Knowledge of Clostridium difficile infection among UK health-care workers: development of a knowledge assessment tool.

Doctors' knowledge provides the basis to support good practice in infection prevention and control. However, there exists a paucity of validated knowledge assessment tools that can be reliably employed to identify poor knowledge levels of Clostridium difficile infection (CDI) within populations of doctors, preventing the effective identification of knowledge deficiencies and focused targeting of educational interventions. Here, we describe a development process to validate a novel CDI knowledge assessment tool for doctors. Two previously published CDI knowledge questionnaires were amalgamated to produce a combined questionnaire. Content was further evaluated by a panel of CDI experts, producing the 'Lothian' questionnaire. These questionnaires were tested in control populations comprising either infection control nurse (ICN) specialists or non-clinically trained individuals, and a cohort of medical staff. We compared the efficacy of the 'Lothian' questionnaire against that of previous questionnaire reports. We found that all of the questionnaires studied significantly discriminated between non-clinical and clinical populations (ICNs and medical staff) (P < 0.001) and had similar levels of sensitivity and specificity in discrimination between these targeted populations. This study describes the development of a robust CDI knowledge assessment tool that can be used to evaluate knowledge levels among doctors, compare populations and assist the targeting of educational interventions and plot trends following such interventions.

Spatio-temporal stochastic modelling of Clostridium difficile.

Clostridium difficile-associated diarrhoea (CDAD) occurs sporadically or in small discrete outbreaks. Stochastic models may help to inform hospital infection control strategies. Bayesian framework using data augmentation and Markov chain Monte Carlo methods were applied to a spatio-temporal model of CDAD. Model simulations were validated against 17 months of observed data from two 30-bedded medical wards for the elderly. Simulating the halving of transmission rates of C. difficile from other patients and the environment reduced CDAD cases by 15%. Doubling the rate at which patients become susceptible increased predicted CDAD incidence by 63%. By contrast, doubling environmental load made hardly any difference, increasing CDAD incidence by only 3%. Simulation of different interventions indicates that for the same effect size, reducing patient susceptibility to infection is more effective in reducing the number of CDAD cases than lowering transmission rates.

Distribution of lipopolysaccharide core types among avian pathogenic Escherichia coli in relation to the major phylogenetic groups.

Five distinct lipopolysaccharide (LPS) core types, namely R1-R4 and K12 have been identified in Escherichia coli. The aims of this study were to determine, primarily by means of PCR, the distribution of those oligosaccharide core types among avian pathogenic E. coli and their relationship to phylogenetic groups. To identify putative avian pathogenic E. coli, serum resistance and the presence of three virulence genes encoding temperature sensitive haemagglutinin (tsh), increased serum survival (iss) and colicin V (cvaC) were determined. Of the 143 clinical isolates examined 62% possessed the R1 core, 22% were R3, 13% were R4 and 3% were R2. Fifty commensal isolates consisted of 58% with R1 core, 38% with R3 core, 4% with R4 core, and none with R2. None of the isolates were of K12 core type. The distribution of core oligosaccharide types in clinical and commensal isolates were not statistically significant (P=0.51). Three genes, tsh, iss and cvaC were found in E. coli of all four core types. The genes tsh (P<0.001) and iss (P=0.03412) were significantly associated with the R4 core oligosaccharide type. The isolates containing R4 core type LPS were mainly confined to phylogenetic group D. The widespread R1 core type showed less ability to possess virulence genes and 83% were in the phylogenetic group A. Results of this study indicated that E. coli with R1, R2, R3 and R4 were important in causing infections in chickens and further, the E. coli with R4 core type were less common among commensals, possessed more virulence genes and were related to phylogenetic groups pathogenic for poultry.

Update of Clostridium difficile infection due to PCR ribotype 027 in Europe, 2008.

Outbreaks of Clostridium difficile infections (CDI) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America and Europe. This emerging strain is referred to as PCR ribotype 027 (Type 027). Since 2005, individual countries have developed surveillance studies about the spread of type 027.C. difficile Type 027 has been reported in 16 European countries. It has been responsible for outbreaks in Belgium, Germany, Finland, France, Ireland, Luxembourg, The Netherlands, Switzerland and the United Kingdom (England, Wales, Northern Ireland and Scotland). It has also been detected in Austria, Denmark, Sweden, Norway, Hungary, Poland and Spain. Three countries experienced imported patients with CDI due to Type 027 who acquired the infection abroad.The antimicrobial resistance pattern is changing, and outbreaks due to clindamycin-resistant ermB positive Type 027 strains have occurred in three European countries. Ongoing epidemiological surveillance of cases of CDI, with periodic characterisation of the strains involved, is required to detect clustering of cases in time and space and to monitor the emergence of new, highly virulent clones.

Prospective study of Clostridium difficile infections in Europe with phenotypic and genotypic characterisation of the isolates.

A 2-month prospective study of Clostridium difficile infections was conducted in 38 hospitals from 14 different European countries in order to obtain an overview of the phenotypic and genotypic features of clinical isolates of C. difficile during 2005. Of 411 isolates from diarrhoeagenic patients with suspected C. difficile-associated diarrhoea (CDAD), 354 were toxigenic, of which 86 (24.3%) were toxin-variant strains. Major toxinotypes included toxinotypes 0 (n = 268), V (n = 28), VIII (n = 22) and III (n = 25). MICs of metronidazole, vancomycin, erythromycin, clindamycin, moxifloxacin and tetracycline were determined using the Etest method. All the toxigenic strains were fully-susceptible to metronidazole and vancomycin. Resistance to erythromycin, clindamycin, tetracycline and moxifloxacin was found in 44.4%, 46.1%, 9.2% and 37.5% of the isolates, respectively. Sixty-six different PCR ribotypes were characterised, with the 027 epidemic strain accounting for 6.2% of isolates. This strain was positive for binary toxin genes, had an 18-bp deletion in the tcdC gene, and was resistant to both erythromycin and moxifloxacin. The mean incidence of CDAD was 2.45 cases/10 000 patient-days, but this figure varied widely among the participating hospitals. Patients infected with the 027 strain were more likely to have a severe disease (OR 3.29, 95% CI 1.19-9.16, p 0.008) and to have been specifically treated with metronidazole or vancomycin (OR 7.46, 95% CI 1.02-154, p 0.02). Ongoing epidemiological surveillance of cases of CDAD, with periodic characterisation of the strains involved, is required to detect clustering of cases in time and space and to monitor the emergence of specific highly virulent clones.

Update of Clostridium difficile-associated disease due to PCR ribotype 027 in Europe.

Recent outbreaks of Clostridium difficile-associated diarrhoea (CDAD) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America, Japan and Europe. Definitions have been proposed by the European Centre of Disease Prevention and Control (ECDC) to identify severe cases of CDAD and to differentiate community-acquired cases from nosocomial CDAD (http://www.ecdc.europa.eu/documents/pdf/Cl_dif_v2.pdf). CDAD is mainly known as a healthcare-associated disease, but it is also increasingly recognised as a community-associated disease. The emerging strain is referred to as North American pulsed-field type 1 (NAP1) and PCR ribotype 027. Since 2005, individual countries have developed surveillance studies to monitor the spread of this strain. C. difficile type 027 has caused outbreaks in England and Wales, Ireland, the Netherlands, Belgium, Luxembourg, and France, and has also been detected in Austria, Scotland, Switzerland, Poland and Denmark. Preliminary data indicated that type 027 was already present in historical isolates collected in Sweden between 1997 and 2001.

Comparison of IgG antibody levels to Clostridium botulinum antigens between euthanased and surviving cases of chronic grass sickness.

Serum from 12 horses suffering from chronic grass sickness (CGS) were assayed for IgG antibodies against botulinum neurotoxins C and D (BoNT/C and BoNT/D) and to a surface antigen extract of a neurotoxin negative strain of Clostridium botulinum type C. Collectively, the six surviving CGS cases demonstrated significantly higher initial IgG levels (P=0.05) against surface antigens than the six that were subsequently euthanased. The surviving animals also demonstrated higher initial IgG levels against the BoNT/C but not reaching significance (P=0.06). The two groups demonstrated no difference between IgG levels against BoNT/D. This study supports existing evidence of the involvement of C. botulinum type C in the aetiology of grass sickness.

Preliminary study of mucosal IgA in the equine small intestine: specific IgA in cases of acute grass sickness and controls.

REASONS FOR PERFORMING STUDY: There is much evidence to suggest that group III Clostridium botulinum (types C and D) are involved in the aetiology of equine grass sickness (EGS). Antibodies have been detected previously in the blood and high levels associated with resistance to disease. Specific mucosal antibodies in the gastrointestinal (GI) tract are likely to be important in protection, and this study was performed to ascertain if such antibodies could be detected and if their levels were related to disease state. OBJECTIVES: To develop a method for quantifying IgA antibodies to C. botulinum types C and D in the GI tract of horses and to relate antibody levels to disease status. METHODS: Samples of tissue (n = 25: 6 duodenum, 7 jejunum and 12 ileum) were taken from acute grass sickness (AGS) cases and from control horses (n = 12; 4 samples from each site) at post mortem. They were extracted with the detergent saponin in the presence of protease inhibitors and assayed for total IgA, for specific IgA against botulinum neurotoxins types C and D (BoNT/C or BoNT/D), and against surface antigens of a BoNT/C negative strain of C. botulinum type C (SA) and of Clostridium tetani (TetSA), as a control. Specific IgA was expressed as percentage total IgA. RESULTS: Compared to controls, significantly higher levels of specific IgA against BoNT/C were detected in the jejunum (P = 0.04) and ileum (P = 0.02) of AGS cases. Similarly, higher specific levels against BoNT/D were demonstrated in duodenum (P = 0.01) and jejunum (P = 0.02). Significantly higher levels of IgA against SA were demonstrated only in duodenal samples (P = 0.01). CONCLUSIONS: Levels of IgA antibody to BoNTs in control horses were at near undetectable levels, suggesting no recent exposure to toxins. In AGS cases, significantly higher levels of specific IgA were detected predominantly in jejunum and ileum. POTENTIAL RELEVANCE: If specific IgA is protective then any successful vaccine for EGS should induce a mucosal response.

Equine grass sickness, but not botulism, causes autonomic and enteric neurodegeneration and increases soluble N-ethylmaleimide-sensitive factor attachment receptor protein expression within neuronal perikarya.

REASONS FOR PERFORMING STUDY: Equine grass sickness (EGS) is of unknown aetiology. Despite some evidence suggesting that it represents a toxico-infection with Clostridium botulinum types C and/or D, the effect of EGS on the functional targets of botulinum neurotoxins, namely the soluble N-ethylmaleimide-sensitive factor attachment receptor (SNARE) proteins, is unknown. Further, while it is commonly stated that, unlike EGS, equine botulism is not associated with autonomic and enteric neurodegeneration, this has not been definitively assessed. OBJECTIVES: To determine: 1) whether botulism causes autonomic and enteric neurodegeneration; and 2) the effect of EGS on the expression of SNARE proteins within cranial cervical ganglion (CCG) and enteric neuronal perikarya. STUDY DESIGN: Descriptive study. METHODS: Light microscopy was used to compare the morphology of neurons in haematoxylin-eosin stained sections of CCG and ileum from 6 EGS horses, 5 botulism horses and 6 control horses. Immunohistochemistry was used to compare the expression of synaptosomal-associated protein-25, synaptobrevin (Syb) and syntaxin within CCG neurons, and of Syb in enteric neurons, from horses with EGS, horses with botulism and control horses. The concentrations of these SNARE proteins in extracts of CCG from EGS and control horses were compared using quantitative fluorescent western blotting. RESULTS: EGS, but not botulism, was associated with autonomic and enteric neurodegeneration and with increased immunoreactivity for SNARE proteins within neuronal perikarya. Quantitative fluorescent western blotting confirmed increased concentrations of synaptosomal-associated protein-25, Syb and syntaxin within CCG extracts from EGS vs. control horses, with the increases in the latter 2 proteins being statistically significant. CONCLUSIONS: The occurrence of autonomic and enteric neurodegeneration, and increased expression of SNARE proteins within neuronal perikarya, in EGS but not botulism, suggests that EGS may not be caused by botulinum neurotoxins. Further investigation of the aetiology of EGS is therefore warranted.

Differential effects of bacterial lipopolysaccharides upon neutrophil function.

Lipopolysaccharide (LPS) is a potent inflammatory agent which augments neutrophil sensitivity to subsequent inflammatory stimuli. In this study, the effects of structurally different LPS types upon neutrophil effector functions were examined. Rough LPS types, which have lost the O-polysaccharide moiety, were found to act more rapidly than smooth LPS types in stimulating neutrophil beta2 integrin activity and fMLP-induced respiratory burst. These findings suggest an involvement of the O-polysaccharide region of LPS in regulating neutrophil responsiveness to different LPS chemotypes with important implications for the mechanisms underlying regulation of the inflammatory response in conditions associated with elevation of LPS in plasma, e.g. septic shock or acute respiratory distress syndrome.

Antibodies to lipopolysaccharide.

Lipopolysaccharides (LPS) are indispensable structural components of the Gram-negative bacterial outer membrane and are major determinants of virulence in pathogenic species. In the infected host LPS is better known as endotoxin where it acts as a potent stimulator of the inflammatory response. This article reviews the methods for the production and measurement of anti-LPS antibodies, and then describes the uses to which these methods have been employed. Antibodies to LPS (either monoclonal or polyclonal) may be used directly as immunotherapeutic agents for the treatment of Gram-negative sepsis or endotoxaemia, or as probes for the diagnosis and epidemiological investigation of Gram-negative bacterial infections. Antibodies are useful tools for investigation of the chemical structure of LPS, its expression on bacteria and to study the role of LPS in pathogenic mechanisms. The detection and quantitation of anti-LPS antibodies has formed the basis of classical and more recent serological studies of major bacterial infections.

An immunochemical method for fingerprinting Clostridium difficile.

The use of sodium dodecyl sulphate-polyacrylamide gel electrophoresis in association with electrophoretic transfer of proteins to nitrocellulose and subsequent probing with antisera appears useful as a method for fingerprinting Clostridium difficile. Thorough testing of the stability of the antigenic nature of isolates of the organism during subculture and antigen preparation has shown it to be remarkably stable both in vitro and in vivo. Minor differences in the method of antigen extraction do not markedly alter the immunoblot patterns produced. It has also been demonstrated that an individual may harbour more than one strain of the organism at any one time. Results show the possible usefulness of this technique in studying the epidemiology of diarrhoeal disease known to be associated with C. difficile. It is suggested that for any serious study several colonies should be subcultured from the primary isolation plate.

A comparison of immunoblotting, flow cytometry and ELISA to monitor the binding of anti-lipopolysaccharide monoclonal antibodies.

This study was designed to assess the use of flow cytometry to observe the binding, under physiological conditions, of anti-lipopolysaccharide (LPS) monoclonal antibodies (mAbs) to whole bacteria, and to compare this with the more conventional whole cell ELISA and immunoblotting techniques. The bacteria consisted of two clinical isolates of E. coli 018:K1 and 06:K5 and two isogenic mutants of the 018 parent: a non-capsulate (018:K-) and a rough mutant (018rf). Two cross-reactive anti-core mAbs and one 018 0-antigen-specific mAb were used. ELISA and flow cytometry showed that capsule and O-polysaccharide influenced the binding of mAbs to the bacteria, whilst the latter technique demonstrated that sub-populations existed. Immunoblotting showed the two anti-core mAbs to be different, one bound only to core which was not substituted with O-antigen, whilst the other bound both to substituted and unsubstituted core. This comparison for monitoring the binding of anti-LPS mAbs demonstrates the potential use of flow cytometry in bacterial cell surface research, and complements results obtained by ELISA and immunoblotting.

Serological identification of Bacteroides species by an enzyme-linked immunosorbent assay.

An enzyme-linked immunosorbent assay was used to titrate antisera raised against live cultures of eight type species (biotypes) of Bacteroides with the EDTA-released outer-membrane complex from 29 characterised strains of Bacteroides species. With only minor exceptions, the strains investigated reacted to titre with the antisera raised against the homologous type species and not against the heterologous type species. Cross-reactivity between heterologous species and antiserum was only significant between closely related biotypes. This cross-reactivity could be removed by absorption of the antisera with whole cells. Significant correlation was found between serotype and biotype with this technique.

Typing of Clostridium difficile causing diarrhoea in an orthopaedic ward.

In an outbreak of diarrhoeal disease in an orthopaedic ward Clostridium difficile was isolated from all six patients with diarrhoea. Attempts were made to type these isolates by means of antibiogram, detection of pre-formed enzymes, analysis of surface proteins by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting, and plasmid profile analysis. This showed that a single strain (type E) indistinguishable by the four distinct methods of typing, was isolated from all six patients at some time during their episodes of diarrhoea. Relapse was caused by the acquisition of a new strain in two patients, and by re-emergence or reacquisition of the original strain in two patients. The immunochemical method was the most sensitive and discriminatory of the typing strategies adopted.

Use of rapid carbohydrate utilisation test for identifying "Streptococcus milleri group".

A short series of biochemical and serological tests were developed for the rapid presumptive identification of "Streptococcus milleri group" isolates. One hundred and seventy seven streptococcal isolates were recovered from the mouths of 10 out of 12 healthy adult volunteers by use of a simple sampling procedure and a single selective medium. In all, 127 oral "S milleri group" isolates were identified by biochemical and serological tests, confirming the indigenous nature of these streptococci in the mouth. Most (70.1%) of "S milleri group" isolates were non-haemolytic, 26% were alpha-haemolytic, and 3.9% beta-haemolytic. Fifty four (42.5%) were serologically typable, of which 46 were Lancefield group F, suggesting that the mouth is an important source of Lancefield group F streptococci. A collection of group F streptococci from a range of sources was indistinguishable from a collection of oral "S milleri group" isolates on the basis of the tests used, supporting the general synonymity of group F streptococcus with the broader "S milleri group". The battery of tests was cheap and simple to perform, and was capable of identifying "S milleri group" isolates from a range of sources, including variants with wide sugar fermentation patterns.

Characterisation of Bacteroides from sheep periodontal disease by SDS-PAGE of outer membrane proteins.

Isolates of Bacteroides species obtained from a longitudinal study of developing periodontal disease in sheep were analysed by SDS-PAGE. Protein profiles of Sarkosyl-insoluble outer membrane extracts were compared within groups of isolates which had already been defined by conventional biochemical techniques. Heterogeneity was exhibited within most groups. Isolates of B. gingivalis and B. asaccharolyticus shown to be similar to human isolates by conventional biochemical tests, gave different protein profiles from the respective type cultures. The sheep B. gingivalis-like isolates were however homogeneous, while the B. asaccharolyticus-like organisms could be divided into 3 subgroups. SDS-PAGE appears to be a useful tool for the examination of bacterial flora and recognition of subgroups of subspecies.

Divergent activity and function of superoxide dismutases in Pasteurella haemolytica serotypes A1 and A2 and Pasteurella trehalosi serotype T10.

Representative strains of Pasteurella haemolytica serotypes A1 and A2 and Pasteurella trehalosi serotype T10 were examined for the presence of superoxide dismutase. Visualisation of superoxide dismutase enzyme activity on polyacrylamide gels, and specific inhibition with potassium cyanide verified a copper/zinc (Cu/Zn) superoxide dismutase only in serotype A2 whereas serotypes A1 and T10 showed other superoxide dismutase activity. Using a simple freeze-thaw method the cellular location of superoxide dismutase enzyme activity was determined in all three serotypes. In serotypes A1 and A2 but not T10 superoxide dismutases were located in the periplasm. The viability of serotypes A2 and T10 cells in the presence of exogenous superoxide was unchanged over a 30 min period, whereas serotype A1 cells declined in viability between 15 and 30 min. Purified immunoglobulin from sheep convalescent serum did not reduce superoxide dismutase activity in the serotypes in an in vitro assay. The presence of this enzyme within the pasteurellae suggests a supportive role in the virulence of this major pathogen of ruminants.