Molecular epidemiology of Clostridium difficile in two tertiary care hospitals in Shandong Province, China

Abstract

Ying Luo,1,2 Wen Zhang,2 Jing-Wei Cheng,3 Meng Xiao,3 Gui-Rong Sun,1 Cheng-Jie Guo,2 Ming-Jun Liu,1 Pei-Shan Cong,1 Timothy Kudinha4,5 1Department of Clinical Laboratory, The Affiliated Hospital of Qingdao University, Qingdao, China; 2Department of Clinical Laboratory, Zibo Central Hospital, Zibo, China; 3Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; 4Charles Sturt University, Orange, NSW, Australia; 5Central West Pathology Laboratory, Orange, NSW, Australia Purpose: The incidence and severity of Clostridium difficile infection (CDI) have markedly increased over the past decade. However, there is very limited epidemiological data on CDI in China so far, specifically no data in Shandong Province. The aim of this study was to evaluate diagnostic algorithm for CDI and to gain data on molecular epidemiology of CDI in the Shandong Province of China.Materials and methods: Nonrepetitive unformed fecal specimens (n=504) were investigated by the glutamate dehydrogenase (GDH), C. difficile toxin A&B (CDAB) tests and toxigenic culture. Furthermore, 85 isolates were characterized by toxin gene detection, multilocus sequence typing, ribotyping and antimicrobial susceptibility testing.Results: The algorithm of combining GDH and CDAB tests could define diagnosis of 54.2% CDI cases and excluded 90% of non-CDI. Further adding the toxigenic culture to the algorithm enhanced the detection sensitivity to 100%. Toxigenic strains comprised 84.7% of isolates, including A+B+CDT− (71.8%, 61/85), A–B+CDT– (11.8%, 10/85) and A+B+CDT+ (1.2%, 1/85) isolates. RT046/ST35 (13.9%, 10/72), RT014/ST2 (12.5%, 9/72) and RT017/ST37 (12.5%, 9/72) were the more common genotypes among toxigenic C. difficile strains. The clinical severity score of A–B+CDT– toxin genes genotype (3.50±0.85) was significantly higher than the A+B+CDT– type (2.59±0.93) (P<0.05). RT046/ST35 isolates were highly prevalent and had high clinical severity scores (3.80±0.92). Variations in resistance from different sequence types (STs) were observed. Toxigenic strains showed higher resistance rates to erythromycin, clindamycin and ciprofloxacin compared to nontoxigenic strains (P<0.05). Conclusion: The epidemiology of C. difficile in Shandong Province differed from other regions in China. Comprehensive optimized diagnosis strategy and continuous surveillance should be established and applied in order to curb the spread of toxigenic C. difficile strains, especially for hospitalized patients.Keywords: Clostridium difficile, genotype, antimicrobial resistance, severity score, Shandong Province, China