Emergence and spread of predominantly community-onset Clostridium difficile PCR ribotype 244 infection in Australia, 2010 to 2012

D W Eyre; L Tracey; B Elliott; C Slimings; P G Huntington; R L Stuart; T M Korman; G Kotsiou; R McCann; D Griffiths; W N Fawley; P Armstrong; K E Dingle; A S Walker; T E Peto; D W Crook; M H Wilcox; T V Riley

doi:10.2807/1560-7917.ES2015.20.10.21059

Surveillance and outbreak reports Open Access

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Emergence and spread of predominantly community-onset Clostridium difficile PCR ribotype 244 infection in Australia, 2010 to 2012
D W Eyre^1,2,3 , L Tracey^3,4 , B Elliott⁵ , C Slimings⁴ , P G Huntington⁶ , R L Stuart⁷ , T M Korman⁷ , G Kotsiou⁶ , R McCann⁴ , D Griffiths¹ , W N Fawley⁸ , P Armstrong⁴ , K E Dingle¹ , A S Walker^1,2 , T E Peto^1,2 , D W Crook^1,2 , M H Wilcox⁸ , T V Riley^5,9
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Affiliations: ¹ Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom ² National Institute for Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, United Kingdom ³ These authors contributed equally to the work ⁴ Communicable Diseases Control Directorate, Health Department of Western Australia, Shenton Park, Australia ⁵ Microbiology and Immunology, The University of Western Australia, Nedlands, Australia ⁶ Microbiology, Pathology North, Royal North Shore Hospital, St Leonards, Australia ⁷ Monash Infectious Diseases and Monash University, Clayton, Australia ⁸ Department of Microbiology, Old Medical School, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds General Infirmary, Leeds, United Kingdom ⁹ Microbiology and Infectious Diseases, PathWest Laboratory Medicine, Nedlands, Australia

Correspondence:
D Eyre
david.eyre ndm.ox.ac.uk
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Citation style for this article: Eyre D W, Tracey L, Elliott B, Slimings C, Huntington P G, Stuart R L, Korman T M, Kotsiou G, McCann R, Griffiths D, Fawley W N, Armstrong P, Dingle K E, Walker A S, Peto T E, Crook D W, Wilcox M H, Riley T V. Emergence and spread of predominantly community-onset Clostridium difficile PCR ribotype 244 infection in Australia, 2010 to 2012. Euro Surveill. 2015;20(10):pii=21059. https://doi.org/10.2807/1560-7917.ES2015.20.10.21059 Received: 18 Feb 2014

Abstract

We describe an Australia-wide Clostridium difficile outbreak in 2011 and 2012 involving the previously uncommon ribotype 244. In Western Australia, 14 of 25 cases were community-associated, 11 were detected in patients younger than?65 years, 14 presented to emergency/outpatient departments, and 14 to non-tertiary/community hospitals. Using whole genome sequencing, we confirm ribotype 244 is from the same C. difficile clade as the epidemic ribotype 027. Like ribotype 027, it produces toxins A, B, and binary toxin, however it is fluoroquinolone-susceptible and thousands of single nucleotide variants distinct from ribotype 027. Fifteen outbreak isolates from across Australia were sequenced. Despite their geographic separation, all were genetically highly related without evidence of geographic clustering, consistent with a point source, for example affecting the national food chain. Comparison with reference laboratory strains revealed the outbreak clone shared a common ancestor with isolates from the United States and United Kingdom (UK). A strain obtained in the UK was phylogenetically related to our outbreak. Follow-up of that case revealed the patient had recently returned from Australia. Our data demonstrate new C. difficile strains are an on-going threat, with potential for rapid spread. Active surveillance is needed to identify and control emerging lineages.