, and four (4.88%) out of 82 horses admitted to the referral clinic were culture-positive for C. difficile. An overall fecal culture prevalence of 7.01% for C. difficile was identified in 742 fecal samples. PCR-ribotyping and toxin gene identification was performed and seventeen 17 PCR-ribotypes were identified among the 52 C. difficile isolates.

Varied prevalence of Clostridium difficile in an integrated swine operation

The objectives of this study were to compare the prevalence of Clostridium difficile (Cd) among different age and production groups of swine in a vertically integrated swine operation in Texas in 2006 and to compare our isolates to other animal and human isolates. Results are based on 131 Cd isolates from 1008 swine fecal samples and pork trim samples (overall prevalence of 13%). The prevalence (number positive/number tested in production type) of Cd was different between the groups (P<or=0.001), and was highest among suckling piglets at 50.0% (61/122), followed by 23.8% (34/143) for lactating sows and effluent from the farrowing barn, 8.4% (10/119) for nursery, 6.5% (4/62) for pork products, 3.9% (15/382) for grower-finisher, and 3.9% (7/180) for breeding boars and sows. Of the 131 isolates, 122 were positive by PCR for both toxins A (tcdA) and B (tcdB) genes, 129 isolates harbored a 39 base pair deletion in the tcdC gene, 120 isolates were toxinotype V, and all 131 of the isolates were positive for the binary toxin gene cdtB. All isolates were resistant to cefoxitin, ciprofloxacin, and imipenem, whereas all were sensitive to metronidazole, piperacillin/tazobactam, amoxicillin/clavulanic acid, and vancomycin. The majority of isolates were resistant to clindamycin; resistant or intermediate to ampicillin; and sensitive to tetracycline and chloramphenicol. There was an increased (P</=0.001) number of isolates for the timeframe of September to February compared to March to August.

Diversity of Clostridium difficile in pigs and other animals in Slovenia

A study of Clostridium difficile diversity in pigs, calves and horses in Slovenia was conducted. A total of 547 samples were collected and C. difficile was isolated from 247/485 (50.9%) piglet samples, from 4/42 (9.5%) calf samples, and 1/20 (5%) horse samples. The isolates were characterized by toxinotyping, PCR-ribotyping, and pulsed-field gel electrophoresis (PFGE) using restriction endonuclease SmaI. Piglet isolates belonged to two toxinotypes (V and 0), four PCR-ribotypes (066, 029, SI 011, SI 010), and six pulsotypes. Bovine isolates were grouped into two toxinotypes (XIa and 0), three PCR-ribotypes (077, 002, 033), and three pulsotypes. The only equine isolate was indistinguishable from one calf isolate (XIa/033) in toxinotype, PCR-ribotype, and pulsotype. None of detected genotypes was present in all three animal hosts.

[Epidemiology of Clostridium difficile PCR ribotype 027 in the Netherlands 2005-present and the emergence of other subtypes]

Outbreaks of Clostridium difficile associated diarrhoea (CDAD) involving the virulent PCRribotype 027, toxinotype III were first reported in the Netherlands in 2005. This ribotype has now been detected in 26 of the 97 hospitals in the Netherlands. In 13 of the hospitals, the introduction of ribotype 027 was linked to increased CDAD incidence; this was found in 2 hospitals since December 2006. Ribotype 027 has also been detected in to nursing homes. In 2007, no evidence of ribotype 27 was found in 6 of the 12 hospitals in which ribotype 027 was confirmed in 2005-2006 and an outbreak of CDAD had occurred. The incidence of CDAD increased again in 2 hospitals that had previously had the epidemic well under control. Meanwhile, other PCR ribotypes appear to be gaining ground in the Netherlands, some of which have the same virulent characteristics as ribotype 027. Notably, ribotype 078, which appears to be associated with livestock, is becoming increasingly common.

Prevention of porcine Clostridium difficile-associated disease by competitive exclusion with nontoxigenic organisms

Clostridium difficile is widely known as a cause of disease in humans, and has emerged as an important problem in neonatal swine. No commercial product is available for immunoprophylaxis of C. difficile-associated disease, but success in preventing experimental infections in hamsters by use of nontoxigenic strains to competitively exclude toxigenic strains led us to try this method in neonatal pigs. Spores were administered orally to newborn pigs or were sprayed onto perineum and teats of dams. Significantly more piglets were weaned among litters receiving spores orally, and average weaning weights were significantly higher for both treatment groups than for controls. Toxins A and B were detected in 44.8% of litters and 16.5% of piglets born to sprayed sows and 58.3% of litters and 15.4% of piglets in the control group. However, toxins were detected in only 13.8% of litters and 3.4% of piglets given spores orally. These data support a contention that precolonization by a nontoxigenic strain can ameliorate the pre-weaning growth retardation associated with C. difficile infection in piglets.

Toxin production by and adhesive properties of Clostridium difficile isolated from humans and horses with antibiotic-associated diarrhea

Clostridium difficile is a common nosocomial pathogen in humans and animals that causes diarrhea and colitis following antibiotic therapy. Isolates of C. difficile obtained from faecal material from 20 human patients and 6 equine subjects with antibiotic-associated diarrhea were investigated regarding production of toxins A and B, their capacity to adhere to the human intestinal Caco-2 cell line and equine intestinal cells, and for the presence of fimbriae. The results showed that most (17/20) of the human clinical isolates produced both toxins A and B. One of the human isolates proved toxin A-negative/toxin B-positive. All (6/6) horse isolates were positive for both toxins A and B. Both the human and horse isolates possessed the capacity to adhere, to varying degree, to human and equine intestinal cells. It appeared that human isolates produced greater amounts of toxin B, and that there was a host-species dependency on ability to attach to intestinal epithelial cells. No fimbriae were found in any of the investigated isolates.

Prevalence of PCR ribotypes among Clostridium difficile isolates from pigs, calves, and other species

PCR ribotypes were obtained for 144 Clostridium difficile isolates from neonatal pigs. Porcine isolates comprised four PCR ribotypes, but one, ribotype 078, predominated (83%). This was also the most common ribotype (94%) among 33 calf isolates but was rarely identified in other species.

Natural and experimental infection of neonatal calves with Clostridium difficile

Clostridium difficile toxins were associated with calf diarrhea in a recent retrospective study; however, no causal relationship has been prospectively investigated. This infection study tested whether the oral inoculation of neonatal calves with a toxigenic strain of C. difficile (PCR-ribotype 077) results in enteric disease.

Fourteen 6–24 h old male colostrums-fed Holstein calves, received either three doses of C. difficile (1.4 × 10⁸ ± 3.5 × 10⁸ cfu) (n = 8) or sterile culture broth (n = 6). Calves were euthanized on day 6 or after the onset of diarrhea, whichever came first. Fecal and intestinal samples were blindly cultured for C. difficile, and tested for its toxin A/B (C. difficile TOX A/B II ELISA, Techlab). PCR-ribotyping was used to compare inoculated and recovered isolates.

Diarrhea was observed in all control calves and 3/8 of inoculated calves (p = 0.03), but it did not occur in calves that tested positive for C. difficile toxins. Fecal toxins were identified only from two controls. PCR-ribotyping confirmed the presence of C. difficile PCR-ribotype 077 in samples of all inoculated calves, but not from controls. The identification of five other PCR-ribotypes in 3/8 (37.5%) and 2/6 (33.3%) of inoculated and control calves, respectively, indicated early natural infection (≤24 h of age). Five of 14 cecal samples had C. difficile (p = 0.01). In conclusion, the oral administration of C. difficile PCR-ribotype 077 to neonatal calves resulted in fecal/intestinal colonization but not in detection of toxins, or signs of enteric disease. Further studies are required to investigate the clinical relevance of C. difficile in calves.

The emergence ofClostridium difficileas a pathogen of food animals

Clostridium difficilecauses pseudomembranous colitis in humans, usually after disruption of the bowel flora by antibiotic therapy. Factors mediating the frank disease include the dose and toxigenicity of the colonizing strain, its ability to adhere to colonic epithelium, the concurrent presence of organisms that affect multiplication and toxin production or activity, and the susceptibility of the host. Toxins A (an enterotoxin) and B (a cytotoxin) play the major role in pathogenesis and the detection of toxins in gut contents is the gold standard for diagnosis. Disease in horses takes the form of often-fatal foal hemorrhagic enteritis. Nosocomial, antibiotic-associated, disease is increasingly common in adult horses. Enteric clinical signs are reported in ostriches, companion animals and recently calves.Clostridium difficilecolitis is now a common diagnosis in neonatal pigs in the USA and elsewhere. Clinical features include onset at 1–5 days of age, sometimes with dyspnea, mild abdominal distension and scrotal edema, and commonly with yellow, pasty diarrhea. There is mesocolonic edema grossly, with microscopic diffuse colitis, mucosal edema, crypt distension, epithelial necrosis and superficial mucosal erosion. Neutrophil infiltration of the lamina propria is common, and fibrin and numerous rod-shaped bacteria are observed on the surface. About two-thirds of litters and one-third of piglets will be affected (based upon positive toxin tests), although this appears to vary with the season. The case fatality rate is probably low if considering only direct effects ofC. difficileinfection. The significance of toxin-positive non-diarrheic pigs and the nature of the interaction of toxins A and B with enterocytes are unknown. Given the widespread occurrence of the disease, there is substantial effort to develop immunoprophylactic products.

Molecular analysis of Clostridium difficile isolates recovered from horses with diarrhea

Clostridium difficile is an important cause of diarrhea in horses, causing sporadic and epidemic disease of varying severity. This study evaluated the molecular characteristics of 48 C. difficile isolates recovered from diarrheic horses admitted to a veterinary hospital by using PCR-ribotyping and toxin gene profile. Additionally, feces were tested for the presence of C. difficile toxin A/B via enzyme immunosorbant assay (EIA) in 38 horses. The toxin genes tcdA, tcdB and cdtB were present in 27 (56.25%), 35 (72.91%) and 2 (4.1%) strains, respectively. Eight isolates (16.6%) were A(-)B(+) variants. Thirteen of forty-eight isolates (27.0%) did not posses any toxin genes (A(-)B(-)CDT(-)). A positive EIA result was reported in 17 (44%) of the cases. There was no association between the presence of different ribotypes or strains and toxin gene(s) profiles and the clinical outcome.

Fatal enterocolitis in Asian elephants (Elephas maximus) caused by Clostridium difficile

Two cases of fatal enteritis caused by Clostridium difficile in captive Asian elephants are reported from an outbreak affecting five females in the same zoo. Post mortem examination including histopathology demonstrated fibrinonecrotic enterocolitis. C. difficile was isolated by selective cultivation from two dead and a third severely affected elephant. Four isolates were obtained and found positive for toxin A and B by PCR. All isolates were positive in a toxigenic culture assay and toxin was demonstrated in the intestinal content from one of the fatal cases and in a surviving but severely affected elephant. PCR ribotyping demonstrated that the C. difficile isolates shared an identical profile, which was different from an epidemiologically unrelated strain, indicating that the outbreak was caused by the same C. difficile clone. It is speculated that the feeding of large quantities of broccoli, a rich source of sulforaphane, which has been shown to inhibit the growth of many intestinal microorganisms may have triggered a subsequent overgrowth by C. difficile. This is the first report of C. difficile as the main cause of fatal enterocolitis in elephants. The findings emphasize the need to regard this organism as potentially dangerous for elephants and caution is recommended concerning antibiotic treatment and feeding with diets containing antimicrobials, which may trigger an expansion of a C. difficile population in the gut.

Clostridium difficile: An important pathogen of food animals

Human Clostridium difficile-associated disease (CDAD) is of unquestioned importance in humans, and has been a not-uncommon cause of enteric disease in horses, dogs, and ratites. Over the past 5 years, C. difficile has emerged as a major cause of neonatal enteritis in pigs. Piglets 1-7 days of age are affected, with gross lesions frequently including mesocolonic edema. Colonic contents may be pasty-to-watery and yellow, although some piglets are constipated or obstipated. Focal suppuration and segmental necrosis are seen on microscopic examination of cecal and colonic lamina propria, and exudation of neutrophils and fibrin into the lumen gives rise to the so-called volcano lesions. Results of one study revealed that more than one-third of piglets with enteritis were affected by C. difficile alone, while an additional quarter of affected piglets may have had mixed infections. C. difficile may be the most important uncontrolled cause of neonatal diarrhea in pigs.

Suspected Clostridium difficile-associated hemorrhagic diarrhea in a 1-week-old elk calf

Clostridium difficile-associated diarrhea was suspected in a 1-week-old elk (Cervus elaphus) calf. The isolation of a toxigenic strain of C. difficile from a diarrheic fecal sample, along with exclusion of other enteropathogens, formed the basis of this presumptive diagnosis. Further study is indicated to evaluate the role of C. difficile in neonatal diarrhea in elk.

Early qualitative risk assessment of the emerging zoonotic potential of animal diseases

Most new human infections are of animal origin, but there is rarely sufficient evidence to make a risk assessment of the zoonotic potential of emerging animal diseases. An algorithm for early qualitative public health risk assessment has been developed to guide risk management

Clostridium difficile diarrhea: infection control in horses

C difficile has emerged as an important cause of diarrheic disease in horses. C difficile diarrhea is usually diagnosed in mature horses, mostly when they are treated with antimicrobials and hospitalized. It is important for clinicians at veterinary hospitals to have knowledge about the organism and the infection. To prevent C difficile diarrhea, judicious use of antimicrobials is important, as is minimizing different stress factors at the animal hospital or clinic. Infected horses must be isolated. Routine examination for C difficile and toxin A or B is recommended in horses with antibiotic-associated diarrhea. When treating foals for R equi pneumonia, it is important to avoid accidental ingestion of erythromycin by the dams. To reduce the number of environmental spores, thorough cleaning and surface disinfection of the animal hospital and clinic are important. Routine handwashing should be performed by all staff.

Experimental Clostridium difficile enterocolitis in foals

Despite empirical clinical association of infection with Clostridium difficile with colitis in horses, a causal link has not been confirmed. The objective of this study was to develop a model of C. difficile-associated diarrhea in foals with normal transfer of passive immunity. Nine 1-day-old pony foals were inoculated intragastrically with spores or vegetative cells of C. difficile. Five foals were challenged with spores, with 2 receiving 10(5) colony-forming units (CFUs) and concurrently 3 receiving 10(7) CFUs once daily for 3 days. Clindamycin was administered orally to disrupt gastrointestinal flora. A further 4 foals were challenged by orogastric administration of 10(10) CFUs of vegetative cells once daily for 3 days or until diarrhea developed. This group did not receive clindamycin. Spore and vegetative cell preparations were negative for toxins of C. difficile and common enteropathogens. Clinical signs varied from mild abdominal discomfort and pasty feces to colic and watery diarrhea in 8 of 9 foals. Four of 5 foals challenged with spores developed mild diarrhea, whereas all foals challenged with vegetative cells developed moderate to severe diarrhea. C. difficile was isolated from feces of all foals between 24 and 72 hours after inoculation and toxins A or B or both were detected in the feces of all foals by an enzyme-linked immunosorbent assay. We concluded that spores and vegetative cells of C. difficile are capable of colonizing the gastrointestinal tract, producing toxins, and inducing clinical signs similar to those encountered in naturally occurring cases. This study fulfilled Koch's postulates for C. difficile-associated diarrhea in foals and provides a model for consistent reproduction of the disease for future studies.

Clostridium difficile: prevalence in horses and environment, and antimicrobial susceptibility

REASONS FOR PERFORMING STUDY

Clostridium difficile has been associated with acute colitis in mature horses.

OBJECTIVES

To survey C. difficile colonisation of the alimentary tract with age, occurrence of diarrhoea and history of antibiotic therapy; and to study the occurrence and survival of C. difficile in the environment and antimicrobial susceptibility of isolated strains.

METHODS

A total of 777 horses of different breeds, age and sex were studied. Further, 598 soil samples and 434 indoor surface samples were examined. Antimicrobial susceptibility of 52 strains was investigated by Etest for 10 antibiotics.

RESULTS

In horses that developed acute colitis during antibiotic treatment, 18 of 43 (42%) were positive to C. difficile culture and 12 of these (28%) were positive in the cytotoxin B test. Furthermore, C. difficile was isolated from a small number of diarrhoeic mature horses (4 of 72 [6%]) with no history of antibiotic treatment, but not from 273 healthy mature horses examined or 65 horses with colic. An interesting new finding was that, in normal healthy foals age < 14 days, C. difficile was isolated from 1/3 of foals (16 of 56 [29%]). All older foals (170) except one were negative. Seven of 16 (44%) nondiarrhoeic foals treated with erythromycin or gentamicin in combination with rifampicin were also excretors of C. difficile. On studfarms, 14 of 132 (11%) outdoor soil samples were positive for C. difficile in culture, whereas only 2 of 220 (1%) soil samples from farms with mature horses were positive for C. difficile (P = < 0.001). By PCR, it was demonstrated that strains from the environment and healthy foals can serve as a potential reservoir of toxigenic C. difficile. The experimental study conducted here found that C. difficile survived in nature and indoors for at least 4 years in inoculated equine faeces. The susceptibility of 52 strains was investigated for 10 antibiotics and all were susceptible to metronidazole (MIC < or = 4 mg/l) and vancomycin (MIC < or = 2 mg/l).

CONCLUSIONS

C. difficile is associated with acute colitis in mature horses, following antibiotic treatment. Furthermore, C. difficile was isolated from 1 in 3 normal healthy foals age < 14 days.

POTENTIAL RELEVANCE

Strains from healthy foals and the environment can serve as a potential reservoir of toxigenic C. difficile.

Clostridium difficile infections in animals with special reference to the horse. A review

In human medicine, Clostridium (C.) difficile is since many years a well-known cause of nosocomial diarrhea induced by antibiotic treatment. In horses, C. difficile was recently suggested as a possible enteric pathogen. The bacterium is associated with acute colitis in mature horses following treatment with antibiotics. C. difficile, and/or its cytotoxin, is also associated with acute colitis in mares when their foals are being treated with erythromycin and rifampicin for Rhodococcus equi pneumonia. The colitis can have resulted from an accidental ingestion of erythromycin by the mares. In an experimental study it was also demonstrated in mature horses that erythromycin can induce severe colitis associated with proliferation of C. difficile. A new interesting finding was that in healthy foals younger than 14 days, C. difficile was isolated from every third foal whereas older foals proved negative. In this paper the current state of knowledge of C. difficile infections in animals, especially in horses, is reviewed. A short description is given of the historical background of Clostridium difficile and the antibiotic-associated colitis and diarrhea caused by infection with this bacterium. The taxonomy of Clostridium difficile is described extensively. A summary is given of the diseases associated with clostridia infections in animals. Special attention is paid to the pathogenesis, epidemiology, clinical symptoms, laboratory diagnosis, and pathology of Clostridium difficile infections in horses. Finally, some other bacterial causes of colitis in horses are discussed shortly.

A survey of agents associated with neonatal diarrhea in Iowa swine including Clostridium difficile and porcine reproductive and respiratory syndrome virus

This survey was undertaken to determine the relative frequency of agents that are currently associated with neonatal diarrhea in swine, including Clostridium difficile and porcine reproductive and respiratory syndrome virus (PRRSV). The subjects for this study were the first 100 live 1-7-day-old piglets submitted to the Iowa State University Veterinary Diagnostic Laboratory with a clinical signalment of diarrhea, beginning on January 1, 2000. The evaluation of each pig included bacterial culture of a section of ileum, 2 sections of jejunum, and a single section of colon; a fluorescent antibody test (FAT) or immunohistochemistry (IHC) for transmissible gastroenteritis virus (TGEV); ELISA's for rotavirus and C. difficile toxins; IHC for PRRSV; and microscopic examination of ileum, midjejunum, spiral colon, liver, spleen, and lung. Survey results demonstrate a decline in the relative number of diagnoses of TGEV, Escherichia coli, and Clostridium perfringens type C compared with retrospective data. The combined case frequency rate for these 3 pathogens dropped from 70% in 1988 to 21% in 2000. This survey also demonstrated the emergence of C. difficile as an important pathogen of neonatal swine. Clostridium difficle toxin was detected in the colon contents of 29% of the piglets, and at least 1 toxin-positive animal was identified in 55% of the cases. All 29 C. difficile toxin-positive piglets had mesocolonic edema, and colitis was observed in 21 of 29 toxin-positive animals. PRRSV-positive macrophages were detected in the lamina propria of intestinal villi by IHC in 10 piglets with diarrhea. In 6 of these cases, PRRSV was the only pathogen detected. Gross and microscopic lung lesions were not a reliable indicator of PRRSV infection in these neonatal pigs with diarrhea. The addition of tests for C. difficile and PRRSV to a routine neonatal diarrhea diagnostic protocol resulted in a significant increase in thediagnostic success rate on both individual animal and case bases.

The first strain of Clostridium perfringens isolated from an avian source has an alpha-toxin with divergent structural and kinetic properties

Clostridium perfringens alpha-toxin is a 370-residue, zinc-dependent, phospholipase C that is the key virulence determinant in gas gangrene. It is also implicated in the pathogenesis of sudden death syndrome in young animals and necrotic enteritis in chickens. Previously characterized alpha-toxins from different strains of C. perfringens are almost identical in sequence and biochemical properties. We describe the cloning, nucleotide sequencing, expression, characterization, and crystal structure of alpha-toxin from an avian strain, SWan C. perfringens (SWCP), which has a large degree of sequence variation and altered substrate specificity compared to these strains. The structure of alpha-toxin from strain CER89L43 has been previously reported in open (active site accessible to substrate) and closed (active site obscured by loop movements) conformations. The SWCP structure is in an open-form conformation, with three zinc ions in the active site. This is the first example of an open form of alpha-toxin crystallizing without the addition of divalent cations to the crystallization buffer, indicating that the protein can retain three zinc ions bound in the active site. The topology of the calcium binding site formed by residues 269, 271, 336, and 337, which is essential for membrane binding, is significantly altered in comparison with both the open and closed alpha-toxin structures. We are able to relate these structural changes to the different substrate specificity and membrane binding properties of this divergent alpha-toxin. This will provide essential information when developing an effective vaccine that will protect against C. perfringens infection in a wide range of domestic livestock.

Evaluation of a test for Clostridium difficile toxins A and B for the diagnosis of neonatal swine enteritis

A commercially available 1-hour enzyme immunoassay (EIA) for detecting the presence of Clostridium difficile toxins A and B was evaluated for use in diagnosis of C. difficile infections in neonatal swine. This test was compared with a tissue culture cytotoxicity assay, which is considered to be the reference standard for the detection of C. difficile toxins. Twenty-seven samples of colonic contents and 23 fecal samples were collected from freshly euthanized neonatal swine with a history of scours. Of the 50 specimens tested, 20 were positive by the EIA test and tissue culture and 24 were negative by both tests, for an overall correlation of 88%. The sensitivity and specificity of the EIA were 91% and 86%, respectively, and the positive and negative predictive values were 84% and 86%, respectively. The EIA test is considered suitable as an aid for the diagnosis of C. difficile enteritis because of the high correlation between EIA results and those of the tissue culture cytotoxicity assay.

Suspected Clostridium difficile-associated diarrhea in two cats

Two adult cats from the same household developed acute diarrhea. Clostridium difficile toxins were detected in the feces of both cats, whereas other recognized causes of diarrhea were not identified. Supportive medical treatment and metronidazole were administered and both cats responded well. A fecal sample obtained from 1 of the affected cats after treatment and a fecal sample obtained from a clinically normal cat in the household did not contain C difficile toxins. The role of C difficile in enteric disease in cats has not been extensively studied and is unclear; however, our findings suggest that toxigenic strains of C difficile may cause diarrhea in cats.

Clostridial enterocolitis

Equine clostridial enterocolitis is being recognized with increasing frequency. It has been identified in foals with diarrhea, antibiotic-associated enterocolitis, or nosocomial enterocolitis. The sporadic occurrence of clostridial enterocolitis, the variety of types of clostridia involved, and the difficulty of experimentally reproducing the disease suggest that it is a poorly defined multifactorial syndrome. The risk factors associated with susceptibility to colonization and progressive infection are largely based on anecdotal observations and extrapolation from human studies. Quantitative studies are needed to decipher the complex interactions between host and indigenous microflora that provide for and maintain a healthy colonization resistance environment. It seems that such studies might be more beneficial in furthering our understanding of the pathogenesis of clostridial enterocolitis than attempting to implicate another agent or toxin as the sole cause of the disease in equids. Treatment protocols that interrupt the pathogenesis of the disease need to be devised and critically evaluated to complement the present protocols emphasizing supportive care. Perhaps it is time to consider clostridial enterocolitis as yet another consequence of the use of antimicrobials analogous to the selective pressures that result in the emergence of multiple drug-resistant pathogens.

Isolation of environmental Clostridium difficile from a veterinary teaching hospital

An environmental survey of a veterinary teaching hospital for the presence of Clostridium difficile was performed using contact plates and cycloserine-cefoxitin-fructose with 0.1% sodium taurocholate agar. Clostridium difficile was isolated from 24 of 381 sites (6.3%). Growth was obtained from 4.5% (9/202) of sites sampled in the Large Animal Clinic, from 8.1% (13/160) of sites within the Small Animal Clinic, and from 20% (2/10) of sites sampled elsewhere. Fourteen of 21 strains tested produced toxins in vitro. A geographic association was found with areas in the large animal clinic where nosocomial C. difficile diarrhea in horses had previously been diagnosed. Several other sites with a potential for nosocomial transmission of the organism were identified. Areas from which C. difficile was isolated tended to be areas with high animal traffic, with increased chance of fecal contamination, and with rough, difficult to clean surfaces. This study documents the prevalence of this organism in the environment and its potential role in nosocomial disease.

Survival of Clostridium difficile and its toxins in equine feces: implications for diagnostic test selection and interpretation

Although Clostridium difficile is recognized as a cause of enterocolitis in horses and humans, there has been little work published regarding the lability of C. difficile and its toxins in feces. A significant decrease in recovery of C. difficile from inoculated equine fecal samples occurred during storage. Recovery after storage in air at 4 degrees C decreased from 76% (37/49) after 24 hours to 67% (33/49) at 48 hours and 29% (14/ 49) after 72 hours. In contrast to aerobic storage, 25 of 26 samples stored anaerobically at 4 degrees C yielded growth of C. difficile for 30 days, whereas the organism was only detected for 2.5 +/- 2.52 days (x +/- SD) in paired samples stored aerobically. The use of an anaerobic transport medium was effective in maintaining viability of C. difficile. These findings indicate that poor aerotolerance is the reason for the rapid decrease in culture yield. In contrast to C. difficile organisms stored aerobically at 4 degrees C, C. difficile toxins were considerably more stable and could be detected by enzyme-linked immunosorbent assay in both broth and inoculated fecal samples for at least 30 days. The poor survival of C. difficile but the stability of its toxins when feces are stored aerobically must be considered when submitting samples for diagnosis of C. difficile-associated enterocolitis in horses and when interpreting laboratory results.

Detection of the ADP-ribosyltransferase toxin gene (cdtA) and its activity in Clostridium difficile isolates from Equidae

Clostridium difficile is an antibiotic-associated emerging pathogen of humans and animals. Thus far three toxins of C. difficile have been described: an enterotoxin (ToxA), a cytotoxin (ToxB) and an ADP-ribosyltransferase (CDT). In the present work we describe the first isolation of CDT producing C. difficile from Equidae with gastro-intestinal disease. Out of 17 C. difficile strains isolated from Equidae, 11 were positive for the genes tcdA and tcdB encoding ToxA and ToxB. In addition four of these 11 isolates were positive for the cdtA gene encoding the catalytic subunit of the ADP-ribosyltransferase CDT. Interestingly none of the isolates derived from canines (41 isolates) and felines (4 isolates) harboured the cdtA gene. In C. difficile field isolates which contained the cdtA gene, ADP-ribosyltransferase activity could also be detected in culture supernatants indicating expression and secretion of CDT. All strains were associated with intestinal disorders, but no association was found for the occurrence of toxins with a specific clinical diagnosis.

Enterocolitis associated with dual infection by Clostridium piliforme and feline panleukopenia virus in three kittens

Dual infection by Clostridium piliforme and feline panleukopenia virus (FPLV) was found in three kittens. In all cases, we found focal necrosis and desquamation of epithelial cells with occasional neutrophil infiltration in the large intestine. Large filamentous bacilli and spores were observed in the epithelium by using the Warthin-Starry method. Electron microscopy revealed the vegetative forms with characteristic peritrichous flagella and spore forms. Immunohistochemically, these bacilli showed a positive reaction with mouse antisera against the RT and MSK C. piliforme strains. Polymerase chain reaction (PCR) using cecum specimens demonstrated the 196-bp band specific to C. piliforme 16S rRNA. All three kittens were also diagnosed as FPLV-infected on the basis of the characteristic mucosal lesions, including intranuclear inclusions and PCR study for the FPLV genomic DNA. The PCR techniques are useful for confirming the C. piliforme and FPLV infection in spontaneous cases.

Clostridium difficile: a survey of fecal carriage in cats in a veterinary medical teaching hospital

Fecal samples collected from 245 cats over a 6-month period were analyzed for the presence of Clostridium difficile. After culture on selective media, isolates were identified by a latex agglutination test, and the presence of toxin A and toxin B gene sequences was determined by polymerase chain reaction. Clostridium difficile was isolated from 23 (9.4%) of the cats, and 34.8% of that group were colonized with toxigenic strains. All of the cats colonized with toxigenic C. difficile had > or = 1 of the risk factors (antibiotic use, antineoplastic therapy, immunosuppressive virus infection) associated with C. difficile infection in humans. Clostridium difficile was not found in any of the cats from a clinically healthy outpatient group of cats examined from the same hospital nor in cats from a specific-pathogen-free research colony on the same campus tested during the same time period. The data obtained in this study confirm the presence of C. difficile in cats at a veterinary teaching hospital. DNA fingerprinting analysis of these isolates allowed separation of the strains into 5 groups. Type 4 strain found in 7 cats was also recovered from the floor drain in the same hospital, suggesting a possible source of infection. Whether the organism is of clinical significance in diarrheal diseases of cats remains to be determined.

Clostridium difficile associated with acute colitis in mares when their foals are treated with erythromycin and rifampicin for Rhodococcus equi pneumonia

In Sweden, mares sometimes develop acute, often fatal, colitis when their foals are treated orally with erythromycin and rifampicin for Rhodococcus (R.) equi infection. Clostridium (C.) difficile, or its cytotoxin, was demonstrated in faecal samples from 5 of 11 (45%) mares with diarrhoea. By contrast C. difficile was not found in the faecal flora of 12 healthy mares with foals treated for R. equi infection or in 56 healthy mares with healthy untreated foals. No other enteric pathogen was isolated from any diarrhoeic mare. Of 7 investigated treated foals, 4 had a high (1651.0, 1468.3, 273.0 and 88.8 microg/g) faecal concentration of erythromycin. The dams of those 4 foals developed acute colitis, whereas the dams of 3 foals with a lower (26.3, 4.6 and 3.7 microg/g) faecal erythromycin concentration remained healthy, indicating that there might have been an accidental intake of erythromycin by mares. The foals treated with antibiotics were regarded as asymptomatic carriers and potential reservoirs, as C. difficile was found in 7 of 16 foals investigated, while 56 untreated foals proved negative. The isolated C. difficile strains proved resistant to both erythromycin (MIC>256 mg/l) and rifampicin (MIC>32 mg/l), a fact that may have favoured the growth of C. difficile in the foal intestine. All mares found positive for C. difficile were, or had recently been, hospitalised together with their foals, indicating that C. difficile may be a nosocomial infection, in horses. The results emphasise that routine testing for C. difficile and its cytotoxin is recommended when acute colitis occurs in mares when their foals are treated with erythromycin and rifampicin. Preventive measures in order to avoid accidental ingestion of erythromycin by mares from the treatment of their foals are suggested.

Five spontaneous deaths associated with Clostridium difficile in a colony of cotton-top tamarins (Saguinus oedipus)

Clostridium difficile toxin was detected in the feces of five cotton-top tamarins (Saguinus oedipus) that died spontaneously over a period of 10 weeks. Deaths occurred subsequent to antibiotic therapy for infectious diarrhea associated with Campylobacter spp. Relevant clinical signs of disease prior to death included weight loss, watery diarrhea, hematochezia, weakness, and sudden collapse. On histologic examination of the colon at necropsy, pseudomembranous colitis was evident in two cases, a lesion consistent with C. difficile lesions in humans. This finding prompted submission of feces for C. difficile toxin analysis from these five cases. Four of the tamarins were from a single room, and the fifth was housed nearby. The proximity of the cases raises the possibility of environmental contamination by resistant C. difficile spores or fecal spread of the organism as reported in hospitals, day-care centers, and nurseries. The relative importance of C. difficile and its potential role as an unrecognized cause of enteric disease secondary to antibiotic therapy in nonhuman primates is discussed.

The association of erythromycin ethylsuccinate with acute colitis in horses in Sweden

In Sweden there are several reports of mares developing acute colitis while their foals were being treated orally for Rhodococcus equi pneumonia with the combination of erythromycin and rifampicin. In this study 6 adult horses were given low oral dosages of these antibiotics, singly or in combination. Within 3 days post administration of erythromycin, in one case in combination with rifampicin, 2 horses developed severe colitis (one fatal). Clostridium difficile was isolated from one of the horses, whereas no specific pathogens were isolated from the other. Both horses had typical changes in blood parameters seen in acute colitis. Clostridium difficile was also isolated from the faeces of a third horse given an even lower dosage of erythromycin in combination with rifampicin. This horse developed very mild clinical symptoms and recovered spontaneously. In the fourth horse given erythromycin only, very high numbers of Clostridium perfringens were isolated. The horses given rifampicin only did not develop any clinical symptoms and there were no major changes in their faecal flora. In conclusion, it has been demonstrated that low dosages of erythromycin ethylsuccinate can induce severe colitis in horses associated with major changes of the intestinal microflora. Clostridium difficile has been demonstrated as a potential aetiological agent in antibiotic-induced acute colitis.

Clostridium difficile associated with acute colitis in mature horses treated with antibiotics

Clostridium (C.) difficile, or its cytoxin, was demonstrated in faecal samples from 10 of 25 (40%) mature horses investigated with acute colitis treated primarily with antibiotics for disorders other than diarrhoea. C. difficile was not found in faecal samples from 140 horses without signs of enteric disorders, from 21 nondiarrhoeic horses treated with antibiotics, nor from 22 horses with colitis untreated with antibiotics. Except for C. difficile neither Salmonella nor any other investigated intestinal pathogen was isolated in any of the diarrhoeic horses. The findings strongly support some earlier reports that C. difficile is associated with acute colitis in mature horses treated with antibiotics. Of the 10 horses, 4 proved positive for C. difficile both in culture and in the cytotoxin test, 4 in culture only and 2 only in the cytotoxin test. Eight of 10 horses positive for C. difficile were or had recently been hospitalised, indicating that C. difficile may be a nosocomial infection in horses. All horses positive for C. difficile were treated with beta-lactam antibiotics.

Prevention of necrotic enteritis in piglets by vaccination of pregnant gilts with a Clostridium perfringens type C and D bacterin-toxoid

On a large pig farm with a known history of necrotic enteritis 12 pregnant gilts were vaccinated s. c. 7 and 2 weeks before expected farrowing with a commercial bacterin-toxoid preparation of toxigenic strains C. perfringens type C and D (DizevakR-Pliva, Zagreb). At the farrowing the titers of beta-antitoxins in serum samples from vaccinated gilts ranged from 9.0 to 26.0 IU/ml with a mean value of 14.16 IU/ml. Colostral titers varied from 12.0 IU/ml with a mean of 16.12 IU/ml. On the second day of life the mean serum titers between litters differed greatly from 4.75 to 24.0 IU/ml. By the age of 7 days the average serum titers were commonly lower and varied between the litters from 2.25 to 15.0 IU/ml, with a low of 1.5 to a high of 16.0 IU/ml in single animals. Ten (8.47%) out of a total of 118 piglets from vaccinated gilts died during the first 7 days of life but the losses were not caused by C. perfringens infection. In unvaccinated control animals 18 (15.9%) of 113 piglets died, eleven of them with clinical and pathoanatomical signs of necrotic enteritis. The affected piglets predominantly succumbed in the first 4 days of life. These data indicate that the investigated bacterin-toxoid can be successfully used in immunoprophylaxis of necrotic enteritis in piglets.

Necrotizing enterocolitis in horses: a retrospective study

The clinical and clinicopathologic characteristics of fatal necrotizing enterocolitis were examined in 16 horses (age 4 months to 12 years). At initial presentation, 8 of 16 horses were pyrexic (median temperature, 38.4 degrees C; range, 33.8 to 40.6 degrees C); all 16 were tachycardic (median heart rate, 93 bpm, range, 66 to 138 bpm); 13 of 16 were tachypneic (median heart rate, 36 bpm, range, 16 to 80 bpm), dehydrated, and had discolored mucous membranes. All horses that were pyrexic were also tachycardic and tachypneic. PCV was high (> 45%) in 14 horses. Six horses were leukopenic (< 5,000 cells/microL); 12 were neutropenic (< 2,300 cells/microL), and 14 had > 100 band neutrophils/microL. Twelve horses were acidemic (pH < 7.37; range, 6.88 to 7.33) and the venous bicarbonate concentration was low (< 23 mEq/L) in 14 horses. Median anion gap in 16 horses was 31.5 mEq/L (> 15 mEq/L in 15 horses). Eleven of 16 horses were hyponatremic (< 137 mEq/L), 1 horse was hypernatremic (> 143 mEq/L), 3 were hypokalemic (< 3.2 mEq/L), 6 were hyperkalemic (> 4.5 mEq/L), and 14 were hypochloremic (< 98 mEq/L). Serum creatinine concentrations were high (> 1.4 mg/dL) in 15 horses. Abdominal fluid was examined in 12 horses 4 had total protein concentrations > 2.5 g/dL and 6 had nucleated cell counts > 5,000/ microL and < 10,000/microL; none had > 10,000/microL. Eight of 12 samples revealed a nondegenerate neutrophilia (> 50%). Abdominal fluid collected from 4 horses immediately before death was normal in 2 horses and indicative of suppurative inflammation in 2. All 8 horses tested had low or nonexistent serum immunofluorescent antibody titers to Ehrlichia risticii. Four of 16 horses had Salmonella spp isolated from feces or tissues. All 16 horses either died (5 of 16; 31%) or were euthanized because of a grave prognosis. Median time to death was 45.5 hours (range, 7 to 113 hours) from the time of admission. Death was preceded by severe abdominal pain in 14 horses. Fatal necrotizing enterocolitis of horses is characterized by a brief course, profound dehydration, electrolyte derangements, acid-base abnormalities, and terminally, severe abdominal pain. Abdominal fluid analysis was frequently not indicative of the severity of disease.

Apparent outbreaks of Clostridium difficile-associated diarrhea in horses in a veterinary medical teaching hospital

Intestinal colonization with toxigenic strains of Clostridium difficile was documented in 9 of 10 horses with acute onset diarrhea in a veterinary medical teaching hospital, whereas a similar isolate was detected in only 1 of 23 other horses without diarrhea in the hospital. One horse with diarrhea was infected simultaneously with both C. difficile and Salmonella krefeld. Clostridium difficile was detected by fecal culture on selective medium, confirmed with a latex particle agglutination test, and identified as toxigenic by polymerase chain reaction amplification of toxin A and toxin B gene sequences. Using an arbitrarily-primed polymerase chain reaction, 6 distinct C. difficile isolates were detected in the feces of the 9 affected horses at the time of the outbreak of diarrhea.

Lincomycin-induced severe colitis in ponies: association with Clostridium cadaveris

Four groups of two ponies, free of fecal Salmonella and Clostridium cadaveris, were treated as follows: Group A, control group; B, single nasogastrically administered dose of lincomycin (25 mg/kg) followed 48 h later by 3 L of C. cadaveris (10(9) organisms/mL); C, the same dose of lincomycin as group B; D, the same dose of C. cadaveris as group B on each of three occasions at 12 h intervals. Groups A and D remained healthy, but groups B and C developed severe colitis 48-56 h (B) or 72 h (C) after administration of lincomycin. Three ponies were euthanized and one in group B died. Clostridium cadaveris was isolated at about 10(6)/mL of colonic contents from these ponies, but one pony in group B also yielded Salmonella typhimurium from the colon. Subsequent challenge of group A ponies (3 L of C. cadaveris 10(9)/mL, three times at 12 h intervals) did not produce colitis. Nasogastric administration of lincomycin (25 mg/kg) to group A and D ponies, 20 days after administration of C. cadaveris, resulted in severe colitis in all ponies within 48-72 h. Salmonella agona was isolated from the colonic contents of one pony and C. cadaveris (10(6)/mL) from all four ponies. Clostridium cadaveris was not isolated from the colonic content of 45 healthy horses examined immediately after death. These studies confirm the potential for lincomycin to induce severe enterocolitis in ponies and implicate C. cadaveris further as a cause of "idiopathic colitis" in ponies.