Hanna Pituch

Clostridium difficile is no longer just a nosocomial infection or an infection of adults

Clostridium difficile is the main cause of nosocomial gastrointestinal disorders. Historically, C. difficile has usually affected older patients, hospital inpatients, and long-term care facility residents. Recent reports suggest that the occurrence and severity of C. difficile-associated disease (CDAD) is increasing in populations previously considered to be at low risk of the infection, and increasing numbers of community-acquired cases of CDAD are being reported. Risk factors for CDAD in paediatric patients include disruption of the normal microflora of the gastrointestinal tract (antibiotic-associated and non-antibiotic-associated), age, immune status, diet, underlying conditions, concurrent infections, and cancer. CDAD in populations previously thought to be at low risk is an emerging problem.

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.

Clostridium difficile PCR ribotype 176 in the Czech Republic and Poland

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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.

Clostridium difficile infection in newly diagnosed pediatric patients with inflammatory bowel disease: Prevalence and risk factors

Background: Epidemiological and microbiological data suggest that Clostridium difficile infection (CDI) plays a substantial role in the clinical initiation of inflammatory bowel disease (IBD). The aim of the present study was to investigate the prevalence and risk factors of CDI in newly diagnosed pediatric patients with IBD. Methods: The current investigation was a retrospective study. All patients newly diagnosed with IBD in the pediatric gastroenterology clinic in Warsaw between 2007 and 2010 were included in the present study. The patients were diagnosed according to Porto criteria and microbiology evaluation screening tests for CDI were conducted. Risk factors including prior hospitalization, use of antibiotics within 2 months of CDI detection, colonic involvement, and the duration of symptoms were evaluated. CDI diagnosis was based on a positive stool enzyme immunoassay. Results: In the present study, 134 patients were evaluated (54 patients with Crohns disease, and 80 with ulcerative colitis; 87% of the patients had colonic disease). The average age of the patients was 12.3 years, and the prevalence of CDI was 47% (95% confidence interval [CI], 38%–56%). Significant differences in the prevalence of CDI between patients with Crohns disease and ulcerative colitis (P = 0.72; odds ratio [OR] = 1.187, 95% CI, 0.56–2.52) were not observed. The risk of CDI was associated with an increase in the age of the patient and the severity of the disease. Conclusions: The prevalence of CDI in newly diagnosed IBD patients was high and was independent of the type of disease. (Inflamm Bowel Dis 2011;)

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.

Recent Emergence of an Epidemic Clindamycin-Resistant Clone of Clostridium difficile among Polish Patients with C. difficile-Associated Diarrhea

ABSTRACT Analysis of both the antibiotic resistance and the virulence characteristics of anaerobic human microbial pathogens is important in order to improve our understanding of a number of clinically significant infectious diseases, including Clostridium difficile-associated diarrhea (CDAD). We determined the presence of the clindamycin resistance-associated gene ermB and the ribotype of 33 C. difficile strains isolated from Polish patients suffering from CDAD. While all strains produced cytotoxin B (TcdB), enterotoxin A (TcdA) was produced by a subset of 15 strains only. The results showed that a single ermB-positive, TcdA−B+C. difficile strain with ribotype A has disseminated widely in the two Warsaw hospitals under investigation. Although different strains with the same phenotype were detected, the genotype A strain appeared to be the only one with a clear epidemic character. Apparently, enhanced local spread of CDAD-causing C. difficile may be restricted to a limited number of bacterial genotypes only.

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.

Comparative genome analysis and global phylogeny of the toxin variant clostridium difficile PCR Ribotype 017 Reveals the evolution of two independent sublineages

ABSTRACT The diarrheal pathogen Clostridium difficile consists of at least six distinct evolutionary lineages. The RT017 lineage is anomalous, as strains only express toxin B, compared to strains from other lineages that produce toxins A and B and, occasionally, binary toxin. Historically, RT017 initially was reported in Asia but now has been reported worldwide. We used whole-genome sequencing and phylogenetic analysis to investigate the patterns of global spread and population structure of 277 RT017 isolates from animal and human origins from six continents, isolated between 1990 and 2013. We reveal two distinct evenly split sublineages (SL1 and SL2) of C. difficile RT017 that contain multiple independent clonal expansions. All 24 animal isolates were contained within SL1 along with human isolates, suggesting potential transmission between animals and humans. Genetic analyses revealed an overrepresentation of antibiotic resistance genes. Phylogeographic analyses show a North American origin for RT017, as has been found for the recently emerged epidemic RT027 lineage. Despite having only one toxin, RT017 strains have evolved in parallel from at least two independent sources and can readily transmit between continents.