Laboratory-Based Surveillance of Clostridium difficile Infection in Australian Health Care and Community Settings, 2013 to 2018

Abstract

Objectives In the early 2000s, a binary toxin (CDT)-producing strain of Clostridium difficile, ribotype (RT) 027, caused extensive outbreaks of diarrhoeal disease in North America and Europe. This strain has not established in Australia and there is a markedly different repertoire of circulating strains compared to other regions of the world. The C. difficile Antimicrobial Resistance Surveillance (CDARS) study is a nationwide longitudinal surveillance study of C. difficile infection (CDI) in Australia. Here, we describe the molecular epidemiology of CDI in Australian healthcare and community settings over the first 5 years of the study, 2013–2018. Methods Between 2013 and 2018, 10 diagnostic microbiology laboratories from five States in Australia participated in the CDARS study. From each of five states, one private (representing community) and one public (representing hospitals), submitted isolates of C. difficile or PCR-positive stool samples during two collection periods per year, February-March (summer/autumn) and August-September (winter/spring). C. difficile was characterised by toxin gene profiling and ribotyping. Results A total of 1523 isolates of C. difficile was studied. PCR ribotyping yielded 203 different RTs, the most prevalent being RT014/020 (n=449, 29.5%). The epidemic CDT+ RTs 027 (n=2) and 078 (n=6), and the recently described RTs 251 (n=10) and 244 (n=6) were not common, while RT126 (n=17) was the most prevalent CDT+ strain. Conclusions A heterogeneous C. difficile population was identified. C. difficile RT014/020 was the most prevalent strain found in humans with CDI. Continued surveillance of CDI in Australia remains critical for the detection of emerging strain lineages.

Whole-genome sequencing links Clostridium (Clostridioides) difficile in a single hospital to diverse environmental sources in the community

“…In our 1‐year study to investigate if C. difficile is being imported into the hospital via contaminated shoe soles, RT 014/020 was the most common cause of CDI at our study hospital, consistent with a decade of surveillance data in Australia (Cheng et al, 2016; Collins et al, 2017; Foster et al, 2014; Hong et al, 2020). Locally, a high prevalence of C. difficile RT 014/020 has also been found in environmental samples, comprising up to 39%, 10%, 7%, 14% and 21% of C. difficile isolates from lawn, compost, root vegetables, hospital grounds and home gardens respectively (Lim et al, 2018, 2020; Moono et al, 2017; Perumalsamy et al, 2019; Shivaperumal et al, 2020).…”

Persistence of spore-formingClostridium(Clostridioides)difficilethrough wastewater treatment plants in Western Australia

“…C. difficile RT014 is a lineage of One Health importance, well-established in humans, pigs and the environment in Australia (19). Nationwide, C. difficile RT014 accounts for approximately 30% of all CDI cases in humans and 23% of isolates from neonatal pigs (44,45). In WA, C. difficile RT014 also represents a significant proportion of C. difficile isolates from lawn (39%), compost (10%), hospital gardens (14%), home gardens (21%), root vegetables (7%) and water bodies (11%) (31,39,42,(46)(47)(48).…”

“…It was the third most common RT of C. difficile isolated from CDI patients in 34 European countries (52). Even though human CDI cases caused by RT078 are uncommon in Australia (44), the finding of RT078 in biosolids is a particular concern from a public health standpoint.…”

Prevalence and outcomes of Clostridioides difficile infection in liver transplant recipients

“…C. difficile ribotyping data were not available in our center but the most commonly identified RTs in Australian are 014/020, 056, and 002. 38,39 Australia has histori-…”