Elsevier

Anaerobe

Volume 65, October 2020, 102252
Anaerobe

Clostridioides (Clostridium) difficile (including epidemiology)
An outbreak of Clostridioides difficile infections due to a 027-like PCR ribotype 181 in a rehabilitation centre: Epidemiological and microbiological characteristics

https://doi.org/10.1016/j.anaerobe.2020.102252Get rights and content

Highlights

  • A rapid spread of a newly identified PCR ribotype 181.

  • Genomic analysis revealed a clonal outbreak of a clade 2 strain.

  • Need for better understanding of overall Clade 2 phylogeny.

Abstract

Clostridioides difficile is one of the most important healthcare-associated pathogens. Recently, several new 027-like types have been found that all belong to the multilocus sequence typing (MLST) Clade 2. We report a rapidly spreading outbreak of C. difficile infections (CDI) due to a newly identified PCR ribotype (RT) 181 in a Rehabilitation Centre (RC). Genomic analysis revealed the outbreak strain, not previously identified in Greece, belonged to clade 2, sequence type (ST) 1 and had a 18bp deletion in tcdC at position 311 together with a single nucleotide deletion at position 117, similarly to RT 027. The presence of a clonal outbreak was confirmed by whole genome sequencing, yet the source of this ribotype remained unclear. The emergence and rapid spread of new C. difficile ribotypes highlights the need for ongoing C. difficile surveillance and better understanding of overall Clade 2 phylogeny.

Introduction

Clostridioides difficile is one of the most important healthcare-associated pathogens and associated with disturbance of the gut microbiota, mostly by antibiotic use. Since 2004, new types have emerged worldwide that are associated with higher morbidity and mortality, such as PCR ribotypes 027 and 078 [[1], [2], [3]]. In 2017, 223,900 cases of C. difficile infections (CDI) occurred and at least 12,800 people died with $130 M as estimated healthcare costs in the United States (US). The American Centre for Disease Prevention and Control (CDC) published an Antibiotic Resistance Threats Report about the most alarming antibiotic-resistant germs in the United States and considered CDI as an urgent threat [4]. The European Centre for Disease Control and Prevention (ECDC) also recognized the emergence of CDI in Europe and initiated a European surveillance in acute care hospitals since January 1, 2016 to estimate the incidence of CDI, to assess the burden of CDI, and to describe the epidemiology of C. difficile at the local, national and European level. A recently published report with CDI incidence data of 23 EU/EEA for 2016–2017 indicated that 1 in 26 Healthcare-Associated (HA) CDI cases died, with CDI as a potential contributing factor to death [5]. ECDC estimates that there were in the order of 7400 deaths annually in the EU/EEA with HA CDI as a contributing cause. Available microbiological data showed that PCR ribotype 027 was found as second most frequently, especially in Eastern European countries. Recently, a few 027-like types have been found that all belong to the same MLST Clade 2 [6] but have an unknown clinical and epidemiological presentation. The 027-like types differ only slightly by PCR ribotyping and have many similarities by whole genome sequencing.

Section snippets

Methods

Here, we identify a rapidly spreading outbreak of nineteen episodes of Clostridioides difficile infections (CDI) in a Greek Rehabilitation Clinic (RC). The outbreak occurred among 16 patients from orthopedic ward and three from neurological ward. Cultured strains showed an unknown 027-like type and were sent to the National Reference Laboratory for C. difficile at Leiden University Medical Centre (LUMC) for further characterization.

Results

The CDI incidence rate of infections was 49 infections per 10,000 patient days (29 March-25 April 2019), which had nearly quadrupled compared to previous infection rates. During the outbreak investigation, fifteen of nineteen patients with CDI were found to be infected with ribotype RT 181 (Table 1). The first diagnosed case (Case A) was a 78-year-old female patient with a history of ovarian cancer in the past and a recently restored femoral fracture in a public hospital 15 days before

Discussion

We report a hospital outbreak of fifteen patients with C. difficile infection due to RT 181 in a rehabilitation centre in Northern Greece. To the best of our knowledge this is the first CDI outbreak reported in a RC in Greece. The RC imports patients from all public and private hospitals of Northern Greece. The source of this outbreak remains unknown but is most likely hospital-associated since all patients with CDI diagnosed were hospitalized before admission to the RC. An alert was released

Conclusions

This outbreak indicates that new C. difficile ribotypes still emerge at unexpected time and location without a clear source. Given the mild to moderate virulence of this newly identified ribotype in contrast to hypervirulent other ribotypes of the Clade 2, the better understanding of overall Clade 2 phylogeny remains essential, particularly the global epidemiology of RTs other than RT027, and their contribution to community acquired (CA)-CDI.

Funding statement

None.

Declaration of competing interest

None of the authors has a conflict of interest.

Acknowledgements

We thank Virginie Viprey and Mark Wilcox (University of Leeds) for kindly providing the reference strain of RT 181. We also thank Karen Burns and Tara Mitchell (Health Protection Surveillance Centre- Dublin) and Kristina Rizzardi (Folkhälsomyndigheten, Laborativ Bakterieövervakning, Sweden) for sending the presumed RT 181 strains. Finally, we thank Pete Kinross (ECDC) for his help with C. difficile Tessy Database.

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