•Between October and December 2016, 36 Slovak hospitals performed Clostridium difficile infection (CDI) surveillance.•The overall mean CDI incidence was 2.8 (95% confidence interval 1.9–3.9) cases ...per 10 000 patient-days.•The most prevalent ribotypes were 001 (n=46, 59.0%) and 176 (n=23, 29.5%).•Almost all isolates showed reduced susceptibility to moxifloxacin (n=73, 93.6%).•A reduced susceptibility to metronidazole was observed in 13 primary fresh isolates.
To obtain standardized epidemiological data for Clostridium difficile infection (CDI) in Slovakia.
Between October and December 2016, 36 hospitals in Slovakia used the European Centre for Disease Prevention and Control (ECDC) Clostridium difficile infection (CDI) surveillance protocol.
The overall mean CDI incidence density was 2.8 (95% confidence interval 1.9–3.9) cases per 10 000 patient-days. Of 332 CDI cases, 273 (84.9%) were healthcare-associated, 45 (15.1%) were community-associated, and 14 (4.2%) were cases of recurrent CDI. A complicated course of CDI was reported in 14.8% of cases (n=51). CDI outcome data were available for 95.5% of cases (n=317). Of the 35 patients (11.1%) who died, 34 did so within 30 days after their CDI diagnosis.
Of the 78 isolates obtained from 12 hospitals, 46 belonged to PCR ribotype 001 (59.0%; 11 hospitals) and 23 belonged to ribotype 176 (29.5%; six hospitals). A total of 73 isolates (93.6%) showed reduced susceptibility to moxifloxacin (ribotypes 001 and 176; p< 0.01). A reduced susceptibility to metronidazole was observed in 13 isolates that subsequently proved to be metronidazole-susceptible when, after thawing, they were retested using the agar dilution method. No reduced susceptibility to vancomycin was found.
These results show the emergence of C. difficile ribotypes 027 and 176 with a predominance of ribotype 001 in Slovakia in 2016. Given that an almost homogeneous reduced susceptibility to moxifloxacin was detected in C. difficile isolates, this stresses the importance of reducing fluoroquinolone prescriptions in Slovak healthcare settings.
We reviewed the molecular epidemiology of Clostridioides difficile infection (CDI) in Japan by reviewing articles in which typing analysis was performed on recovered C. difficile isolates. Most of ...the multicenter studies showed that the major prevalent PCR-ribotypes (RT018-related type, RT014, RT002, RT369, and RT017) accounted for more than 75% of clinical isolates in Japan, which has not changed significantly since the late 1990s. Within the RT018-related isolates, a shift from RT018 to RT018ʹʹ (QX239) and the persistence of high levels of antimicrobial resistance were observed. Among toxin A-negative, toxin B-positive C. difficile, RT017 was replaced by RT369, which was more resistant to fluoroquinolone. The isolation rate of binary toxin-positive isolates was low (2–6%), except in one study (10%). Isolation of RT027 and RT078 was rare in endemic settings, while there was a first report of a nosocomial outbreak due to RT027 C. difficile in 2019. Notably, the vast majority of RT027 isolates, including the epidemic strain responsible for the outbreak, were susceptible to moxifloxacin, suggesting that Japanese RT027 represents the pre-epidemic RT027 genetic background. To understand the CDI burden in Japan, a nationwide strain-based surveillance system is imperative.
•C.difficile prevalent in Japan are RT018-related, RT014, RT002, RT369, and RT017.•The prevalence of the major ribotypes has not significantly changed for decades.•Within RT018-related type, a shift from RT018 to RT018ʹʹ (QX239) has occurred.•In A−B+ isolates, RT017 was replaced by RT369 with fluoroquinolone resistance.
Clostridium difficile is an important enteric pathogen in humans causing infections in the healthcare environment and the community. Carriage of C. difficile and C. difficile-related enterocolitis ...has been reported in piglets worldwide. The aim of this study was to investigate the rates of C. difficile isolation from pigs in Ireland. Faecal samples from piglet litters and sows were collected from six farms in 2015. The sows were non-diarrhoeal at the time of sampling. The diarrhoeal status of the piglets was unknown. C. difficile was isolated from 34/44 (77%) of piglet litter samples and from 33/156 (21%) of sow samples. The isolation rate in sows varied from 3 to 39% and in piglet litters from 72 to 86% depending on farm location. Toxin A and toxin B were present in 99% (66/67) of isolates; and binary toxin in 85% (57/67). Only PCR-ribotypes 078 (88%) and 193 (12%) were identified in piglets. Seven PCR-ribotypes were detected in sow C. difficile isolates: PCR-ribotypes 078 (67%), 050 (12%), 014/020 (6%), 015 (6%), 029 (3%), 035 (3%) and 193 (3%). This study shows that toxigenic C. difficile strains such as PCR-ribotype 078 can be commonly isolated from pigs at different geographical locations in Ireland. Since PCR-ribotype 078 is frequently found in humans in Ireland, this highlights the potential for interspecies transmission.
•Irish Sows and piglets are frequently colonized with PCR-ribotype 078.•Sows during service and piglets age 14–28 days showed the highest C. difficile carriage rates.
Recent surveys indicate that the majority of toxigenic Clostridium difficile strains isolated in European hospitals belonged to PCR-ribotypes (RTs) different from RT 027 or RT 078. Among these types, ...RT 018 has been reported in Italy and, more recently, in Korea and Japan. In Italy, strains RT 018 have become predominant in the early 2000s, whereas the majority of strains isolated before were RT 126, a type belonging to the same lineage as the RT 078. In this study, we have found that Italian strains RT 018 are resistant to erythromycin, clindamycin, moxifloxacin and rifampicin. Rifampicin resistance is rarely observed in strains RT 018 from other countries and in Italian strains RT 078 and RT 126, therefore the decennial use of rifamycin antibiotics in Italy may be one of the driving factors for the spread of RT 018 in our country. The strains RT 018 examined showed a significant higher adhesion to Caco-2 cells compared to strains RT 078 and RT 126. Furthermore, strains RT 018 became predominant in in vitro competition assays with strains RT 078 or RT 126. If maintained in vivo, these characteristics could lead to a rapid colonization of the intestine by strains RT 018. Under the conditions used, isolates RT 018 produced significantly higher toxins levels compared to strains RT 078 and RT 126, while heat-resistant CFUs production seems to be strain-dependent. Robust toxin production and enhanced sporulation could in part explain the high diffusion and interpatient transmissibility observed for strains RT 018 in the hospital environment. In conclusion, the characteristics observed in the Italian isolates RT 018 seem to contribute in conferring an adaptive advantage to these strains, allowing their successful spread in our country.
•A comparison was performed between Italian strains RT 018 and RT 126/RT 078.•Under the conditions used, RT 018 produced significantly higher toxins levels.•Strains RT 018 had a significantly higher adhesion to Caco-2 cells compared to the others strains.•RT 018 became predominant in a short time in competition assays in vitro.
Clostridioides (Clostridium) difficile commonly causes hospital-acquired infection which can range from mild diarrhoea to life-threatening toxic megacolon and even death. Reports on C. difficile ...infection (CDI) in Vietnam are limited, so this study was designed to evaluate the prevalence, molecular epidemiology and antimicrobial susceptibility of C. difficile isolated from children with diarrhoea in Vietnam. Infants are often colonised with C. difficile and it was hypothesised that those colonising strains would represent strains of C. difficile circulating in the hospital/region at the time, however, this was not an attempt to determine if C. difficile was the cause of the diarrhoea.
Diarrhoeal stool samples collected at two children's hospitals in northern Vietnam from October 1, 2020 to February 28, 2021 were transported to Perth, Western Australia, for culture of C. difficile and further investigations on isolates; PCR ribotyping, toxin gene profiling and antimicrobial susceptibility testing.
From these hospitals, 370 diarrhoeal stool samples were collected, most from children aged 1–15 months (71.9%; 266/370). The overall prevalence of C. difficile in stool samples from children aged ≤16 years was 37.8% (140/370) and the highest prevalence was in the 2–12 months age group (52.9%; 74/140). In total, 151 isolates of C. difficile were recovered; the proportion of toxigenic isolates was 16.6% (25/151). Of the 25 toxigenic C. difficile isolates, the toxin gene profiles A+B+CDT− and A−B+CDT− comprised 72% and 28%, respectively. The four most prevalent C. difficile ribotypes (RTs) were QX 011 (25/151), RT 010 (25/151), QX 107 (12/151) and RT 012 (11/151). All isolates were susceptible to vancomycin, metronidazole and fidaxomicin, while there was significant resistance to clindamycin (90.1%), and some to moxifloxacin (6.6%) and rifaximin (3.3%).
The prevalence of C. difficile in children with diarrhoea was high (37.8%) although the proportion of toxigenic strains was comparatively low. The clinical significance of any isolate needs to be determined.
•The prevalence of C. difficile in stool samples of children with diarrhoea in Vietnam was high (approximately 38%).•C. difficile RT 012 was the most prevalent toxigenic strain, however, most isolates were non-toxigenic.•Most Vietnamese C. difficile strains were resistant to clindamycin.•The data give a snapshot of the strains of C. difficile circulating in northern Vietnam.
Abstract
Objectives
To investigate the relationship between
Clostridium (Clostridioides) difficile
strain characteristics and
C. difficile
infection (CDI) outcome.
Methods
Between October and ...December 2017, 16 hospitals collected epidemiological data according to the European Centre for Disease Prevention and Control (ECDC) surveillance protocol for CDI.
C. difficile
isolates were characterized by ribotyping, toxin genes detection and antibiotic susceptibility testing to metronidazole, vancomycin and moxifloxacin.
Results
The overall mean CDI incidence density was 4.5 95% CI 3.6–5.3 cases per 10,000 patient-days. From the 433 CDI cases, 330 (76.2%) were healthcare-associated, 52 (12.0%) cases were community-associated or of unknown origin and 51 (11.8%) CDI cases recurrent; a complicated course of CDI was reported in 65 cases (15.0%). Eighty-eight (20.3%) of patients died and 59 of them within 30 days after the CDI diagnosis.
From the 379
C. difficile
isolates, the most prevalent PCR ribotypes were 001 (
n
= 127, 33.5%) and 176 (
n
= 44, 11.6%). A total of 186 (49.1%) isolates showed a reduced susceptibility to moxifloxacin (> 4 mg/L) and 96.4% of them had Thr82Ile in the GyrA. Nineteen isolates revealed reduced susceptibility to metronidazole and two isolates to vancomycin (> 2 mg/L).
A fatal outcome was associated with a reduced susceptibility to moxifloxacin, the advanced age of the patients and a complicated course of CDI (
p
<0.05). No association between ribotype, binary toxin and a reduced susceptibility to moxifloxacin and complicated course or recurrent CDI was found.
Conclusions
A reduced susceptibility to moxifloxacin, in causative
C. difficile
strains was associated with fatal outcome of the patients, therefore it is an important marker in surveillance of CDI.
•Clostridioides difficile was isolated from environment, food, animals and humans.•The most common PCR ribotypes were 126, 078, 011/018, 014/020/077, and 010.•Toxigenic strains were isolated from ...bovine raw milk and ready-to-eat vegetable samples.•MLVA showed that many isolates from different sources were genetically undistinguishable.•Environment, food and animals could be important sources of virulent C. difficile strains.
One hundred and thirty-eight C. difficile isolates from different sources (66 from the environment, 36 from animals, 9 from food and 27 from humans) were ribotyped by capillary electrophoresis PCR ribotyping (CE-PCR). A multilocus variable tandem repeat analysis (MLVA) was carried out on a sample subset.
The most frequently isolated PCR ribotypes were 126 (15.9%), 078 (14.5%), 011/018 (11.6%), 014/020/077 (10.1%), and 010 (2.8%). In particular, strains of PCR ribotype 011/018 were isolated from human, raw milk and environmental samples. The hypervirulent PCR ribotype 027 was isolated from two human samples.
The majority of the strains were toxigenic (34.1% showed the toxigenic profile A+B+CDT+ and 38.9% the profile A+B+CDT−). MLVA allowed to identify 4 clonal complexes of genetically related isolates: complex n. 1 grouped together human, environmental and food strains, whereas complex n. 3 included human and environmental isolates. The use of MLVA gave further evidence to the possible role of environment, animals and food as routes of transmission of C. difficile infections to human.
This study aimed to characterize Clostridium difficile isolates cultured from stool samples of patients with C. difficile infection (CDI) and swabs from a medical environment in a gastroenterology ...center in Tehran, Iran. A total of 158 samples (105 stool samples from hospitalized patients and 53 swabs from medical devices and the environment) were collected from January 2011 to August 2011 and investigated for the presence of C. difficile by direct anaerobic culture on a selective media for C. difficile. C. difficile isolates were further characterized by capillary electrophoresis (CE) ribotyping and toxin gene multiplex PCR. Of 158 samples, C. difficile was cultured in 19 of 105 stool samples (18%) and in 4 of 53 swabs (7.5%). C. difficile PCR ribotype (RT) 126 was the most common RT in the study (21.7%). Further RTs were: 001, 003, 014, 017, 029, 039, 081, 103 and 150. RTs 126, 001, 150 were cultured from both the stool samples and swabs of medical devices and the hospital environment which suggest a possible route of transmission.
•We investigated 105 stool samples and 53 swabs from hospital environment.•C. difficile were cultured in 18% (n = 19) of stool samples and 7.5% (n = 4) of swabs.•PCR ribotype (RT) 126 was the most common RT in the study (21%).•RTs 001, 126 and 150 were cultured from both stool samples and medical equipment.
Clostridioides (Clostridium) difficile is the leading cause of healthcare-associated infectious diarrhea in the developed world. Retrospective studies have shown a lower incidence of C. difficile ...infection (CDI) in Japan than in Europe or North America. Prospective studies are needed to determine if this is due lack of testing for C. difficile or a true difference in CDI epidemiology.
A prospective cohort study of CDI was conducted from May 2014 to May 2015 at 12 medical facilities (20 wards) in Japan. Patients with at least three diarrheal bowel movements (Bristol stool grade 6–7) in the preceding 24 h were enrolled. CDI was defined by positive result on enzyme immunoassay for toxins A/B, nucleic acid amplification test for the toxin B gene or toxigenic culture. C. difficile isolates were subjected to PCR-ribotyping (RT), slpA-sequence typing (slpA-ST), and antimicrobial susceptibility testing.
The overall incidence of CDI was 7.4/10,000 patient-days (PD). The incidence was highest in the five ICU wards (22.2 CDI/10,000 PD; range: 13.9–75.5/10,000 PD). The testing frequency and CDI incidence rate were highly correlated (R2 = 0.91). Of the 146 isolates, RT018/018″ was dominant (29%), followed by types 014 (23%), 002 (12%), and 369 (11%). Among the 15 non-ICU wards, two had high CDI incidence rates (13.0 and 15.9 CDI/10,000 PD), with clusters of RT018/slpA-ST smz-02 and 018”/smz-01, respectively. Three non-RT027 or 078 binary toxin-positive isolates were found. All RT018/018” isolates were resistant to moxifloxacin, gatifloxacin, clindamycin, and erythromycin.
This study identified a higher CDI incidence in Japanese hospitals than previously reported by actively identifying and testing patients with clinically significant diarrhea. This suggests numerous patients with CDI are being overlooked due to inadequate diagnostic testing in Japan.
•A prospective and multi-center study of CDI was conducted in Japan.•The incidence rate (7.4/10,000 patient-days) of CDI was high.•The incidence was highest in five ICU wards (22.2 CDI/10,000 patient-days).•PCR-ribotypes 018, 014, 002, and 369 were predominant.
A laboratory diagnosis survey of Clostridium difficile infection (CDI) was performed in Italy in 2012–2013. Questionnaires from 278 healthcare settings from 15 regions of Italy were collected and ...analysed. Eighty seven percent of the laboratories declared to routinely perform CDI diagnosis, 99% of them only after the clinician's request. Among the 216 laboratories providing information on the size of the hospitals in which they were located, 65 had more than 500 beds (large hospitals), while 151 had less than 500 beds (small hospitals). The average percentage of positive tests for C. difficile toxins was 12.2%. Almost half of the laboratories (42%) used immunoenzymatic assay (EIA) for Tox A/B as a stand-alone method, while only 34% used an algorithm for CDI as indicated by the European guidelines. A low percentage of laboratories performed molecular assays or C. difficile culture, 25% and 29%, respectively. Most laboratories (161/278) declared to type C. difficile strains, the majority in collaboration with a reference laboratory. Among the 103 C. difficile clinical isolates collected during the study, 31 different PCR-ribotypes were identified. PCR-ribotype 356/607 (27%) was predominant, followed by 018 (12%). These two PCR-ribotypes show 87.5% of similarity in ribotyping profile. PCR-ribotypes 027 and 078 represented 8% and 4% of the strains, respectively. Four PCR-ribotypes (027, 033, 078 and 126) were positive for the binary toxin CDT. In particular, PCR-ribotype 033 produces only CDT, and it has recently been associated with symptomatic cases. The majority of strains were multidrug resistant. In particular, all strains PCR-ribotypes 356/607 and 018 were resistant to moxifloxacin, rifampicin, erythromycin and clindamycin. The results obtained highlight the need to raise awareness to the microbiological diagnosis of CDI among clinicians and to implement and harmonize diagnostic methods for CDI in Italian laboratories in the perspective of a future national surveillance.
•First laboratory diagnosis survey of Clostridium difficile infection (CDI) performed in Italy.•Eighty seven percent of the laboratories declared to routinely perform CDI diagnosis, 99% of them after clinician's request.•42% laboratories used EIA for Tox A/B as a stand-alone test, 25% molecular assays and 29% C. difficile culture.•Only 34% of laboratories used an algorithm for CDI as indicated by the European guideline.•The predominant PCR-ribotype detected was 356/607 (27%), followed by 018 (12%). PCR-ribotype 027 and 078 are emerging.
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