UNIVERSITY OF NIGERIA,NSUKKA

FACULTY OF BIOLOGICAL SCIENCES DEPARTMENT OF MICROBIOLOGY

SEMINAR TOPIC:
CLOSTRIDIUM DIFFICILE FROM OBSCURITY TO SUPERBUG

BY AGBO JENNIFFER.C 2008/160703

INTRODUCTION
C. difficile is a Gram positive, spore forming anaerobic bacteria. It is associated with enteric disease. This bacterium has two specific features, one is the production of toxins which can damage the cells lining the bowel and the other is the ability for form spores which enable the bacterium to persist in the environment for long periods of time Clostridium difficile (C. difficile) is an increasing cause of morbidity and mortality especially in hospitalised patients. These are resistant to exposure to air, drying and heat, survive in the environment and are considered to be the main transmissible form of the organism. C. difficile is distinguished from other clostridia on the basis of biochemical tests and the toxins it produces. These include two major toxins that are linked to its pathogenicity toxin A, which causes loss of fluid from the gut mucosa, and toxin B, a potent cytopathic toxin.

HISTORY
Clostridium difficile was discovered in 1935 by Hall and

O'Toole ,it was originally named Bacillus difficilis because it was resistant to early attempts at isolation and grew very slowly in culture, it was renamed in 1970 After the discovery of the bacterium in 1935, it was initially considered to be a commensal in healthy human beings, particularly in children (Hall and O'Toole, 1935). However, the combination of an infection with C. difficile, the use of broad spectrum antibiotics and hospitalisation were found to be risk factors for development of C. difficile associated diarrhea (CDAD) (Poutanen and Simor, 2004). Nowadays it seems that infections are not restricted to hospital settings. A study, conducted in the Netherlands, found 1,5% (37/2423) of patients with diarrhea submitted by general practitioners (GPs) C. difficile toxin positive (Bauer et al., 2009). Eighteen percent of these patients were under the age of 20, twenty-six percent had not used antibiotics during

last 6 months nor stayed at a healthcare facility in the year before (Bauer et al., 2009). In a UK study, 2,1% (42/2000) of fecal samples from patients with diarrhea who consulted a GP were cytotoxin-positive, thirty-five percent of CDI (C. difficile infection) cases neither had exposure to antibiotics nor hospitalization (Wilcox et al., 2008). C. difficile is found in many animal species, including food animals such as pigs (Keel et al., 2007). Only a few studies report the prevalence of C. difficile in pigs around age of slaughter. The prevalences found in older pigs are much lower compared to young piglets (Alvarez-Perez et al., 2009; Norman et al., 2009; Weese et al., 2010b). In a longitudinal study colonization of C. difficile significantly decreased from 56% (66/117) on day 2 to 3,7% (2/54) on 62 days of age (Weese et al., 2010b). Prevalences for C. difficile found in older pigs are 3,9% (15/382; USA) for sampled grower-finisher pigs (Norman et al., 2009) and 6,9% (30/435; Canada) for grower-finisher pigs close to the time of slaughter (Weese et al., 2010a) at the North-American continent. In Europe percentages of

respectively 3,3% (2/61; Austria) and 0% (0/165; Switzerland)

were found at the abattoir (Hoffer et al., 2010; Indra et al., 2009). In a pilot study performed in the Netherlands we found 28% (14/50) C. difficile positive in samples taken at the abattoir (unpublished data). Many different C. difficile strains have already been discovered, these strains are classified in ribotypes (Stubbs et al., 1999). There are important human strains of C. difficile found in food animals, especially ribotype 078/toxinotype V is of great importance. One study found that 83% (119/144) of the C. difficile isolates from neonatal pigs were ribotype 078 (Keel et al., 2007). There is also evidence that ribotype 078 may be overrepresented in community associated infections (Goorhuis et al., 2008a; Goorhuis et al., 2008b; Jhung et al., 2008). At the moment ribotype 078 is the third most frequent found ribotype by CDI-patients in the Netherlands (Hensgens et al., 2010). Ribotype 078 isolates that were cultured from faecal samples of humans and piglets, showed a high degree of similarity (Debast et al., 2009; Goorhuis et al., 2008a). Almost all of these isolates contain genes for toxin A (tcdA), toxin B (tcdB), binary toxin, and a 39-base pair deletion in toxin

regulator gene (tcdC) (Debast et al., 2009; Goorhuis et al., 2008a; Goorhuis et al., 2008b; Jhung et al., 2008).

EPIDEMIOLOGY
Clostridium difficile is transmitted by the fecaloral route. The spores are acid resistant and can transverse the stomach, ending up in the colon, where they reside; C. difficile overgrowth occurs during antibiotic therapy, as the normal intestinal flora is disrupted. The frequency of C. difficile carriage is about 13% in healthy adults and is higher among hospital employees and caregivers of susceptible patients. Stool carriage of C. difficile reaches 1635% in hospital inpatients, with the percentage

proportional to the duration of hospital stay and increasing with exposure to antibiotics. Between 1% and 3% of healthy adults and up to 50% of patients residing in hospitals and nursing homes are colonized with and asymptomatically carry C. difficile in their stool. Interestingly, the rates of colonization are higher in neonates, with reported ranges between 5% and 70%, although this population is less likely to develop the disease than adults. It

is believed that the lower rates of disease in neonates are due to the immaturity of their intestinal cells, which lack receptors for one of the organism's disease-producing toxins.4 C. diffidle is currently recognized as the most common cause of nosocomial infectious diarrhea in nursing homes, and overall mortality assodated with CDI is estimated to be more than 17% in the older adult population. CDI occurs in up to 8% of hospitalized patients and results in an estimated $1.3 billion annually in healthcare costs in the United States.6,7 As previously mentioned, CDI is increasing in frequency and severity of disease. During the 1990s, the inddence of CDI in U.S. hospitals was

approximately 30 to 40 cases per 100,000 persons; this number increased to 84 per 100,000 in 2005. The number of fatal CDI cases has also increased over this time. A new strain of C. diffidle, which has caused disease outbreaks in the United States, Canada, Europe, and Asia, was reported by the Centers for Disease Control and Prevention (CDC) in 2004.8 This hypervirulent strain produces toxins A and B in quantities 16-fold to 20-fold higher than

seen in other strains, and produces an additional third toxin, as well. This strain has been referred to by several different names: "North American pulsed-field gel electrophoresis type 1 (NAP-I)"; "restriction endonudease pattern ?G; or "PCR linotype 027." It is now commonly referred to as "NAPl/ BI/027." Overall, the NAP1/BI/027 strain is considered to be easier to transmit, more virulent, and more difficult to treat than previously identified strains.
TRANSMISSION

Transmission of C. diffidle occurs via the fecal-oral route, through ingestion of either the vegetative form or the spore form of the miCTOorganism. The spore form of C. diffidle may survive on manimate surfaces and is iesbtant to alcohol and routine disinfectants.10 Transmission of the microorganism occurs in healthcare facilities via the fecal-oral route either directly from person to person (particularly from the sporeconteminated hands of healthcare workers) or from a

oentaniinated environment, especially in institutions with improper hygiene practices, isolation precautions, or

environmental deaning practices.

CAUSES OF CLOSTRIDIUM DIFFICILEASSOCIATED DISEASE

This disease has been associated with all classes of antibiotics. The initial antibiotic that led to recognition of CDAD was clindamycin. In more recent years, this infection has been highly related to third-generation cephalosporins and fluoroquinolones,2325 a finding that has raised the issue of implementing policies to restrict these drugs in tertiary care hospitals. Despite differential claims by manufacturers of currently used

fluoroquinolones, experts believe that all fluoroquinolones are implicated. In general, broad-spectrum antimicrobial therapy is more likely than narrow-spectrum antibiotic treatment to lead to CDAD.