Clostridioides difficile infection (CDI) remains an urgent global One Health threat. The genetic heterogeneity seen across C. difficile underscores its wide ecological versatility and has driven the significant changes in CDI epidemiology seen in the last 20 years. We analysed an international collection of over 12,000 C. difficile genomes spanning the eight currently defined phylogenetic clades. Through whole-genome average nucleotide identity, and pangenomic and Bayesian analyses, we identified major taxonomic incoherence with clear species boundaries for each of the recently described cryptic clades CI-III. The emergence of these three novel genomospecies predates clades C1-5 by millions of years, rewriting the global population structure of C. difficile specifically and taxonomy of the Peptostreptococcaceae in general. These genomospecies all show unique and highly divergent toxin gene architecture, advancing our understanding of the evolution of C. difficile and close relatives. Beyond the taxonomic ramifications, this work may impact the diagnosis of CDI.

Clostridium difficile ribotype (RT) 017 is an important toxigenic C. difficile RT which, due to a deletion in the repetitive region of the tcdA gene, only produces functional toxin B. Strains belonging to this RT were initially dismissed as nonpathogenic and circulated largely undetected for almost two decades until they rose to prominence following a series of outbreaks in the early 2000s. Despite lacking a functional toxin A, C. difficile RT 017 strains have been shown subsequently to be capable of causing disease as severe as that caused by strains producing both toxins A and B. While C. difficile RT 017 strains can be found in almost every continent today, epidemiological studies suggest that the RT is endemic in Asia and that the global spread of this MLST clade 4 lineage member is a relatively recent event. C. difficile RT 017 transmission appears to be mostly from human to human with only a handful of reports of isolations from animals. An important feature of C. difficile RT 017 strains is their resistance to several antimicrobials and this has been documented as a possible factor driving multiple outbreaks in different parts of the world. This review summarizes what is currently known regarding the emergence and evolution of strains belonging to C. difficile RT 017 as well as features that have allowed it to become an RT of global importance.

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Imwattana, K., Wangroongsarb, P. and Riley, T.V. (2019) High prevalence and diversity of tcdA-negative and tcdBpositive, and non-toxigenic, Clostridium difficile in Thailand. Anaerobe Abstract 19 Studies on the prevalence and diversity of Clostridium difficile in Thailand have been 20 limited to those derived from a few tertiary hospitals in Central Thailand. In this study, 145 21 C. difficile isolates collected in 13 provinces in Thailand during 2006-2018 were 22 characterized by ribotyping and detection of toxin genes. Minimum inhibitory 23 concentrations of eight antimicrobial agents were determined also for all 100 C. difficile 24 strains collected from 2006 until 2015. Of the 145 strains of C. difficile, 71 (49%) were non-25 toxigenic, 46 (32%) were toxin A-negative, toxin B-positive (A-B+) and 28 (19%) were A+B+. 26 No binary toxin-positive strain was found. The most common ribotype (RT) was RT 017 (A-27 B+CDT-, 19%, 28/145). Besides RT 017, 20 novel non-toxigenic and A-B+ ribotyping profiles, 28 which may be related to RT 017 by the similarity of ribotyping profile, were identified. All 29 C. difficile strains remained susceptible to metronidazole and vancomycin, however, a slight 30 increase in MIC for metronidazole was seen in both toxigenic and non-toxigenic strains 31 (overall MIC 50/90 0.25/0.25 mg/L during 2006 -2010 compared to overall MIC 50/90 1.0/2.0 32 mg/L during 2011 -2015). There was a high rate of fluoroquinolone resistance among RT 33 017 strains (77%), but there was little resistance among non-toxigenic strains. These results 34 suggest that RT 017 is endemic in Thailand, and that the misuse of fluoroquinolones may 35 lead to outbreaks of RT 017 infection in this country. Further studies on non-toxigenic C. 36 difficile are needed to understand whether they have a role in the pathogenesis of C. difficile 37 infection in Asia. 38 39

Antimicrobial resistance (AMR) plays an important role in the pathogenesis and spread of Clostridioides difficile infection (CDI), the leading healthcare-related gastrointestinal infection in the world. An association between AMR and CDI outbreaks is well documented, however, data is limited to a few ‘epidemic’ strains in specific geographical regions. Here, through detailed analysis of 10 330 publicly-available C. difficile genomes from strains isolated worldwide (spanning 270 multilocus sequence types (STs) across all known evolutionary clades), this study provides the first species-wide snapshot of AMR genomic epidemiology in C. difficile . Of the 10 330 C . difficile genomes, 4532 (43.9 %) in 89 STs across clades 1–5 carried at least one genotypic AMR determinant, with 901 genomes (8.7 %) carrying AMR determinants for three or more antimicrobial classes (multidrug-resistant, MDR). No AMR genotype was identified in any strains belonging to the cryptic clades. C. difficile from Australia/New Zealand had the lowest AMR prevalence compared to strains from Asia, Europe and North America (P<0.0001). Based on the phylogenetic clade, AMR prevalence was higher in clades 2 (84.3 %), 4 (81.5 %) and 5 (64.8 %) compared to other clades (collectively 26.9 %) (P<0.0001). MDR prevalence was highest in clade 4 (61.6 %) which was over three times higher than in clade 2, the clade with the second-highest MDR prevalence (18.3 %). There was a strong association between specific AMR determinants and three major epidemic C. difficile STs: ST1 (clade 2) with fluoroquinolone resistance (mainly T82I substitution in GyrA) (P<0.0001), ST11 (clade 5) with tetracycline resistance (various tet-family genes) (P<0.0001) and ST37 (clade 4) with macrolide-lincosamide-streptogramin B (MLSB) resistance (mainly ermB) (P<0.0001) and MDR (P<0.0001). A novel and previously overlooked tetM-positive transposon designated Tn6944 was identified, predominantly among clade 2 strains. This study provides a comprehensive review of AMR in the global C. difficile population which may aid in the early detection of drug-resistant C. difficile strains, and prevention of their dissemination worldwide.

Background: Antimicrobial resistance (AMR) plays an important role in the pathogenesis and spread of Clostridioides difficile infection (CDI). Many antimicrobials, such as fluoroquinolones, have been associated with outbreaks of CDI globally.Objectives: This study aimed to characterise AMR among clinical C. difficile strains in Thailand, a country where the use of antimicrobials remains inadequately regulated.Methods: Stool samples were screened for tcdB and positives were cultured. C. difficile isolates were characterised by toxin profiling and PCR ribotyping. Antimicrobial susceptibility testing was performed using an agar incorporation method, and whole-genome sequencing and AMR genotyping performed on a subset of strains.Results: There were 321 C. difficile strains isolated from 326 stool samples. The most common toxigenic ribotype (RT) was RT 017 (18%), followed by RTs 014 (12%) and 020 (7%). There was a high resistance prevalence (≥ 10%) to clindamycin, erythromycin, moxifloxacin and rifaximin, and resistance prevalence was greatest among RT 017 strains. AMR genotyping revealed a strong correlation between resistance genotype and phenotype for moxifloxacin and rifampicin. The presence of erm-class genes was associated with high-level clindamycin and erythromycin resistance. Point substitutions on the penicillin-binding proteins (PBP1 and PBP3) were not sufficient to confer meropenem resistance, however, a Y721S substitution in PBP3 was associated with a slight increase in meropenem MIC. No resistance to metronidazole, vancomycin or fidaxomicin was observed.Conclusion: There was a large proportion of C. difficile RT 017 in Thailand and a high AMR prevalence among these strains. The concordance between AMR phenotype and genotype was strong..

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Clostridium difficile isolates from the environment are closely related to those from humans, indicating a possible environmental transmission route for C. difficile infection (CDI). In this study, C. difficile was isolated from 47.3% (53/112) of lake/pond, 23.0% (14/61) of river, 20.0% (3/15) of estuary and 0.0% (0/89) of seawater samples. The most common toxigenic strain isolated was C. difficile PCR ribotype (RT) 014/020 (10.5%, 8/76). All water isolates were susceptible to fidaxomicin, metronidazole, rifaximin, amoxicillin/clavulanic acid, moxifloxacin and tetracycline. Resistance to vancomycin, clindamycin, erythromycin and meropenem was detected in 5.3% (4/76), 26.3% (20/76), 1.3% (1/76) and 6.6% (5/76) of isolates, respectively. High-resolution core-genome analysis was performed on RT 014/020 isolates of water origin and 26 clinical RT 014/020 isolates from the same year and geographical location. Notably, both human and water strains were intermixed across three sequence types (STs), 2, 13 and 49. Six closely related groups with ≤10 core-genome single nucleotide polymorphisms were identified, five of which comprised human and water strains. Overall, 19.2% (5/26) of human strains shared a recent genomic relationship with one or more water strains. This study supports the growing hypothesis that environmental contamination by C. difficile plays a role in CDI transmission.