Abstract
While the developed world has seen a significant increase in the number of scientific articles on Clostridium difficile infection (CDI), the developing world still lags behind on this subject due to limited laboratory capacity, low awareness, and limited surveillance of this problem. As such, CDI is considered a neglected but potentially huge problem in developing countries. The major aim of this study was to systemically evaluate the utility of several molecular typing tools for CDI, including their relevance in epidemiological studies in developing countries such as China. A total of 116 non-repetitive toxigenic C. difficile isolates from Chinese patients, were studied. The isolates comprised 83 (71.6%) A+B+CDT- isolates, 27 (23.3%) A-B+CDT- isolates, and 6 (5.1%) A+B+CDT+ isolates. Typing methods evaluated included multilocus variable-number tandem-repeat analysis, PCR ribotyping, multilocus sequence typing, and sequencing of slpA and tcdC genes, which identified 113, 30, 22, 18, and 8 genotypes each and exhibited discriminatory powers of 0.999, 0.916, 0.907, 0.883, and 0.765, respectively. Compared to A+B+ strains, A-B+ strains exhibited higher prevalence of drug resistance to clindamycin, erythromycin, levofloxacin, rifampicin, rifaximin, and tetracycline. Furthermore, drug resistance rates of strains with different PCR ribotypes differed, supporting the importance of molecular typing in management and control of CDI. Based on our earlier suggestion to improve the diagnostic laboratory capacity of CDI in developing countries, setting up efficient surveillance programs complemented by relevant molecular typing methods is warranted.
Highlights
Clostridium difficile is a leading cause of both nosocomial and antibiotic-associated diarrhea
The objective of this study was to evaluate the utility of different molecular typing assays for C. difficile, in relation to toxigenicity and antimicrobial susceptibility, using isolates obtained from one hospital in China
All specimens were initially tested for toxin A/B using enzyme immunoassay (EIA; VIDAS C. difficile Toxin A&B, bioMérieux, Marcy l’Etiole, France) and cultured on selective cycloserine–cefoxitin–fructose agar (CCFA) plates
Summary
Clostridium difficile is a leading cause of both nosocomial and antibiotic-associated diarrhea. The clinical manifestation of C. difficile infection (CDI) ranges from asymptomatic colonization to mild diarrhea to toxic megacolon and fulminant colitis. Most CDI cases have largely been attributed to the presence of the hyper-virulent C. difficile strain BI/NAP1/027 [restriction endonuclease analysis (REA) group BI, North American pulsefield type 1, PCR ribotype 027; McDonald et al, 2005]. Ribotype 027 strains have caused major epidemics in North America and Europe, only sporadic cases have been reported in Asia (Collins et al, 2013). Some strains that produce a binary toxin called C. difficile binary toxin (CDT), and whose role in causing disease is not yet clear, have been described and are associated with increased virulence and recurrence rates (Popoff et al, 1988)
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