Infect Chemother.  2013 Jun;45(2):175-183. 10.3947/ic.2013.45.2.175.

Clinical and Microbiologic Characteristics of Clostridium difficile Infection Caused by Binary Toxin Producing Strain in Korea

Affiliations
  • 1Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea. paihyunjoo@gmail.com
  • 2Department of Laboratory Medicine, Hanyang University College of Medicine, Seoul, Korea.

Abstract

BACKGROUND
Binary toxin-producing Clostridium difficile infections (CDI) are known to be more severe and to cause higher case fatality rates than those by binary toxin-negative isolates. There has been few data of binary toxin-producing CDI in Korea. Objective of the study is to characterize clinical and microbiological trait of CDI cause by binary-toxin producing isolates in Korea.
MATERIALS AND METHODS
From September 2008 through January 2010, clinical characteristics, medication history and treatment outcome of all the CDI patients were collected prospectively. Toxin characterization, PCR ribotyping and antibiotic susceptibility were performed with the stool isolates of C. difficile.
RESULTS
During the period, CDI caused by 11binary toxin-producing isolates and 105 toxin A & toxin B-positive binary toxin-negative isolates were identified. Comparing the disease severity and clinical findings between two groups, leukocytosis and mucoid stool were more frequently observed in patients with binary toxin-positive isolates (OR: 5.2, 95% CI: 1.1 to 25.4, P = 0.043; OR: 7.6, 95% CI: 1.6 to 35.6, P = 0.010, respectively), but clinical outcome of 2 groups did not show any difference. For the risk factors for acquisition of binary toxin-positive isolates, previous use of glycopeptides was the significant risk factor (OR: 6.2, 95% CI: 1.4 to 28.6, P = 0.019), but use of probiotics worked as an inhibitory factor (OR: 0.1, 95% CI: 0.0 to 0.8; P = 0.026). PCR ribotypes of binary toxinproducing C. difficile showed variable patterns: ribotype 130, 4 isolates; 027, 3 isolates; 267 and 122, 1 each isolate and unidentified C1, 2 isolates. All 11 binary toxin-positive isolates were highly susceptible to clindamycin, moxifloxacin, metronidazole, vancomycin and piperacillin-tazobactam, however, 1 of 11 of the isolates was resistant to rifaximin.
CONCLUSIONS
Binary toxin-producing C. difficile infection was not common in Korea and those isolates showed diverse PCR ribotypes with high susceptibility to antimicrobial agents. Glycopeptide use was a risk factor for CDI by those isolates.

Keyword

Clostridium difficile; Binary toxin; Clinical characteristics; PCR ribotype; Susceptibility

MeSH Terms

Anti-Infective Agents
Aza Compounds
Clindamycin
Clostridium
Clostridium difficile
Glycopeptides
Humans
Korea
Leukocytosis
Metronidazole
Polymerase Chain Reaction
Probiotics
Prospective Studies
Quinolines
Ribotyping
Risk Factors
Sprains and Strains
Treatment Outcome
Vancomycin
Anti-Infective Agents
Aza Compounds
Clindamycin
Glycopeptides
Metronidazole
Quinolines
Vancomycin

Reference

1. Hubert B, Loo VG, Bourgault AM, Poirier L, Dascal A, Fortin E, Dionne M, Lorange M. A portrait of the geographic dissemination of the Clostridium difficile North American pulsed-field type 1 strain and the epidemiology of C. difficile-associated disease in Québec. Clin Infect Dis. 2007. 44:238–244.
Article
2. Cheknis AK, Sambol SP, Davidson DM, Nagaro KJ, Mancini MC, Hidalgo-Arroyo GA, Brazier JS, Johnson S, Gerding DN. Distribution of Clostridium difficile strains from a North American, European and Australian trial of treatment for C. difficile infections: 2005-2007. Anaerobe. 2009. 15:230–233.
Article
3. Kim J, Kang JO, Kim H, Seo MR, Choi TY, Pai H, Kuijper EJ, Sanders I, Fawley W. Epidemiology of Clostridium difficile infections in a tertiary-care hospital in Korea. Clin Microbiol Infect. 2012. 19:521–527.
Article
4. Kim H, Jeong SH, Roh KH, Hong SG, Kim JW, Shin MG, Kim MN, Shin HB, Uh Y, Lee H, Lee K. Investigation of toxin gene diversity, molecular epidemiology, and antimicrobial resistance of Clostridium difficile isolated from 12 hospitals in South Korea. Korean J Lab Med. 2010. 30:491–497.
Article
5. Carroll KC, Bartlett JG. Biology of Clostridium difficile: implications for epidemiology and diagnosis. Annu Rev Microbiol. 2011. 65:501–521.
6. Geric B, Carman RJ, Rupnik M, Genheimer CW, Sambol SP, Lyerly DM, Gerding DN, Johnson S. Binary toxin-producing, large clostridial toxin-negative Clostridium difficile strains are enterotoxic but do not cause disease in hamsters. J Infect Dis. 2006. 193:1143–1150.
Article
7. Schwan C, Stecher B, Tzivelekidis T, van Ham M, Rohde M, Hardt WD, Wehland J, Aktories K. Clostridium difficile toxin CDT induces formation of microtubule-based protrusions and increases adherence of bacteria. PLoS Pathog. 2009. 5:e1000626.
8. Kelly CP, LaMont JT. Clostridium difficile--more difficult than ever. N Engl J Med. 2008. 359:1932–1940.
9. Warny M, Pepin J, Fang A, Killgore G, Thompson A, Brazier J, Frost E, McDonald LC. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet. 2005. 366:1079–1084.
Article
10. McDonald LC, Killgore GE, Thompson A, Owens RC Jr, Kazakova SV, Sambol SP, Johnson S, Gerding DN. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005. 353:2433–2441.
Article
11. Tae CH, Jung SA, Song HJ, Kim SE, Choi HJ, Lee M, Hwang Y, Kim H, Lee K. The first case of antibiotic-associated colitis by Clostridium difficile PCR ribotype 027 in Korea. J Korean Med Sci. 2009. 24:520–524.
Article
12. Kim J, Pai H, Seo MR, Kang JO. Epidemiology and clinical characteristics of Clostridium difficile infection in a Korean tertiary hospital. J Korean Med Sci. 2011. 26:1258–1264.
Article
13. Ferguson MK. The rationale for developing scoring systems for clinical practice. Thorac Surg Clin. 2007. 17:343–351.
Article
14. . World Health Organisation. The anatomical therapeutic chemical (ATC) and defined daily dosing (DDD) system index 2010. Accessed 28 October 2010. Available at: http://www.whocc.no/.
15. Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007. 45:302–307.
Article
16. Gerding DN, Muto CA, Owens RC Jr. Treatment of Clostridium difficile infection. Clin Infect Dis. 2008. 46:Suppl 1. S32–S42.
17. Cheong HS, Kim JK, Lim TK, Kwon KT, Ryu SY, Heo ST, Ko KS, Oh WS, Peck KR, Lee NY, Song JH. Therapeutic efficacy of metronidazole for patients with Clostridium difficile-associated diarrhea. Korean J Med. 2007. 72:639–646.
18. Barbut F, Richard A, Hamadi K, Chomette V, Burghoffer B, Petit JC. Epidemiology of recurrences or reinfections of Clostridium difficile-associated diarrhea. J Clin Microbiol. 2000. 38:2386–2388.
Article
19. Seo MR, Kim J, Kang JO, Choi TY, Pai H. Multiplex PCR method for detection of Clostridium difficile tcdA, tcdB and binary toxin genes. In : 2012 Annual Meeting of the Korean Society of Infectious Disease and the Korean Society for Chemotherapy; 2012 Sep 1-2; Jeju, Korea. 179.
20. Kim J, Kang JO, Pai H, Choi TY. Association between PCR ribotypes and antimicrobial susceptibility among Clostridium difficile isolates from healthcare-associated infections in South Korea. Int J Antimicrob Agents. 2012. 40:24–29.
Article
21. Kim H, Lee Y, Moon HW, Lim CS, Lee K, Chong Y. Emergence of Clostridium difficile Ribotype 027 in Korea. Korean J Lab Med. 2011. 31:191–196.
22. Bauer MP, Notermans DW, van Benthem BH, Brazier JS, Wilcox MH, Rupnik M, Monnet DL, van Dissel JT, Kuijper EJ. ECDIS Study Group. Clostridium difficile infection in Europe: a hospital-based survey. Lancet. 2011. 377:63–73.
23. Bacci S, Mølbak K, Kjeldsen MK, Olsen KE. Binary toxin and death after Clostridium difficile infection. Emerg Infect Dis. 2011. 17:976–982.
24. Barbut F, Decré D, Lalande V, Burghoffer B, Noussair L, Gigandon A, Espinasse F, Raskine L, Robert J, Mangeol A, Branger C, Petit JC. Clinical features of Clostridium difficile-associated diarrhoea due to binary toxin (actin-specific ADP-ribosyltransferase)-producing strains. J Med Microbiol. 2005. 54:181–185.
Article
25. Barbut F, Gariazzo B, Bonné L, Lalande V, Burghoffer B, Luiuz R, Petit JC. Clinical features of Clostridium difficile-associated infections and molecular characterization of strains: results of a retrospective study, 2000-2004. Infect Control Hosp Epidemiol. 2007. 28:131–139.
Article
26. Walk ST, Micic D, Jain R, Lo ES, Trivedi I, Liu EW, Almassalha LM, Ewing SA, Ring C, Galecki AT, Rogers MA, Washer L, Newton DW, Malani PN, Young VB, Aronoff DM. Clostridium difficile ribotype does not predict severe infection. Clin Infect Dis. 2012. 55:1661–1668.
27. Jobe BA, Grasley A, Deveney KE, Deveney CW, Sheppard BC. Clostridium difficile colitis: an increasing hospital-acquired illness. Am J Surg. 1995. 169:480–483.
28. Lyytikäinen O, Turunen H, Sund R, Rasinperä M, Könönen E, Ruutu P, Keskimäki I. Hospitalizations and deaths associated with Clostridium difficile infection, Finland, 1996-2004. Emerg Infect Dis. 2009. 15:761–765.
Article
29. Rubin MS, Bodenstein LE, Kent KC. Severe Clostridium difficile colitis. Dis Colon Rectum. 1995. 38:350–354.
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