Clinical characteristics of relapses and re-infections in Clostridium difficile infection

Kim, J.; Seo, Min Ji; Kang, Jung Oak; Kim, Y.; Hong, Sung Pil; Pai, Hyunjoo

doi:10.1111/1469-0691.12704

Cited by 19 publications

(18 citation statements)

References 29 publications

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“…In this study, we provided for the first time epidemiological evidence for inclusion of RT018 among successful epidemic genotypes. Our findings were further corroborated by recent works showing that RT018 was not only predominant and responsible for outbreaks in Asia, particularly in Korea and Japan, but also associated with CDI relapse (43)(44)(45).…”

Section: Discussionsupporting

confidence: 89%

Clostridium difficile PCR Ribotype 018, a Successful Epidemic Genotype

et al. 2015

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e Clostridium difficile infection (CDI) became a public health problem for the global spreading of the so-called hypervirulent PCR ribotypes (RTs) 027 and 078, associated with increases in the transmission and severity of the disease. However, especially in Europe, several RTs are prevalent, and the concept of hypervirulence is currently debated. We investigated the toxin and resistance profiles and the genetic relatedness of 312 C. difficile strains isolated in a large Italian teaching hospital during a 5-year period. We evaluated the role of CDI-related antibiotic consumption and infection control practices on the RT predominance in association with their molecular features and transmission capacity. Excluding secondary cases due to nosocomial transmission, RT018 was the predominant genotype (42.4%) followed by RT078 (13.6%), while RT027 accounted for 0.8% of the strains. RT078 was most frequently isolated from patients in intensive care units. Its prevalence significantly increased over time, but its transmission capacity was very low. In contrast, RT018 was highly transmissible and accounted for 95.7% of the secondary cases. Patients with the RT018 genotype were significantly older than those with RT078 and other RTs, indicating an association between epidemic RT and age. We provide here the first epidemiological evidence to consider RT018 as a successful epidemic genotype that deserves more attention in clinical practice.C lostridium difficile infection (CDI) is one of the most common hospital-acquired infections and the main known cause of antibiotic-associated diarrhea in hospitals in industrialized countries (1). Previous antibiotic treatment, hospitalization, old age, and underlying diseases represent major risk factors for CDI. The disease spectrum ranges from mild diarrhea to severe pseudomembranous enterocolitis, sepsis, and death (2, 3).In the past decade, many countries in North America and Europe have registered an increase in CDI rates and related severity and mortality (4, 5). These epidemiological changes coincided with the emergence and epidemic spread of C. difficile strains belonging to the PCR ribotype (RT) 027/North American pulsedfield gel electrophoresis type 1 (NAP1) (6). Indeed, RT027 became the predominant strain in many geographical regions, as documented in different epidemiological studies, and, since 2005, several countries have conducted epidemiological surveillance to monitor its spread (7,8). It has been reported to occur in at least 38 U.S. states and in 16 European countries, being also responsible for outbreaks (7, 9). Moreover, an increase in community-acquired CDI has been reported; in Europe, this phenomenon correlates with the diffusion of RT078/NAP7 or NAP8 which, like RT027, has been associated with higher disease severity and attributable mortality (1, 10).RT027 and RT078 are often referred to as hypervirulent genotypes of C. difficile, but this definition is not without controversy. Though this term denotes an increase in virulence, it has often been misused to ident...

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Section: Discussionsupporting

confidence: 89%

Clostridium difficile PCR Ribotype 018, a Successful Epidemic Genotype

et al. 2015

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“…R017 is among several clonal lineages of C . difficile known to cause parallel increases in disease severity, mortality and recurrence [8, 9], but having similar clinical outcome in a report [2]. …”

Section: Introductionmentioning

confidence: 81%

“…First, the sum of scores ascribed to the following factor (1 point each) was measured: age over 60 years, temperature over 38.3°C, albumin level below 2.5 mg/dL, or WBC count ≥ 15,000 cells/μL. When the score was ≥ 2, disease was regarded as severe [8]. Second, if a patient had a WBC count ≥ 15,000 cells/μL or a>1.5 fold rise in serum creatinine, the disease was regarded as severe [17].…”

Section: Methodsmentioning

confidence: 99%

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Clinical Characteristics and Treatment Outcomes of Clostridium difficile Infections by PCR Ribotype 017 and 018 Strains

Kim

Pai

2016

PLoS ONE

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The objective of this study was to identify the clinical characteristics of Clostridium difficile infections (CDIs) caused by toxin A-negative/toxin B-positive (A-B+) PCR ribotype 017 (R017) and A+B+ ribotype 018 (R018) strains, prevalent in Asian countries. From February 2010 through January 2013, all CDI patients in our hospital were enrolled; their medical records were retrospectively reviewed, and the isolates were characterized by toxigenic culture and PCR ribotyping. Based on the ribotypes, a total of 510 cases were categorized as R017 (139, 27.3%), R018 (157, 30.8%) and other ribotypes groups (214, 42.0%), and clinical variables were compared between R017 and other ribotypes, R018 and other ribotypes and R018 and R017 groups. The patients with R017 infections had a higher mean Charlson’s comorbidity index (OR 1.1, 1–1.21, p = 0.05), lower serum albumin (OR 0.47, 0.31–0.73, p = 0.001) and lower CRP levels (OR 0.96, 0.92–0.99, p = 0.022) than those with other ribotypes. R018 infections caused more azotemia (OR 4.06, 1.28–12.91, p = 0.018) and more frequent severe CDI (OR 1.87, 1.12–3.13, p = 0.016) than the other ribotypes infections. R017 and R018 infections were more often associated with toxin positive stools (OR 2.94, 1.65–4.09, p<0.001; OR 4.55, 2.82–7.33, p<0.001). In terms of treatment outcomes, R017 infections caused a marginally higher 30-day mortality than other ribotypes infection. In a final multiple logistic regression model, 30-day mortality was associated with leukocytosis (OR 2.45, 1.0–6.01, p = 0.05) and hypoalbuminemia (OR 4.57, 1.83–11.39, p = 0.001), but only marginally with R017 infection (OR 2.14, 0.88–5.22, p = 0.094). In conclusion, infections by C. difficile R018 strains tend to cause more severe disease, while there was a trend for higher mortality with R017 infections.

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“…found relapse rates of ribotype 017 and 018 isolates were higher than those of other ribotypes (63.6% and 63.6% vs . 22.2%, respectively) [30]. The clinical impact of C .…”

Section: Discussionmentioning

confidence: 99%

Predominance of Clostridium difficile Ribotypes 017 and 078 among Toxigenic Clinical Isolates in Southern Taiwan

et al. 2016

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Ribotypes and toxin genotypes of clinical C. difficile isolates in Taiwan are rarely reported. A prospective surveillance study from January 2011 to January 2013 was conducted at the medical wards of a district hospital in southern Taiwan. Of the first toxigenic isolates from 120 patients, 68 (56.7%) of 120 isolates possessed both tcdA and tcdB. Of 52 (43.3%) with tcdB and truncated tcdA (tcdA-/tcdB+), all were ribotype 017 and none had binary toxin or tcdC deletion. Eighteen (15%) toxigenic isolates harbored binary toxins (cdtA and cdtB) and all had tcdC deletion, including Δ39 (C184T) deletion (14 isolates), Δ18 in-frame deletion (3 isolates), and Δ18 (Δ117A) deletion (1 isolate). Eleven of 14 isolates with Δ39 (C184T) deletion belonged to the ribotype 078 family, including ribotype 127 (6 isolates), ribotype 126 (4 isolates), and ribotype 078 (1 isolate). Among 8 patients with consecutive C. difficile isolates, these isolates from 6 (75%) patients were identical, irrespective of the presence or absence of diarrhea, suggestive of persistent fecal carriage or colonization. In conclusion in southern Taiwan, ribotype 017 isolates with a tcdA-/tcdB+ genotype were not uncommon and of C. difficile isolates with binary toxin, the ribotype 078 family was predominant.

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Clinical characteristics of relapses and re-infections in Clostridium difficile infection

Cited by 19 publications

References 29 publications

Clostridium difficile PCR Ribotype 018, a Successful Epidemic Genotype

Clostridium difficile PCR Ribotype 018, a Successful Epidemic Genotype

Clinical Characteristics and Treatment Outcomes of Clostridium difficile Infections by PCR Ribotype 017 and 018 Strains

Predominance of Clostridium difficile Ribotypes 017 and 078 among Toxigenic Clinical Isolates in Southern Taiwan

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