Clostridium difficile isolates with increased sporulation: emergence of PCR ribotype 002 in Hong Kong

Abstract

We identified a predominant clone of Clostridium difficile PCR ribotype 002, which was associated with an increased sporulation frequency. In 2009, 3,528 stool samples from 2,440 patients were tested for toxigenic C. difficile in a healthcare region in Hong Kong. A total of 345 toxigenic strains from 307 (13.3%) patients were found. Ribotype 002 was the predominant ribotype, which constituted 35 samples from 29 (9.4%) patients. The mean sporulation frequency of ribotype 002 was 20.2%, which was significantly higher than that of the 56 randomly selected ribotypes other than 002 as concurrent controls (3.7%, p < 0.001). Patients carrying toxigenic ribotype 002 were more frequently admitted from an elderly home (p = 0.01) and received more β-lactam antibiotics in the preceding 3 months compared with the controls (p = 0.04) . The identification of toxigenic ribotype 002 in 2009 was temporally related to a significant increase in both the incidence of toxigenic C. difficile from 0.53 to 0.95 per 1,000 admissions (p < 0.001) and the rate of positive detection from 4.17% to 6.28% (p < 0.001) between period 1 (2004–2008) and period 2 (2009). This finding should alert both the physician and the infection control team to the establishment of and possible outbreaks by ribotype 002 in our hospitals, as in the case of ribotype 027.

Molecular Epidemiology of Clostridium difficile Infection in a Major Chinese Hospital: an Underrecognized Problem in Asia?

“…The only survey of ribotypes from Hong Kong was from a single hospital and used a limited number of standard ribotypes for comparison (but did include 017, 046, and 012). Unusually, 70% were of an unknown pattern, with a further 11.6% being nontypeable (16). Only 0.6% of isolates were 017 and 2.3% were 012, with no 046 identified, which is markedly different from our findings in mainland China.…”

“…Only 0.6% of isolates were 017 and 2.3% were 012, with no 046 identified, which is markedly different from our findings in mainland China. However, 10.1% of isolates were 002, representing a local endemic strain which was presumed to be causing cross-infection (16). The distribution of ribotypes in European countries varies quite markedly between countries and is very different from that of mainland China (1).…”

“…Studies in Hong Kong of the occurrence of C. difficile in patients receiving enteral feeding identified 12 cases in 38 patients treated for tuber-culosis between 1999 and 2005 (14, 15). There have been only two published epidemiological studies from Hong Kong, both of which identified hospital outbreaks of ribotype 002 (16,17). Interestingly C. difficile has also been recognized in Taiwan for the last 20 years (18).…”

Epidemiology of Klebsiella oxytoca-Associated Diarrhea Detected by Simmons Citrate Agar Supplemented with Inositol, Tryptophan, and Bile Salts

“…When symptoms developed 4 to 12 weeks after hospital discharge, the association was indeterminate. Infection control nurses would advise frontline health care workers on contact precautions for all diarrheal cases and conduct an outbreak investigation if there was epidemiological evidence of a nosocomial transmission of K. oxytoca, as previously described (11,12). The demographic, clinical, and laboratory findings for patients with health care-associated and community-associated diarrhea with stool cultures that were positive for K. oxytoca were described.…”

“…Proactive infection control measures may play a role in preventing nosocomial outbreaks due to norovirus (11), but only a few studies have demonstrated the successful control of nosocomial outbreaks due to C. difficile by a bundle approach (6,27). While the increasing use of broad-spectrum antimicrobials, especially fluoroquinolones, poses a major risk for C. difficile-associated diarrhea and hemorrhagic colitis (22,29), the intrinsic characteristic of hypersporulation of certain ribotypes of C. difficile, such as ribotypes 027 and 002, leading to the prolonged environmental survival of spores, may further contribute to the persistence of nosocomial outbreaks (2,12).…”