AiM  Vol.5 No.5 , May 2015
Surveillance for Antibiotic Resistance in Clostridium difficile Strains Isolated from Patients in a Tertiary Care Center
Abstract: Clostridium difficile is the major etiological agent of nosocomial diarrhea primarily precipitated by antimicrobial therapy. We prospectively investigated the antibiogram profile of C. difficile strains isolated from patients reporting to a tertiary care hospital in North India. Fecal samples obtained from 1110 suspected cases of C. difficile infection were cultured for isolation of C. difficile. Colonies suspected as those of C. difficile were identified by phenotypic and molecular methods. Antimicrobial susceptibility of C. difficile isolates for different classes of antibiotics was determined using the Epsilon test for vancomycin, metronidazole, clindamycin and ciprofloxacin. The fecal samples cultured for C. difficile belonged to 709 (63.9%) males and 401 (36.1%) females. The mean age of the patients was 38.7 years. C. difficile was cultured from 174 (15.7%) of the total samples. Antibiotic resistance was largely observed towards clindamycin (57.5%) and ciprofloxacin (38.5%) but was significantly low towards metronidazole (1.72%) and nil (0%) towards vancomycin. C. difficile isolates had a high degree of resistance towards clindamycin and ciprofloxacin with low level of resistance to metronidazole and none towards vancomycin. Antibiogram surveillance of C. difficile will help for clinical practice and add to the epidemiological data of the organisms.
Cite this paper: Singh, M. , Vaishnavi, C. , Mahmood, S. and Kochhar, R. (2015) Surveillance for Antibiotic Resistance in Clostridium difficile Strains Isolated from Patients in a Tertiary Care Center. Advances in Microbiology, 5, 336-345. doi: 10.4236/aim.2015.55034.

[1]   Vaishnavi, C., Bhasin, D.K., Kochhar, R. and Singh, K. (2000) Clostridium difficile Toxin and Faecal Lactoferrin Assays in Adult Patients. Microbes and Infection, 2, 1827-1830.

[2]   Burke, K.E. and Lamont, J.T. (2014) Clostridium difficile Infection: A Worldwide Disease. Gut and Liver, 8, 1-6.

[3]   Jalali, M., Khorvash, F., Warriner, K. and Weese, J.S. (2012) Clostridium difficile Infection in an Iranian Hospital. BMC Research Notes, 5, 159.

[4]   Zar, F.A., Bakkanagari, S.R., Moorthi, K.M. and Davis, M.B. (2007) A Comparison of Vancomycin and Metronidazole for the Treatment of Clostridium difficile-Associated Diarrhea, Stratified by Disease Severity. Clinical Infectious Diseases, 45, 302-307.

[5]   Barbut, F., Delmee, M., Brazier, J.S., Petit, J.C., Poxton, I.R., Rupnik, M., Lalande, V., Schneider, C., Mastrantonio, P., Alonso, R., Kuipjer, E., Tvede, M. and The ESCMID Study Group on Clostridium difficile (ESGCD) (2003) A European Survey of Diagnostic Methods and Testing Protocols for Clostridium difficile. Clinical Microbiology and Infection, 9, 989-996.

[6]   Arroyo, L.G., Rousseau, J., Willey, B.M., Low, D.E., Staempfli, H., McGeer, A. and Weese, J.S. (2005) Use of a Selective Enrichment Broth to Recover Clostridium difficile from Stool Swabs Stored under Different Conditions. Journal of Clinical Microbiology, 43, 5341-5343.

[7]   George, W.L., Sutter, V.L., Citron, D. and Finegold, S.M. (1979) Selective and Differential Medium for Isolation of Clostridium difficile. Journal of Clinical Microbiology, 9, 214-219.

[8]   Perry, J.D., Asir, K., Halimi, D., Orenga, S., Dale, J., Payne, M., Carlton, R., Evans, J. and Gould, F.K. (2010) Evaluation of a Chromogenic Culture Medium for Isolation of Clostridium difficile within 24 Hours. Journal of Clinical Microbiology, 48, 3852-3858.

[9]   Wilcox, M.H., Fawley, W.N. and Parnell, P. (2000) Value of Lysozyme Agar Incorporation and Alkaline Thioglycollate Exposure for the Environmental Recovery of Clostridium difficile. Journal of Hospital Infection, 44, 65-69.

[10]   Wren, M. (2010) Clostridium difficile Isolation and Culture Techniques Methods. Journal of Molecular Biology, 646, 39-52.

[11]   Drudy, D., Kyne, L., O’Mahony, R. and Fanning, S. (2007) GyrA Mutations in Fluoroquinolone-Resistant Clostridium difficile PCR-027. Emerging Infectious Diseases, 13, 504-505.

[12]   Muto, C.A., Pokrywka, M., Shutt, K., Mendelsohn, A.B., Nouri, K., Posey, K., Roberts, T., Croyle, K., Krystofiak, S., Patel-Brown, S., Pasculle, A.W., Paterson, D.L., Saul, M. and Harrison, L.H. (2005) A Large Outbreak of Clostridium difficile-Associated Disease with an Unexpected Proportion of Deaths and Colectomies at a Teaching Hospital Following Increased Fluoroquinolone Use. Infection Control and Hospital Epidemiology, 26, 273-280.

[13]   Drudy, D., Quinn, T., O’Mahony, R., Kyne, L., O’Gaora, P. and Fanning, S. (2006) High-Level Resistance to Moxifloxacin and Gatifloxacin Associated with a Novel Mutation in GyrB in Toxin-A-Negative, Toxin-B-Positive Clostridium difficile. Journal of Antimicrobial Chemotherapy, 58, 1264-1267.

[14]   Poilane, I., Cruaud, P., Torlotin, J.C. and Collignon, A. (2000) Comparison of the E-Test to the Reference Agar Dilution Method for Antibiotic Susceptibility Testing of Clostridium difficile. Clinical Microbiology and Infection, 6, 155-156.

[15]   Kuijper, E.J., Barbut, F., Brazier, J.S., Kleinkauf, N., Eckmanns, T., Lambert, M.L., Drudy, D., Fitzpatrick, F., Wiuff, C., Brown, D.J., Coia, J.E., Pituch, H., Reichert, P., Even, J., Mossong, J., Widmer, A.F., Olsen, K.E., Allerberger, F., Notermans, D.W., Delmée, M., Coignard, B., Wilcox, M., Patel, B., Frei, R., Nagy, E., Bouza, E., Marin, M., Akerlund, T., Virolainen-Julkunen, A., Lyytikainen, O., Kotila, S., Ingebretsen, A., Smyth, B., Rooney, P., Poxton, I.R. and Monnet, D.L. (2008) Update of Clostridium difficile Infection Due to PCR Ribotype 027 in Europe 2008. Euro Surveillance, 13, Article ID: 18942.

[16]   Cohen, S.H., Gerding, D.N., Johnson, S., Kelly, C.P., Loo, V.G., McDonald, L.C., Pepin, J. and Wilcox, M.H., Society for Healthcare Epidemiology of America and Infectious Diseases Society of America (2010) Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology, 31, 431-455.

[17]   Lee, K., Yong, D., Yum, J., Sohn, Y.S. and Chong, Y. (2000) Modification of Cycloserine Cefoxitin Fructose Agar to Suppress Growth of Yeasts from Stool Specimens. Anaerobe, 6, 269-271.

[18]   Gupta, U. and Yadav, R.N. (1985) Clostridium difficile in Hospital Patients. Indian Journal of Medical Research, 82, 398-401.

[19]   Ayyagari, A., Sharma, P., Venkateswarlu, Mehta, S. and Agarwal, K.C. (1986) Prevalence of Clostridium difficile in Pseudomembranous and Antibiotic Associated Colitis in North India. Journal of Diarrhoeal Diseases Research, 4, 157-160.

[20]   Niyogi, S.K., Dutta, P., Dutta, D., Mitra, U. and Sikdar, S. (1991) Clostridium difficile and Its Cytotoxin in Hospitalized Children with Acute Diarrhea. Indian Pediatrics, 28, 1129-1132.

[21]   Dutta, P., Niyogi, S.K., Mitra, U., Rasaily, R., Bhattacharya, M.K., Chakraborty, S. and Mitra, A. (1994) Clostridium difficile in Antibiotic Associated Pediatric Diarrhea. Indian Pediatrics, 31, 121-126.

[22]   Gogate, A., De, A., Nanivadekar, R., Mathur, M., Saraswathi, K., Jog, A. and Kulkarni, M.V. (2005) Diagnostic Role of Stool Culture and Toxin Detection in Antibiotic Associated Diarrhoea Due to Clostridium difficile in Children. Indian Journal of Medical Research, 122, 518-524.

[23]   Dhawan, B., Chaudhry, R. and Sharma, N. (1999) Incidence of Clostridium difficile Infection: A Prospective Study in an Indian Hospital. Journal of Hospital Infection, 43, 275-280.

[24]   Vaishnavi, C., Kochhar, R., Bhasin, D.K., Thapa, B.R. and Singh, K. (1999) Detection of Clostridium difficile Toxin by an Indigenously Developed Latex Agglutination Assay. Tropical Gastroenterology, 22, 33-35.

[25]   Vaishnavi, C., Thapa, B.R., Thennarasu, K. and Singh, K. (2002) Faecal Lactoferrin Assay as an Adjunct to Clostridium difficile Diarrhea. Indian Journal of Pathology and Microbiology, 45, 69-73.

[26]   Vishwanath, S., Singhal, A., D’Souza, A., Mukhopadhyay, C., Varma, M. and Bairy, I. (2013) Clostridium difficile Infection at a Tertiary Care Hospital in South India. Journal of the Association of Physicians of India, 61, 804-806.

[27]   Holloway, K.A. (2011) Promoting the Rational Use of Antibiotics, Regional Health Forum WHO South East Asia Region. Volume 15, 122-130.

[28]   Austin, D.J. and Anderson, R.M. (1999) Transmission Dynamics of Epidemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci in England and Wales. Journal of Infectious Diseases, 179, 883-891.

[29]   Cocanour, C.S. (2005) Best Strategies in Recurrent or Persistent Clostridium difficile Infection. Surgical Infections, 12, 235-239.

[30]   Dong, D., Zhang, L., Chen, X., Jiang, C., Yu, B., Wang, X. and Peng, Y. (2013) Antimicrobial Susceptibility and Resistance Mechanisms of Clinical Clostridium difficile from a Chinese Tertiary Hospital. International Journal of Antimicrobial Agents, 41, 80-84.

[31]   Goudarzi, M., Goudarzi, H., Alebouyeh, M., Rad, M.A., Mehr, F.S.S., Mohammad, R.Z. and Mohammad, M.A. (2013) Antimicrobial Susceptibility of Clostridium difficile Clinical Isolates in Iran. Iranian Red Crescent Medical Journal, 15, 704-711.

[32]   Vecchio, A.L. and Zacur, G.M. (2012) Clostridium difficile Infection: An Update on Epidemiology, Risk Factors and Therapeutic Options. Current Opinion in Gastroenterology, 28, 1-9.

[33]   Sebaihia, M., Wren, B.W., Mullany, P., Fairweather, N.F., Minton, N., Stabler, R., Thomson, N.R., Roberts, A.P., Cerdeno-Tárraga, A.M., Wang, H., Holden, M.T., Wright, A., Churcher, C., Quail, M.A., Baker, S., Bason, N., Brooks, K., Chillingworth, T., Cronin, A., Davis, P., Dowd, L., Fraser, A., Feltwell, T., Hance, Z., Holroyd, S., Jagels, K., Moule, S., Mungall, K., Price, C., Rabbinowitsch, E., Sharp, S., Simmonds, M., Stevens, K., Unwin, L., Whithead, S., Dupuy, B., Dougan, G., Barrell, B. and Parkhill, J. (2006) The Multidrug-Resistant Human Pathogen Clostridium difficile Has a Highly Mobile, Mosaic Genome. Nature Genetics, 38, 779-786.

[34]   Spigaglia, P., Barbanti, F. and Mastrantonio, P. (2011) Multidrug Resistance in European Clostridium difficile Clinical Isolates. Journal of Antimicrobial Chemotherapy, 66, 2227-2234.

[35]   Brazier, J.S. (2001) Typing of Clostridium difficile. Clinical Microbiology and Infection, 7, 428-431.

[36]   Chong, P.M., Lynch, T., McCorrister, S., Kibsey, P., Miller, M., Gravel, D., Westmacott, G.R. and Mulvey, M.R., The Canadian Nosocomial Infection Surveillance Program (CNISP) (2014) Proteomic Analysis of a NAP1 Clostridium difficile Clinical Isolate Resistant to Metronidazole. PLoS ONE, 9, e82622.

[37]   Peláez, T., Alcalá, L., Alonso, R., Rodriguez-Creixems, M., García-Lechuz, J. and Bouza, E. (2002) Reassessment of Clostridium difficile Susceptibility to Metronidazole and Vancomycin. Antimicrobial Agents and Chemotherapy, 46, 1647-1650.

[38]   Fernandez, A., Anand, G. and Friedenberg, F. (2004) Factors Associated with Failure of Metronidazole in Clostridium difficile-Associated Disease. Journal of Clinical Gastroenterology, 38, 414-418.

[39]   Peláez, T., Cercenado, E., Alcalá, L., Marín, M., Martin-Lopez, A., Martínez-Alarcón, J., Catalán, P., Sánchez-Somolinos, M. and Bouza, E. (2008) Metronidazole Resistance in Clostridium difficile Is Heterogeneous. Journal of Clinical Microbiology, 46, 3028-3032.

[40]   McFarland, L.V. (2005) Alternative Treatments for Clostridium difficile Disease: What Really Works? Journal of Medical Microbiology, 54, 101-111.

[41]   Pépin, J., Valiquette, L., Gagnon, S., Routhier, S. and Brazeau, I. (2007) Outcomes of Clostridium difficile-Associated Disease Treated with Metronidazole or Vancomycin before and after the Emergence of NAP1/027. The American Journal of Gastroenterology, 102, 2781-2788.

[42]   Huang, H., Fang, H., Weintraub, A. and Nord, C.E. (2009) Distinct Ribotypes and Rates of Antimicrobial Drug Resistance in Clostridium difficile from Shanghai and Stockholm. Clinical Microbiology and Infection, 15, 1170-1173.

[43]   Spigaglia, P. and Mastrantonio, P. (2004) Comparative Analysis of Clostridium difficile Clinical Isolates Belonging to Different Genetic Lineages and Time Periods. Journal of Medical Microbiology, 53, 1129-1136.

[44]   Tenover, F.C., Tickler, I.A. and Persing, D.H. (2012) Antimicrobial-Resistant Strains of Clostridium difficile from North America. Antimicrobial Agents and Chemotherapy, 56, 2929-2932.

[45]   Collins, D.A., Hawkey, P.M. and Riley, T.V. (2013) Epidemiology of Clostridium difficile Infection in Asia. Antimicrobial Resistance and Infection Control, 2, 21.

[46]   Borgmann, S., Jakobiak, T., Gruber, H., Reil, M., Schroder, H., Kist, M. and Sagel, U. (2010) Association of Ciprofloxacin Prescriptions to Outpatients to Clostridium difficile Infections. Euro Surveillance, 15, Article ID: 19479.

[47]   Gerding, D.N. (2004) Clindamycin, Cephalosporins, Fluoroquinolones, and Clostridium difficile-Associated Diarrhea: This Is an Antimicrobial Resistance Problem. Clinical Infectious Diseases, 38, 646-648.

[48]   Loo, V.G., Poirier, L., Miller, M.A., Oughton, M., Libman, M.D., Michaud, S., Bourgault, A.M., Nguyen, T., Frenette, C., Kelly, M., Vibien, A., Brasssard, P., Fenn, S., Dewar, K., Hudson, T.J., Horn, R., René, P., Monczak, Y. and Dascal, A. (2005) A Predominantly Clonal Multi-Institutional Outbreak of Clostridium difficile Associated Diarrhea with High Morbidity and Mortality. New England Journal of Medicine, 353, 2442-2449.

[49]   Drudy, D., Goorhuis, B., Bakker, D., Kyne, L., van den Berg, R., Fenelon, L., Fanning, S. and Kuijper, E.J. (2008) Clindamycin-Resistant Clone of Clostridium difficile PCR Ribotype 027, Europe. Emerging Infectious Diseases, 14, 1485-1487.

[50]   Mooyottu, S., Flock, G., Kollanoor-Johny, A., Upadhyaya, I., Jayarao, B.A. and Venkitanarayanan, K. (2005) Characterization of a Multidrug Resistant Clostridium difficile Meat Isolate. International Journal of Food Microbiology, 192, 111-116.