Clinical and microbial characterization of toxigenic Clostridium difficile isolated from antibiotic associated diarrhea in Egypt

  • Sherein G. Elgendy Mail Department of Medical Microbiology and Immunology, School of Medicine, Assiut University, Assiut, Egypt
  • Sherine A. Aly Department of Medical Microbiology and Immunology, School of Medicine, Assiut University, Assiut, Egypt
  • Rawhia Fathy Department of Medical Microbiology and Immunology, School of Medicine, Assiut University, Assiut, Egypt
  • Enas A.E. Deaf Department of Medical Microbiology and Immunology, School of Medicine, Assiut University, Assiut, Egypt
  • Naglaa H. Abu Faddan Department of Pediatric Medicine, Assiut University Hospitals, Assiut University, Assiut, Egypt
  • Muhamad R. Abdel Hameed Department of Internal Medicine, Hematology Unit, Assiut University Hospitals, Assiut University, Assiut, Egypt
Risk factor;, Clostridium difficile;, Toxigenic culture;, Toxin genes


Background and Objectives: Clostridium difficile infection (CDI) has become a significant healthcare-associated infection throughout the world and is particularly important in developing countries. This study aimed to investigate clinical characterization and risk factors related to toxigenic C. difficile infection in adult and pediatric patients, antimicrobial susceptibility pattern. Also, to evaluate different diagnostic methods for rapid detection of C. difficile associated diarrhea (CDAD) in Egypt.
Materials and Methods: Stool samples were collected from 95 pediatric patients and 37 adult patients suffering from antibiotic associated diarrhea and were subjected to direct toxin immunoassay and culture on cycloserine/cefoxitin/fructose agar. The presence of tcdA and tcdB genes was tested by PCR.
Results: Toxigenic C. difficile was isolated from pediatric and adult patients at a rate of 17.89% (17/95) and 27% (10/37) respectively. The sensitivity and specificity of direct PCR from stool are (100%, 100% and 82.4%, 100%) in adult and pediatric samples respectively. The susceptibility of C. difficile to vancomycin and metronidazole were found to be 66.7% and 48.2% respectively.
Conclusion: Diabetes mellitus, prior antibiotic treatment, hematological malignancy on chemotherapy, malnutrition, neutropenia and Ryle feeding are risk factors for development of CDAD. Tight restriction of unnecessary antibiotic uses is necessary in our locality. Direct detection of toxin genes in stool by PCR is sensitive and specific method for early detection of C. difficile.


1. Yanyan X, Yong L, Xiaosong Q. Comparative study of Clostridium difficile clinical detection methods in patients with diarrhoea. Can J Infect Dis Med Microbiol 2020; 2020: 8753284.
2. Diana LU, Carlos QG, Mónica MR, María MG. Predominance and high antibiotic resistance of the emerging Clostridium difficile genotypes NAPCR1 and NAP9 in a Costa Rican hospital over a 2-year period without outbreaks. Emerg Microbes Infect 2016; 5(5):e42.
3. Reinert DJ, Jank T, Aktories K, Schulz GE. Structural basis for the function of Clostridium difficile toxin B. J Mol Biol 2005;351:973-981.
4. Alexandre RM, Eli NP, Richard EN, Matthew S, Karim K, Hsiu-Yin C, et al. Incidence and outcomes associated with Clostridium difficile infections: A systematic review and meta-analysis. JAMA Netw Open 2020; 3(1): e1917597.
5. Jacek C, Mirosław D, Hanna P, Ed J Kuijper, William P, Aleksandra M, et al. Clostridium difficile infection: review. Eur J Clin Microbiol Infect Dis 2019; 38: 1211-1221.
6. Bouza E, Aguado JM, Alcalá L, Almirante B, Alonso-Fernández P, Borges M, et al. Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish society of chemotherapy (SEQ), Spanish society of internal medicine (SEMI) and the working group of postoperative infection of the Spanish society of anesthesia and reanimation (SEDAR). Rev Esp Quimioter 2020;33:151-175.
7. Mcdonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children. Clin Infect Dis 2018; 66; e1-e48.
8. Ferreira CE, Nakano V, Durigon EL, Avila-Campos MJ. Prevalence of Clostridium spp. and Clostridium difficile in children with acute diarrhea in São Paulo city, Brazil. Mem Inst Oswaldo Cruz 2003;98:451-454.
9. Zare Mirzaei E, Rajabnia M, Farzin Sadeghi F, Ferdosi-Shahandashti E, Sadeghi-Haddad-Zavareh M, Khafri S, et al. Diagnosis of Clostridium difficile infection by toxigenic culture and PCR assay. Iran J Microbiol 2018; 10: 287-293.
10. Peterson LR, Kelly PJ, Nordbrock HA. Role of culture and toxin detection in laboratory testing for diagnosis of Clostridium difficile-associated diarrhea. Eur J Clin Microbiol Infect Dis 1996;15:330-336.
11. Lemee L, Dhalluin A, Testelin S, Mattrat M, Maillard K, Lemeland J, et al. Multiplex PCR targeting tpi (triose phosphate isomerase), tcdA (Toxin A), and tcdB (Toxin B) genes for toxigenic culture of Clostridium difficile. J Clin Microbiol 2004;42:5710-5714.
12. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: Fifteenth Informational Supplement CLSI, Wayne, PA, USA. M100-S15. 2014.
13. Riddle DJ, Dubberke ER. Clostridium difficile infection in the intensive care unit. Infect Dis Clin North Am 2009; 23: 727-743.
14. Barbut F, Ramé L, Petit A, Suzon L, Chevigny A, Eckert C, et al. [Prevalence of Clostridium difficile infection in hospitalized patients with diarrhea: results of a French prospective multicenter bi-annual point prevalence study]. Presse Med 2015;44:e75-83.
15. Gerding DN. Clindamycin, cephalosporins, fluoroquinolones, and Clostridium difficile-associated diarrhea: this is an antimicrobial resistance problem. Clin Infect Dis 2004;38:646-648.
16. Sandora TJ, Fung M, Flaherty K, Helsing L, Scanlon P, Potter-Bynoe G, et al. Epidemiology and risk factors for Clostridium difficile infection in children. Pediatr Infect Dis J 2011;30:580-584.
17. Helmi H, Hamdy G. Prevalent PCR ribotypes and antibiotic sensitivity of clinical isolates of Clostridium difficile. Egypt J Med Microbiol 2006; 15: 639-650.
18. Azizi O, Aslani MM, Azimi Rad M, Alebouyeh M, Mousavi SF, Zali MR. The frequency of toxigenic strains of Clostridium difficile in hospitalized patients with diarrhea in Tehran/Iran by PCR method. J Kerman Univ Med Sci 2013;20:129-137.
19. Ang CW, Heyes G, Morrison P, Carr B. The acquisition and outcome of ICU-acquired Clostridium difficile infection in a single centre in the UK. J Infect 2008;57:435-440.
20. Sadeghifard N, Salari MH, Ghassemi MR, Eshraghi S, Amin HF. The incidence of nosocomial toxigenic Clostridium difficile associated diarrhea in Tehran tertiary medical centers. Acta Med Iran 2010; 48: 320-325.
21. Al-Tawfiq JA, Abed MS. Clostridium difficile-associated disease among patients in Dhahran, Saudi Arabia. Travel Med Infect Dis 2010; 8:373-376.
22. Nasereddin LM, Bakri FG, Shehabi AA. Clostridium difficile infections among Jordanian adult hospitalized patients. Am J Infect Control 2009; 37:864-866.
23. Nawar NN, Ahmed MA, El Shereif RH, Hussein FA. Prevalence of Clostridium difficile among cases of antibiotics associated diarrhea in hospitalized patients in an Egyptian hospital. GARJM 2014; 3: 089-097.
24. Zhong P, Lifen L, Charles WS, Chunhui L, Christopher RP, Bin W, et al. Advances in the diagnosis and treatment of Clostridium difficile infections. Emerg Microbes Infect 2018; 7: 15.
25. Patel PV, Desai PB. Study of Clostridium difficile in South Gujarat region of India. Res J Recent Sci 2014; 3; 34-41.
26. Hui-Qi Q, Jiang ZD. Clostridium difficile infection in diabetes. Diabetes Res Clin Pract 2014; 105:285-294.
27. Gianni BS, Anthony JP, Jerod LN, Dale LB, Bernard LM. Risk factors and impact of Clostridium difficile recurrence on haematology patients. J Antimicrob Chemother 2017; 72: 1488-1495.
28. Timothy J, Douglas K, Asaf B, Deborah S. Clinical risk factors for severe Clostridium difficile–associated disease. Emerg Infect Dis 2009;15: 415-422.
29. Aseeri M, Todd S, Joan RZ. Gastric acid suppression by proton pump inhibitors as a risk factor for C. difficile associated diarrhea in hospitalized patients. Am J Gastroenterol 2008; 103: 2308-2313.
30. Sahil K, Darrell SP. Clostridium difficile infection: new insights into management. Mayo Clin Proc 2012; 87:1106-1117.
31. Al-Musa Z, Shorman M. Risk factors associated with Clostridium difficile infection in a pediatric hematology-oncology ward with analysis of the infection control measures. J Clin Infect Dis Pract 2016;1: 106.
32. Poilane I, Bert f, Cruaud P, Nicolas-chanoine MH, Collignon A. [Interest of the disk diffusion method for screening Clostridium difficile isolates with decreased susceptibility to antibiotics]. Pathol Biol (Paris) 2007; 55: 429-433.
33. Douglas NC, Pharm D. Moxifloxacin-induced Clostridium difficile-associated diarrhea. Pharmacotherapy
2003; 23:1517-1519.
34. Goudarzi M, Goudarzi H, Alebouyeh M, Masoumeh A, Farahnaz S, Mohammad R, et al. Antimicrobial susceptibility of Clostridium difficile clinical isolates in Iran. Iran Red Crescent Med J 2013;15: 704-711.
35. El-Sokkary R, Marian A, Hend E, Fattah LB, Amer FA, Tash RME, et al. Clostridium difficile occurrence, toxin profile and antibiotic susceptibility: An Egyptian center experience. Egypt J Med Microbiol 2017; 26: 31-36.
36. Aaron F, Pradeep K, Ewa G, Leila K, Molly O, Ismail H, et al. Retrospective study analyzing the appropriateness of initial treatment of Clostridium difficile in patients with active malignancy. Gastroenterol Res Pract 2018;2018:7192728.
37. Gardner E, Meghani N, Mancuso P, Thomson A. Recognizing metronidazole resistant C. difficile. Nurse Pract 2011; 36:8-11.
How to Cite
Elgendy S, Aly S, Fathy R, Deaf E, Abu Faddan N, Abdel Hameed M. Clinical and microbial characterization of toxigenic Clostridium difficile isolated from antibiotic associated diarrhea in Egypt. Iran J Microbiol. 12(4):296-304.
Original Article(s)