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Clinical and microbiological risk factors for severe Clostridioides difficile infections in Korea

Original article

Kim YA, Kim H, Kim D, Liu C, Jeong SH. Clinical and microbiological risk factors for severe Clostridioides difficile infections in Korea. Ann Clin Microbiol 2022;25:17-23.

Annals of Clinical Microbiology (Ann Clin Microbiol) 2022 March, Volume 25, Issue 1, pages 17-23. https://doi.org/10.5145/ACM.2022.25.1.3

Received on 16 February 2022, Revised on 8 March 2022, Accepted on 14 March 2022, Published on 20 March 2022.

Clinical and microbiological risk factors for severe Clostridioides difficile infections in Korea

Young Ah Kim1, Heejung Kim2,3, Dokyun Kim3, Changseung Liu3, Seok Hoon Jeong3

1Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, 2Department of Laboratory Medicine, Yongin Severance Hospital, YongIn, 3Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea

Corresponding author: Heejung Kim, E-mail: hjkim12@yuhs.ac

Abstract

Background: There has been a marked increase in the mortality rate associated with Clostridioides difficile infection (CDI) globally since 2003, with the emergence of binary toxinproducing ribotype 027 strains. However, the molecular epidemiology of C. difficile shows regional differences and ribotype 027 is not common in Korea. In this study, the risk factors for severe CDI were evaluated, while considering the region-specific molecular epidemiology. 

Methods: A retrospective case-control study was performed. Cases (n = 149) included patients with severe CDI or severe complicated CDI. Controls (n = 155) consisted of patients with nonsevere CDI. 

Results: Advanced age (odds ratio [OR] = 1.017, P = 0.0358), a history of chemotherapy (OR = 2.695, P = 0.0464), and ribotype 002 (OR = 3.406, P = 0.0231) were statistically significant factors associated with severe CDI in a multivariate analysis. 

Conclusion: Ribotype 002 was found to be a significant risk factor for severe CDI in this study. Therefore, the surveillance of C. difficile ribotypes is recommended to monitor the spread of high-risk clones.

Keywords

Clostridioides difficile, Risk factor, Severe infection

Introduction

Clostridioides dif f icile is a gram-positive anaerobe that causes infectious diarrhea that can range in severity from mild to severe [1]. The incidence and mortality rate of C. difficile infection (CDI) has also increased dramatically worldwide since 2003, and severe clinical conditions of CDI were reported in association with binary toxin-producing ribotype 027 strains [2,3]. However, molecular epidemiology is different according to regions and the ribotype 027 is not prevalent in Korea [4,5].

Advanced age, antibiotic use, gastric acid suppression, and infection with hypervirulent strain are wellknown risk factors for recurrent CDI [6]. According to a recent large national cohort study, treatment with certain antibiotics, proton pump inhibitors (PPIs), immune suppressants, and underlying disease were also important risk factors for the first CDI recurrence [7].

Although severe CDI can precede recurrence or treatment failure, the contexts were mixed [8]. Early prediction of severe CDI is essential so that adequate management can be applied to high-risk patients. However, the recent data is limited as far as we know. In this study, we evaluated risk factors for severe CDI, considering the region-specific molecular epidemiology.

Materials and methods

Study population and definition

All study populations had visited Ilsan Hospital or Gangnam Severance Hospital in 2019 and they had been diagnosed with CDI based on clinical and laboratory evidence (stool culture for C. difficle plus nucleic acid amplification tests for C. difficile toxin genes). The first infection case was only included to avoid duplication. A retrospective case-control study was performed. Cases (n = 149) included patients with severe CDI or severe complicated CDI. Controls (n = 155) consisted of patients with non-severe CDI.

The level of severity was classified as follows [9]: The severe CDI case was defined if they have a serum albumin level < 3.0 g/dL plus either a white blood cell (WBC) count > 15,000/mm3 or abdominal tenderness. The severe complicated CDI case was defined if they were admitted to the intensive care unit with any one of the following attributes (hypotension, body temperature > 38.5 °C, ileus or significant abdominal distension, mental changes, WBC > 35,000/mm3 or < 2,000/mm3, serum lactate levels > 2.2 mmol/L, and development of end-organ failure).

We obtained clinical features by reviewing the electronic medical records. Variables included age, sex, associated disease, history of antimicrobials within the previous 12 weeks, history of chemotherapy within the previous 12 weeks, history of PPIs within the previous 12 weeks, sites of acquisition, CDI treatments, history of CDI within the previous 12 weeks, recurrence after eight weeks, death, toxin types, and C. difficile ribotype. Community-associated cases were those cases that had occurred in the community without admission to a healthcare facility during the previous 12 weeks [10]. Others were regarded as hospitalassociated cases.

Molecular study

The toxin production and molecular epidemiology were determined with polymerase chain reaction (PCR)-sequencing [4]. For toxin A and B genes, the primer pairs we used were tcdA-F and tcdA-R for tcdA, NK104 and NK105 for tcdB, cdtA-pos and cdtA-rev for cdtA, and cdtB-pos and cdtB-rev for cdtB [4]. PCR ribotyping with CD1-CD1445 primers was performed as previously described [4]. We visually compared PCR ribotyping patterns with known standards (VPI 10463, UK078, 48489ATCC9689, ATCC43598, and ATCC70057). Those ribotype patterns that differed by at least 1 band were assigned to different types. Multilocus sequence typing (MLST) was done, using a previously described scheme with a set of seven housekeeping genes (adk, atpA, dxr, glyA, recA, soda, and tpi) [11]. PCR of the seven loci and sequenced amplicons was done with forward and reverse primers. DNA sequences were submitted to the MLST database (https://pubmlst.org/cdifficile/) to obtain the sequence type (ST).

Statistical analysis

Continuous variables were analyzed by the Mann-Whitney U test. The chi-squared test was used for the comparative analysis of categorical variables to determine independent risk factors. The odds ratio (OR) was calculated at 95% confidence interval (CI) values for binomial variables. Variables with P values of less than 0.1 in univariate analyses were included in a multivariate logistic regression analysis model to determine the independent risk factors. We defined the statistical significance as being P < 0.05. We used the SPSS 23.0 software (SPSS, Chicago, IL, USA) for univariate analyses and multivariate analyses. 

Results

Clinical features of patients with severe or severe complicated CDI

More frequent factors in severe or severe complicated CDI were advanced age, pneumonia, heart failure, previous use of penicillin, previous use of carbapenem, previous use of teicoplanin, crude mortality, ribotype 002, and ribotype 018. Whereas, previous use of narrow-spectrum cephalosporin and more frequent recovery were observed in non-severe CDI (Table 1).

Table 1. Comparison of severe (or severe complicated) CDI and non-severe CDI (to be continued)
Table 1. Comparison of severe (or severe complicated) CDI and non-severe CDI (to be continued)

Data in number (%) except for age, Charlson comorbidity index, and laboratory findings, which were in mean + standard deviation. Bold formatting indicates statistical significance. *Other included AB11, AB16, AB21, AB27, AB28, AB37, AB43, AB46, AB47, AB48, AB67, AB68, AB76, AB79, AB84, AB89, AB90, AB91, C14, C29, C32, R005, R023, R027, R078, R103, R122, R126, R137, R159, R161, R163, R267, and R369. Abbreviations: CDI, C. difficile infection; PPI, proton pump inhibitor; ST, sequence type.

The risk factors of severe or severe-complicated CDI

In univariate analysis, variables with P values of less than 0.1 were advanced age, cancer, pneumonia, heart failure, nutrition deficiency, previous use of antimicrobials (penicillin, narrow-spectrum cephalosporin, carbapenem, and teicoplanin), history of chemotherapy, recovery, crude mortality, specific ribotypes (ribotype 001, ribotype 002 and ribotype 018).

These variables were included in multivariate analysis. Advanced age (odds ratio [OR] = 1.017, P = 0.0358), history of chemotherapy (OR = 2.695, P = 0.0464), and the ribotype 002 (OR = 3.406, P = 0.0231) were statistically significant (Table 2).

Table 2. Risk factors for severe or severe complicated CDI over non-severe CDI: a multivariate analysis

*Statistical significances were maintained after the adjustment for age, associated disease (cancer, pneumonia, heart failure, nutrition deficiency), previous use of antimicrobials (penicillin, narrow-spectrum cephalosporin, carbapenem, teicoplanin), recovery, ribotype 001, ribotype 002, and ribotype 018. Abbreviations: CDI, C. difficile infection; OR, odds ratio; CI, confidence interval.

Discussion

Risk factors such as malignancy, chronic obstructive pulmonary disease, immunosuppression, antiperistaltic medications, renal failure, or clindamycin use were previously reported to be predictive of either intensive care unit admission or death in patients with CDI [12]. Others reported that the mortality was associated with variables such as low serum albumin, an abrupt decrease of serum albumin, use of more than three antibiotics, and persistence of positive cytotoxin in C. difficile colitis [13]. These early studies were performed in the late 1990s and focused on predictors of survival.

After the rise of hypervirulent strains, other definitions were used [2]. Briefly, they defined severe cases as being positive C. difficile cytotoxicity assay result or endoscopic (histopathological) evidence of pseudomembranous colitis. Complicated cases had one or more of the following: megacolon, perforation, colectomy, shock requiring vasopressor therapy, or death within 30 days following diagnosis. This approach seems to be more practical for clinicians to use in predicting which patients have a higher risk of severe CDI, many of whom do not respond to the recommended anti-CDI antibiotic therapy [14].

The ribotype 027 is a well-known risk factor for the severe or severe complicated CDI and this ribotype produces a binary toxin with a higher toxin level (16 to 23-times greater than do the wild-type strains) [15]. In Korea, ribotype 027 has been known as a minor major type [4,5] and only three C. difficile isolates were typed to ribotype 027 also in this study. Therefore, the hypervirulent strain with ribotype 027 can’t play a big role in the severe clinical presentation of CDI in Korea.

The ribotype 002 was defined as a significant risk factor for severe CDI in this study. The C. difficile ribotype 002 has been reported as a major clone in Hong Kong [16]. Moreover, this clone was associated with a higher virulence of toxin production, sporulation, and germination rates [17]. C. difficile ribotype 002 showed increased mortality [18]. The C. difficile ribotype has been monitored as part of the South Korean national antimicrobial resistance surveillance system, Kor-GLASS [19].

This is the first report that the risk factors for severe CDI were evaluated, considering the region-specific molecular epidemiology. Considering the clinical importance of C. difficile ribotype 002, it is needed to monitor the spread of high-risk clones in Korea. In conclusion, we found advanced age, history of chemotherapy, and ribotype 002 as being significant risk factors for severe CDI.

Ethics statement

This study was approved by the Institutional Review Board of National Health Insurance Service Ilsan Hospital as required by the hospital policy (IRB No. NHIMC-2020-05-014).

Conflicts of interest

No potential conflicts of interest relevant to this article were reported.

Acknowledgements

I want to thank So Ra Yoon, Ph.D., for the statistics from the Research Institute of National Health Insurance Ilsan Hospital.

Funding

This research was supported by a fund from the Research of Korea Centers for Disease Control and Prevention (2017E4400202).

References

1. Bartlett JG. Clostridium difficile: history of its role as an enteric pathogen and the current state of knowledge about the organism. Clin Infect Dis 1994;18:S 265-72.

2. Pepin J. Valiquette L, Alary M, Villemure P, Pelletier A, Forget K, et al. Clostridium difficileassociated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. Can Med Assoc J 2004;171:466–72.

3. Loo VG, Poirier L, Miller MA, Oughton M, Libman MD, Michaud S, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:2442-9.

4. Byun JH, Kim H, Kim JL, Kim D, Jeong SH, Shin JH, et al. A nationwide study of molecular epidemiology and antimicrobial susceptibility of Clostridioides difficile in South Korea. Anaerobe 2019;60:102106.

5. Nicholas A, Kim YK, Lee WK, Selasi GN, Na SH, Kwon HI, et al. Molecular epidemiology and antimicrobial susceptibility of Clostridium difficile isolates from two Korean hospitals. PLoS One 2017;12:e0174716.

6. Song JH, Kim YS. Recurrent Clostridium difficile infection: risk factors, treatment, and prevention. Gut Liver 2019;13:16-24.

7. Appaneal HJ, Caffrey AR, Beganovic M, Avramovic S, LaPlante KL. Predictors of Clostridioides difficile recurrence across a national cohort of veterans in outpatient, acute, and long-term care settings. Am J Health-Syst Pharm 2019;76:581–90.

8. Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007;45:302-7.

9. Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium dif f icile infections. Am J Gastroenterol 2013;108:478-98.

10. Liu C, Yoon EJ, Kim D, Shin JH, Shin JH, Shin KS, et al. Antimicrobial resistance in South Korea: a report from the Korean global antimicrobial resistance surveillance system (KorGLASS) for 2017. J Infect Chemother 2019;25:845‐59.

11. Griffiths D, Fawley W, Kachrimanidou M, Bowden R, Crook DW, Fung R, et al. Multilocus sequence typing of Clostridium difficile. J Clin Microbiol 2010;48:770-8.

12. Rubin MS, Bodenstein LE, Kent KC. Severe Clostridium dif f icile colitis. Dis Colon Rectum 1995;38:350–4.

13. Ramaswamy R, Grover H, Corpuz M, Daniels P, Pitchumoni CS. Prognostic criteria in Clostridium difficile colitis. Am J Gastroenterol 1996;91:460–4.

14. Cheng YW, Fischer M. Treatment of severe and fulminnant Clostridioides difficile infection. Curr Treat Options Gastroenterol 2019;17:524‐33.

15. Wamy M, Pe´pin J, Fang A, Killgore G, Thompson A, Brazier J, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 2005;366:1079–84.

16. Luk S, Ho AYM, Chan EHY, Tsang IHL, Ng TK, To WK, et al. High prevalence and frequent acquisition of Clostridium dif f icile ribotype 002 among nursing home residents in Hong Kong. Infect Control Hosp Epidemiol 2018;39:782-7.

17. Kong KY, Kwong TNY, Chan H, Wong K, Wong SSY, Chaparala AP, et al. Biological characteristics associated with virulence in Clostridioides dif f icile ribotype 002 in Hong Kong. Emerg Microbes Infect 2020;9:631-8.

18. Wong SH, Ip M, Hawkey PM, Lo N, Hardy K, Manzoor S, et al. High morbidity and mortality of Clostridium difficile infection and its associations with ribotype 002 in Hong Kong. J Infect 2016;73:115-22.

19. Lee H, Yoon EJ, Kim D, Jeong SH, Shin JH, Shin JH, et al. Establishment of the South Korean national antimicrobial resistance surveillance system, Kor-GLASS, in 2016. Euro Surveill 2018;23:1700734.

Table 1
Table 2

1. Bartlett JG. Clostridium difficile: history of its role as an enteric pathogen and the current state of knowledge about the organism. Clin Infect Dis 1994;18:S 265-72.

2. Pepin J. Valiquette L, Alary M, Villemure P, Pelletier A, Forget K, et al. Clostridium difficileassociated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. Can Med Assoc J 2004;171:466–72.

3. Loo VG, Poirier L, Miller MA, Oughton M, Libman MD, Michaud S, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353:2442-9.

4. Byun JH, Kim H, Kim JL, Kim D, Jeong SH, Shin JH, et al. A nationwide study of molecular epidemiology and antimicrobial susceptibility of Clostridioides difficile in South Korea. Anaerobe 2019;60:102106.

5. Nicholas A, Kim YK, Lee WK, Selasi GN, Na SH, Kwon HI, et al. Molecular epidemiology and antimicrobial susceptibility of Clostridium difficile isolates from two Korean hospitals. PLoS One 2017;12:e0174716.

6. Song JH, Kim YS. Recurrent Clostridium difficile infection: risk factors, treatment, and prevention. Gut Liver 2019;13:16-24.

7. Appaneal HJ, Caffrey AR, Beganovic M, Avramovic S, LaPlante KL. Predictors of Clostridioides difficile recurrence across a national cohort of veterans in outpatient, acute, and long-term care settings. Am J Health-Syst Pharm 2019;76:581–90.

8. Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007;45:302-7.

9. Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium dif f icile infections. Am J Gastroenterol 2013;108:478-98.

10. Liu C, Yoon EJ, Kim D, Shin JH, Shin JH, Shin KS, et al. Antimicrobial resistance in South Korea: a report from the Korean global antimicrobial resistance surveillance system (KorGLASS) for 2017. J Infect Chemother 2019;25:845‐59.

11. Griffiths D, Fawley W, Kachrimanidou M, Bowden R, Crook DW, Fung R, et al. Multilocus sequence typing of Clostridium difficile. J Clin Microbiol 2010;48:770-8.

12. Rubin MS, Bodenstein LE, Kent KC. Severe Clostridium dif f icile colitis. Dis Colon Rectum 1995;38:350–4.

13. Ramaswamy R, Grover H, Corpuz M, Daniels P, Pitchumoni CS. Prognostic criteria in Clostridium difficile colitis. Am J Gastroenterol 1996;91:460–4.

14. Cheng YW, Fischer M. Treatment of severe and fulminnant Clostridioides difficile infection. Curr Treat Options Gastroenterol 2019;17:524‐33.

15. Wamy M, Pe´pin J, Fang A, Killgore G, Thompson A, Brazier J, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 2005;366:1079–84.

16. Luk S, Ho AYM, Chan EHY, Tsang IHL, Ng TK, To WK, et al. High prevalence and frequent acquisition of Clostridium dif f icile ribotype 002 among nursing home residents in Hong Kong. Infect Control Hosp Epidemiol 2018;39:782-7.

17. Kong KY, Kwong TNY, Chan H, Wong K, Wong SSY, Chaparala AP, et al. Biological characteristics associated with virulence in Clostridioides dif f icile ribotype 002 in Hong Kong. Emerg Microbes Infect 2020;9:631-8.

18. Wong SH, Ip M, Hawkey PM, Lo N, Hardy K, Manzoor S, et al. High morbidity and mortality of Clostridium difficile infection and its associations with ribotype 002 in Hong Kong. J Infect 2016;73:115-22.

19. Lee H, Yoon EJ, Kim D, Jeong SH, Shin JH, Shin JH, et al. Establishment of the South Korean national antimicrobial resistance surveillance system, Kor-GLASS, in 2016. Euro Surveill 2018;23:1700734.