Epidemiology and virulence-associated genes of Clostridioides difficile isolates and factors associated with toxin EIA results at a university hospital in Japan
Introduction.Clostridioides difficile is one of the most important nosocomial pathogens; however, reports regarding its clinical and molecular characteristics from Japan are scarce.
Aims. We studied the multilocus sequence typing (MLST)-based epidemiology and virulence-associated genes of isolates and the clinical backgrounds of patients from whom the isolates had been recovered.
Methods. A total of 105 stool samples tested in a C. difficile toxin enzyme immune assay (EIA) were analysed at the University of Tokyo Hospital from March 2013 to July 2014. PCR for MLST and the virulence-associated genes tcdA, tcdB, cdtA, cdtB and tcdC was performed on C. difficile isolates meeting our inclusion criteria following retrospective review of medical records. EIA-positive and EIA-negative groups with toxigenic strains underwent clinical and molecular background comparison.
Results. The toxigenic strains ST17, ST81, ST2, ST54, ST8, ST3, ST37 and ST53 and the non-toxigenic strains ST109, ST15 and ST100 were frequently recovered. The prevalence rate of tcdA-negative ST81 and ST37, endemic in China and Korea, was higher (11.4%) than that reported in North America and Europe, and hypervirulent ST1(RT027) and ST11(RT078) strains that occur in North America and Europe were not recovered. The linkage between the EIA results and cdt A/B positivity, tcdC deletion, or tcdA variation was absent among toxigenic strains. Compared with the 38 EIA-negative cases, the 36 EIA-positive cases showed that the patients in EIA-positive cases were older and more frequently had chronic kidney disease, as well as a history of beta-lactam use and proton pump inhibitor therapy.
Conclusion. In Japan, the prevalence rates for tcdA-negative strains are high, whereas the cdtA/B-positive strains are rare. EIA positivity is linked to older age, chronic kidney disease and the use of beta-lactams and proton pump inhibitors.
CassiniA,
PlachourasD,
EckmannsT,
Abu SinM,
BlankH-P et al. Burden of six healthcare-associated infections on European population health: estimating incidence-based Disability-Adjusted life years through a population Prevalence-Based modelling study. PLoS Med2016; 13:e1002150 [View Article]
MagillSS,
O'LearyE,
JanelleSJ,
ThompsonDL,
DumyatiG et al. Changes in prevalence of health care-associated infections in U.S. hospitals. N Engl J Med2018; 379:1732–1744 [View Article]
BraunV,
HundsbergerT,
LeukelP,
SauerbornM,
von Eichel-StreiberC.
Definition of the single integration site of the pathogenicity locus in Clostridium difficile
. Gene1996; 181:29–38 [View Article]
CarterGP,
LyrasD,
AllenDL,
MackinKE,
HowarthPM et al. Binary toxin production in Clostridium difficile is regulated by cdtR, a LytTR family response regulator. J Bacteriol2007; 189:7290–7301 [View Article]
PopoffMR,
RubinEJ,
GillDM,
BoquetP.
Actin-Specific ADP-ribosyltransferase produced by a Clostridium difficile strain. Infection and immunity1988; 56:2299–2306
EckertC,
EmirianA,
Le MonnierA,
CathalaL,
De MontclosH et al. Prevalence and pathogenicity of binary toxin-positive Clostridium difficile strains that do not produce toxins A and B. New Microbes New Infect2015; 3:12–17 [View Article]
ManiN,
DupuyB.
Regulation of toxin synthesis in Clostridium difficile by an alternative RNA polymerase sigma factor. Proc Natl Acad Sci USA2001; 98:5844–5849 [View Article]
StareBG,
DelmeeM,
RupnikM.
Variant forms of the binary toxin CDT locus and tcdC gene in Clostridium difficile strains. J Med Microbiol2007; 56:329–335 [View Article]
LooVG,
PoirierL,
MillerMA,
OughtonM,
LibmanMD et al. A Predominantly Clonal Multi-Institutional Outbreak of Clostridium difficile –Associated Diarrhea with High Morbidity and Mortality. N Engl J Med Overseas Ed2005; 353:2442–2449 [View Article]
WarnyM,
PepinJ,
FangA,
KillgoreG,
ThompsonA et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. The Lancet2005; 366:1079–1084 [View Article]
DaviesKA,
AshwinH,
LongshawCM,
BurnsDA,
DavisGL et al. Diversity of Clostridium difficile PCR ribotypes in Europe: results from the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID), 2012 and 2013. Euro Surveill.2016; 21: [View Article]
TicklerIA,
GoeringRV,
WhitmoreJD,
LynnANW,
PersingDH et al. Strain types and antimicrobial resistance patterns of Clostridium difficile isolates from the United States, 2011 to 2013. Antimicrob Agents Chemother2014; 58:4214–4218 [View Article]
KnetschCW,
LawleyTD,
HensgensMP,
CorverJ,
WilcoxMW et al. Current application and future perspectives of molecular typing methods to study Clostridium difficile infections. Eurosurveillance2013; 18:20381 [View Article]
KuwataY,
TanimotoS,
SawabeE,
ShimaM,
TakahashiY et al. Molecular epidemiology and antimicrobial susceptibility of Clostridium difficile isolated from a university teaching hospital in Japan. Eur J Clin Microbiol Infect Dis2015; 34:763–772 [View Article]
PerssonS,
TorpdahlM,
OlsenKEP.
New multiplex PCR method for the detection of Clostridium difficile toxin A (tcdA) and toxin B (tcdB) and the binary toxin (cdtA/cdtB) genes applied to a Danish strain collection. Clin Microbiol Infect2008; 14:1057–1064 [View Article]
McDonaldLC,
GerdingDN,
JohnsonS,
BakkenJS,
CarrollKC et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the infectious diseases Society of America (IDSA) and Society for healthcare epidemiology of America (SheA). Clin Infect Dis2018; 66:e1–e48 [View Article]
IwashimaY,
NakamuraA,
KatoH,
KatoH,
WakimotoY et al. A retrospective study of the epidemiology of Clostridium difficile infection at a university hospital in Japan: genotypic features of the isolates and clinical characteristics of the patients. J Infect Chemother2010; 16:329–333 [View Article]
KatoH,
KatoN,
WatanabeK,
YamamotoT,
SuzukiK et al. Analysis of Clostridium difficile isolates from nosocomial outbreaks at three hospitals in diverse areas of Japan. J Clin Microbiol2001; 39:1391–1395 [View Article]
SawabeE,
KatoH,
OsawaK,
ChidaT,
TojoN et al. Molecular analysis of Clostridium difficile at a university teaching hospital in Japan: a shift in the predominant type over a five-year period. Eur J Clin Microbiol Infect Dis2007; 26:695–703 [View Article]
ChenY-B,
GuS-L,
ShenP,
LvT,
FangY-H et al. Molecular epidemiology and antimicrobial susceptibility of Clostridium difficile isolated from hospitals during a 4-year period in China. J Med Microbiol2018; 67:52–59 [View Article]
KimJ,
KangJO,
KimH,
SeoM-R,
ChoiTY et al. Epidemiology of Clostridium difficile infections in a tertiary-care hospital in Korea. Clin Microbiol Infect2013; 19:521–527 [View Article]
LuoY,
ZhangW,
ChengJW,
XiaoM,
SunGR et al. Molecular epidemiology of Clostridium difficile in two tertiary care hospitals in Shandong Province, China. Infect Drug Resist2018; 11:489–500 [View Article]
WangB,
LvZ,
ZhangP,
SuJ.
Molecular epidemiology and antimicrobial susceptibility of human Clostridium difficile isolates from a single institution in northern China. Medicine2018; 97:e11219 [View Article]
AlfaMJ,
KabaniA,
LyerlyD,
MoncriefS,
NevilleLM et al. Characterization of a toxin A-negative, toxin B-positive strain of Clostridium difficile responsible for a nosocomial outbreak of Clostridium difficile-associated diarrhea. J Clin Microbiol2000; 38:2706–2714
LessaFC,
MuY,
BambergWM,
BeldavsZG,
DumyatiGK et al. Burden of Clostridium difficile infection in the United States. N Engl J Med2015; 372:825–834 [View Article]
CostaCL,
López-UreñaD,
de Oliveira AssisT,
RibeiroRA,
SilvaROS et al. A MLST clade 2 Clostridium difficile strain with a variant tcdB induces severe inflammatory and oxidative response associated with mucosal disruption. Anaerobe2016; 40:76–84 [View Article]
LimSK,
StuartRL,
MackinKE,
CarterGP,
KotsanasD et al. Emergence of a ribotype 244 strain of Clostridium difficile associated with severe disease and related to the epidemic ribotype 027 strain. Clin Infect Dis2014; 58:1723–1730 [View Article]
WehrhahnMC,
KeighleyC,
KurtovicJ,
KnightDR,
HongS et al. A series of three cases of severe Clostridium difficile infection in Australia associated with a binary toxin producing clade 2 ribotype 251 strain. Anaerobe2019; 55:117–123 [View Article]
Quesada-GómezC,
López-UreñaD,
ChumblerN,
KrohHK,
Castro-PeñaC et al. Analysis of tcdB proteins within the hypervirulent clade 2 reveals an impact of RhoA glucosylation on Clostridium difficile proinflammatory activities. Infect Immun2016; 84:856–865 [View Article]
GerdingDN,
MeyerT,
LeeC,
CohenSH,
MurthyUK et al. Administration of spores of nontoxigenic Clostridium difficile strain M3 for prevention of recurrent C. difficile infection: a randomized clinical trial. Jama2015; 313:1719–1727
NagaroKJ,
PhillipsST,
CheknisAK,
SambolSP,
ZukowskiWE et al. Nontoxigenic Clostridium difficile protects hamsters against challenge with historic and epidemic strains of toxigenic BI/NAP1/027 C. difficile. Antimicrob Agents Chemother2013; 57:5266–5270 [View Article]
ChenY-B,
GuS-L,
WeiZ-Q,
ShenP,
KongH-S et al. Molecular epidemiology of Clostridium difficile in a tertiary hospital of China. J Med Microbiol2014; 63:562–569 [View Article]
WangR,
SuoL,
ChenHX,
SongLJ,
ShenYY et al. Molecular epidemiology and antimicrobial susceptibility of Clostridium difficile isolated from the Chinese people's liberation army General Hospital in China. Int J Infect Dis2018; 67:86–91 [View Article]
DubberkeER,
ReskeKA,
HinkT,
KwonJH,
CassC et al.Clostridium difficile colonization among patients with clinically significant diarrhea and no identifiable cause of diarrhea. Infect Control Hosp Epidemiol2018; 39:1330–1333 [View Article]
PolageCR,
GyorkeCE,
KennedyMA,
LeslieJL,
ChinDL et al. Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era. JAMA Intern Med2015; 175:1792–1801 [View Article]
GoldenbergSD,
FrenchGL.
Lack of association of tcdC type and binary toxin status with disease severity and outcome in toxigenic Clostridium difficile
. J Infect2011; 62:355–362 [View Article]
KawadaM,
AnnakaM,
KatoH,
ShibasakiS,
HikosakaK et al. Evaluation of a simultaneous detection kit for the glutamate dehydrogenase antigen and toxin A/B in feces for diagnosis of Clostridium difficile infection. J Infect Chemother2011; 17:807–811 [View Article]
HensgensMPM,
GoorhuisA,
DekkersOM,
KuijperEJ.
Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother2012; 67:742–748 [View Article]
LooVG,
BourgaultA-M,
PoirierL,
LamotheF,
MichaudS et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med2011; 365:1693–1703 [View Article]
MutoCA,
PokrywkaM,
ShuttK,
MendelsohnAB,
NouriK et al. A large outbreak of Clostridium difficile –associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol2005; 26:273–280 [View Article]
RaoK,
MicicD,
NatarajanM,
WintersS,
KielMJ et al.Clostridium difficile ribotype 027: relationship to age, detectability of toxins A or B in stool with rapid testing, severe infection, and mortality. Clin Infect Dis2015; 61:233–241 [View Article]
LauCS,
ChamberlainRS.
Probiotics are effective at preventing Clostridium difficile-associated diarrhea: a systematic review and meta-analysis. Int J Gen Med2016; 9:27–37 [View Article]
ShenNT,
MawA,
TmanovaLL,
PinoA,
AncyK et al. Timely use of probiotics in hospitalized adults prevents Clostridium difficile infection: a systematic review with meta-regression analysis. Gastroenterology2017; 152:e18891889–1900 [View Article]
Epidemiology and virulence-associated genes of Clostridioides difficile isolates and factors associated with toxin EIA results at a university hospital in Japan