title: Clostridium difficile ribotype 176 - A predictor for high mortality and risk of nosocomial spread?
abstract: OBJECTIVE
  The objective of this survey was to determine the incidence of Clostridium difficile infections (CDI) at the Department of Infectious Diseases, Bulovka Hospital, and to evaluate clinical and epidemiological data on CDI patients together with a detailed molecular characterisation of C. difficile isolates. The patient outcomes were correlated to causative C. difficile PCR-ribotype.
  
  
  METHODS
  The twelve-month study (2013) comprised patients two years of age and older with CDI. CDI severity was estimated using ESCMID criteria and ATLAS scoring. C. difficile isolates were further characterized using ribotyping, Multiple-Locus Variable Tandem-Repeats analysis (MLVA) and investigation of antibiotic-resistance determinants (gyrA, gyrB, rpoB, ermB).
  
  
  RESULTS
  A total of 619 diarrhoeal stools were investigated. Seventy-two stool samples were GDH and toxin A/B positive, and 39 samples were GDH positive only and subsequently toxigenic C. difficile was cultured. In total, 111 C. difficile isolates were characterized, of which 64 (57.7%) belonged to PCR-ribotype 176. MLVA analysis of PCR-ribotype 176 isolates revealed 11 clonal complexes. Seventy-two isolates (64.9%) showed amino acid substitution Thr82Ile in the GyrA, and sixty-two isolates (55.9%) showed amino acid substitutions Arg505Lys together with His502Asn, or Asp492Glu together with Arg505Lys in the RpoB. Twelve isolates (10.8%) were ermB positive. Severe CDI according to the ESCMID criteria was recorded in forty-two patients (37.8%), and sixteen patients (14.4%) had ATLAS score ≥ 6. Twenty-nine patients (26.1%) had recurrent CDI and twenty-four patients (21.6%) died during the study period.
  
  
  CONCLUSIONS
  A higher rate of severe CDI, recurrences and mortality in association with PCR-ribotype 176 infections were observed. The high incidence of PCR-ribotype 176 in the study, and the presence of clonal relatedness between PCR-ribotype 176 isolates, indicate its higher capacity to spread in a hospital setting, which in turn highlights the need to implement strict epidemic measures when PCR-ribotype 176 occurs.
authors.affiliation: Department of Infectious Diseases, 3rd Faculty of Medicine, Bulovka Teaching Hospital, Prague, Czech Republic.
authors.forename: Sylvia
authors.initials: S
authors.lastname: Polivkova
authors.affiliation: Department of Medical Microbiology, Charles University, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic; DNA Laboratory, Department of Paediatric Neurology, Charles University, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic. Electronic address: marcela.krutova@seznam.cz.
authors.forename: Marcela
authors.initials: M
authors.lastname: Krutova
authors.affiliation: Department of Clinical Microbiology, Bulovka Teaching Hospital, Prague, Czech Republic.
authors.forename: Katarina
authors.initials: K
authors.lastname: Petrlova
authors.affiliation: Department of Infectious Diseases, 3rd Faculty of Medicine, Bulovka Teaching Hospital, Prague, Czech Republic.
authors.forename: Jiri
authors.initials: J
authors.lastname: Benes
authors.affiliation: Department of Medical Microbiology, Charles University, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic.
authors.forename: Otakar
authors.initials: O
authors.lastname: Nyc
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001426:Bacterial Proteins / Q000235:genetics*; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000145:classification* / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification; D003428:Cross Infection / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality / Q000473:pathology; D003967:Diarrhea / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality / Q000473:pathology; D024881:Drug Resistance, Bacterial / Q000235:genetics; D004761:Enterocolitis, Pseudomembranous / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality / Q000473:pathology; D005260:Female; D015870:Gene Expression; D006801:Humans; D008297:Male; D008875:Middle Aged; D058885:Multilocus Sequence Typing; D009154:Mutation; D012189:Retrospective Studies; D021521:Ribotyping; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D001426:Bacterial Proteins
keywords: ATLAS score; Clostridium difficile; MLVA; PCR-Ribotype 176; Ribotyping; Thr82Ile