Abstract
Extraintestinal manifestations of Clostridioides difficile infections (CDIs) are very uncommon, and according to the literature, poor outcomes and a high mortality have been observed among affected individuals. The objective of this study was to investigate the incidence rate of extraintestinal infections caused by C. difficile (ECD) in a tertiary-care university hospital in Hungary. During a 10-year study period, the microbiology laboratory isolated 4129 individual strains of C. difficile; among these, the majority were either from diarrheal fecal samples or from colonic material and only n = 24 (0.58%) were from extraintestinal sources. The 24 extraintestinal C. difficile isolates were recovered from 22 patients (female-to-male ratio: 1, average age: 55.4 years). The isolates in n = 8 patients were obtained from abdominal infections, e.g., appendicitis, rectal abscess or Crohn’s disease. These extraintestinal cases occurred without concomitant diarrhea. In all, but two cases C. difficile was obtained as a part of a polymicrobial flora. Our isolates were frequently toxigenic and mostly belonged to PCR ribotype 027. Resistance to metronidazole, vancomycin, clindamycin and rifampin were 0%, 0%, 20.5% and 9.7%, respectively. The increasing amount of reports of C. difficile extraintestinal infections should be noted, as these infections are characterized by a poor outcome and high mortality rate.
Highlights
Clostridioides difficile is a Gram-positive, spore-forming, anaerobic bacillus, which is commonly found in the intestinal tract of animals and humans and in the environment [1]
Most of the extraintestinal Cd containing-samples originated from the Dept. of Surgery (n = 12), while n = 3 samples had come from the Dept. of Dermatology and Immunology, Dept. of Pediatrics and Dept. of Internal Medicine and n = 1 sample from the Dept. of Obstetrics and Gynecology, Dept. of Maxillofacial and Oral Surgery and Dept. of Urology, respectively
Our patient had none of the well-known risk factors of recent hospitalization and broad-spectrum antibiotic use prior to the extraintestinal manifestations; in line with this, there are increased reporting of abscesses caused by this the organism in the absence of diarrhea: this is a concerning finding and may be a sign of the emergence of new toxigenic strains in the asymptomatic carriers
Summary
Clostridioides difficile (formerly Clostridium difficile, Cd) is a Gram-positive, spore-forming, anaerobic bacillus, which is commonly found in the intestinal tract of animals and humans and in the environment [1]. The bacteria could produce exotoxins, namely toxin A (tcdA), toxin B (tcdB) and binary toxin (CDT); the toxin-producing strains are the common cause of antibiotic-associated diarrhea (AAD), accounting for 15%–25% of all episodes of AAD [2]. Risk factors associated with transmission are exposure to antibiotics (especially broad-spectrum agents, e.g., amoxicillin-clavulanic acid, clindamycin and fluoroquinolones), gastrointestinal surgery/manipulation, an extended stay in hospital, serious underlying illnesses (e.g., immunosuppression and cancer) and advanced age. In the last several decades, the frequency and severity of intestinal Cd infections (CDIs) have been increasing worldwide to become one of the most common and serious hospital-acquired infections (HAIs) [3]. North American pulsed-field gel electrophoresis type 1 (NAP1 or PCR ribotype 027) [4].
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