Clostridium difficile

Some of the most important bacterial infections involve nosocomial infections also known as hospital-
acquired infections. These infections could severely affect the patient’s health and cause prolonged
hospitalization which eventually leads to a major economic burden on healthcare systems. 2 One of the
most common nosocomial infections is Clostridium difficile.

While I was listening to lecture three my grandfather overheard and proceeded to tell me that he had
experienced Clostridium difficile when he returned from India. My grandparents immigrated from India
around 50 years ago and continue to India 4 months out of the year even though they permanently
reside in British Columbia. During their last visit, my grandfather returned home very ill and my family
and I decided to take him to the hospital, and during his stay he acquired a bacterial infection. I decided
to take a deeper look into this infection as I am extremely curious to evaluate the microscopic effects of
this infection that make it so fatal.

Clostridium difficile is an obligate anaerobic, gram- positive bacillus. 1 One of the most critical
characteristics of this particular bacterium is the fact that is spore-forming. 1 Initially this bacterium was
named Bacillus difficilis due to the strenuous measures scientists would have to take to isolate it. 3 While
the steps to culture this bacterium are quite intricate, selective media make it appropriate to isolate
from human fecal specimens.1 C. difficile is said to have polysaccharides within the cell wall which serves
as an anchor for other proteins and teichoic acid. 9 The attachment of C. difficile to host cells is mediated
by they enzyme cysteine transpeptidase sortase. 9 This enzyme releases covalently attached proteins to
enhance attachment to the host cell. 9 Additionally, this bacterium contains an S- layer which has various
molecular weight components as well as 28 paralogous proteins which include many factors
contributing to the pathogenesis of this infection such as adhesion as well as degeneration of host cell
proteins.2 These proteins form a heterodimer on the surface which as well contributes to the adhesion. 9
The multiple proteins within the S layer form a sequence of select proteins that allow the organism to
bind to the host cell more efficiently. 9 Flagella is present within C. difficile but it does not contribute
anything very useful to the organism. 2 The transmission of Clostridium difficile is through direct contact
as well as indirect fecal oral contact. 5 The ingestion of endospores from this disease is crucial as is the
main mode of transmission which serves as an explanation to why it is a community-acquired disease. 1

While C. difficile remains very fatal and is extremely hard to prevent especially in healthcare
environments, the copious amounts of virulence factors allow the organism to infect more easily. While
there may be various virulence factors the two main ones include toxin A (TcdA) and Toxin B (TcdB). 2
These two toxins contribute many factors on the cellular level such as increased fluid secretion, cytokine
production, neutrophil recruitment which eventually causes tissue damage within the intestinal tract. 10
Many C.difficile strains initiate an additional binary toxin also known as CDT which is encoded by genes
cdtA and cdtB and may be associated with severe disease 2 3 It is difficult to elaborate on the role toxins
play in infection as it remains unclear.2 A new strain known as B1/NAP1/027 was found to increase
fatality and increases the production of exotoxins TcdA and TcdB. 3 A disruption of normal microbiota
within the intestinal tract with antibiotics allows the germination of spores 3 As I mentioned before the C.
difficile bacterium is composed of an abundant amount of S-layer proteins which allow for attachment
to the intestinal mucosa.3 Attachment specifically is conducted by two adhesion molecules known as
Cwp66 and Cwp84 as well as the surface binding protein, Fbp68. 3 Two additional proteins are involved
as well to enhance adherence to penetrate the mucosa within the gut, these two are known as flagellin
(FliC) and flagellar cap protein (FliD).3 An important component within C. difficile is biofilms. While
biofilms are associated with antimicrobial resistance as they are used to protect bacteria and allow them
to survive more easily.6 Clostridium difficile has shown to have well-structured biofilms that accumulate
toxins.6 Lastly, and most important virulence factor is the ability for this bacterium to produce
endospores. Spore production is mediated by the sporulation pathway known as spo0A. 6 These spores
are especially important as they protect C. difficile from extreme environmental conditions and protect
the bacterium from preventative measures such as disinfectants and antimicrobial agents. 6 Many
virulence factors accompany this bacterium in terms of attachment, motility, sporulation, toxin
production, and biofilm production.3 Quorum sensing is the regulation of gene expression within these
various virulence factors while responding to environmental changes. 6 This sensing is monitored by
small molecules known as autoinducers which are produced by individual bacteria. 6 Higher levels of
autoinducers are detected by other bacterial species which then allows them to coordinate physiological
activities.6

While this bacterial infection contains many virulence factors it is important to understand exactly how
those proteins and toxins allow this bacterium to cause disease within humans. One of the most
commonly known effects of this disease is diarrhea and colonic inflammation. 1 These fatal symptoms are
due to toxin A and toxin B, which are both apart of the pathogenicity locus (PaLoc) on the C. difficile
chromosome.1 These toxins specifically disrupt the actin cytoskeleton of intestinal epithelial cells. 7 This
effect of toxins indicates the importance of healthy gut microbiota to prevent this fatal bacterial
infection.7 Since there are various strains of this bacterium it is difficult to isolate one specific effect and
severity of a virulence factor and exactly how it contributes to the pathogenicity of the organism. 7 The
severity of the disease depends on various factors that involve host cells, microbiota composition, and
type of strain.7 While sporulation remains one of the most important virulence factors within this
organism, studies have shown the sporulation rates do not contribute to the pathogenicity of this
organism.7 While it may be related to transmission the sporulation does not affect on the ability of this
organism to cause disease.7

This organism’s main symptom is mild to severe diarrhea, pseudomembranous colitis, toxic megacolon,
and death.2 Both toxins affect the large intestine and cause inflammation of epithelial cells which leads
to colitis3 Mild infections include diarrhea that develops with or without blood including mild abdominal
pain and fever.3 Whereas in severe infections symptoms include bloody diarrhea, leukocytosis, high-
grade fever, severe abdominal cramps, severe colitis, and toxic megacolon which can be life-
threatening.3 While severity can vary from patient to patient the immune response is crucial as it results
in how severe the infection can be.

While analyzing this bacterium there are risk factors that contribute to the development of this bacterial
infection. Frequent use of antibiotics can attribute to the development as these antimicrobials kill
normal microbiota within the gut.3 As well, older age and recent or prolonged hospital stay continue to
be two major risk factors.3 Previous history of gastrointestinal tract surgery, inflammatory bowel
disease, obesity, and low serum albumin levels. 3

When referring to the treatment of this fatal bacterial infection vancomycin and fidaxomicin are two of
the most important antimicrobials to start with. 4 There may be a presence of toxin A or toxin B within
the body but it should not be treated with antimicrobials unless symptoms are present. 4 Metronidazole
is used within non-severe C. difficile infections and studies have shown that vancomycin is more
effective in treating this kind of bacterial infection. 4 Metronidazole contains a high absorption rate
therefore cannot retain the needed concentration in the gut to kill these bacterial cells. 3 Alternatively,
vancomycin contains a low absorption rate within the intestinal tract and contains the high
concentrations needed to kill C. difficile cells.3 Therefore, vancomycin is considered the drug of choice
within most severe infections of Clostridium difficile.3 4 Another antimicrobial that is commonly used in
conjunction with vancomycin is rifaximin to treat recurrent C. difficile infections.3 An additional
advantage of rifaximin is the ability for it to remain active again hypervirulent strains. 3 A disadvantage
commonly known within the use of most antimicrobials is that they are unable to distinguish beneficial
bacteria from harmful bacteria and their tendency to kill common microbiota within the body which in
turn gives rise to resistant strains or recurrence of bacterial infections. 3 The use of probiotics while
taking any antibiotic is beneficial as it restores healthy microbiota within the gut. 3 Another antibiotic was
previously used to treat this bacterial infection which is known as fidaxomicin which is an RNA
polymerase inhibitor.3 Fidaxomicin is a narrow-spectrum antibiotic and known to prevent recurrence of
this bacterial infection specifically by inhibiting the growth of spores. 3 8 While this antimicrobial is
beneficial to prevent a chronic C. difficile infection vancomycin continues to remain the best antibiotic to
treat this bacterium. Lastly, an important treatment for C. difficile infections is known as faecal
transplants. This treatment is known to restore healthy microbiota within the gut as well as recovery of
secondary bile acids.8 This treatment is used after antibiotic therapy for a certain number of days and
administered through duodenal tube. 8 The organism itself takes a toll on gut microbiota and decreases
the bodies ability to resist colonization of other organisms. 8

A vaccine is currently unavailable to treat Clostridium difficile.3 Intravenous immunoglobulin and human
antibodies are used to severe CDI by reducing the severity and duration of the infection. 3 Intravenous
immunoglobulin and human monoclonal antibodies neutralize toxins as antibodies are unable to
neutralize TcdA and TcdB alone.3 While this nonantibiotic treatment is used to lessen the severity of C.
difficile infections there is limited scientific evidence available to justify an exact dosage and duration to
use for effective treatment.3 Essentially, all antibiotic and non antibiotic treatments are effective to treat
C. difficile infections.3 However, treating hypervirulent strains is quite difficult and research is being
completed to treat epidemic NAP1 strains. 3

All in all, this disease can be extremely fatal and the severity can vary from patient to patient due to a
variety of risk factors. The transmission of this bacteria specifically allows it to be spread extremely
easily and many other virulence factors, pathogenicity, and complications contribute to this infection.

References:
1 Curry Scott. Clostridium difficile. Clin Lab Med [Internet]. 2017 [cited 2020 Nov 13];37(2):341-369.
Available from: http://www.sciencedirect.com/science/article/pii/S0272271217300094 DOI:
https://doi.org/10.1016/j.cll.2017.01.007.

2 Elliott Briony, Androga Grace, Knight Daniel, Riley Thomas. Clostridium difficile infection: evolution,
phylogeny and molecular epidemiology. Infect Genet Evol [Internet]. 2017 [cited 2020 Nov 13];49(1):1-
11. Available from http://www.sciencedirect.com/science/article/pii/S1567134816305470 DOI:
https://doi.org/10.1016/j.meegid.2016.12.018.

3 Alyousef Abdullah. Clostridium difficile: epidemiology, pathogenicity, and an update on the limitations
of and challenges in its diagnosis. J AOAC Int [Internet]. 2018 [cited 2020 Nov 13];101(4):1119-1126.
Available from https://academic-oup-com.login.ezproxy.library.ualberta.ca/jaoac/article/
101/4/1119/5654010 DOI: https://doi-org.login.ezproxy.library.ualberta.ca/10.5740/jaoacint.17-0352

4 Czepial Jacek, Drozdz Miroslaw, Pituch Hanna, Kuijper Ed, Perucki William, Mielimonka Aleksandra et
al. Clostridium difficile infection: review. Eur J Clin Microbiol Infect Dis [Internet]. 2019 [cited 2020 Nov
13];38:1211-1221. Available from https://link-springer-com.login.ezproxy.library.ualberta.ca/article/
10.1007/s10096-019-03539-6 DOI:
https://doi-org.login.ezproxy.library.ualberta.ca/10.1007/s10096-019-03539-6

5 Canada Public Health Agency. Transmission of infectious agents. 2014. 7 p.

6 Rodriguez Laura – Tijerina, Villarreal – Trevino Licet, Morfin-Otero Rayo, Camacho-Ortiz Adrian, Garza
– Gonzalex, Elivira. Virulence factors of clostridium difficile linked to recurrent infections. Can J Infect Dis
Med Microbiol [Internet]. 2019 [cited 2020 Nov 13];2019:1-7. Available from
https://www.hindawi.com/journals/cjidmm/2019/7127850/ DOI:
https://doi.org/10.1155/2019/7127850

7 Lewis Brittany, Carter Rebecca, Ling Lilian, Leiner Ingrid, Taur Ying, Kamboj Mini et al. Pathogenicity
locus, core genome, and accessory gene contributions to clostridium difficile virulence. J Microbiol Biol
Educ [Internet]. 2017 [cited 2020 Nov 13];8(4):00885-17. Available from https://mbio-asm-
org.login.ezproxy.library.ualberta.ca/content/8/4/e00885-17.long DOI: 10.1128/mBio.00885-17

8. Ooijevaar R, Beurden Van, Terveer EM, Goorhuis A, Bauer MP, Keller JJ et al. Update of treatment
algorithms for clostridium difficile infection. Clin Microbiol Infect [Internet]. 2018 [cited 2020 Nov
25];24(5):452-462. Available from
https://www-sciencedirect-com.login.ezproxy.library.ualberta.ca/science/article/pii/
S1198743X18300211?via%3Dihub DOI:10.1016/j.cmi.2017.12.022

9. Corver Jeroen, Cordo Valentina, Leeuwen Hans, Klychnikov Oleg, Hensbergen Paul. Covalent
attachement and pro-pro endopeptidase (PPEP-1)-mediated release of clostridium difficile cell surface
proteins involved in adhesion. Mol Microbiol [Internet]. 2017 [cited 2020 Nov 25];105(5):663-673.
Available from https://onlinelibrary -
wileycom.login.ezproxy.library.ualberta.ca/doi/full/10.1111/mmi.13736 DOI: https://doi-
org.login.ezproxy.library.ualberta.ca/10.1111/mmi.13736
10. Chandrasekaran Ramyavardhanee, Borden Lacy D. The role of tozins in clostridium difficile infection.
FEMS Microbiol Rev [Internet].2017 [cited 2020 Nov 25]; 41(6):723-750. Available from https://pubmed-
ncbi-nlm-nih-gov.login.ezproxy.library.ualberta.ca/29048477/ DOI: 10.1093/femsre/fux048.