First Report of Clostridium difficile NAP1/027 in a Mexican Hospital
April
First Report of Clostridium difficile NAP1/027 in a Mexican Hospital
Adrin Camacho-Ortiz 0 1
Daniel Lpez-Barrera 0 1
Ral Hernndez-Garca 0 1
Alejandra M. Galvn-De los Santos 0 1
Samantha M. Flores-Trevio 0 1
Jorge M. Llaca-Daz 0 1
Hctor J. Maldonado Garza 0 1
Francisco J. Bosques-Padilla 0 1
Elvira Garza-Gonzlez 0 1
0 1 Servicio de Infectologia, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey, Nuevo Leon , Mexico , 2 Servicio de Gastroenterologia, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey, Nuevo Leon , Mexico , 3 Departamento de Patologia Clinica, Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon , Monterrey, Nuevo Leon , Mexico
1 Academic Editor: Markus M. Heimesaat , Charite, Campus Benjamin Franklin, GERMANY
Background and Objective Clostridium difficile NAP1/ribotype 027 is associated with severe disease and high mortality rates. Our aim was to determine the prevalence of NAP1/ribotype 027 among C. difficile isolates in a tertiary care hospital, and review the main clinical data.
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Competing Interests: The authors have declared
that no competing interests exist.
We included 106 stool samples from 106 patients. Samples were tested for A&B toxins and
were cultured on CCFA agar. The genes tcdA, tcdB, tcdC, cdtA, and cdtB were amplified
using PCR in clinical isolates. The tcdA 3-end deletion analysis, PCR-ribotyping, and
pulsed-field gel electrophoresis (PFGE) were also performed. Stool samples that were
positive for culture were tested by the GeneXpert C. difficile assay. Clinical data were collected.
Thirty-six patients tested positive for A&B toxins; and 22 patients had positive culture for C.
difficile, 14 of which tested positive for the A&B toxins and all 22 patients tested positive by
the GeneXpert C. difficile assay. Risk factors included an average hospital stay of 16.1
days prior to toxin detection, average antibiotic use for 16.2 days, and a median of 3
antibiotics used. The 30-day crude mortality rate was 8.4%. Six of the 22 patients died, and 3 of
those deaths were directly attributed to C. difficile infection. The majority of isolates, 90.9%
(20/22), carried genes tcdB, tcdA, cdtA, and cdtB; and these strains carried the
corresponding downregulator gene tcdC, with an 18-bp deletion. PFGE was performed on 17
isolates, and one main pattern was observed. Analysis of the ribotyping data showed
similar results.
The above findings represent the clonal spread of C. difficile in our institution, which mainly
includes the NAP1/027 strain. This is the first report of C. difficile ribotype NAP1/027 in
Mexico.
Clostridium difficile is a Gram-positive anaerobic bacterium that is able to produce spores. This
bacterial species causes a potentially fatal diarrheal disease due to the production of its
principal virulence factors toxin A and toxin B, which are encoded by their genes tcdA and tcdB that
are located on a 21-kilobase section of chromosomal DNA known as the pathogenicity locus
(PaLoc). The tcdC gene is thought to encode a negative regulator of toxin production.
Therefore, enhanced toxin production, and thus increased virulence, is often derived in strains with
an aberrant tcdC genotype. In addition to toxins A and B, some strains also produce a third
toxin known as binary toxin, encoded by ctdA and ctdB, located outside the PaLoc [1]. The
spores of this anaerobic bacterium are widely distributed in hospital environments, and their
ingestion by patients with an altered gut microflora contributes to colonization and disease
[1,2].
The spectrum of C. difficile infection (CDI) is very wide, starting from asymptomatic
carriage to severe diarrhea that may progress to pseudomembranous colitis and toxic megacolon.
The epidemiology of C. difficile has changed in the past decade, and a new type has emerged:
polymerase chain reaction (PCR) ribotype (RT) 027/North American Pulsed (NAP)-field type
01. Major outbreaks associated with this strain have been described since 2004, first in Canada
followed by the USA and Europe [1,35]. C. difficile NAP1/027 is associated with a severe
disease presentation and high morbidity and mortality rates; therefore, it presents a major clinical
and financial burden [6]. In Latin America, this strain has been found in Costa Rica and more
recently in Chile [7]. In Mexico, studies have shown the clinical characteristics of patients with
CDI demonstrating a significant risks of developing CDI following the use of H2 blockers, if
they had a prior hospitalization within 12 weeks of diagnosis, if they had been in the intensive
care unit, prior use of cephalosporins, fluoroquinolones [7] and clindamycin [7] but genetic
analysis of Mexican isolates have not been published. Thus, our aim was to determine the
prevalence of NAP1/027 among C. difficile isolates in a tertiary care hospital, and review the main
clinical data.
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