High Prevalence of Multidrug-Resistant Clostridioides difficile Following Extensive Use of Antimicrobials in Hospitalized Patients in Kenya

Abstract

IntroductionClostridioides difficile is a neglected pathogen in many African countries as it is generally not regarded as one of the major contributors toward the diarrheal disease burden in the continent. However, several studies have suggested that C. difficile infection (CDI) may be underreported in many African settings. The aim of this study was to determine the prevalence of CDI in hospitalized patients, evaluate antimicrobial exposure, and detect toxin and antimicrobial resistance profiles of the isolated C. difficile strains.MethodsIn this cross-sectional study, 333 hospitalized patients with hospital-onset diarrhoea were selected. The stool samples were collected and cultured on cycloserine-cefoxitin egg yolk agar (CCEY). Isolates were presumptively identified by phenotypic characteristics and Gram stain and confirmed by singleplex real-time PCR (qPCR) assays detecting the species-specific tpi gene, toxin A (tcdA) gene, toxin B (tcdB) gene, and the binary toxin (cdtA/cdtB) genes. Confirmed C. difficile isolates were tested against a panel of eight antimicrobials (vancomycin, metronidazole, rifampicin, ciprofloxacin, tetracycline, clindamycin, erythromycin, and ceftriaxone) using E-test strips.ResultsC. difficile was detected in 57 (25%) of diarrheal patients over the age of two, 56 (98.2%) of whom received antimicrobials before the diarrheal episode. Amongst the 71 confirmed isolates, 69 (97.1%) harbored at least one toxin gene. More than half of the toxigenic isolates harbored a truncated tcdA gene. All isolates were sensitive to vancomycin, while three isolates (2.1%) were resistant to metronidazole (MIC >32 mg/L). High levels of resistance were observed to rifampicin (65/71, 91.5%), erythromycin (63/71, 88.7%), ciprofloxacin (59/71, 83.1%), clindamycin (57/71, 80.3%), and ceftriaxone (36/71, 50.7.8%). Among the resistant isolates, 61 (85.9%) were multidrug-resistant.ConclusionMultidrug-resistant C. difficile strains were a significant cause of healthcare facility-onset C. difficile infections in patients with prior antimicrobial exposure in this Kenyan hospital.

Assessment of independent comorbidities and comorbidity measures in predicting healthcare facility-onset Clostridioides difficile infection in Kenya

“…Study population. Using a cross sectional study approach, we enrolled 333 hospitalized patients between 2016-2018 [9]. The inclusion criteria comprised of all age groups who developed diarrhoea > 3days after admission.…”

“…Until recently, studies in Kenya have demonstrated the existence of CDI in hospitalized patients; however, none of them have evaluated the comorbidities defined by the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) as potential risk factors for HO-CDI [9][10][11]. To build on existing knowledge and generate data from developing countries, we assessed comorbidities in a population previously tested for HO-CDI.…”

Metagenomic analysis of the abundance and composition of antibiotic resistance genes in hospital wastewater in Benin, Burkina Faso, and Finland

“…In LICs, diarrheal infections caused by pathogens such as Clostridioides difficile and other anaerobic bacteria, as well as protozoa, are common. The consumption of metronidazole commonly used to treat these infections may be high in these countries as these drugs are being prescribed, for example, both with and without a positive diagnostic test for Clostridioides difficile 92 . However, multidrug-resistant strains of C. difficile seem to already be prevalent in hospitals in certain parts of Africa as a consequence of the heavy use of antimicrobials among in-patients 92 .…”

“…In LICs, diarrheal infections caused by pathogens such as Clostridioides difficile and other anaerobic bacteria, as well as protozoa, are common. Therefore, the consumption of metronidazole commonly used to treat these infections may be high in these countries as these drugs are being prescribed, for example, both with and without a positive diagnostic test for C. difficile (62).…”

“…However, multidrug-resistant strains of C. difficile seem to already be prevalent in hospitals in certain parts of Africa as a consequence of the heavy use of antimicrobials among in-patients (62).…”