High Prevalence of Toxigenic and Nontoxigenic Clostridium difficile Strains in Malaysia

Riley, Thomas V.; Collins, Deirdre A.; Karunakaran, Rina; Kahar, Maria Abdul; Adnan, Azlan; Hassan, Siti Hasnah; Zainul, N H; Rustam, F. R. Mohammed; Wahab, Z. Abd; Ramli, Ramliza; Lee, Yeong Yeh; Hassan, Hamimah

doi:10.1128/jcm.00170-18

Cited by 25 publications

(31 citation statements)

References 27 publications

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“…Less is known of the molecular epidemiology of C. difficile in South America, but RTs 027, 106, 012, 046, and 014/020 are reportedly the most common strains [31,33,34]. Similar to the current study, RT 017 (followed by RT 001) has also been found at high prevalence in South Africa [35], and in Ghana, Malawi, and Tanzania the few studies which performed molecular typing have shown a high prevalence of non-toxigenic strains [36,37], similar to reports from Southeast Asian countries [15].…”

Section: Discussionsupporting

confidence: 89%

“…Due to uncertainty about whether they were carried with a toxigenic strain, cases, where they were isolated, were excluded from the logistic regression analyses. The prevalence of colonization with non-toxigenic strains in Asian countries appears to be high among hospital inpatients (10.4-28.6%) [15][16][17]27,41]. This is interesting given that clinical trials have found that administration of non-toxigenic strains reduces risk of recurrent infection in CDI cases [42], making it plausible that the high prevalence of colonization with non-toxigenic strains in Asia-Pacific countries may explain the low rate of recurrent CDI found in this study.…”

Section: Discussionmentioning

confidence: 52%

“…C. difficile RT 017 has been the predominant strain identified in most Asian studies to date, particularly in Northern Asia and China [4,6]. Recent studies in Malaysia [15], Indonesia [16], and Thailand [17] have shown a high prevalence of RT 017 together with many non-toxigenic strains in Southeast Asia, supporting the importance of Clade 4 strains in the region. Another A−B+ strain, RT 369, has also been reported in significant numbers from Japan [18,19].…”

Section: Introductionmentioning

confidence: 99%

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Clostridioides difficile infection in the Asia-Pacific region

Collins

Sohn

et al. 2019

Emerging Microbes & Infections

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Clostridioides difficile causes healthcare-related diarrhoea in high-income countries. Highly resistant spores persist in healthcare facilities, primarily infecting patients who have recently received antimicrobials. C. difficile infection (CDI) has been studied in detail in North America and Europe; however, the epidemiology of CDI elsewhere, including the Asia-Pacific region, is largely unknown. A survey of CDI was performed in 13 Asia-Pacific countries. Epidemiological data on 600 cases were collected and molecular typing undertaken on 414 C. difficile isolates. Healthcare facilityassociated CDI comprised 53.6% of cases, while community-associated CDI was 16.5%. The median age of cases was 63.0 years and 45.3% were female, 77.5% had used antibiotics in the previous 8 weeks, most frequently thirdgeneration cephalosporins (31.7%), and 47.3% had used proton pump inhibitors. Recurrence (9.1%) and mortality (5.2%) rates were low, while complications including colitis or pseudomembranous colitis (13.8%), colectomy (0.4%), and toxic megacolon (0.2%) were uncommon. Common C. difficile strains were ribotypes 017 (16.7%), 014/020 (11.1%) and 018 (9.9%), with wide variation between countries. Binary toxin-positive strains of C. difficile were detected rarely. Overall, disease severity appeared mild, and mortality and recurrence were low. Continued education about, and surveillance of, CDI in Asia are required to reduce the burden of disease.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 52%

Section: Introductionmentioning

confidence: 99%

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Clostridioides difficile infection in the Asia-Pacific region

Collins

Sohn

et al. 2019

Emerging Microbes & Infections

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“…Surprisingly, several RTs identified in our study carried toxin genes (RTs 031, 038, 039, 084, 085) but in other studies an absence of the toxin genes in these ribotypes was identified [28,[45][46][47][48][49][50][51]. The differences in PaLoc arrangements in certain RTs were also noted previously.…”

Section: Discussionsupporting

confidence: 75%

Clostridioides difficile ribotypes 001 and 126 were predominant in Tehran healthcare settings from 2004 to 2018: a 14-year-long cross-sectional study

Azimirad

Krutova

Yadegar

et al. 2020

Emerging Microbes & Infections

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Clostridioides difficile infection (CDI) remains a major healthcare problem worldwide, however, little is known about CDI epidemiology in Iran. Between December 2004 and November 2018, 3649 stool samples were collected from patients in 69 hospitals and medical centres in Tehran and were cultured for the presence of C. difficile; isolates were characterized by PCR ribotyping and toxin genes detection. A total of 582 C. difficile isolates were obtained and the overall CDI prevalence was 15.9%; 290 (49.8%) cases were healthcare-associated (HA) and 292 (50.2%) cases were community-associated (CA). Of these, DNA of 513 isolates submitted for ribotyping. The ribotype and/or WEBRIBO type could be assessed in 366 (62.9%) isolates. The most frequent RTs were 001 (n = 75, 12.9%), 126 (n = 65, 11.2%) and 084 (n = 19, 3.3%); the toxin gene profile tcdA + B + /cdtA + B + (n = 112, 19.2%) was the most common. Fifteen C. difficile isolates (2.6%) did not carry any toxin genes. There was no difference between frequently found RTs in HA-CDI and CA-CDI, except for RT 029 which was more likely to be associated with healthcare origin (12/15, p-value = 0.02). No isolate of RTs 027 or 078 was identified. Importantly, RTs 031, 038, 039, 084, 085 reported previously as RTs with an absence of toxin genes, revealed the presence of toxin genes in our study. Using Simpson's reciprocal index of diversity, we found that RT diversity decreased as the prevalence of the RT 084 increased (R = −0.78, p-value = 0.041). Different patterns in CDI epidemiology underscore the importance of local surveillance and infection control measures in Tehran healthcare settings.

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“…This rate had a mild influence on the specificity of both GDH tests in this study, which was kept above 92%. Although the rates of patients with nontoxigenic strains are generally similar to that seen in this study [5,19], there are reports of rates higher than 50% in some other institutions [18,[20][21][22]. Thus, it should be considered that the use of GDH as a single method should be preceded by an evaluation of its specificity and PPV in the institution, thus avoiding unnecessary antimicrobial treatment for CDI in asymptomatic carriers [9].…”

supporting

confidence: 73%

Evaluation of glutamate dehydrogenase (GDH) and toxin A/B rapid tests for Clostridioides (prev. Clostridium) difficile diagnosis in a university hospital in Minas Gerais, Brazil

et al. 2020

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Clostridioides (Clostridium) difficile is responsible for most cases of nosocomial diarrhea and, despite the high prevalence of the disease worldwide, the best laboratory diagnostic approach to diagnose C. difficile infection (CDI) is a subject of ongoing debate. Although the use of multiple tests is recommended, the cost of these algorithms commonly exceeds the affordability in some countries. Thus, to improve CDI diagnosis in a university hospital in Brazil, this study analyzed two immunochromatographic tests and one enzyme immunoassay (ELISA) to evaluate the detection of glutamate dehydrogenase (GDH) and A/B toxins of C. difficile. Stool samples of 89 adult patients presenting nosocomial diarrhea during hospitalization were included. The toxigenic culture was used as the reference method. GDH detection by both commercial tests showed high sensitivity (100%) and specificity (92.1%). On the other hand, toxin-based methods showed a sensitivity between 19.2 and 57.7%. In conclusion, the results suggest that rapid tests for GDH detection are not only suitable for CDI diagnosis as screening tests but also as a single method. Keywords Pseudomembranous colitis. Nosocomial diarrhea Clostridioides (Clostridium) difficile is responsible for most cases of antibiotic-associated diarrhea worldwide [1]. Despite the severity of the disease, the best laboratory diagnostic approach to diagnose C. difficile infection (CDI) is a subject of ongoing debate [2]. The diagnosis of CDI is frequently based on the clinical history and the detection of A/B toxins, and/or toxigenic isolates, by a combination of laborious methods [3]. In this context, the use of rapid tests for the detection of C. difficile glutamate dehydrogenase (GDH) is increasing as a screening method due to its low cost, high sensitivity, and fast results [4, 5]. However, if this method is not capable of differentiating non-toxigenic from toxigenic C. difficile strains, a stool sample positive for GDH is usually subjected to a second test involving a toxin-detecting assay, such as enzyme immunoassays (ELISA) and lateral flow tests, or a DNA-based test, commonly nucleic acid amplification-based tests [3]. Although the use of multiple tests is highly recommended to diagnose CDI [3], the cost of these algorithms commonly exceeds the affordability in developing countries [5]. In Brazil, despite the low sensitivity of ELISAs for the detection of A/B toxins, this method is still largely used as a single test in several hospitals [6, 7]. The use of a low sensitivity test can jeopardize the efficacy of control measures if infected individuals are kept without the necessary isolation and are not properly treated [6, 8]. Thus, to improve CDI diagnosis, this study aimed to evaluate two commercial assays for CDI diagnosis through detection of the GDH component and A/B toxins in hospitalized adults with diarrhea in a university hospital in Brazil.

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High Prevalence of Toxigenic and Nontoxigenic Clostridium difficile Strains in Malaysia

Cited by 25 publications

References 27 publications

Clostridioides difficile infection in the Asia-Pacific region

Clostridioides difficile infection in the Asia-Pacific region

Clostridioides difficile ribotypes 001 and 126 were predominant in Tehran healthcare settings from 2004 to 2018: a 14-year-long cross-sectional study

Evaluation of glutamate dehydrogenase (GDH) and toxin A/B rapid tests for Clostridioides (prev. Clostridium) difficile diagnosis in a university hospital in Minas Gerais, Brazil

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