MOLECULAR PATHOGENESIS OF CLOSTRIDIUM DIFFICILE AND ITS ROLE IN ANTIBIOTIC-ASSOCIATED DIARRHEA
Main Article Content
Keywords
Clostridium difficile, Antibiotic-associated diarrhea, Gut microbiota, Toxin production, Immune response, Cytokines
Abstract
Background: Clostridium difficile (C. difficile) is a leading cause of antibiotic-associated diarrhea (AAD), with increasing prevalence due to its toxin-mediated pathogenesis, microbiota disruption, and antibiotic resistance. This study investigates the molecular mechanisms of C. difficile infection (CDI), focusing on toxin production, microbiota dysbiosis, antimicrobial resistance, and immune responses to identify potential therapeutic interventions.
Methods: Five C. difficile clinical isolates (CDI-001 to CDI-005) were analyzed for toxin production using Enzyme-Linked Immunosorbent Assay (ELISA), microbiota composition via 16S rRNA sequencing, and antibiotic resistance through Minimum Inhibitory Concentrations (MIC) testing. Host immune responses were assessed using multiplex cytokine assays, and genomic sequencing identified resistance-associated mutations.
Results: TcdA and TcdB levels varied across strains, with CDI-003 exhibiting the highest TcdA (50.1 ng/mL) and CDI-002 the highest TcdB (60.2 ng/mL). CDI patients exhibited reduced microbial diversity (Shannon index-1.9 vs. 3.8 in controls, Simpson index-0.45 vs. 0.85). Ciprofloxacin and clindamycin resistance was 55% and 40%, respectively, while fidaxomicin retained 97% susceptibility. Cytokine analysis revealed significantly elevated IL-6 (18.6 pg/mL) and IL-8 (24.2 pg/mL) levels in CDI patients, suggesting immune dysregulation.
Conclusion: C. difficile infection is driven by toxin overproduction, gut microbiota disruption, and antibiotic resistance. Targeted therapies restoring microbiota balance and neutralizing toxins are essential for reducing recurrence and severity. Future research should explore microbiome-based and immunomodulatory treatments to improve CDI management.
References
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20. Soliman S, Abdalla S, Zedan A, Enany S. Genomic profiling of pan-drug resistant proteus mirabilis Isolates reveals antimicrobial resistance and virulence gene landscape. Functional & Integrative Genomics. 2024 Oct;24(5):154.
21. Crobach MJ, Planche T, Eckert C, Barbut F, Terveer EM, Dekkers OM, Wilcox MH, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: update of the diagnostic guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2016 Aug;22 Suppl 4:S63-81. doi: 10.1016/j.cmi.2016.03.010. Epub 2016 Jul 25. PMID: 27460910.
22. Kowalska-Krochmal B, Dudek-Wicher R. The Minimum Inhibitory Concentration of Antibiotics: Methods, Interpretation, Clinical Relevance. Pathogens. 2021 Feb 4;10(2):165. doi: 10.3390/pathogens10020165. PMID: 33557078; PMCID: PMC7913839.
23. Quesada-Gómez C, López-Ureña D, Chumbler N, Kroh HK, Castro-Peña C, Rodríguez C, Orozco-Aguilar J, González-Camacho S, Rucavado A, Guzmán-Verri C, Lawley TD, Lacy DB, Chaves-Olarte E. Analysis of TcdB Proteins within the Hypervirulent Clade 2 Reveals an Impact of RhoA Glucosylation on Clostridium difficile Proinflammatory Activities. Infect Immun. 2016 Jan 11;84(3):856-65. doi: 10.1128/IAI.01291-15. PMID: 26755157; PMCID: PMC4771349.
24. Kordus SL, Thomas AK, Lacy DB. Clostridioides difficile toxins: mechanisms of action and antitoxin therapeutics. Nat Rev Microbiol. 2022 May;20(5):285-298. doi: 10.1038/s41579-021-00660-2. Epub 2021 Nov 26. PMID: 34837014; PMCID: PMC9018519.
25. Singh H, Dange K, Gujarathi RH, Loganathan S, Bhuyan D, Jani H. Discovering the impact of dietary interventions on gut microbiome and human health: The clinical trial perspective. J Appl Bioanal. 2024;10(2):28-36. doi:10.53555/jab.v10i2.158.
26. Patangia DV, Anthony Ryan C, Dempsey E, Paul Ross R, Stanton C. Impact of antibiotics on the human microbiome and consequences for host health. Microbiologyopen. 2022 Feb;11(1):e1260. doi: 10.1002/mbo3.1260. PMID: 35212478; PMCID: PMC8756738.
27. Ogbonnaya CE, Chinweuba AU, Ogbonnaya N, Ihudiebube-Splendor C, Williams JM. Validity and reliability of the Home Management of Diarrhoea Assessment Scale for mothers in Nigeria: A Rasch analysis. Afr J Biomed Res. 2024;27(1):115-120. doi:10.4314/ajbr.v27i1.15.
28. Gazzola A, Panelli S, Corbella M, Merla C, Comandatore F, De Silvestri A, Piralla A, Zuccaro V, Bandi C, Marone P, Cambieri P. Microbiota in Clostridioides difficile-Associated Diarrhea: Comparison in Recurrent and Non-Recurrent Infections. Biomedicines. 2020 Sep 8;8(9):335. doi: 10.3390/biomedicines8090335. PMID: 32911854; PMCID: PMC7554755.
29. McMillan AS, Theriot CM. Bile acids impact the microbiota, host, and C. difficile dynamics providing insight into mechanisms of efficacy of FMTs and microbiota-focused therapeutics. Gut Microbes. 2024 Jan-Dec;16(1):2393766. doi: 10.1080/19490976.2024.2393766. Epub 2024 Sep 3. Erratum in: Gut Microbes. 2024 Jan-Dec;16(1):2411134. doi: 10.1080/19490976.2024.2411134. PMID: 39224076; PMCID: PMC11376424.
30. Jose S, Madan R. Neutrophil-mediated inflammation in the pathogenesis of Clostridium difficile infections. Anaerobe. 2016 Oct;41:85-90. doi: 10.1016/j.anaerobe.2016.04.001. Epub 2016 Apr 5. PMID: 27063896; PMCID: PMC5050096.
31. Bratkovič T, Zahirović A, Bizjak M, Rupnik M, Štrukelj B, Berlec A. New treatment approaches for Clostridioides difficile infections: alternatives to antibiotics and fecal microbiota transplantation. Gut Microbes. 2024 Jan-Dec;16(1):2337312. doi: 10.1080/19490976.2024.2337312. Epub 2024 Apr 9. PMID: 38591915; PMCID: PMC11005816.
2. Debast SB, Bauer MP, Kuijper EJ, Committee. European Society of Clinical Microbiology and Infectious Diseases: update of the treatment guidance document for Clostridium difficile infection. Clinical microbiology and infection. 2014 Mar;20:1-26.
3. Di Bella S, Sanson G, Monticelli J, Zerbato V, Principe L, Giuffrè M, Pipitone G, Luzzati R. Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options. Clin Microbiol Rev. 2024 Jun 13;37(2):e0013523. doi: 10.1128/cmr.00135-23. Epub 2024 Feb 29. PMID: 38421181; PMCID: PMC11324037.
4. Rineh A, Kelso MJ, Vatansever F, Tegos GP, Hamblin MR. Clostridium difficile infection: molecular pathogenesis and novel therapeutics. Expert Rev Anti Infect Ther. 2014 Jan;12(1):131-50. doi: 10.1586/14787210.2014.866515. PMID: 24410618; PMCID: PMC4306399.
5. Chandra H, Sorg JA, Hassett DJ, Sun X. Regulatory transcription factors of Clostridioides difficile pathogenesis with a focus on toxin regulation. Crit Rev Microbiol. 2023 May;49(3):334-349. doi: 10.1080/1040841X.2022.2054307. Epub 2022 Apr 7. PMID: 35389761; PMCID: PMC11209739.
6. Pourliotopoulou E, Karampatakis T, Kachrimanidou M. Exploring the Toxin-Mediated Mechanisms in Clostridioides difficile Infection. Microorganisms. 2024 May 16;12(5):1004. doi: 10.3390/microorganisms12051004. PMID: 38792835; PMCID: PMC11124097.
7. Genth H, Just I. Large clostridial glycosylating toxins modifying small GTPases: cellular aspects. The Comprehensive Sourcebook of Bacterial Protein Toxins. 2015 May 29:441.
8. Chumbler NM, Farrow MA, Lapierre LA, Franklin JL, Lacy DB. Clostridium difficile Toxins TcdA and TcdB Cause Colonic Tissue Damage by Distinct Mechanisms. Infect Immun. 2016 Sep 19;84(10):2871-7. doi: 10.1128/IAI.00583-16. PMID: 27456833; PMCID: PMC5038081.
9. Li C, Harmanus C, Zhu D, Meng X, Wang S, Duan J, Liu S, Fu C, Zhou P, Liu R, Wu A, Kuijper EJ, Smits WK, Fu L, Sun X. Characterization of the virulence of a non-RT027, non-RT078 and binary toxin-positive Clostridium difficile strain associated with severe diarrhea. Emerg Microbes Infect. 2018 Dec 12;7(1):211. doi: 10.1038/s41426-018-0211-1. PMID: 30542069; PMCID: PMC6291415.
10. Chandra H, Kovall RA, Yadav JS, Sun X. Host Immune Responses to Surface S-Layer Proteins (SLPs) of Clostridioides difficile. Microorganisms. 2023 Feb 2;11(2):380. doi: 10.3390/microorganisms11020380. PMID: 36838345; PMCID: PMC9963625.
11. Phanchana M, Harnvoravongchai P, Wongkuna S, Phetruen T, Phothichaisri W, Panturat S, Pipatthana M, Charoensutthivarakul S, Chankhamhaengdecha S, Janvilisri T. Frontiers in antibiotic alternatives for Clostridioides difficile infection. World J Gastroenterol. 2021 Nov 14;27(42):7210-7232. doi: 10.3748/wjg.v27.i42.7210. PMID: 34876784; PMCID: PMC8611198.
12. Sharma S, Mohler J, Mahajan SD, Schwartz SA, Bruggemann L, Aalinkeel R. Microbial Biofilm: A Review on Formation, Infection, Antibiotic Resistance, Control Measures, and Innovative Treatment. Microorganisms. 2023 Jun 19;11(6):1614. doi: 10.3390/microorganisms11061614. Erratum in: Microorganisms. 2024 Sep 27;12(10):1961. doi: 10.3390/microorganisms12101961. PMID: 37375116; PMCID: PMC10305407.
13. Seekatz AM, Young VB. Clostridium difficile and the microbiota. J Clin Invest. 2014 Oct;124(10):4182-9. doi: 10.1172/JCI72336. Epub 2014 Jul 18. PMID: 25036699; PMCID: PMC4191019.
14. Newman KM, Rank KM, Vaughn BP, Khoruts A. Treatment of recurrent Clostridium difficile infection using fecal microbiota transplantation in patients with inflammatory bowel disease. Gut Microbes. 2017 May 4;8(3):303-309. doi: 10.1080/19490976.2017.1279377. Epub 2017 Jan 19. PMID: 28102756; PMCID: PMC5479399.
15. Solomon K. The host immune response to Clostridium difficile infection. Ther Adv Infect Dis. 2013 Feb;1(1):19-35. doi: 10.1177/2049936112472173. PMID: 25165542; PMCID: PMC4040718.
16. Zhao S, Ghose-Paul C, Zhang K, Tzipori S, Sun X. Immune-based treatment and prevention of Clostridium difficile infection. Hum Vaccin Immunother. 2014;10(12):3522-30. doi: 10.4161/21645515.2014.980193. PMID: 25668664; PMCID: PMC4514135.
17. Al-Jashaami LS, DuPont HL. Management of Clostridium difficile Infection. Gastroenterol Hepatol (N Y). 2016 Oct;12(10):609-616. PMID: 27917075; PMCID: PMC5114503.
18. Monaghan TM, Seekatz AM, Mullish BH, Moore-Gillon CC, Dawson LF, Ahmed A, Kao D, Chan WC. Clostridioides difficile: innovations in target discovery and potential for therapeutic success. Expert Opinion on Therapeutic Targets. 2021 Nov 2;25(11):949-63.
19. Martínez-Meléndez A, Camacho-Ortiz A, Morfin-Otero R, Maldonado-Garza HJ, Villarreal-Treviño L, Garza-González E. Current knowledge on the laboratory diagnosis of Clostridium difficile infection. World J Gastroenterol. 2017 Mar 7;23(9):1552-1567. doi: 10.3748/wjg.v23.i9.1552. PMID: 28321156; PMCID: PMC5340807.
20. Soliman S, Abdalla S, Zedan A, Enany S. Genomic profiling of pan-drug resistant proteus mirabilis Isolates reveals antimicrobial resistance and virulence gene landscape. Functional & Integrative Genomics. 2024 Oct;24(5):154.
21. Crobach MJ, Planche T, Eckert C, Barbut F, Terveer EM, Dekkers OM, Wilcox MH, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases: update of the diagnostic guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2016 Aug;22 Suppl 4:S63-81. doi: 10.1016/j.cmi.2016.03.010. Epub 2016 Jul 25. PMID: 27460910.
22. Kowalska-Krochmal B, Dudek-Wicher R. The Minimum Inhibitory Concentration of Antibiotics: Methods, Interpretation, Clinical Relevance. Pathogens. 2021 Feb 4;10(2):165. doi: 10.3390/pathogens10020165. PMID: 33557078; PMCID: PMC7913839.
23. Quesada-Gómez C, López-Ureña D, Chumbler N, Kroh HK, Castro-Peña C, Rodríguez C, Orozco-Aguilar J, González-Camacho S, Rucavado A, Guzmán-Verri C, Lawley TD, Lacy DB, Chaves-Olarte E. Analysis of TcdB Proteins within the Hypervirulent Clade 2 Reveals an Impact of RhoA Glucosylation on Clostridium difficile Proinflammatory Activities. Infect Immun. 2016 Jan 11;84(3):856-65. doi: 10.1128/IAI.01291-15. PMID: 26755157; PMCID: PMC4771349.
24. Kordus SL, Thomas AK, Lacy DB. Clostridioides difficile toxins: mechanisms of action and antitoxin therapeutics. Nat Rev Microbiol. 2022 May;20(5):285-298. doi: 10.1038/s41579-021-00660-2. Epub 2021 Nov 26. PMID: 34837014; PMCID: PMC9018519.
25. Singh H, Dange K, Gujarathi RH, Loganathan S, Bhuyan D, Jani H. Discovering the impact of dietary interventions on gut microbiome and human health: The clinical trial perspective. J Appl Bioanal. 2024;10(2):28-36. doi:10.53555/jab.v10i2.158.
26. Patangia DV, Anthony Ryan C, Dempsey E, Paul Ross R, Stanton C. Impact of antibiotics on the human microbiome and consequences for host health. Microbiologyopen. 2022 Feb;11(1):e1260. doi: 10.1002/mbo3.1260. PMID: 35212478; PMCID: PMC8756738.
27. Ogbonnaya CE, Chinweuba AU, Ogbonnaya N, Ihudiebube-Splendor C, Williams JM. Validity and reliability of the Home Management of Diarrhoea Assessment Scale for mothers in Nigeria: A Rasch analysis. Afr J Biomed Res. 2024;27(1):115-120. doi:10.4314/ajbr.v27i1.15.
28. Gazzola A, Panelli S, Corbella M, Merla C, Comandatore F, De Silvestri A, Piralla A, Zuccaro V, Bandi C, Marone P, Cambieri P. Microbiota in Clostridioides difficile-Associated Diarrhea: Comparison in Recurrent and Non-Recurrent Infections. Biomedicines. 2020 Sep 8;8(9):335. doi: 10.3390/biomedicines8090335. PMID: 32911854; PMCID: PMC7554755.
29. McMillan AS, Theriot CM. Bile acids impact the microbiota, host, and C. difficile dynamics providing insight into mechanisms of efficacy of FMTs and microbiota-focused therapeutics. Gut Microbes. 2024 Jan-Dec;16(1):2393766. doi: 10.1080/19490976.2024.2393766. Epub 2024 Sep 3. Erratum in: Gut Microbes. 2024 Jan-Dec;16(1):2411134. doi: 10.1080/19490976.2024.2411134. PMID: 39224076; PMCID: PMC11376424.
30. Jose S, Madan R. Neutrophil-mediated inflammation in the pathogenesis of Clostridium difficile infections. Anaerobe. 2016 Oct;41:85-90. doi: 10.1016/j.anaerobe.2016.04.001. Epub 2016 Apr 5. PMID: 27063896; PMCID: PMC5050096.
31. Bratkovič T, Zahirović A, Bizjak M, Rupnik M, Štrukelj B, Berlec A. New treatment approaches for Clostridioides difficile infections: alternatives to antibiotics and fecal microbiota transplantation. Gut Microbes. 2024 Jan-Dec;16(1):2337312. doi: 10.1080/19490976.2024.2337312. Epub 2024 Apr 9. PMID: 38591915; PMCID: PMC11005816.
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Mar 20, 2024
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Mrs. Madhuri Musunuru, & Mrs. T. Uma Maheswari. (2024). MOLECULAR PATHOGENESIS OF CLOSTRIDIUM DIFFICILE AND ITS ROLE IN ANTIBIOTIC-ASSOCIATED DIARRHEA. Journal of Population Therapeutics and Clinical Pharmacology, 31(3), 2562-2571. https://doi.org/10.53555/53zv8292
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Author Biographies
Mrs. Madhuri Musunuru
Assistant Professor, Department of Microbiology, Maheshwara Medical College and Hospital
Mrs. T. Uma Maheswari
Department of Microbiology, Maheshwara Medical College and Hospital
How to Cite
Mrs. Madhuri Musunuru, & Mrs. T. Uma Maheswari. (2024). MOLECULAR PATHOGENESIS OF CLOSTRIDIUM DIFFICILE AND ITS ROLE IN ANTIBIOTIC-ASSOCIATED DIARRHEA. Journal of Population Therapeutics and Clinical Pharmacology, 31(3), 2562-2571. https://doi.org/10.53555/53zv8292