Abstract
Accurate tracking of Clostridium difficile transmission within healthcare settings is key to its containment but is hindered by the lack of discriminatory power of standard genotyping methods. We describe a whole-genome phylogenetic-based method to track the transmission of individual clones in infected hospital patients from the epidemic C. difficile 027/ST1 lineage, and to distinguish between the 2 causes of recurrent disease, relapse (same strain), or reinfection (different strain). We monitored patients with C. difficile infection in a UK hospital over a 2-year period. We performed whole-genome sequencing and phylogenetic analysis of 108 strains isolated from symptomatic patients. High-resolution phylogeny was integrated with in-hospital transfers and contact data to create an infection network linking individual patients and specific hospital wards. Epidemic C. difficile 027/ST1 caused the majority of infections during our sampling period. Integration of whole-genome single nucleotide polymorphism (SNP) phylogenetic analysis, which accurately discriminated between 27 distinct SNP genotypes, with patient movement and contact data identified 32 plausible transmission events, including ward-based contamination (66%) or direct donor-recipient contact (34%). Highly contagious donors were identified who contributed to the persistence of clones within distinct hospital wards and the spread of clones between wards, especially in areas of intense turnover. Recurrent cases were identified between 4 and 26 weeks, highlighting the limitation of the standard <8-week cutoff used for patient diagnosis and management. Genome-based infection tracking to monitor the persistence and spread of C. difficile within healthcare facilities could inform infection control and patient management.
Highlights
MethodsWe monitored patients with C. difficile infection in a UK hospital over a 2-year period
Accurate tracking of Clostridium difficile transmission within healthcare settings is key to its containment but is hindered by the lack of discriminatory power of standard genotyping methods
We describe a whole-genome phylogenetic-based method to track the transmission of individual clones in infected hospital patients from the epidemic C. difficile 027/ST1 lineage, and to distinguish between the 2 causes of recurrent disease, relapse, or reinfection
Summary
We monitored patients with C. difficile infection in a UK hospital over a 2-year period. High-resolution phylogeny was integrated with in-hospital transfers and contact data to create an infection network linking individual patients and specific hospital wards. Patients with Clostridium difficile infection (CDI) were recruited from the Royal Liverpool and Broadgreen University Hospitals National Health Service (NHS) Trust, which manages 870 acute beds, between July 2008 and May 2010. 746 CID 2016:62 (15 March) Kumar et al were adult patients (aged ≥18 years) who developed healthcareassociated diarrhea (ie, passed ≥3 liquid stools in the 24 hours before assessment), had a positive C. difficile toxin test (TOX A/ B II enzyme-linked immunosorbent assay; Techlab, Blacksburg, Virginia) and a confirmed diagnosis by independent clinicians using national guidelines [16]. The study was approved by the Liverpool Research Ethics Committee (approval reference number 08/H1005/32).
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