scholarly journals High Prevalence of Clostridium difficile in Home Gardens in Western Australia

2020 ◽  
Vol 87 (1) ◽  
Author(s):  
Nirajmohan Shivaperumal ◽  
Barbara J. Chang ◽  
Thomas V. Riley
Keyword(s):  
Risk Factors ◽  
Clostridium Difficile ◽  
Western Australia ◽  
Brain Heart Infusion ◽  
Home Gardens ◽  
Home Garden ◽  
Toxin Gene ◽  
Content Type ◽  
High Prevalence ◽  
Shoe Soles

ABSTRACT In recent years, community-associated Clostridium difficile infection (CA-CDI) has emerged as a significant health problem, accounting for ∼50% of all CDI cases. We hypothesized that the home garden environment could contribute to the dissemination of C. difficile spores in the community and investigated 23 homes in 22 suburbs of Perth, Western Australia. We identified a high prevalence of toxigenic C. difficile in this environment. In total, 97 samples consisting of soil (n = 48), compost (n = 15), manure (n = 12), and shoe sole swabs (n = 22) were collected. All samples were cultured anaerobically on C. difficile ChromID agar and enriched in brain heart infusion broth, and isolates were characterized by toxin gene PCR and PCR ribotyping. Two-thirds (67%; 95% confidence interval [CI], 57 to 76%) of home garden samples, including 79% (95% CI, 68 to 91%) of soil, 67% (95% CI, 43 to 90%) of compost, 83% (95% CI, 62% to 100%) of manure, and 32% (95% CI, 12 to 51%) of shoe sole samples, contained C. difficile. Of 87 isolates, 38% (95% CI, 28 to 48%) were toxigenic, and 26 PCR ribotypes (RTs), 5 of which were novel, were identified. The toxigenic C. difficile strain RT014/020 was the most prevalent RT. Interestingly, 19 esculin hydrolysis-negative strains giving white colonies were identified on C. difficile ChromID agar, 5 of which were novel toxigenic RTs that produced only toxin A. Clearly, there is the potential for transmission of C. difficile in the community due to the contamination of home gardens. Our findings highlight the importance of a “One Health” approach to dealing with CDI. IMPORTANCE Recently, community-associated Clostridium difficile infection (CA-CDI) has emerged as a significant problem, accounting for ∼50% of all CDI cases and reported to affect a younger population without traditional risk factors. Possible sources of CA-CDI are soil, food, and water contaminated by animal feces, and recent reports show overlapping ribotypes of C. difficile in animals, humans, and the environment; however, the epidemiology of CA-CDI and related risk factors need to be better understood. Our research aimed to determine the prevalence of C. difficile in home gardens and on the shoe soles of homeowners in Perth, Western Australia. There were high rates of contamination with C. difficile in gardens, and some of the ribotypes identified had been isolated from human cases of CDI in Western Australia. This study shows that home gardens and shoes may be a source of C. difficile in CA-CDI.

scholarly journals Cross-Sectional Study Reveals High Prevalence of Clostridium difficile Non-PCR Ribotype 078 Strains in Australian Veal Calves at Slaughter

2013 ◽  
Vol 79 (8) ◽  
pp. 2630-2635 ◽  
Author(s):  
Daniel R. Knight ◽  
Sara Thean ◽  
Papanin Putsathit ◽  
Stan Fenwick ◽  
Thomas V. Riley
Keyword(s):  
Clostridium Difficile ◽  
Cross Sectional Study ◽  
Sectional Study ◽  
Cross Sectional ◽  
Adult Cattle ◽  
Content Type ◽  
Retail Meats ◽  
High Prevalence ◽  
Pcr Ribotyping ◽  
Ribotype 078

ABSTRACTRecent reports in North America and Europe ofClostridium difficilebeing isolated from livestock and retail meats of bovine origin have raised concerns about the risk to public health. To assess the situation in Australia, we investigated the prevalence and genetic diversity ofC. difficilein adult cattle and calves at slaughter. Carcass washings, gastrointestinal contents, and feces were collected from abattoirs across five Australian states. Selective culture, toxin profiling, and PCR ribotyping were performed. The prevalence ofC. difficilewas 56% (203/360 samples) in feces from <7-day-old calves, 3.8% (1/26) in 2- to 6-month-old calves, and 1.8% (5/280) in adult cattle. Three PCR ribotypes (RTs), RT127, RT033, and RT126, predominated in <7-day-old calves and comprised 77.8% (158/203 samples) of isolates. RT056, which has not been reported in cattle before, was found in 16 <7-day-old calves (7.7%). Surprisingly, RT078 strains, which dominate production animal carriage studies in the Northern Hemisphere, were not isolated.

scholarly journals Cwp19 Is a Novel Lytic Transglycosylase Involved in Stationary-Phase Autolysis Resulting in Toxin Release inClostridium difficile

mBio ◽  
2018 ◽  
Vol 9 (3) ◽  
Author(s):  
Sandra Wydau-Dematteis ◽  
Imane El Meouche ◽  
Pascal Courtin ◽  
Audrey Hamiot ◽  
René Lai-Kuen ◽  
...  
Keyword(s):  
Health Care ◽  
Clostridium Difficile ◽  
Stationary Phase ◽  
Catalytic Domain ◽  
Brain Heart Infusion ◽  
Surface Protein ◽  
Wild Type ◽  
Content Type ◽  
Lytic Transglycosylase ◽  
Cell Autolysis

ABSTRACTClostridium difficileis the major etiologic agent of antibiotic-associated intestinal disease. Pathogenesis ofC. difficileis mainly attributed to the production and secretion of toxins A and B. Unlike most clostridial toxins, toxins A and B have no signal peptide, and they are therefore secreted by unusual mechanisms involving the holin-like TcdE protein and/or autolysis. In this study, we characterized the cell surface protein Cwp19, a newly identified peptidoglycan-degrading enzyme containing a novel catalytic domain. We purified a recombinant His6-tagged Cwp19 protein and showed that it has lytic transglycosylase activity. Moreover, we observed that Cwp19 is involved in cell autolysis and that aC. difficilecwp19mutant exhibited delayed autolysis in stationary phase compared to the wild type when bacteria were grown in brain heart infusion (BHI) medium. Wild-type cell autolysis is correlated to strong alterations of cell wall thickness and integrity and to release of cytoplasmic material. Furthermore, we demonstrated that toxins were released into the extracellular medium as a result of Cwp19-induced autolysis when cells were grown in BHI medium. In contrast, Cwp19 did not induce autolysis or toxin release when cells were grown in tryptone-yeast extract (TY) medium. These data provide evidence for the first time that TcdE and bacteriolysis are coexisting mechanisms for toxin release, with their relative contributionsin vitrodepending on growth conditions. Thus, Cwp19 is an important surface protein involved in autolysis of vegetative cells ofC. difficilethat mediates the release of the toxins from the cell cytosol in response to specific environment conditions.IMPORTANCEClostridium difficile-associated disease is mainly known as a health care-associated infection. It represents the most problematic hospital-acquired infection in North America and Europe and exerts significant economic pressure on health care systems. Virulent strains ofC. difficilegenerally produce two toxins that have been identified as the major virulence factors. The mechanism for release of these toxins from bacterial cells is not yet fully understood but is thought to be partly mediated by bacteriolysis. Here we identify a novel peptidoglycan hydrolase inC. difficile, Cwp19, exhibiting lytic transglycosylase activity. We show that Cwp19 contributes toC. difficilecell autolysis in the stationary phase and, consequently, to toxin release, most probably as a response to environmental conditions such as nutritional signals. These data highlight that Cwp19 constitutes a promising target for the development of new preventive and curative strategies.

scholarly journals Carriage of Clostridium difficile by Wild Urban Norway Rats (Rattus norvegicus) and Black Rats (Rattus rattus)

2013 ◽  
Vol 80 (4) ◽  
pp. 1299-1305 ◽  
Author(s):  
Chelsea G. Himsworth ◽  
David M. Patrick ◽  
Sunny Mak ◽  
Claire M. Jardine ◽  
Patrick Tang ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Mixed Models ◽  
Generalized Linear Mixed Models ◽  
Rattus Rattus ◽  
Gene Identification ◽  
Toxin Gene ◽  
Content Type ◽  
Domestic Species ◽  
Enteric Infections ◽  
Norway Rats

ABSTRACTClostridium difficileis an important cause of enteric infections in humans. Recently, concerns have been raised regarding whether animals could be a source ofC. difficilespores. Although colonization has been identified in a number of domestic species, the ability of commensal pests to serve as a reservoir forC. difficilehas not been well investigated. The objective of this study was to determine whether urban rats (Rattusspp.) from Vancouver, Canada, carryC. difficile.Clostridium difficilewas isolated from the colon contents of trapped rats and was characterized using ribotyping, toxinotyping, and toxin gene identification. Generalized linear mixed models and spatial analysis were used to characterize the ecology ofC. difficilein rats.Clostridium difficilewas isolated from 95 of 724 (13.1%) rats, although prevalence differed from 0% to 46.7% among city blocks. The odds of beingC. difficilepositive decreased with increasing weight (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.53 to 0.87), suggesting that carriage is more common in younger animals. The strains isolated included 9 ribotypes that matched recognized international designations, 5 identified by our laboratory in previous studies, and 21 “novel” ribotypes. Some strains were clustered geographically; however, the majority were dispersed throughout the study area, supporting environmental sources of exposure and widespread environmental contamination with a variety ofC. difficilestrains. Given that urban rats are the source of a number of other pathogens responsible for human morbidity and mortality, the potential for rats to be a source ofC. difficilefor humans deserves further consideration.

scholarly journals Effect of tcdR Mutation on Sporulation in the Epidemic Clostridium difficile Strain R20291

mSphere ◽  
2017 ◽  
Vol 2 (1) ◽  
Author(s):  
Brintha P. Girinathan ◽  
Marc Monot ◽  
Daniel Boyle ◽  
Kathleen N. McAllister ◽  
Joseph A. Sorg ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Toxin Production ◽  
Hospitalized Patients ◽  
Host Tissue ◽  
Hospital Environment ◽  
Pivotal Role ◽  
Toxin Gene ◽  
Bacterial Cells ◽  
Significant Morbidity ◽  
Content Type

ABSTRACT C. difficile infects thousands of hospitalized patients every year, causing significant morbidity and mortality. C. difficile spores play a pivotal role in the transmission of the pathogen in the hospital environment. During infection, the spores germinate, and the vegetative bacterial cells produce toxins that damage host tissue. Thus, sporulation and toxin production are two important traits of C. difficile. In this study, we showed that a mutation in tcdR, the toxin gene regulator, affects both toxin production and sporulation in epidemic-type C. difficile strain R20291. Clostridium difficile is an important nosocomial pathogen and the leading cause of hospital-acquired diarrhea. Antibiotic use is the primary risk factor for the development of C. difficile-associated disease because it disrupts normally protective gut flora and enables C. difficile to colonize the colon. C. difficile damages host tissue by secreting toxins and disseminates by forming spores. The toxin-encoding genes, tcdA and tcdB, are part of a pathogenicity locus, which also includes the tcdR gene that codes for TcdR, an alternate sigma factor that initiates transcription of tcdA and tcdB genes. We created a tcdR mutant in epidemic-type C. difficile strain R20291 in an attempt to identify the global role of tcdR. A site-directed mutation in tcdR affected both toxin production and sporulation in C. difficile R20291. Spores of the tcdR mutant were more heat sensitive than the wild type (WT). Nearly 3-fold more taurocholate was needed to germinate spores from the tcdR mutant than to germinate the spores prepared from the WT strain. Transmission electron microscopic analysis of the spores also revealed a weakly assembled exosporium on the tcdR mutant spores. Accordingly, comparative transcriptome analysis showed many differentially expressed sporulation genes in the tcdR mutant compared to the WT strain. These data suggest that regulatory networks of toxin production and sporulation in C. difficile strain R20291 are linked with each other. IMPORTANCE C. difficile infects thousands of hospitalized patients every year, causing significant morbidity and mortality. C. difficile spores play a pivotal role in the transmission of the pathogen in the hospital environment. During infection, the spores germinate, and the vegetative bacterial cells produce toxins that damage host tissue. Thus, sporulation and toxin production are two important traits of C. difficile. In this study, we showed that a mutation in tcdR, the toxin gene regulator, affects both toxin production and sporulation in epidemic-type C. difficile strain R20291.

scholarly journals Contribution of Spores to the Ability of Clostridium difficile To Adhere to Surfaces

2012 ◽  
Vol 78 (21) ◽  
pp. 7671-7679 ◽  
Author(s):  
Lovleen Tina Joshi ◽  
Daniel S. Phillips ◽  
Catrin F. Williams ◽  
Abdullah Alyousef ◽  
Les Baillie
Keyword(s):  
Stainless Steel ◽  
Clostridium Difficile ◽  
Culture Media ◽  
Bacterial Species ◽  
Disease Process ◽  
Brain Heart Infusion ◽  
Content Type ◽  
Hospital Acquired Infection ◽  
The United Kingdom ◽  
Hospital Acquired

ABSTRACTClostridium difficileis the commonest cause of hospital-acquired infection in the United Kingdom. We characterized the abilities of 21 clinical isolates to form spores; to adhere to inorganic and organic surfaces, including stainless steel and human adenocarcinoma cells; and to germinate. The composition of culture media had a significant effect on spore formation, as significantly more spores were produced in brain heart infusion broth (Student'sttest;P= 0.018). The spore surface relative hydrophobicity (RH) varied markedly (14 to 77%) and was correlated with the ability to adhere to stainless steel. We observed no correlation between the ribotype and the ability to adhere to steel. When the binding of hydrophobic (DS1813; ribotype 027; RH, 77%) and hydrophilic (DS1748; ribotype 002; RH, 14%) spores to human gut epithelial cells at different stages of cell development was examined, DS1813 spores adhered more strongly, suggesting the presence of surface properties that aid attachment to human cells. Electron microscopy studies revealed the presence of an exosporium surrounding DS1813 spores that was absent from spores of DS1748. Finally, the ability of spores to germinate was found to be strain and medium dependent. While the significance of these findings to the disease process has yet to be determined, this study has highlighted the importance of analyzing multiple isolates when attempting to characterize the behavior of a bacterial species.

scholarly journals U.S.-Based National Sentinel Surveillance Study for the Epidemiology of Clostridium difficile-Associated Diarrheal Isolates and Their Susceptibility to Fidaxomicin

2015 ◽  
Vol 59 (10) ◽  
pp. 6437-6443 ◽  
Author(s):  
D. R. Snydman ◽  
L. A. McDermott ◽  
N. V. Jacobus ◽  
C. Thorpe ◽  
S. Stone ◽  
...  
Keyword(s):  
Clostridium Difficile ◽  
Antimicrobial Susceptibility ◽  
The United States ◽  
Surveillance Study ◽  
Binary Toxin ◽  
Toxin Gene ◽  
Gene Profile ◽  
Geographic Variations ◽  
Convenience Sample ◽  
Content Type

ABSTRACTIn 2011 a surveillance study for the susceptibility to fidaxomicin and epidemiology ofClostridium difficileisolates in the United States was undertaken in seven geographically dispersed medical centers. This report encompasses baseline surveillance in 2011 and 2012 on 925 isolates. A convenience sample ofC. difficileisolates or toxin positive stools from patients were referred to a central laboratory. Antimicrobial susceptibility was determined by agar dilution (CLSI M11-A8). Clinical and Laboratory Standards Institute (CLSI), Food and Drug Administration, or European Union of Clinical Antimicrobial Susceptibility Testing (EUCAST) breakpoints were applied where applicable. Toxin gene profiles were characterized by multiplex PCR on each isolate. A random sample of 322 strains, stratified by institution, underwent restriction endonuclease analysis (REA). The fidaxomicin MIC90was 0.5 μg/ml for all isolates regardless of REA type or toxin gene profile, and all isolates were inhibited at ≤1.0 μg/ml. By REA typing, BI strains represented 25.5% of the isolates. The toxin gene profile oftcdA,tcdB, andcdtA/Bpositive with atcdC18-bp deletion correlated with BI REA group. Moxifloxacin and clindamycin resistance was increased among either BI or binary toxin-positive isolates. Metronidazole and vancomycin showed reduced susceptibility (EUCAST criteria) in these isolates. Geographic variations in susceptibility, REA group and binary toxin gene presence were observed. Fidaxomicin activity againstC. difficileisolated in a national surveillance study did not change more than 1 year after licensure. This analysis provides baseline results for future comparisons.

scholarly journals Mild or Malign: Clinical Characteristics and Outcomes of Clostridium difficile Infection in Thailand

2020 ◽  
Vol 58 (9) ◽  
Author(s):  
Korakrit Imwattana ◽  
Papanin Putsathit ◽  
Teera Leepattarakit ◽  
Pattarachai Kiratisin ◽  
Thomas V. Riley
Keyword(s):  
Mortality Rate ◽  
Clostridium Difficile ◽  
Clinical Characteristics ◽  
Treatment Options ◽  
Gene Profiling ◽  
Control Group ◽  
Toxin Gene ◽  
Direct Pcr ◽  
Effective Treatment Option ◽  
Content Type

ABSTRACT Little is known about the clinical characteristics of Clostridium difficile infection (CDI) in Asia in general, and Thailand specifically, with a few studies suggesting that the disease may be milder than elsewhere. This study aimed to describe CDI in Thailand, evaluate treatment options and their outcomes, and explore possible protective factors responsible for any unique disease characteristics. From 2015 to 2018, 469 patients were included in the study. All patients had their stools tested for the tcdB gene by direct PCR and detection of toxigenic C. difficile by culture. C. difficile isolates were subjected to toxin gene profiling and ribotyping, and patient medical records were reviewed retrospectively. There were 248 and 221 patients included in CDI and control groups, respectively. The CDI group had a higher overall 30-day mortality rate than the control group (21% versus 14%, P = 0.046), but only 2 deaths (1%) were directly attributable to CDI. Metronidazole treatment was not inferior to vancomycin in this population, and vancomycin was associated with a higher 30-day mortality rate (P = 0.047). The prevalence of severe CDI and disease outcomes were not different between patients infected with A–B+ C. difficile and A+B+ C. difficile strains or between patients with and without colonization by nontoxigenic C. difficile. Besides C. difficile-specific tests, neither a single laboratory result nor a combination of results was predictive of CDI. In conclusion, CDI in Thailand was relatively mild, and metronidazole remained an effective treatment option for these mild infections.

scholarly journals Control of Clostridium difficile Physiopathology in Response to Cysteine Availability

2016 ◽  
Vol 84 (8) ◽  
pp. 2389-2405 ◽  
Author(s):  
Thomas Dubois ◽  
Marie Dancer-Thibonnier ◽  
Marc Monot ◽  
Audrey Hamiot ◽  
Laurent Bouillaut ◽  
...  
Keyword(s):  
Gene Expression ◽  
Clostridium Difficile ◽  
Molecular Mechanisms ◽  
Sulfur Metabolism ◽  
Toxin Production ◽  
Toxin Gene ◽  
Wild Type ◽  
Control Of Gene Expression ◽  
Content Type ◽  
Toxin Gene Expression

The pathogenicity ofClostridium difficileis linked to its ability to produce two toxins: TcdA and TcdB. The level of toxin synthesis is influenced by environmental signals, such as phosphotransferase system (PTS) sugars, biotin, and amino acids, especially cysteine. To understand the molecular mechanisms of cysteine-dependent repression of toxin production, we reconstructed the sulfur metabolism pathways ofC. difficilestrain 630in silicoand validated some of them by testingC. difficilegrowth in the presence of various sulfur sources. High levels of sulfide and pyruvate were produced in the presence of 10 mM cysteine, indicating that cysteine is actively catabolized by cysteine desulfhydrases. Using a transcriptomic approach, we analyzed cysteine-dependent control of gene expression and showed that cysteine modulates the expression of genes involved in cysteine metabolism, amino acid biosynthesis, fermentation, energy metabolism, iron acquisition, and the stress response. Additionally, a sigma factor (SigL) and global regulators (CcpA, CodY, and Fur) were tested to elucidate their roles in the cysteine-dependent regulation of toxin production. Among these regulators, onlysigLinactivation resulted in the derepression of toxin gene expression in the presence of cysteine. Interestingly, thesigLmutant produced less pyruvate and H2S than the wild-type strain. Unlike cysteine, the addition of 10 mM pyruvate to the medium for a short time during the growth of the wild-type andsigLmutant strains reduced expression of the toxin genes, indicating that cysteine-dependent repression of toxin production is mainly due to the accumulation of cysteine by-products during growth. Finally, we showed that the effect of pyruvate on toxin gene expression is mediated at least in part by the two-component system CD2602-CD2601.

scholarly journals Laboratory-Based Surveillance of Clostridium difficile Infection in Australian Health Care and Community Settings, 2013 to 2018

2020 ◽  
Vol 58 (11) ◽  
Author(s):  
Stacey Hong ◽  
Papanin Putsathit ◽  
Narelle George ◽  
Christine Hemphill ◽  
Peter G. Huntington ◽  
...  
Keyword(s):  
Health Care ◽  
Clostridium Difficile ◽  
Diarrheal Disease ◽  
Gene Profiling ◽  
Binary Toxin ◽  
Toxin Gene ◽  
Community Settings ◽  
Content Type ◽  
Australian Health ◽  
Diagnostic Microbiology

ABSTRACT In the early 2000s, a binary toxin (CDT)-producing strain of Clostridium difficile, ribotype 027 (RT027), caused extensive outbreaks of diarrheal disease in North America and Europe. This strain has not become established in Australia, and there is a markedly different repertoire of circulating strains there compared to other regions of the world. The C. difficile Antimicrobial Resistance Surveillance (CDARS) study is a nationwide longitudinal surveillance study of C. difficile infection (CDI) in Australia. Here, we describe the molecular epidemiology of CDI in Australian health care and community settings over the first 5 years of the study, 2013 to 2018. Between 2013 and 2018, 10 diagnostic microbiology laboratories from five states in Australia participated in the CDARS study. From each of five states, one private (representing community) and one public (representing hospitals) laboratory submitted isolates of C. difficile or PCR-positive stool samples during two collection periods per year, February-March (summer/autumn) and August-September (winter/spring). C. difficile was characterized by toxin gene profiling and ribotyping. A total of 1,523 isolates of C. difficile were studied. PCR ribotyping yielded 203 different RTs, the most prevalent being RT014/020 (n = 449; 29.5%). The epidemic CDT+ RT027 (n = 2) and RT078 (n = 6), and the recently described RT251 (n = 10) and RT244 (n = 6) were not common, while RT126 (n = 17) was the most prevalent CDT+ type. A heterogeneous C. difficile population was identified. C. difficile RT014/020 was the most prevalent type found in humans with CDI. Continued surveillance of CDI in Australia remains critical for the detection of emerging strain lineages.

scholarly journals Risk Factors and Outcomes for Bloodstream Infections Secondary to Clostridium difficile Infection

2015 ◽  
Vol 60 (1) ◽  
pp. 252-257 ◽  
Author(s):  
Marco Falcone ◽  
Alessandro Russo ◽  
Federica Iraci ◽  
Paolo Carfagna ◽  
Paola Goldoni ◽  
...  
Keyword(s):  
Risk Factors ◽  
Clostridium Difficile ◽  
Clinical Evidence ◽  
Bloodstream Infections ◽  
Final Analysis ◽  
Enteric Bacteria ◽  
Content Type ◽  
Etiologic Agents ◽  
Incidence Risk ◽  
Poor Outcomes

ABSTRACTWe determined the incidence, risk factors, and outcomes of bloodstream infections (BSI) subsequent toClostridium difficileinfection (CDI). We performed a retrospective study of all patients with definite diagnosis of CDI admitted from January 2014 to December 2014 in two large hospitals in Rome. Two groups of patients were analyzed: those with CDI and subsequent BSI (CDI/BSI+) and those with CDI and no evidence of primary BSI (CDI/BSI−). Data about clinical features, microbiology, treatments, and mortality were obtained. Overall, 393 cases of CDI were included in the final analysis: 72 developed a primary nosocomial BSI, while 321 had CDI without microbiological and clinical evidence of BSI. Etiologic agents of BSI wereCandidaspecies (47.3%),Enterobacteriaceae(19.4%), enterococci (13.9%), and mixed infections (19.4%). In multivariate analysis, ribotype 027 status (odds ratio [OR], 6.5), CDI recurrence (OR, 5.5), severe CDI infection (OR, 8.3), and oral vancomycin at >500 mg/day (OR, 3.1) were recognized as factors independently associated with the development of nosocomial BSI. Thirty-day mortality from CDI diagnosis was higher for patients of the CDI/BSI+group than for the controls (38.9 versus 13.1%;P< 0.001). Among patients of the CDI/BSI+group, mortality attributable to primary BSI was as high as 57%. Our findings suggest that severe CDI is complicated by the development of nosocomial BSI.Candidaspecies and enteric bacteria appear to be the leading causative pathogens and are associated with poor outcomes.

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