title: Predominance and high antibiotic resistance of the emerging Clostridium difficile genotypes NAPCR1 and NAP9 in a Costa Rican hospital over a 2-year period without outbreaks.
abstract: Clostridium difficile is the major causative agent of nosocomial antibiotic-associated diarrhea. In a 2009 outbreak of C. difficile-associated diarrhea that was recorded in a major Costa Rican hospital, the hypervirulent NAP1 strain (45%) predominated together with a local genotype variant (NAPCR1, 31%). Both strains were fluoroquinolone-resistant and the NAPCR1 genotype, in addition, was resistant to clindamycin and rifampicin. We now report on the genotypes and antibiotic susceptibilities of 68 C. difficile isolates from a major Costa Rican hospital over a 2-year period without outbreaks. In contrast to our previous findings, no NAP1 strains were detected, and for the first time in a Costa Rican hospital, a significant fraction of the isolates were NAP9 strains (n=14, 21%). The local NAPCR1 genotype remained prevalent (n=18, 26%) and coexisted with 14 strains (21%) of classic hospital NAP types (NAP2, NAP4, and NAP6), eight new genotypes (12%), four environmental strains classified as NAP10 or NAP11 (6%), three strains without NAP designation (4%) and seven non-toxigenic strains (10%). All 68 strains were resistant to ciprofloxacin, 88% were resistant to clindamycin and 50% were resistant to moxifloxacin and rifampicin. Metronidazole and vancomycin susceptibilities were universal. The NAPCR1 and NAP9 strains, which have been associated with more severe clinical infections, were more resistant to antibiotics than the other strains. Altogether, our results confirm that the epidemiology of C. difficile infection is dynamic and that A(-)B(+) strains from the NAP9 type are on the rise not only in the developed world. Moreover, our results reveal that the local NAPCR1 strains still circulate in the country without causing outbreaks but with equally high antibiotic-resistance rates and levels.
authors.affiliation: Laboratory of Research in Anaerobic Bacteriology and Research Center in Tropical Diseases, University of Costa Rica, San José 11501-2060, Costa Rica.
authors.forename: Diana
authors.initials: D
authors.lastname: López-Ureña
authors.affiliation: Laboratory of Research in Anaerobic Bacteriology and Research Center in Tropical Diseases, University of Costa Rica, San José 11501-2060, Costa Rica.
authors.forename: Carlos
authors.initials: C
authors.lastname: Quesada-Gómez
authors.affiliation: Laboratory of Research in Anaerobic Bacteriology and Research Center in Tropical Diseases, University of Costa Rica, San José 11501-2060, Costa Rica.
authors.forename: Mónica
authors.initials: M
authors.lastname: Montoya-Ramírez
authors.affiliation: Laboratory of Research in Anaerobic Bacteriology and Research Center in Tropical Diseases, University of Costa Rica, San José 11501-2060, Costa Rica.
authors.forename: María
authors.initials: M
authors.lastname: del Mar Gamboa-Coronado
authors.affiliation: Laboratory of Research in Anaerobic Bacteriology and Research Center in Tropical Diseases, University of Costa Rica, San José 11501-2060, Costa Rica.
authors.forename: Teresita
authors.initials: T
authors.lastname: Somogyi
authors.affiliation: Laboratory of Research in Anaerobic Bacteriology and Research Center in Tropical Diseases, University of Costa Rica, San José 11501-2060, Costa Rica.
authors.forename: César
authors.initials: C
authors.lastname: Rodríguez
authors.affiliation: Laboratory of Research in Anaerobic Bacteriology and Research Center in Tropical Diseases, University of Costa Rica, San José 11501-2060, Costa Rica.
authors.forename: Evelyn
authors.initials: E
authors.lastname: Rodríguez-Cavallini
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology; D002981:Clindamycin / Q000494:pharmacology; D016360:Clostridioides difficile / Q000145:classification / Q000187:drug effects* / Q000235:genetics* / Q000302:isolation & purification; D003015:Clostridium Infections / Q000453:epidemiology / Q000382:microbiology*; D021821:Communicable Diseases, Emerging / Q000382:microbiology; D003364:Costa Rica / Q000453:epidemiology; D003428:Cross Infection / Q000453:epidemiology; D003967:Diarrhea / Q000453:epidemiology; D004196:Disease Outbreaks; D024881:Drug Resistance, Bacterial / Q000235:genetics; D016521:Electrophoresis, Gel, Pulsed-Field; D004761:Enterocolitis, Pseudomembranous / Q000453:epidemiology / Q000382:microbiology; D024841:Fluoroquinolones / Q000494:pharmacology; D005798:Genes, Bacterial; D005838:Genotype; D006761:Hospitals; D006801:Humans; D008826:Microbial Sensitivity Tests; D058889:Molecular Typing; D000077266:Moxifloxacin; D021521:Ribotyping; D013997:Time Factors; D014640:Vancomycin / Q000494:pharmacology
chemical_list: D000900:Anti-Bacterial Agents; D024841:Fluoroquinolones; D002981:Clindamycin; D014640:Vancomycin; D000077266:Moxifloxacin