Dorota Wultańska

Clostridium difficile infection in Polish pediatric outpatients with inflammatory bowel disease

The prevalence of Clostridium difficile infection (CDI) in pediatric patients with inflammatory bowel disease (IBD) is still not sufficiently recognized. We assessed the prevalence of CDI and recurrences in outpatients with IBD. In addition, the influence of IBD therapy on CDI and antimicrobial susceptibility of the potentially causative C. difficile strains was assessed. This was a prospective, single-center, observational study. All specimens were obtained between January 2005 and January 2007 from the IBD outpatient service and screened for C. difficile and its toxins. C. difficile isolates were genotyped by PCR ribotyping. Diagnosis of Crohn’s disease (CD) and ulcerative colitis (UC) was based on Porto criteria. Severity of disease was assessed using the Hyams scale (for Crohn’s disease) and the Truelove–Witts scale (for ulcerative colitis). One hundred and forty-three fecal samples from 58 pediatric IBD patients (21 with Crohn’s disease and 37 with ulcerative colitis) were screened. The risk of C. difficile infection was 60% and was independent of disease type (CD or UC) (χ2 = 2.5821, df = 3, p = 0.4606). About 17% of pediatric IBD patients experienced a recurrence of CDI. All C. difficile strains were susceptible to metronidazole, vancomycin and rifampin. A high prevalence of C. difficile infection and recurrences in pediatric outpatients with IBD was observed, independent of disease type. There was no significant correlation between C. difficile infection and IBD therapy. PCR ribotyping revealed C. difficile re-infection and relapses during episodes of IBD in pediatric outpatients.

Hospital-based Clostridium difficile infection surveillance reveals high proportions of PCR ribotypes 027 and 176 in different areas of Poland, 2011 to 2013

As part of the European Clostridium difficile infections (CDI) surveillance Network (ECDIS-Net), which aims to build capacity for CDI surveillance in Europe, we constructed a new network of hospital-based laboratories in Poland. We performed a survey in 13 randomly selected hospital-laboratories in different sites of the country to determine their annual CDI incidence rates from 2011 to 2013. Information on C. difficile laboratory diagnostic testing and indications for testing was also collected. Moreover, for 2012 and 2013 respectively, participating hospital-laboratories sent all consecutive isolates from CDI patients between February and March to the Anaerobe Laboratory in Warsaw for further molecular characterisation, including the detection of toxin-encoding genes and polymerase chain reaction (PCR)-ribotyping. Within the network, the mean annual hospital CDI incidence rates were 6.1, 8.6 and 9.6 CDI per 10,000 patient-days in 2011, 2012, and 2013 respectively. Six of the 13 laboratories tested specimens only on the request of a physician, five tested samples of antibiotic-associated diarrhoea or samples from patients who developed diarrhoea more than two days after admission (nosocomial diarrhoea), while two tested all submitted diarrhoeal faecal samples. Most laboratories (9/13) used tests to detect glutamate dehydrogenase and toxin A/B either separately or in combination. In the two periods of molecular surveillance, a total of 166 strains were characterised. Of these, 159 were toxigenic and the majority belonged to two PCR-ribotypes: 027 (n=99; 62%) and the closely related ribotype 176 (n=22; 14%). The annual frequency of PCR-ribotype 027 was not significantly different during the surveillance periods (62.9% in 2012; 61.8% in 2013). Our results indicate that CDIs caused by PCR-ribotype 027 predominate in Polish hospitals participating in the surveillance, with the closely related 176 ribotype being the second most common agent of infection.

Characterization and antimicrobial susceptibility of Clostridium difficile strains isolated from adult patients with diarrhoea hospitalized in two university hospitals in Poland, 2004-2006.

This study analysed 330 Clostridium difficile strains isolated from patients with C. difficile infection who were hospitalized in two university hospitals (H1 and H2) in Warsaw, Poland, over the period 2004-2006. Strains were investigated for the presence of tcdA (A), tcdB (B) and binary toxin (CDT) genes, and antimicrobial susceptibility was determined against nine agents. Among the 330 C. difficile isolates, 150 (45.4 %) were classified as A(+)B(+)CDT(-), 18 (5.5 %) as A(+)B(+)CDT(+), 144 (43.6 %) as A(-)B(+)CDT(-) and 18 (5.5 %) as A(-)B(-)CDT(-). The predominant PCR ribotype in hospitals H1 and H2 was type 017 and accounted for 48.3 and 40.0 %, respectively. Only one PCR ribotype 027 strain was found. The rates of resistance to erythromycin and clindamycin in hospitals H1 and H2 were 53.6 and 53.6 %, and 48.6 and 47.5 %, respectively, whereas resistance rates to the newer fluoroquinolones gatifloxacin and moxifloxacin were 38.5 and 38.5 % (H1) and 38.4 and 40.1 % (H2). Erythromycin resistance was frequently associated with resistance to clindamycin and newer fluoroquinolones in strains belonging to type 017. No metronidazole- and vancomycin-resistant isolates were found, although two C. difficile isolates had elevated MIC values of metronidazole (MIC range 1.0-1.5 mg l(-1)) and 15 strains revealed elevated MIC values for vancomycin (MIC range 1.5-2.0 mg l(-1)). In conclusion, an increase in non-027 CDT-producing C. difficile strains was observed in Poland, but C. difficile PCR ribotype 017 remains a major circulating type.

Clonal Spread of a Clostridium difficile Strain with a Complete Set of Toxin A, Toxin B, and Binary Toxin Genes among Polish Patients with Clostridium difficile-Associated Diarrhea

ABSTRACT Clinically relevant Clostridium difficile strains usually produce toxins A and B. Some C. difficile strains can produce an additional binary toxin. We report clonality among five strains carrying all toxin genes from Polish patients with C. difficile-associated diarrhea. In another strain, possible recombination between binary toxin genes is documented.

Toxin Profiles and Resistances to Macrolides and Newer Fluoroquinolones as Epidemicity Determinants of Clinical Isolates of Clostridium difficile from Warsaw, Poland

ABSTRACT Amplified fragment length polymorphism genotypes, antibiotic resistance profiles, and toxin profiles of Clostridium difficile strains from Warsaw were determined. The isolates segregate in six major genotypes, coinciding with toxin profiles. Most of the toxin A-negative toxin B-positive toxin CDT-negative strains possess ermB, and several strains were resistant to fluoroquinolones. Resistograms and toxin types of C. difficile strains are epidemicity determinants.

Emergence of Clostridium difficile infection in tuberculosis patients due to a highly rifampicin-resistant PCR ribotype 046 clone in Poland

Clostridium difficile infection (CDI) is a major cause of nosocomial diarrhea. CDI is known to develop after antibiotic administration, but anti-tuberculosis agents have rarely been implicated. We documented an outbreak caused by a highly rifampicin-resistant C. difficile strain of polymerase chain reaction (PCR) ribotype 046 in patients with active tuberculosis.

Prevalence of Clostridium difficile infection in Polish pediatric patients with inflammatory bowel disease.

To the Editor: Epidemiological and microbiologic studies suggest that Clostridium difficile infection plays a substantial role in the clinical initiation and relapses of inflammatory bowel disease (IBD). However, the exact relationship between the clinical assessment of inflammatory bowel disease and the presence of C. difficile in the stool remains unknown. Since 2000, the frequency of C. difficile infection in adult IBD patients has dramatically increased. The retrospective study by Pascarella et al. is the first regarding the prevalence of C. difficile infection in children with IBD, which was found to be 24%. We present the surprising results of our prospective study performed in Polish pediatric patients with inflammatory bowel disease (diagnosed according to Porto criteria). The methods we used were similar to those described by Pascarella et al. Fecal samples from IBD children ages 3–17 years were screened for the presence of the C. difficile toxins TcdA/TcdB. Sixty-four fecal samples were submitted from 28 patients suffering from IBD. Forty samples were received from IBD active patients and 24 from IBD nonactive patients. We identified C. difficile toxins in 70% of the samples; C. difficile– positive patients had active disease more frequently (30 of 45). The prevalence of C. difficile observed in our study is multiply higher than that reported by Pascarella et al. and among adults with IBD (5.5%–20%). Several factors could explain our results. First, most of our children were outpatients; the results of previous studies showed that the majority of IBD patients appear to contract C. difficile infections as outpatients. A second reason may be the high recurrence of C. difficile infection in patients with IBD. A third possible reason is the way we controlled our patients: a fecal sample for toxin detection was collected during every follow-up visit. Finally, the incidence of C. difficile infection in Poland is unknown, but it could be higher than that in Western Europe or the United States. Our data confirm that the presence of C. difficile in stool is related to disease activity in IBD. The risk of infection was the same in the ulcerative colitis (34 of 47) and Crohn’s disease (11 of 17) subgroups; it correlated with the results of Pascarella et al. but not with results in adults. Further prospective studies are needed to establish the real prevalence of C. difficile infection in pediatric IBD patients. Aleksandra Banaszkiewicz, MD, PhD* Dorota Wultanska, MD, PhD Hanna Pituch, MD, PhD Andrzej Radzikowski, MD, PhD Associate Professor* *Department of Pediatric Gastroenterology and Nutrition Medical University of Warsaw, Poland Department of Medical Microbiology, Medical University of Warsaw, Poland

Infections with Clostridium difficile – diagnostics and treatment in the elderly

Burden for health-care systems associated with Clostridium difficile infection (C. difficile infection – CDI) has increased recently due to an increase in the incidence of CDI cases and the rising costs of medical care for a patient with CDI. CDI in particular affects older people due to numerous conditions such as: impaired immune system, disorders of the intestinal microbiome, malnutrition, increasing antibiotic consumption, and more frequent exposure to drugs other than antibiotics. Two out of three CDIs related to healthcare are found in patients who are 65 years old or older. In addition, older people are more prone to CDI recurrence m