Sensitivity to antibiotics of Clostridium difficile toxigenic nosocomial strains

Clostridium difficile is the etiological agent of diarrhoea and colitis, especially in elderly patients. The incidence of these diseases has increased during the last 10 years. Emergence of so-called hypervirulent strains is considered as one of the main factors responsible for the more severe disease and changed profile of sensitivity to antimicrobial agents. The aim of this work was to determine the sensitivity profile of toxigenic strains of C. difficile in the Czech Republic in 2011–2012 to selected antibiotics. The antibiotics clindamycin, metronidazole, vancomycin and amoxicillin with clavulanic acid were used for this purpose. Isolates cultured on Brazier's C. difficile selective agar were analysed for the presence of toxin genes using Xpert detection system. Xpert analysis revealed that 33 strains carried the genes for toxins tcdB, cdt and tcdCΔ117, thus showing characteristics typical for the hypervirulent ribotype 027/PFGE type NAP1/REA type B1. The remaining 29 strains carried only the gene for toxin B (tcdB) and not cdt and tcdCΔ117. Our results indicate the higher susceptibility of C. difficile hypertoxigenic strains to three out of four tested antibiotics (except vancomycin) than it is for the other toxigenic strains. We found that only 10.34 % of other toxigenic strains were resistant to clindamycin, and no resistance was found in all other cases. All the isolates were sensitive to amoxicillin/clavulanic acid in vitro. However, its use is not recommended for therapy of infections caused by C. difficile.     

Analysis of ultra low genome conservation in Clostridium difficile

Microarray-based comparative genome hybridisations (CGH) and genome sequencing of Clostridium difficile isolates have shown that the genomes of this species are highly variable. To further characterize their genome variation, we employed integration of data from CGH, genome sequencing and putative cellular pathways. Transcontinental strain comparison using CGH data confirmed the emergence of a human-specific hypervirulent cluster. However, there was no correlation between total toxin production and hypervirulent phenotype, indicating the possibility of involvement of additional factors towards hypervirulence. Calculation of C. difficile core and pan genome size using CGH and sequence data estimated that the core genome is composed of 947 to 1,033 genes and a pan genome comprised of 9,640 genes. The reconstruction, annotation and analysis of cellular pathways revealed highly conserved pathways despite large genome variation. However, few pathways such as tetrahydrofolate biosynthesis were found to be variable and could be contributing to adaptation towards virulence such as antibiotic resistance.     

Efficient expression and purification of methyltransferase in acetyl-coenzyme a synthesis pathway of the human pathogen Clostridium difficile

The Wood-Ljungdahl pathway is responsible for acetyl-CoA biosynthesis and used as a major mean of generating energy for growth in some anaerobic microbes. Series of genes, from the anaerobic human pathogen Clostridium difficile, have been identified that show striking similarity to the genes involved in this pathway including methyltetrahydrofolate- and corrinoid-dependent methyltransferase. This methyltransferase plays a central role in this pathway that transfers the methyl group from methyltetrahydrofolate to a cob(I)amide center in the corrinoid iron-sulfur protein. In this study, we developed two efficient expression and purification methods for methyltransferase from C. difficile for the first time with two expression vectors MBPHT-mCherry2 and pETDuet-1, respectively. Using the latter vector, more than 50mg MeTr was produced per liter Luria-Bertani broth media. The recombinant methyltransferase was well characterized by SDS-PAGE, gel filtration chromatography, enzyme assay and far-UV circular dichroism (CD). Furthermore, a highly effective approach was established for determining the methyl transfer activity of the methyltetrahydrofolate- and cobalamin-dependent methyltransferase using exogenous cobalamin as a substrate by stopped-flow method. These results will provide a solid basis for further study of the methyltransferase and the Wood-Ljungdahl pathway.     

Sporulation studies in Clostridium difficile

Clostridium difficile is a leading cause of healthcare-associated diarrhoea. In recent years, certain C. difficile types have become highly represented among clinical isolates and are associated with outbreaks of increased disease severity, higher relapse rates and an expanded repertoire of antibiotic resistance. Endospores, produced during sporulation, play a pivotal role in infection and disease transmission and it has been suggested in the literature that these so-called ‘hypervirulent’ C. difficile types are more prolific in terms of sporulation in vitro. However, work in our laboratory has provided evidence to the contrary suggesting that although there is significant strain-to-strain variation in C. difficile sporulation characteristics this variation does not appear to be type-associated. On analysis of the literature, it is apparent that the methods used to quantify sporulation in previous studies have varied greatly and sample sizes have remained small. The conflicting data in the literature may, therefore, not necessarily be generally representative of C. difficile sporulation. Instead, these inconsistencies may reflect differences in the experimental design of each study. In this review, the need for further investigations of C. difficile sporulation rates is highlighted. Specifically, the advantages and disadvantages of the different experimental approaches previously used are discussed and a standard set of principles for measuring C. difficile sporulation in the future is proposed.     

Inhibition by glycine of the catabolic reduction of proline in Clostridium sticklandii: evidence on the regulation of amino acid reduction

The growth of Clostridium sticklandii on the substrate pair L-alanine-L-proline (reductant-oxidant each 40 mM) in a medium containing 2 g/l yeast extract was completely inhibited by equimolar amounts of glycine, although glycine itself should be used as oxidant by the cells. The effect of glycine was the same, whether L-alanine, L-arginine, or L-serine wwere used as reductants. Performance of the growth experiments in media of high osmolarity excluded the possibility that the inhibition effected by glycine was caused by the synthesis of defective cell wall peptidoglycan. In cell-free extracts an inhibition of L-proline reduction by glycine was observed that did not belong to anyone of the known types of kinetic inhibition. It depended upon the presence of a functioning glycine-reducing enzyme system, besides glycine itself, and was lost after the purification of D-proline reductase. It was concluded from these results that a protein, besides glycine, participated in the inhibition of L-proline reduction. The regulatory implications of the inhibition for the energy metabolism of C. sticklandii are discussed.     

Structure-Function Analysis of Inositol Hexakisphosphate-induced Autoprocessing in Clostridium difficile Toxin A

The action of Clostridium difficile toxins A and B depends on inactivation of host small G-proteins by glucosylation. Cellular inositol hexakisphosphate (InsP6) induces an autocatalytic cleavage of the toxins, releasing an N-terminal glucosyltransferase domain into the host cell cytosol. We have defined the cysteine protease domain (CPD) responsible for autoprocessing within toxin A (TcdA) and report the 1.6 Å x-ray crystal structure of the domain bound to InsP6. InsP6 is bound in a highly basic pocket that is separated from an unusual active site by a β-flap structure. Functional studies confirm an intramolecular mechanism of cleavage and highlight specific residues required for InsP6-induced TcdA processing. Analysis of the structural and functional data in the context of sequences from similar and diverse origins highlights a C-terminal extension and a π-cation interaction within the β-flap that appear to be unique among the large clostridial cytotoxins.Clostridium difficile is a Gram-positive, spore-forming anaerobe that infects the colon and causes a range of disorders, including diarrhea, pseudomembranous colitis, and toxic megacolon (1, 2). Two large toxins, TcdA² and TcdB (308 and 270 kDa, respectively) are recognized as the main virulence factors of C. difficile, although their relative importance is the subject of on-going study (3, 4). These proteins belong to a class of homologous toxins called large clostridial toxins (LCTs) and have been classified more broadly as AB toxins, wherein a B moiety is involved in the delivery of an enzymatic A moiety into the cytosol of a target cell. In LCTs, the A subunit is an N-terminal glucosyltransferase that inactivates small G-proteins, such as Rho, leading to cell rounding and apoptosis of the intoxicated cell (5, 6). The B subunit corresponds to the remainder of the toxin and is responsible for binding the target cell through a C-terminal receptor-binding domain (7–9) and forming the membrane pore needed for translocation of the A subunit (10, 11). Unlike other known AB toxins, the glucosyltransferase A domains of LCTs are released from the B subunits by an autoproteolytic cleavage event (12). Cleavage is triggered by host inositol phosphates and the reducing environment of the cytosol (12).In LCTs, autoproteolysis has been attributed to a cysteine protease activity located within the N-terminal region of the B subunit (13). This region was identified based on homology with the cysteine protease domain (CPD) found in the multifunctional autoprocessing repeats in toxins (MARTX) toxins from Gram-negative bacteria (14). Autoprocessing in the MARTX toxin from Vibrio cholera (VcRTx) is also stimulated by InsP6 (15). A recent crystal structure of VcRTx CPD bound to InsP6 suggests a novel mechanism of InsP6-induced allosteric activation (16). The CPDs of TcdA and VcRTx share only 19% sequence identity. To gain insight into the mechanistic commonalities between these entirely different toxins and to delineate the LCT-specific modes of InsP6-induced processing, we performed structural and functional analyses on the cysteine protease from TcdA.     

艰难梭菌的研究进展

艰难梭菌为革兰阳性厌氧芽胞杆菌,可引起艰难梭菌相关性腹泻,导致一系列肠道感染症状和相关临床表现。近年来由于高致病株的出现、菌株耐药性的增加,艰难梭菌感染在全球呈蔓延趋势。本文就艰难梭菌的耐药机制、检测技术、防治及国内感染现状等作一简要综述。     

Clostridium difficile in seafood and fish

The objective of this study was to determine the prevalence of Clostridium difficile contamination in retail seafood and fish from Canadian grocery stores. C.?difficile was found in 4.8% (5/119) of the samples. This study, combined with studies of other food sources, suggests that widespread contamination of food is common.     

Clostridium difficile in vegetables, Canada

Background: Clostridium difficile is an important gastrointestinal pathogen of humans and animals. It has been isolated from various foods, including meat and ready‐to‐eat salads, and concern has been expressed regarding food as a possible source of human C. difficile infection (CDI). Aims: We sought to isolate C. difficile from a variety of vegetables obtained from local grocery stores and to characterize these isolates. Materials and Methods: Vegetables were purchased from 11 different grocery stores in Guelph, Ontario, Canada between May and August 2009. Enrichment culture was performed and isolates were characterized by ribotyping, PFGE, toxinotyping and PCR detection of toxin genes. Results: Clostridium difficile was isolated from 4.5% (5/111) of retail vegetables. Two different ribotypes and two different toxinotypes were identified. Three isolates were ribotype 078/NAP 7/toxinotype V, possessing all three toxin genes. The other two isolates shared a ribotype with a toxigenic strain previously found in humans with CDI in this region. Discussion: Contamination of vegetables was found at relatively low levels, however, all isolates were toxigenic and belonging to ribotypes previously associated with CDI. Conclusions: Contamination of vegetables with CDI‐associated isolates can occur and although the implications for food safety practices remain elusive, the presence of toxigenic isolates suggests vegetables could be a source of C. difficile in humans.     

Diversity of moxifloxacin resistance during a nosocomial outbreak of a predominantly ribotype ARU 027 Clostridium difficile diarrhea

To characterize the extent and diversity of moxifloxacin resistance among Clostridium difficile isolates recovered during a predominantly Anaerobe Reference Unit (ARU) ribotype 027-associated nosocomial outbreak of antibiotic associated diarrhea we measured the susceptibility of 34 field isolates and 6 laboratory strains of C. difficile to moxifloxacin. We ribotyped the isolates as well as assaying them by PCR for the metabolic gene, gdh, and the virulence genes, tcdA, tcdB, tcdC, cdtA and cdtB. All the laboratory isolates, including the historical ARU 027 isolate Cd196, were susceptible to moxifloxacin (≤2 μg/mL). 13 field isolates were susceptible to ≤2 μg/mL. Five were resistant to from 4 to 12 μg/mL (moderate resistance); 16 were resistant to ≥16 μg/mL (high resistance). We sequenced the quinolone resistance determining regions of gyrA (position 71-460) and gyrB (position 1059-1448) from two susceptible laboratory strains, all five isolates with moderate resistance and two highly resistant isolates. Two highly resistant isolates (Pitt 40, ribotype ARU 027 and Pitt 33, ribotype ARU 001) had the same C245T (Thr₈₂ΔIle) mutation. No other changes were seen. Amplification with primer pairs specific for the C245T mutant gyrA and for the wild type gene respectively confirmed all 16 highly resistant ARU 027 isolates, as well as the highly resistant isolates from other ribotypes, had the C245T mutation and that the mutation was absent from all other isolates. Among the five isolates with moderate resistance we found combinations of mutations within gyrA (T128A, Val₄₃ΔAsp and G349T, Ala₁₁₇ΔSer) and gyrB (G1276A, Arg₄₂₆ΔAsn). The G1396A (Glu₄₆₆ΔLys) mutation was not associated with increased resistance.     

Variation in the surface layer proteins of Clostridium difficile

Surface layers (S-layers) form regular crystalline structures on the outermost surface of many bacteria. Clostridium difficile possesses such an S-layer consisting of two protein subunits. Treatment of whole cells of C. difficile with 5 M guanidine hydrochloride revealed two major proteins of different molecular masses characteristic of the S-layer on SDS-PAGE. In this study 25 isolates were investigated. A high degree of variability in the molecular mass of the two S-layer proteins was evident. Molecular masses ranged from 48 to 56 kDa for the heavier protein and from 37 to 45 kDa for the lighter protein. A further protein component of 70 kDa was detectable in all isolates. No cross-reaction was seen between the two major proteins from isolates that produced different S-layer patterns, and most S-layer proteins from isolates with the same or similar banding patterns did not cross-react. The S-layer proteins, when detected by a combination of Coomassie blue staining and immunoblotting, are a useful marker for phenotyping.     

Phospholipid profiles of Clostridium difficile.

Phospholipid molecular species present in 32 isolates of Clostridium difficile were examined by fast atom bombardment-mass spectrometry in negative-ion mode. This revealed major anions consistent with the expected presence of the following phosphatidylglycerol (PG) analogs: PG(31:2), PG(32:1), PG(33:2), PG(33:1), PG(34:2), and PG(34:1). The major phospholipid molecular species are distinct from those of other bacterial groups examined.     

Secretome analysis of Clostridium difficile strains

Clostridium difficile causes infections ranging from mild C. difficile-associated diarrhea to severe pseudomembranous colitis. Since 2003 new hypervirulent C. difficile strains (PCR ribotype 027) emerged characterized by a dramatically increased mortality. The secretomes of the three C. difficile strains CDR20291, CD196, and CD630 were analyzed and compared. Proteins were separated and analyzed by means of SDS--PAGE and LC-MS. MS data were analyzed using Mascot and proteins were checked for export signals with SecretomeP and SignalP. LC-MS analysis revealed 158 different proteins in the supernatant of C. difficile. Most of the identified proteins originate from the cytoplasm. Thirty-two proteins in CDR20291, 36 in CD196 and 26 in CD630 were identified to be secreted by C. difficile strains. Those were mainly S-layer proteins, substrate-binding proteins of ABC-transporters, cell wall hydrolases, pilin and unknown hypothetical proteins. Toxin A and toxin B were identified after growth in brain heart infusion medium using immunological techniques. The ADP-ribosyltransferase-binding component protein, which is a part of the binary toxin CDT, was only identified in the hypervirulent ribotype 027 strains. Further proteins that are secreted specifically by hypervirulent strains were identified.     

Surface layers of Clostridium difficile endospores

Clostridium difficile is an important human pathogen and one where the primary cause of disease is due to the transmission of spores. We have investigated the proteins found in the outer coat layers of C. difficile spores of pathogenic strain 630 (CD630). Five coat proteins, CotA, CotB, CotCB, CotD, and CotE, were shown to be expressed on the outer coat layers of the spore. We demonstrate that purified spores carry catalase, peroxiredoxin, and chitinase activity and that this activity correlates with the predicted functions of three spore coat proteins identified here, CotCB, CotD, and CotE. CotCB and CotD are putative manganese catalases, and CotE is a novel bifunctional protein with peroxiredoxin activity at its amino terminus and chitinase activity at its carboxy terminus. These enzymes could play an important role in coat assembly by polymerizing protein monomers in the coat. CotE, in addition to a role in macromolecular degradation, could play an important role in inflammation, and this may be of direct relevance to the development of the gastrointestinal symptoms that accompany C. difficile infection. Although specific enzyme activity has not yet been assigned to the proteins identified here, this work provides the first detailed study of the C. difficile spore coat.     

Effect of toxins produced by various Clostridium difficile strains on cecum size reduction in gnotobiotic mice

Inoculation of axenic mice with Clostridium difficile strains induced a significant reduction in ceca weight (dry or wet), whereas a nontoxinogenic strain led to a partial reduction. A strain, which produces cytotoxin and no enterotoxin in vivo, caused a reduction similar to that observed with a nontoxinogenic strain. Simultaneous cytotoxin and enterotoxin production by various C. difficile strains caused the cecum size to diminish to that observed for conventional control mice.     

Clostridium difficile infection in adult hamsters.

Diarrhea was encountered in a group of adult female golden Syrian hamsters (Mesocricetus auratus) used for titrating the scrapie agent. Ninety percent of the cases occurred in animals over 210 days old even though animals of all age groups lived in the colony concurrently. The cause of diarrhea was investigated in both uninoculated animals and those receiving greater than a limiting dilution of scrapie infectivity, i.e., animals that were not expected to contract the experimental scrapie disease. Three forms of diarrhea were observed. The most commonly encountered was profuse and watery. A chronic form presented with semiformed, thin fecal material smearing the retroperitoneal region. Hemorrhagic diarrhea was observed rarely. Mortality was high among animals with acute watery or hemorrhagic diarrhea. Animals with semiformed soft stools were dehydrated, had a roughened hair-coat, and hunched back. Cardinal lesions were necrosis, inflammation, and mucosal hyperplasia of the cecum and colon and cholangiohepatitis with amyloid deposition. Diffuse renal amyloidosis was present in chronic cases. Toxigenic, cytotoxin B-positive Clostridium difficile was isolated from a majority of affected animals. Cytotoxin B was also present in cecal homogenates of diarrheic animals with C. difficile. The pathological and microbiologic findings indicated a typhlitis and colitis in adult hamsters that was associated with C. difficile infection.     

Motility and Flagellar Glycosylation in Clostridium difficile

In this study, intact flagellin proteins were purified from strains of Clostridium difficile and analyzed using quadrupole time of flight and linear ion trap mass spectrometers. Top-down studies showed the flagellin proteins to have a mass greater than that predicted from the corresponding gene sequence. These top-down studies revealed marker ions characteristic of glycan modifications. Additionally, diversity in the observed masses of glycan modifications was seen between strains. Electron transfer dissociation mass spectrometry was used to demonstrate that the glycan was attached to the flagellin protein backbone in O linkage via a HexNAc residue in all strains examined. Bioinformatic analysis of C. difficile genomes revealed diversity with respect to glycan biosynthesis gene content within the flagellar biosynthesis locus, likely reflected by the observed flagellar glycan diversity. In C. difficile strain 630, insertional inactivation of a glycosyltransferase gene (CD0240) present in all sequenced genomes resulted in an inability to produce flagellar filaments at the cell surface and only minor amounts of unmodified flagellin protein.Clostridium difficile, a gram-positive, anaerobic, spore-forming bacterium, is an emerging opportunistic pathogen and the leading cause of antibiotic-associated diarrhea and pseudomembranous colitis in humans. The recent emergence of the hypervirulent NAP1/027 strain in hospitals of North America has resulted in increased mortality rates (18, 19). While previous reports of C. difficile epidemics were restricted to single institutions or wards, more recently, there appears to be a wider distribution of outbreaks (20), accompanied by increasing severity of disease as well as a significant increase in the numbers of case fatalities reported (21). The pathogen is most frequently associated with antibiotic treatment, which disrupts the gut flora, allowing C. difficile to colonize and multiply (16). Extensive studies have demonstrated that two toxins, TcdA and TcdB, are responsible for severe tissue damage and consequent manifestation of disease (34). Infection with C. difficile can lead to severe diarrhea, abdominal pain, and further complications, such as pseudomembranous colitis, inflammation, and ulceration of the lining of the intestinal wall (5, 16). Importantly, recurrence rates following treatment can be as high as 35% irrespective of the drug used in initial treatment (10, 35). The estimated incidence in Canadian hospitals ranges from 38 to 95 cases per 100,000 patients (1), while in the United States, the estimated number of cases of C. difficile disease exceeds 250,000/year (36), with related health care costs of $1 billion annually (16). While prevention through antibiotic stewardship and optimal management of disease is the most obvious strategy currently used, there is a great need for alternate methods of treatment.Prior to the production and release of toxin, the organism must germinate from a recalcitrant spore form and proceed to colonize the gastrointestinal tract. This colonization process is an important first step in the disease process, whereby the organism penetrates the mucus layer and adheres to the underlying colonic epithelial cells, thereby facilitating the delivery of toxins to host cell receptors. Adhesion, an early critical step in colonization, involves a number of virulence factors, but the precise mechanisms by which bacteria adhere to the mucosa and initiate infection remain to be elucidated. Such adhesins include the flagellum (29) and the high-molecular-weight surface layer protein (6). C. difficile is known to express peritrichous flagella, and it has been observed that the level of adherence of flagellated strains to the mouse cecum is 10-fold higher than the level of adherence of nonflagellated strains (29).The flagellum plays a role in the ability of bacteria to adapt to their unique biological niches. Flagella from a wide range of bacteria have been shown to be important as both colonization and virulence factors, as well as critical to biofilm formation in many species (3, 37). In recent years, a rapidly increasing body of work has described the process of flagellar glycosylation in a diverse number of bacterial species (reviewed in reference 17). The diversity of glycan structures found on these organisms from unique environments points to a novel biological role for the respective glycans, which has yet to be revealed. In some cases, it has been demonstrated that the process of flagellar glycosylation has a role in both flagellar assembly and host-pathogen interactions (17). In Campylobacter spp., for example, in addition to being required for flagellar assembly, flagellar glycosylation plays a role in autoagglutination properties of cells and subsequent virulence and contributes to antigenic specificity (11). The sites of glycosylation of flagellin monomers from a diverse number of bacterial species have all been shown to reside within the two surface-exposed domains (denoted D2 and D3) of the flagellin monomer when assembled within the flagellar filament (22). Structural analysis of Salmonella enterica flagellin has revealed that these regions are surface exposed in the assembled filament and, hence, are well positioned to facilitate a myriad of extracellular interactions with either host cells or environmental substrates.Many of the studies of bacterial flagellar glycosylation have focused upon gram-negative organisms. Of the motile gram-positive bacteria, flagellin from Listeria monocytogenes has been shown to be glycosylated with β-O-linked GlcNAc at up to six sites/flagellin (23). The flagellins of Clostridium botulinum have also been reported to be glycosylated with legionaminic or hexuronic acid derivatives (32), and preliminary evidence for glycosylation of C. tyrobutyricum flagellin has been reported (4). However, a functional role for glycosylation has yet to be revealed for any of these organisms. It has been reported that purified C. difficile flagellin monomers from various strains migrate at a molecular weight greater than that predicted from the translated DNA sequence, but flagellin monomers showed no reactivity with standard glycan staining kits (31).In this study, we show that flagellins of C. difficile strain 630 as well as those from recent clinical isolates of C. difficile are modified with diverse O-linked glycan moieties. In addition, we have identified through mutagenesis a glycosyltransferase gene from the flagellar biosynthesis locus; it is involved in the glycosylation process and, upon inactivation, leads to loss of surface-associated flagellin protein.