title: Clostridium difficile infection in an Iranian hospital.
abstract: BACKGROUND
  Clostridium difficile infection (CDI) is an important cause of morbidity and mortality internationally, yet there are important regional differences in the epidemiology and microbiology of disease. Most reports have come from North America and Europe, with limited information from other regions, including the Middle East. Given the changes in the epidemiology of CDI in developed countries, particularly associated with the dissemination of hypervirulent epidemic clones, an understanding of the epidemiology and microbiology of CDI in diverse regions is warranted. This study involved collection of stool samples from individuals with diarrhea at the Isfahan University of Medical Sciences Teaching Hospital, Isfahan, Iran, between October 2010 and March 2011. Selective enrichment culture for C. difficile was performed and isolates were characterised using ribotyping, PCR for the detection of tcdA, tcdB and cdtB genes, and tcdC sequence analysis.
  
  
  RESULTS
  Clostridium difficile was isolated from 19/89 (21%) stool samples of 17/86 (20%) patients. 13/17 (77%) cases of CDI were hospital-associated. Patients with CDI were significantly older (43 ± 28y) than those with non-CDI diarrhea (24, ± 26y)(P = 0.018). All isolates were toxigenic, and possessed genes encoding for toxins A and B. Six (32%) of 19 isolates also possessed cdtB. Twelve ribotypes were identified. Ribotype 078/toxinotype V was most common, accounting for 4 (21%) of isolates. A single isolate of a different toxinotype V ribotype was identified, as was a toxinotype XXIV isolate. The remaining isolates consisted of 9 different toxinotype 0 ribotypes.
  
  
  CONCLUSIONS
  CDI is an important cause of diarrhea in patients in this hospital. The diversity of ribotypes was striking, and the number of different types suggests the presence of a broad range of strains in the community, the hospital or both. The predominance of toxinotype V strains, which have been associated with community-associated disease and food animals, was unexpected and possible sources of this type require further investigation.
authors.affiliation: School of Nutrition and Food Sciences and Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Jalali
authors.forename: Farzin
authors.initials: F
authors.lastname: Khorvash
authors.forename: Keith
authors.initials: K
authors.lastname: Warriner
authors.forename: J Scott
authors.initials: JS
authors.lastname: Weese
mesh_terms: D036002:ADP Ribose Transferases / Q000235:genetics; D000293:Adolescent; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001426:Bacterial Proteins / Q000235:genetics; D001427:Bacterial Toxins / Q000235:genetics; D016360:Clostridioides difficile / Q000145:classification / Q000235:genetics* / Q000302:isolation & purification; D003428:Cross Infection / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D003967:Diarrhea / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D004761:Enterocolitis, Pseudomembranous / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D004768:Enterotoxins / Q000235:genetics; D005243:Feces / Q000382:microbiology; D005260:Female; D014644:Genetic Variation; D006761:Hospitals; D006801:Humans; D007492:Iran / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D012097:Repressor Proteins / Q000235:genetics; D021521:Ribotyping
chemical_list: D000900:Anti-Bacterial Agents; D001426:Bacterial Proteins; D001427:Bacterial Toxins; D004768:Enterotoxins; D012097:Repressor Proteins; C105615:TcdC protein, Clostridium difficile; C041348:tcdA protein, Clostridium difficile; C031815:toxB protein, Clostridium difficile; D036002:ADP Ribose Transferases; C410164:actin-specific ADP-ribosyltransferase, Clostridium