Elsevier

Anaerobe

Volume 28, August 2014, Pages 13-17
Anaerobe

Clinical microbiology
Occurrence of Clostridium difficile PCR-ribotype 027 and it's closely related PCR-ribotype 176 in hospitals in Poland in 2008–2010

https://doi.org/10.1016/j.anaerobe.2014.04.007Get rights and content

Highlights

  • CDI outbreaks associated with types 027 and 176 have been documented in Poland.

  • 64% of patients with CDI were treated with broad-spectrum antibiotics.

  • 50% patients infected by PCR-ribotype 027 and 176 had a severe form of CDI.

  • 100% of isolates PCR-ribotype 027 and 176 were multi-resistant.

  • Studies evaluating the clinical impact of type 176 are urgently needed.

Abstract

Since 2003, a rising incidence of Clostridium difficile infection (CDI) in North America and Europe has coincided with outbreaks of C. difficile PCR ribotype 027. This ribotype was not observed in Poland until 2008. In the period 2008–2010, outbreaks of antibiotic-associated diarrhoea occurred in three different hospitals in Poland. Of 30 C. difficile isolates available for microbiological characterisation, 17 (56%) were positive for binary toxin genes and belonged to PCR ribotype 027 (n = 7) and its closely related PCR ribotype 176 (n = 10). All 17 binary toxin–positive C. difficile strains demonstrated high-level resistance to fluoroquinolones (minimum inhibitory concentration (MIC) ≥ 32 mg/L), including ciprofloxacin, gatifloxacin, and moxifloxacin, as well as erythromycin and clindamycin (MIC ≥ 256 mg/L for both). Of 14 patients from whom clinical information was available, 50% had a severe form of CDI, defined by fever (>38.5 °C), decreased kidney function, and high leucocyte count. We conclude that outbreaks of CDI associated with hypervirulent strains belonging to PCR ribotypes 027 and 176 occurred in hospitals in Poland. Further studies evaluating the clinical impact of type 176 are urgently needed.

Introduction

Clostridium difficile, a gram-positive, spore-forming, anaerobic bacterium, is an important causative agent of antibiotic-associated diarrhoea. The main virulence factors contributing to C. difficile infection (CDI) are two toxins: toxin A (TcdA), an enterotoxin, and toxin B (TcdB), a cytotoxin [1], [2]. Some strains can produce a third toxin, the so-called binary toxin (CDT) [3]. Since early 2003, increasing rates of CDI caused by binary toxin-positive C. difficile strains belonging to PCR ribotype 027 (type 027) were observed across North America and Europe [4], [5], [6]. These infections were characterised by a more severe course, higher mortality, increased frequency of relapse, and more complications [5], [7]. Outbreaks of CDI due to type 027 have been associated with fluoroquinolone use in particular, probably due to resistance against newer generation fluoroquinolones [8], [9], [10]. In Europe, C. difficile type 027 was first detected in 2005 in England and shortly thereafter, in the Netherlands. The first Polish isolate of C. difficile type 027 was found in 2005 and its related type 176 in 2008 [4], [11], [12]. We here report on the epidemiology of CDI caused by C. difficile types 027 and 176 in Poland during 2008–2010.

Section snippets

Materials and methods

An episode of CDI was defined for a patient with diarrhoea who tested positive for C. difficile toxins A/B and negative for other enteric pathogens, and/or showed evidence of toxin-producing C. difficile in the stool on the basis of toxigenic culture. We also defined CDI for any patient with pseudomembranous colitis diagnosed by colonoscopy. According to the European Centre for Disease Prevention and Control (ECDC)-proposed definitions [4], CDI is divided into healthcare-associated CDI,

Results

During the study period, a total of 2340 patients in three hospitals (H1, H2, and H3) were tested for CDI. Of these, 882 (37.7%) tested positive. The high positivity rate of 48% (2008) and 65% (2009) in hospital H1 can be explained by the local epidemiology of CDI in this hospital and the sensitivity of the routine testing protocol for stool samples. The CDI incidence in the three hospitals ranged from 3.2 to 3.9/10,000 patient-days (average, 3.6/1000 patient-days). Data of the incidence of CDI

Discussion

CDI outbreaks associated with types 027 and 176 have been documented in 3 hospitals in Poland in 2008–2010. Most likely, other hospitals in Poland also encountered outbreaks, since 2 patients had been transferred from another hospital. The CDI incidence in one hospital was higher (5.1 per 10,000 patient-days) than the CDI incidence reported in a pan-European study performed in 2008 (4.1 per 10,000 patient-days) [18]. The first ribotype 027 isolate of C. difficile from Poland originated in 2005

Competing interests

None declared.

Acknowledgements

This work was supported by National Centre of Science, Grant number DEC-2011/01/B/NZ7/02720.

We kindly thank Professor J. Wyzgał (Infant Jesus Teaching Hospital in Warsaw) in support and epidemiological data (hospital H1).

References (18)

There are more references available in the full text version of this article.

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