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BMC Pediatrics
Published in: BMC Pediatrics 1/2018

Open Access 01-12-2018 | Research article

Clostridium difficile stool shedding in infants hospitalized in two neonatal intensive care units is lower than previous point prevalence estimates using molecular diagnostic methods

Authors: Andrea Green Hines, Alison Freifeld, Xing Zhao, Ann Anderson Berry, Lynne Willett, Peter C. Iwen, Kari A. Simonsen

Published in: BMC Pediatrics | Issue 1/2018

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Abstract

Background

The point prevalence of Clostridium difficile stool shedding in hospitalized infants from two neonatal intensive care units (NICUs) was examined utilizing standard clinical testing compared with duplex PCR to identify toxigenic and non-toxigenic C. difficile strains.

Methods

All infants from the two NICUs affiliated with a single academic medical center were eligible for inclusion. Stool collection was blinded to patient characteristics and occurred during a one week period at each NICU and repeated with a second weeklong collection 6 months later to increase sample size. Stools were tested for C. difficile using EIA (GDH/toxin A/B) with samples testing +/+ or +/− subsequently evaluated by Loop-Mediated Isothermal Amplification (LAMP) and by duplex PCR amplification of tcdB and tpi (housekeeping) genes. Cytotoxicity assays were performed on all samples positive for C. difficile by any modality.

Results

Eighty-four stools were collected from unique infants for evaluation. EIA results showed 6+/+ [7.1%], 7 +/− [8.3%], and 71 −/− [84.5%] samples. All 6 EIA +/+ were confirmed as toxigenic C. difficile by LAMP; 6/7 EIA +/− were negative by LAMP with one identified as invalid. Duplex PCR concurred with LAMP in all 6 stools positive for toxigenic C. difficile. PCR identified 2 EIA −/− stools positive for tpi, indicating shedding of non-toxigenic C. difficile. Cytotoxicity assay was positive in 4/6 duplex PCR positive samples and negative for all stools that were EIA +/− but negative by molecular testing.

Conclusions

C. difficile blinded point prevalence in infants from two NICUs was 7.1% by molecular methods; and lower than expected based on historical incidence estimates. In house duplex PCR had excellent concordance with clinically available LAMP and EIA tests, and added detection of non-toxigenic C. difficile strain shedding. Evolving NICU care practices may be influencing the composition of infant gut microbiota and reducing the point prevalence of C. difficile shedding in NICU patient stools.
Literature
1.
2.
Centers for Disease Control and Prevention (CDC). Severe Clostridium difficile-associated disease in populations previously at low risk--four states, 2005. MMWR Morb Mortal Wkly Rep. 2005;54(47):1201–5.
3.
Chitnis AS, Holzbauer SM, Belflower RM, Winston LG, Bamberg WM, Lyons C, Farley MM, Dumyati GK, Wilson LE, Beldavs ZG, Dunn JR, Gould LH, Maccannell DR, Gerding DN, McDonald LC, Lessa FC. Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011. JAMA Intern Med. 2013;173(14):1359–67.CrossRefPubMed
4.
Kuntz JL, Chrischilles EA, Pendergast JF, Herwaldt LA, Polgreen PM. Incidence of and risk factors for community-associated Clostridium difficile infection: a nested case-control study. BMC Infect Dis. 2011;11:194.CrossRefPubMedPubMedCentral
5.
Riggs MM, Sethi AK, Zabarsky TF, Eckstein EC, Jump RL, Donskey CJ. Asymptomatic carriers are a potential source for transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis. 2007;45(8):992–8.CrossRefPubMed
6.
Clabots CR, Johnson S, Olson MM, Peterson LR, Gerding DN. Acquisition of Clostridium difficile by hospitalized patients: evidence for colonized new admissions as a source of infection. J Infect Dis. 1992;166(3):561–7.CrossRefPubMed
7.
Curry SR, Muto CA, Schlackman JL, Pasculle AW, Shutt KA, Marsh JW, Harrison LH. Use of multilocus variable number of tandem repeats analysis genotyping to determine the role of asymptomatic carriers in Clostridium difficile transmission. Clin Infect Dis. 2013;57(8):1094–102.CrossRefPubMedPubMedCentral
8.
Hecker MT, Riggs MM, Hoyen CK, Lancioni C, Donskey CJ. Recurrent infection with epidemic Clostridium difficile in a peripartum woman whose infant was asymptomatically colonized with the same strain. Clin Infect Dis. 2008;46(6):956–7.CrossRefPubMed
9.
McFarland LV, Surawicz CM, Greenberg RN, Bowen KE, Melcher SA, Mulligan ME. Possible role of cross-transmission between neonates and mothers with recurrent Clostridium difficile infections. Am J Infect Control. 1999;27(3):301–3.CrossRefPubMed
10.
Rousseau C, Poilane I, De Pontual L, Maherault AC, Le Monnier A, Collignon A. Clostridium difficile carriage in healthy infants in the community: a potential reservoir for pathogenic strains. Clin Infect Dis. 2012;55(9):1209–15.CrossRefPubMed
11.
Stoesser N, Crook DW, Fung R, Griffiths D, Harding RM, Kachrimanidou M, Keshav S, Peto TE, Vaughan A, Walker AS, Dingle KE. Molecular epidemiology of Clostridium difficile strains in children compared with that of strains circulating in adults with Clostridium difficile-associated infection. J Clin Microbiol. 2011;49(11):3994–6.CrossRefPubMedPubMedCentral
12.
Blixt T, Gradel KO, Homann C, Seidelin JB, Schønning K, Lester A, Houlind J, Stangerup M, Gottlieb M, Knudsen JD. Asymptomatic carriers contribute to nosocomial Clostridium difficile infection: a cohort study of 4508 patients. Gastroenterology. 2017;152(5):1031–41. e2CrossRefPubMed
13.
Al-Jumaili IJ, Shibley M, Lishman AH, Record CO. Incidence and origin of Clostridium difficile in neonates. J Clin Microbiol. 1984;19(1):77–8.PubMedPubMedCentral
14.
Bacon AE, Fekety R, Schaberg DR, Faix RG. Epidemiology of Clostridium difficile colonization in newborns: results using a bacteriophage and bacteriocin typing system. J Infect Dis. 1988;158(2):349–54.CrossRefPubMed
15.
16.
Collignon A, Ticchi L, Depitre C, Gaudelus J, Delmee M, Corthier G. Heterogeneity of Clostridium difficile isolates from infants. Eur J Pediatr. 1993;152(4):319–22.CrossRefPubMed
17.
Cooperstock M, Riegle L, Woodruff CW, Onderdonk A. Influence of age, sex, and diet on asymptomatic colonization of infants with Clostridium difficile. J Clin Microbiol. 1983;17(5):830–3.PubMedPubMedCentral
18.
Donta ST, Myers MG. Clostridium difficile toxin in asymptomatic neonates. J Pediatr. 1982;100(3):431–4.CrossRefPubMed
19.
Enad D, Meislich D, Brodsky NL, Hurt H. Is Clostridium difficile a pathogen in the newborn intensive care unit? A prospective evaluation. J Perinatol. 1997;17(5):355–9.PubMed
20.
Faden HS, Dryja D. Importance of asymptomatic shedding of Clostridium difficile in environmental contamination of a neonatal intensive care unit. Am J Infect Control. 2015;43(8):887–8.CrossRefPubMed
21.
Holst E, Helin I, Mardh PA. Recovery of Clostridium difficile from children. Scand J Infect Dis. 1981;13(1):41–5.CrossRefPubMed
22.
Jangi S, Lamont JT. Asymptomatic colonization by clostridium difficile in infants: implications for disease in later life. J Pediatr Gastroenterol Nutr. 2010;51(1):2–7.CrossRefPubMed
23.
Larson HE, Barclay FE, Honour P, Hill ID. Epidemiology of Clostridium difficile in infants. J Infect Dis. 1982;146(6):727–33.CrossRefPubMed
24.
Penders J, Stobberingh EE, van den Brandt PA, van Ree R, Thijs C. Toxigenic and non-toxigenic Clostridium difficile: determinants of intestinal colonisation and role in childhood atopic manifestations. Gut. 2008;57(7):1025–6.CrossRefPubMed
25.
Sherertz RJ, Sarubbi FA. The prevalence of Clostridium difficile and toxin in a nursery population: a comparison between patients with necrotizing enterocolitis and an asymptomatic group. J Pediatr. 1982;100(3):435–9.CrossRefPubMed
26.
Stark PL, Lee A, Parsonage BD. Colonization of the large bowel by Clostridium difficile in healthy infants: quantitative study. Infect Immun. 1982;35(3):895–9.PubMedPubMedCentral
27.
Svedhem A, Kaijser B, MacDowall I. Intestinal occurrence of campylobacter fetus subspecies jejuni and Clostridium difficile in children in Sweden. Eur J Clin Microbiol. 1982;1(1):29–32.CrossRefPubMed
28.
Viscidi R, Willey S, Bartlett JG. Isolation rates and toxigenic potential of Clostridium difficile isolates from various patient populations. Gastroenterology. 1981;81(1):5–9.PubMed
29.
Wongwanich S, Pongpech P, Dhiraputra C, Huttayananont S, Sawanpanyalert P. Characteristics of Clostridium difficile strains isolated from asymptomatic individuals and from diarrheal patients. Clin Microbiol Infect. 2001;7(8):438–41.CrossRefPubMed
30.
Alfa MJ, Robson D, Davi M, Bernard K, Van Caeseele P, Harding GK. An outbreak of necrotizing enterocolitis associated with a novel clostridium species in a neonatal intensive care unit. Clin Infect Dis. 2002;35(Suppl 1):S101–5.CrossRefPubMed
31.
Blakey JL, Lubitz L, Barnes GL, Bishop RF, Campbell NT, Gillam GL. Development of gut colonisation in pre-term neonates. J Med Microbiol. 1982;15(4):519–29.CrossRefPubMed
32.
Cardines R, Luzzi I, Menichella G, Virgili Q, Mastrantonio P. Clostridium difficile in preterm neonates. Microbiologica. 1988;11(3):259–61.PubMed
33.
Chang JY, Shim JO, Ko JS, Seo JK, Lee JA, Kim HS, Choi JH, Shin S, Shin SM. Monitoring of Clostridium difficile colonization in preterm infants in neonatal intensive care units. Pediatr Gastroenterol Hepatol Nutr. 2012;15(1):29–37.CrossRef
34.
el-Mohandes AE, Keiser JF, Refat M, Jackson BJ. Prevalence and toxigenicity of Clostridium difficile isolates in fecal microflora of preterm infants in the intensive care nursery. Biol Neonate. 1993;63(4):225–9.CrossRefPubMed
35.
Ferraris L, Butel MJ, Campeotto F, Vodovar M, Roze JC, Aires J. Clostridia in premature neonates’ gut: incidence, antibiotic susceptibility, and perinatal determinants influencing colonization. PLoS One. 2012;7(1):e30594.CrossRefPubMedPubMedCentral
36.
Kato H, Kato N, Watanabe K, Ueno K, Ushijima H, Hashira S, Abe T. Application of typing by pulsed-field gel electrophoresis to the study of Clostridium difficile in a neonatal intensive care unit. J Clin Microbiol. 1994;32(9):2067–70.PubMedPubMedCentral
37.
Kim KH, Fekety R, Batts DH, Brown D, Cudmore M, Silva J Jr, Waters D. Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis. J Infect Dis. 1981;143(1):42–50.CrossRefPubMed
38.
Lishman AH, Al Jumaili IJ, Elshibly E, Hey E, Record CO. Clostridium difficile isolation in neonates in a special care unit. Lack of correlation with necrotizing enterocolitis. Scand J Gastroenterol. 1984;19(3):441–4.PubMed
39.
Malamou-Ladas H, O'Farrell S, Nash JQ, Tabaqchali S. Isolation of Clostridium difficile from patients and the environment of hospital wards. J Clin Pathol. 1983;36(1):88–92.CrossRefPubMedPubMedCentral
40.
Phua TJ, Rogers TR, Pallett AP. Prospective study of Clostridium difficile colonization and paracresol detection in the stools of babies on a special care unit. J Hyg (Lond). 1984;93(1):17–25.CrossRef
41.
Tina LG, Proto N, Sciacca A. Asymptomatic intestinal colonization by Clostridium difficile in preterm neonates. Pediatr Infect Dis J. 1994;13(12):1158–9.CrossRefPubMed
42.
Zedd AJ, Sell TL, Schaberg DR, Fekety FR, Cooperstock MS. Nosocomial Clostridium difficile reservoir in a neonatal intensive care unit. Pediatr Infect Dis. 1984;3(5):429–32.CrossRefPubMed
43.
Freifeld AG, Simonsen KA, Booth CS, Zhao X, Whitney SE, Karre T, Iwen PC, Viljoen HJ. A new rapid method for Clostridium difficile DNA extraction and detection in stool: toward point-of-care diagnostic testing. J Mol Diagn. 2012;14(3):274–9.CrossRefPubMed
44.
de Jong E, de Jong AS, Bartels CJ, van der Rijt-van den Biggelaar C, Melchers WJ, Sturm PD. Clinical and laboratory evaluation of a real-time PCR for Clostridium difficile toxin a and B genes. Eur J Clin Microbiol Infect Dis. 2012;31(9):2219–25.CrossRefPubMedPubMedCentral
45.
Fong KS, Fatica C, Hall G, Procop G, Schindler S, Gordon SM, Fraser TG. Impact of PCR testing for Clostridium difficile on incident rates and potential on public reporting: is the playing field level? Infect Control Hosp Epidemiol. 2011;32(9):932–3.CrossRefPubMed
46.
Gould CV, Edwards JR, Cohen J, Bamberg WM, Clark LA, Farley MM, Johnston H, Nadle J, Winston L, Gerding DN, McDonald LC, Lessa FC, Clostridium difficile Infection Surveillance Investigators, Centers for Disease Control and Prevention. Effect of nucleic acid amplification testing on population-based incidence rates of Clostridium difficile infection. Clin Infect Dis. 2013;57(9):1304–7.CrossRefPubMed
47.
Koo HL, Van JN, Zhao M, Ye X, Revell PA, Jiang ZD, Grimes CZ, Koo DC, Lasco T, Kozinetz CA, Garey KW, DuPont HL. Real-time polymerase chain reaction detection of asymptomatic Clostridium difficile colonization and rising C. Difficile-associated disease rates. Infect Control Hosp Epidemiol. 2014;35(6):667–73.CrossRefPubMed
48.
Lyerly DM, Ball DW, Toth J, Wilkins TD. Characterization of cross-reactive proteins detected by Culturette brand rapid latex test for Clostridium difficile. J Clin Microbiol. 1988;26(3):397–400.PubMedPubMedCentral
49.
Miles BL, Siders JA, Allen SD. Evaluation of a commercial latex test for Clostridium difficile for reactivity with C. Difficile and cross-reactions with other bacteria. J Clin Microbiol. 1988;26(11):2452–5.PubMedPubMedCentral
50.
Penders J, Vink C, Driessen C, London N, Thijs C, Stobberingh EE. Quantification of Bifidobacterium spp., Escherichia coli and Clostridium difficile in faecal samples of breast-fed and formula-fed infants by real-time PCR. FEMS Microbiol Lett. 2005;243(1):141–7.CrossRefPubMed
51.
Vael C, Desager K. The importance of the development of the intestinal microbiota in infancy. Curr Opin Pediatr. 2009;21(6):794–800.CrossRefPubMed
Metadata
Title
Clostridium difficile stool shedding in infants hospitalized in two neonatal intensive care units is lower than previous point prevalence estimates using molecular diagnostic methods
Authors
Andrea Green Hines
Alison Freifeld
Xing Zhao
Ann Anderson Berry
Lynne Willett
Peter C. Iwen
Kari A. Simonsen
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Pediatrics / Issue 1/2018
Electronic ISSN: 1471-2431
DOI
https://doi.org/10.1186/s12887-018-1113-z

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