Implementation Guide for Surveillance of Clostridium Difficile Infection -- [Consultation Edition]

The Implementation Guide for hospital surveillance of Clostridium difficile infection (CDI) has been produced by the Healthcare Associated Infection (HAI) Technical Working Group of the Australian Commission on Safety and Quality in Health Care (ACSQHC), and endorsed by the HAI Advisory Group. State jurisdictions and the ACSQHC have representatives on the Technical Working Group, and have had input into this document. (See acknowledgements on inside front cover)...

Implementation guide for surveillance of Clostridium difficile infection

The Implementation Guide for hospital surveillance of Clostridium difficile infection (CDI) has been produced by the Healthcare Associated Infection (HAI) Technical Working Group of the Australian Commission on Safety and Quality in Health Care (ACSQHC), and endorsed by the HAI Advisory Group. State jurisdictions and the ACSQHC have representatives on the Technical Working Group, and have had input into this document. The Guide is intended to be used by Australian hospitals and organisations to support the implementation of hospital-identified Clostridium difficile infection (CDI) surveillance using the endorsed case definition in this guide. It has been produced to support consistency of surveillance activities and is not intended to replace clinical assessment of infection for patient management.

Increasing incidence of Clostridium difficile infection, Australia, 2011–2012

Objectives: To report the quarterly incidence of hospital-identified Clostridium difficile infection (HI-CDI) in Australia, and to estimate the burden ascribed to hospital-associated (HA) and community-associated (CA) infections. Design, setting and patients: Prospective surveillance of all cases of CDI diagnosed in hospital patients from 1 January 2011 to 31 December 2012 in 450 public hospitals in all Australian states and the Australian Capital Territory. All patients admitted to inpatient wards or units in acute public hospitals, including psychiatry, rehabilitation and aged care, were included, as well as those attending emergency departments and outpatient clinics. Main outcome measures: Incidence of HI-CDI (primary outcome); proportion and incidence of HA-CDI and CA-CDI (secondary outcomes). Results: The annual incidence of HI-CDI increased from 3.25/10 000 patient-days (PD) in 2011 to 4.03/10 000 PD in 2012. Poisson regression modelling demonstrated a 29% increase (95% CI, 25% to 34%) per quarter between April and December 2011, with a peak of 4.49/10 000 PD in the October–December quarter. The incidence plateaued in January–March 2012 and then declined by 8% (95% CI, − 11% to − 5%) per quarter to 3.76/10 000 PD in July–September 2012, after which the rate rose again by 11% (95% CI, 4% to 19%) per quarter to 4.09/10 000 PD in October–December 2012. Trends were similar for HA-CDI and CA-CDI. A subgroup analysis determined that 26% of cases were CA-CDI. Conclusions: A significant increase in both HA-CDI and CA-CDI identified through hospital surveillance occurred in Australia during 2011–2012. Studies are required to further characterise the epidemiology of CDI in Australia.

Epidemiology of Clostridium difficile infection (CDI) in Queensland, Australia

Background: International epidemic clones (ribotypes 027 and 078) of Clostridium difficile have been associated with death, toxic megacolon and other adverse outcomes in North America and Europe. In 2010, the first local transmission of an epidemic strain (027) of C. difficile was reported in the state of Victoria, Australia, but no cases of infection with this strain were reported in the state of Queensland. In 2012, a prevalence study was undertaken in all public and selected private hospitals to examine the epidemiology of CDI and determine the prevalence of epidemic C. difficile strains in Queensland. Methods: Enhanced surveillance was undertaken on all hospital identified CDI cases aged over 2 years between 10 April and 15 June 2012. Where available, patient samples were cultured and isolates of C. difficile ribotyped. The toxin profile of each isolate was determined by PCR. Results: In total, 168 cases of CDI were identified during the study period. A majority (58.3%) of cases had onset of symptoms in hospital. Of the 62 patients with community onset of symptoms, most (74%) had a hospital admission in the previous 3 months. Only 4 of 168 patients had onset of symptoms within a residential care facility. Thirteen out of the 168 (7.7%) patients included in the study had severe disease (ICU admission and/or death within 30 days of onset). Overall 136/168 (81%) of cases had been prescribed antibiotics in the last month. Of concern was the emergence of a novel ribotype (244) which has recently been described in other parts of Australia and is genetically related to ribotype 027. Seven patients were infected with C. difficile ribotype 244 (8% of 83 samples ribotyped), including one patient requiring ICU admission and one patient who died. Ribotype 244 was tcdA, tcdB and CDT positive and contained a tcdC mutation at position 117. Conclusion: Ongoing surveillance is required to determine the origin and epidemiology of C. difficile ribotype 244 infections in Australia.

The prolongation of length of stay because of Clostridium difficile infection

Background Clostridium difficile infection (CDI) possibly extends hospital length of stay (LOS); however, the current evidence does not account for the time-dependent bias, ie, when infection is incorrectly analyzed as a baseline covariate. The aim of this study was to determine whether CDI increases LOS after managing this bias. Methods We examined the estimated extra LOS because of CDI using a multistate model. Data from all persons hospitalized >48 hours over 4 years in a tertiary hospital in Australia were analyzed. Persons with health care-associated CDIs were identified. Cox proportional hazards models were applied together with multistate modeling. Results One hundred fifty-eight of 58,942 admissions examined had CDI. The mean extra LOS because of infection was 0.9 days (95% confidence interval: −1.8 to 3.6 days, P = .51) when a multistate model was applied. The hazard of discharge was lower in persons who had CDI (adjusted hazard ratio, 0.42; P < .001) when a Cox proportional hazard model was applied. Conclusion This study is the first to use multistate models to determine the extra LOS because of CDI. Results suggest CDI does not significantly contribute to hospital LOS, contradicting findings published elsewhere. Conversely, when methods prone to result in time-dependent bias were applied to the data, the hazard of discharge significantly increased. These findings contribute to discussion on methods used to evaluate LOS and health care-associated infections.

Development of a log-quadratic model to describe microbial inactivation, illustrated by thermal inactivation of Clostridium botulinum

In the commercial food industry, demonstration of microbiological safety and thermal process equivalence often involves a mathematical framework that assumes log-linear inactivation kinetics and invokes concepts of decimal reduction time (DT), z values, and accumulated lethality. However, many microbes, particularly spores, exhibit inactivation kinetics that are not log linear. This has led to alternative modeling approaches, such as the biphasic and Weibull models, that relax strong log-linear assumptions. Using a statistical framework, we developed a novel log-quadratic model, which approximates the biphasic and Weibull models and provides additional physiological interpretability. As a statistical linear model, the log-quadratic model is relatively simple to fit and straightforwardly provides confidence intervals for its fitted values. It allows a DT-like value to be derived, even from data that exhibit obvious "tailing." We also showed how existing models of non-log-linear microbial inactivation, such as the Weibull model, can fit into a statistical linear model framework that dramatically simplifies their solution. We applied the log-quadratic model to thermal inactivation data for the spore-forming bacterium Clostridium botulinum and evaluated its merits compared with those of popular previously described approaches. The log-quadratic model was used as the basis of a secondary model that can capture the dependence of microbial inactivation kinetics on temperature. This model, in turn, was linked to models of spore inactivation of Sapru et al. and Rodriguez et al. that posit different physiological states for spores within a population. We believe that the log-quadratic model provides a useful framework in which to test vitalistic and mechanistic hypotheses of inactivation by thermal and other processes. Copyright © 2009, American Society for Microbiology. All Rights Reserved.

Surveillance snapshot of Clostridium difficile infection in hospitals across Queensland detects binary toxin producing ribotype UK 244

In North America and Europe, the binary toxin positive Clostridium difficile strains of the ribotypes 027 and 078 have been associated with death, toxic megacolon and other adverse outcomes. Following an increase in C. difficile infections (CDIs) in Queensland, a prevalence study involving 175 hospitals was undertaken in early 2012, identifying 168 cases of CDI over a 2 month period. Patient demographics and clinical characteristics were recorded, and C. difficile isolates were ribotyped and tested for the presence of binary toxin genes. Most patients (106/168, 63.1%) were aged over 60 years. Overall, 98 (58.3%) developed symptoms after hospitalisation; 89 cases (53.0%) developed symptoms more than 48 hours after admission. Furthermore, 27 of the 62 (67.7%) patients who developed symptoms in the community ad been hospitalised within the last 3 months. Thirteen of the 168 (7.7%) cases identified had severe disease, resulting in admission to the Intensive Care Unit or death within 30 days of the onset of symptoms. The 3 most common ribotypes isolated were UK 002 (22.9%), UK 014 (13.3%) and the binary toxin-positive ribotype UK 244 (8.4%). The only other binary toxin positive ribotype isolated was UK 078 (n = 1). Of concern was the detection of the binary toxin positive ribotype UK 244, which has recently been described in other parts of Australia and New Zealand. No isolates were of the international epidemic clone of ribotype UK 027, although ribotype UK 244 is genetically related to this clone. Further studies are required to track the epidemiology of ribotype UK 244 in Australia and New Zealand. Commun Dis Intell 2014;38(4):E279–E284.

Physiological role of FolD (methylenetetrahydrofolate dehydrogenase), FchA (methenyltetrahydrofolate cyclohydrolase) and Fhs (formyltetrahydrofolate synthetase) from Clostridium perfringens in a heterologous model of Escherichia coli

Most organisms possess bifunctional FolD 5,10-methylenetetrahydrofolate (5,10-CH2-THF) dehydrogenase-cyclohydrolase] to generate NADPH and 10-formyltetrandrofolate (10-CHO-THF) required in various metabolic steps. In addition, some organisms including Clostridium perfringens possess another protein, Fhs (formyltetrahydrofolate synthetase), to synthesize 10-CHO-THF. Here, we show that unlike the bifunctional FolD of Escherichia coli (Eco FolD), and contrary to its annotated bifunctional nature, C. perfringens FolD (Cpe FoID) is a monofunctional 5,10-CH2-THF dehydrogenase. The dehydrogenase activity of Cpe FoID is about five times more efficient than that of Eco FolD. The 5,10-methenyltetrahydrofolate (5,10-CH+-THF) cyclohydrolase activity in C. perfringens is provided by another protein, FchA (5,10-CH+-THF cyclohydrolase), whose cyclohydrolase activity is similar to 10 times more efficient than that of Eco FolD. Kinetic parameters for Cpe Fhs were also determined for utilization of all of its substrates. Both Cpe FoID and Cpe FchA are required to substitute for the single bifunctional FolD in E. coli. The simultaneous presence of Cpe FoID and Cpe FchA is also necessary to rescue an E coli folD deletion strain (harbouring Cpe Fhs support) for its formate and glycine auxotrophies, and to alleviate its susceptibility to trimethoprim (an antifolate drug) or UV light. The presence of the three clostridial proteins (FolD, FchA and Fhs) is required to maintain folate homeostasis in the cell.

Bacteriological investigations of prawn canneries 2. Incidence of Clostridium perfringens

Prawn processing factories of the three major fish processing centres of the West Coast of India, viz., Cochin, Mangalore and Calicut were surveyed to determine the occurrence of Clostridium perfringens in processing areas, and in processed products. Direct plating on Sulphite-polymyxin- sulphadiazine Agar and enrichment techniques were used. Samples of prawn, prawn guts, frozen prawns, canned prawns, water, ice, swab from utensils and soil from the factory premises were examined. Among a total of 461 samples examined, only 32 (6.9%) gave positive results. The incidence of C. perfringens was more in prawn guts (80%), followed by soil (50%), prawn (38%), ice (33.3%), frozen prawns (11%), swab (5.0%) and water (1.1%). No C. perfringens was isolated from canned prawns.

Incidence of Clostridium perfrigens in fishes

Fish collected from local landing centres and also from local markets were examined for the presence and enumeration of Clostridium perfringens. A medium described by Beerens et al. (1982) was used for the detection and enumeration of C. perfringens. C. perfringens occurs in low numbers in fishes compared to prawns. Proper handling of fishes after landing can reduce the chance of any public health hazard by C. perfringens.

Comparison of media and methods for the detection and enumeration of Clostridium perfringens in seafoods

Three direct plating methods and two most probable number (MPN) procedures were compared for the enumeration of Clostridium perfringens in seafoods the sulfitecycloserine (SC) agar, sulfite-polymyxin-sulfadiazine (SPS) agar, tryptone-sulfite- neomycin (TSN) agar, LS medium MPN procedure and iron milk MPN procedure. Isolates were confirmed as C. perfringens. The two MPN procedures compared very well with the three plating media tested with stock culture of C. perfringens from our laboratory collection and the reference strain NCIB 6125. But in fish samples, the two liquid media were found to be more sensitive and hence the MPN procedure using LS medium for the detection of C. perfringens in seafoods is suggested.

Analysis of the elements of catabolite repression in Clostridium acetobutylicum.

The ptsH gene, encoding the phosphotransferase protein HPr, from Clostridium acetobutylicum ATCC 824 was identified from the genome sequence, cloned and shown to complement a ptsH mutant of Escherichia coli. The deduced protein sequence shares significant homology with HPr proteins from other low-GC gram-positive bacteria, although the highly conserved sequence surrounding the Ser-46 phosphorylation site is not well preserved in the clostridial protein. Nevertheless, the HPr was phosphorylated in an ATP-dependent manner in cell-free extracts of C. acetobutylicum. Furthermore, purified His-tagged HPr from Bacillus subtilis was also a substrate for the clostridial HPr kinase/phosphorylase. This phosphorylation reaction is a key step in the mechanism of carbon catabolite repression proposed to operate in B. subtilis and other low-GC gram-positive bacteria. Putative genes encoding the HPr kinase/phosphorylase and the other element of this model, namely the catabolite control protein CcpA, were identified from the C. acetobutylicum genome sequence, suggesting that a similar mechanism of carbon catabolite repression may operate in this industrially important organism.

Analysis of the mechanism and regulation of lactose transport and metabolism in Clostridium acetobutylicum ATCC 824.

Although the acetone-butanol-ethanol (ABE) fermentation of Clostridium acetobutylicum is currently uneconomic, the ability of the bacterium to metabolise a wide range of carbohydrates offers the potential for revival based on the use of cheap, low grade substrates. We have investigated the uptake and metabolism of lactose, the major sugar in industrial whey waste, by C. acetobutylicum ATCC 824. Lactose is taken up via a phosphoenolpyruvate (PEP)-dependent phosphotransferase system (PTS) comprising both soluble and membrane-associated components, and the resulting phosphorylated derivative is hydrolysed by a phospho--galactosidase. These activities are induced during growth on lactose, but are absent in glucose-grown cells. Analysis of the C. acetobutylicum genome sequence identified a gene system, lacRFEG, encoding a transcriptional regulator of the DeoR family, IIA and IICB components of a lactose PTS, and phospho--galactosidase. During growth in medium containing both glucose and lactose, C. acetobutylicum exhibited a classical diauxic growth, and the lac operon was not expressed until glucose was exhausted from the medium. The presence upstream of lacR of a potential catabolite responsive element (cre) encompassing the transcriptional start site is indicative of the mechanism of carbon catabolite repression characteristic of low-GC Gram-positive bacteria. A pathway for the uptake and metabolism of lactose by this industrially important organism is proposed.

As neurotoxinas de clostridium sp.

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Ciências Farmacêuticas