Clostridioides difficile infections were predominantly driven by fluoroquinolone-resistant Clostridioides difficile ribotypes 176 and 001 in Slovakia in 2018-2019

Abstract

AIMS: We aimed to investigate Clostridioides difficile (CDI) epidemiology in Slovakian hospitals after the emergence of ribotype 176 (027-like) in 2016. METHODS: Between 2018 and 2019, the ECDC CDI surveillance protocol v2.3 was applied to 14 hospitals, with additional data collected on recent antimicrobial use and the characterisation of C. difficile isolates. RESULTS: The hospital mean CDI incidence of 4.1 cases per 10,000 patient bed-days. An in-hospital fatal outcome was reported in 27.6% (n=105) of the 381 cases. Antimicrobial treatment within the previous 4 weeks was recorded in 90.5% (333/368). Ribotype (RT)176 was detected in 50% (n=185/370; 14 hospitals) and RT001 in 34.6% (n=128/370;13/14 hospitals) cases with RT data. A total of 86% (n=318/370) of isolates were moxifloxacin-resistant by Thr82Ile in GyrA (99.7%). Multilocus Variable Tandem Repeat Analysis showed clonal relatedness of predominant RTs within and between hospitals. Seven of 14 sequenced RT176 isolates and 5 of 13 RT001 isolates showed only 0-3 allele differences by wgMLST. The majority of sequenced isolates (24/27) carried the erm(B) gene and 16/27 also carried aac(6')-aph(2'') gene with the corresponding antimicrobial susceptibility phenotypes. Nine RT176 strains carried the cfr(E)gene and one RT001 strain carried the cfr(C) gene, but without a linezolid resistance. CONCLUSIONS: The newly-predominant RT176 and endemic RT001 drive CDI epidemiology in Slovakia. In addition to fluoroquinolones, the use of macrolide-lincosamide-streptogramin B group of antibiotics can represent another driving force for the spread of these epidemic lineages. In C. difficile, linezolid resistance should be confirmed phenotypically in strains with detected cfr-gene(s).