Next Article in Journal
Transforming Medicinal Oil into Advanced Gel: An Update on Advancements
Previous Article in Journal
Tissue Regeneration and Remodeling in Rat Models after Application of Hypericum perforatum L. Extract-Loaded Bigels
Previous Article in Special Issue
Preparation and Performance Evaluation of Temperature-Resistant and Salt-Resistant Gels
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Gels
Volume 10
Issue 5
10.3390/gels10050343
gels-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Usefulness of Capillary Gel Electrophoresis-Based PCR for Detection of Clostridioides difficile Strains with Hypervirulent Ribotypes

by
Tomasz Bogiel
1,2,*,
Alicja Dura
3,
Marcin Woźniak
3,
Agnieszka Mikucka
1,2 and
Piotr Kanarek
4,*
1
Department of Microbiology, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
2
Department of Clinical Microbiology, Antoni Jurasz University Hospital No. 1, 85-094 Bydgoszcz, Poland
3
Department of Forensic Medicine, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland
4
Department of Microbiology and Food Technology, Faculty of Agriculture and Biotechnology, Bydgoszcz University of Science and Technology, 85-029 Bydgoszcz, Poland
*
Authors to whom correspondence should be addressed.
Gels 2024, 10(5), 343; https://doi.org/10.3390/gels10050343
Submission received: 29 April 2024 / Revised: 10 May 2024 / Accepted: 16 May 2024 / Published: 17 May 2024
(This article belongs to the Special Issue Multifunctional Polymer Nano-, Micro- and Hydro- Gels: Synthesis, Properties and Applications)
Browse Figure
Versions Notes

Abstract

:
Clostridioides difficile is a complex of anaerobic bacteria responsible for the epidemics of post-antibiotic diarrhea as one of the examples of CDI (Clostridioides difficile infection). As many as 70% of cases concern hospitalized patients, particularly those in intensive care units. Ribotyping is one of the most common methods for differentiating bacterial strains. The purpose of this work was to show the effectiveness of the gel electrophoresis-based PCR ribotyping method and the Webribo database for typing C. difficile isolates, including the hypervirulent 027 ribotype. DNA samples extracted from 69 C. difficile strains with previously marked genotypes were included in this study. PCR was performed using 16S–23S primers, and capillary gel electrophoresis was performed on the Applied Biosystem 3130xl Genetic Analyzer. The Webribo database was applied for ribotype assignment. Out of 69 samples, 48 belonged to already known ribotypes, 13 represented new ribotypes and 8 was indicated as similar to the existing ones, having some differences. Capillary gel electrophoresis-based PCR is an effective method for the differentiation of C. difficile ribotypes and can be recognized as a very useful tool in epidemiological studies, while the Webribo database is a useful and an accessible database for a quick analysis of C. difficile ribotypes.

1. Introduction

Capillary gel electrophoresis is a molecular technique of amplified DNA separation that provides advantages in terms of analytical simplicity, high separation efficiency, low sample and solvent volume consumption. The short time necessary for data analysis and its applicability to a wide range of substances of biomedical importance makes it increasingly more popular in different kinds of analytical laboratories, including molecular biology and microbiological labs [1]. It has also been proven that applying appropriate sequences (e.g., 16S-23S, ITS) in capillary gel electrophoresis is useful for bacteria and yeast identification [2,3]. Therefore, capillary gel electrophoresis has already been applied to a number of research studies dedicated to particular microbial investigation and differentiation, including viruses [4,5], bacteria [6,7,8,9,10] and fungi [11]. Other application aspects are especially dedicated to foodborne pathogen detection [8,12,13,14,15] and their typing [16,17,18,19,20].
Clostridioides difficile bacteria are a Gram-positive, toxin- and spore-producing obligate anaerobes with a broad spectrum of distribution in the environment [21]. The microorganism was first isolated in the 1930s from the feces of healthy infants and has since been classified as a part of the natural human microbiota. The association of C. difficile with post-antibiotic diseases was not discovered until the 1970s [21].
This bacterium is the causative agent of healthcare-associated diarrhea. It typically arises from prolonged therapy with clindamycin, third- and fourth-generation cephalosporins, fluoroquinolones, and proton pump inhibitors [21,22]. Additional factors contributing to the development of the disease include advanced age, compromised immunity, and hospitalization [23,24]. It is important to note that C. difficile infections (CDI) are gaining increased attention from clinicians around the world due to the continued rise in the number of cases of these infections [24,25]. High morbidity and mortality rates make CDI considered one of the most important infections in North America and Europe [25,26,27,28].
The prevalent diagnostic criteria typically involve diarrhea, manifesting at least five times daily, along with symptoms indicative of toxic megacolon (toxic colonic dilatation syndrome). Additional indicators encompass abdominal pain, elevated fever, escalating leukocytosis, clinical signs of peritonitis and an overall deterioration of health [23,28].
The disease’s progression is linked to an imbalance in the intestinal microbiota’s homeostasis due to prolonged antibiotic exposure. The pathogenesis involves an elimination of certain competing bacteria which reduce environmental pressure, facilitating an unrestricted proliferation of C. difficile [23,28]. An excessive pathogen proliferation is further promoted by virulence factors: toxin A (tcdA) and toxin B (tcdB), encoded at the pathogenicity locus (PaLoc), which inactivate Rho and/or Ras GTPases by glucosylation [29,30]. Moreover, during the early 2000s, the emergence of a hypervirulent, epidemic ribotype 027 (027/NAP1/BI) was noted. This strain not only demonstrated higher resistance to fluoroquinolones but also, due to some mutation, showed an increased expression of the pathogenicity locus and the capability to produce another toxin: binary C. difficile toxin (C. difficile transferase-CDT) [30,31,32]. Since its discovery, ribotype 027/NAP1/BI has been regarded as the most significant hypervirulent ribotype of C. difficile strains [33,34].
A vital aspect of CDI control is a standardized diagnosis, methods of which are summarized herein (Table 1). It is noteworthy that CDIs are frequently underdiagnosed due to persistently low awareness among doctors [35,36]. Meanwhile, an early and swift detection of hypervirulent strains is imperative, as it enables the prompt implementation of effective control measures [37]. It is essential due to the elevated mortality rate and heightened risk of infection transmission associated with strains belonging to hypervirulent ribotypes [38,39].
Reference techniques for diagnosing CDI include toxigenic strain culture and cytotoxicity tests. However, due to their labor-intensive and time-consuming nature, these techniques are commonly replaced in clinical practice by an algorithm involving immunoenzymatic tests and the detection of the glutamate dehydrogenase gene (GDH) [41,42]. Furthermore, sensitive molecular biology techniques are incorporated into the algorithm. One of the major challenges in CDI diagnosis lies in both underdiagnosis (missed detection) and overdiagnosis (interpreting asymptomatic colonization as infection). This issue may partly stem from the absence of an integrated approach in CDI detection [43,44].
The utilization of nucleic acid amplification tests (NAATs), such as real-time PCR or loop-mediated isothermal amplification, has increased in recent years [45,46]. In light of this, ribotyping stands as one of the most prevalent and stable methods for distinguishing and differentiating bacterial strains [47]. The PCR-based ribotyping technique leverages variability in copy number and size of intergenic regions between 16S and 23S rRNA genes to generate a distinct ribotype profile [48,49]. The method is based on finding differences in a highly variable rrn operon region, which contains genes encoding ribosomal RNA (rRNA). Each bacterial cell contains an rrn operon in species-dependent copy numbers, and depends on their variable amount. Given its high conservative nature, deciphering the 16S rRNA sequences has been acknowledged as the molecular “gold standard” in taxonomic classification and bacterial species identification [50,51,52]. Also, in the field of gel techniques, the use of capillary gel electrophoresis in visualizing genome fragments of 16S-23S rRNA genes has been recently applied in research for C. difficile ribotyping. It should be routinely used to ribotype particular strains during the diagnosis of CDI [38,53,54].
Capillary electrophoresis offers an improved separation of amplified nucleic acid fragments, leading to enhanced sensitivity of the assay compared to traditional agarose electrophoresis [52,55,56]. Therefore, it may lead to relatively fast recognition of CDI hospital outbreaks worldwide [57,58,59] and facilitate antimicrobial resistant strains’ elimination [60,61,62,63], including those derived from children [64], the environment, plants and animals [65,66,67,68,69,70,71]. As it has been previously proven, an ineffective decontamination with non-optimal time of exposure or a concentration of sporicidal disinfectants may result in an extensive C. difficile strain transmission [60]. This is especially possible for strains belonging to a specific hypervirulent ribotype [63]. Moreover, the use of a particular antimicrobial may improve the overall epidemiological situation on the ward [61,62].
Webribo (http://webribo.ages.at (accessed on 8 May 2024) [72] is a database which allows for the automatic analysis and comparison of capillary-sequencer-based PCR ribotyping data and efficiently simplifies laboratory PCR-ribotyping methods [57]. Moreover, an application of the mentioned database does not require own reference strains/DNA patterns of C. difficile strains with a particular ribotype to each investigation round, unlike the traditional ribotyping method based on PCR and agarose gel electrophoresis.
The aim of this study was to demonstrate the effectiveness of differentiation methods based on PCR ribotyping for C. difficile clinical strains, capillary gel electrophoresis and analysis in the Webribo database.

2. Results and Discussion

2.1. PCR Ribotyping

2.1.1. Capillary Gel Electrophoresis and Analysis in the Webribo Database

According to Webribo database analysis, out of the 69 tested samples, 48 belonged to already known ribotypes, 13 represented new ribotypes and 8 indicated similarities to existing ones, with some differences, e.g., the length of fragments (all summarized in Figure 1).
The detailed results of the Webribo analysis are presented in Table 2.
Some of the ribotypes were determined by an automated algorithm to be the best fit for the selected sample. Due to the large distance, it is very likely that some of the samples established a new ribotype, and the match found by the algorithm was of no consequence.

2.1.2. Toxinogenic Genes’ Presence among the Investigated Strains—Ribotype and Genotype Correlation Analysis

Upon analyzing the data from this study using the Webribo database, it was confirmed that 027 is the most frequently appearing ribotype. Out of five existing ribotypes, genotype matching could not be achieved. For samples 3, 4, 5 and 6, the contents of tcdA, tcdB and cdtA/cdtB were excluded. For sample 17 at the same time, ribotype 009 in the Webribo system did not find toxin content. Compared to the ribotypes defined as the most likely to appear, only two out of eight samples matched the Webribo database (Table 3).
Samples 33 and 14 were determined to be the probable ribotype 014/0, but only the second coincides with the genotypes contained in the system (Table 4).

2.2. Discussion

The pathogenicity of the C. difficile is due to their production of cytotoxic proteins. All of them which contain tcdA, tcdB and cdtA/cdtB can cause diarrhea and colitis, and the intensity of the manifested course of the disease depends on the amount of secreted toxins. Many studies focus on the resistance of the given strains to antibiotics, and more information is still missing for ribotypes than 027.
Rates and severity of C. difficile infections in American hospitals, Northern Europe and Europe have been increasing steadily since 2000 [73]. They correlate with an epidemic spread of the strain, which is characterized by a higher production of toxins than their non-toxigenic counterparts and resistance to several antibiotics. The strain that appears most often in studies from around the world is BI/NAP1/027. The mere fact of such a rapid geographical spread producing severe cases of CDI disease with fatal outcomes has been the subject of many studies.
It is noteworthy that the distribution of virulent ribotypes remains closely associated with geographical location. Snydman et al. [74] observed a change in the prevalence dynamics of the 027 ribotype in the United States. The authors highlight that this shift could be attributed to several factors, including transmission patterns, the efficacy of cleaning and infection prevention measures, and the usage of different antimicrobial agents. A study conducted by Tóth et al. [57] in Hungary revealed regional variations in the prevalence of distinct ribotypes. Discrepancies were noted between the central and southeastern regions of Hungary, with the occurrence of BI/NAP1/027 isolates accounting for 45.8% in the central region and 20.8% in the southeastern region. Conversely, the second most prevalent ribotype, 036 (19.8%), was more commonly found among isolates from the southeastern region compared to the central region, with percentages of 29.1% and 10.4% noted, respectively.
In this context, the natural ecological habitats of these bacteria, including wildlife and farm animals, may serve as significant reservoirs. A study conducted by Zhang et al. [33] underscored the importance of C. difficile transmission monitoring between animals intended for meat consumption and humans. The authors emphasize the necessity of future studies investigating the genetic relatedness between C. difficile strains found in animals and those affecting humans. Such research is crucial for enhancing our understanding of their involvement in the transmission of this pathogen. Mengoli et al. [75] also highlight a significant concern in CDI therapy, which is the absence of data regarding non-clinical transmission routes, such as through food chain or environmental sources. Alongside methodological standardization, future research endeavors should prioritize improved sampling techniques and the inclusion of diverse geographic regions. This approach is essential for gaining a more precise understanding of the dynamics of C. difficile transmission and developing effective strategies to disrupt it.
O’Connor et al. [76], in their study on the population of C. difficile strains in the USA and Canada, showed that most cases with high fatality rates were caused by the presence of the hypervirulent strain BI/NAP1/027. It is present in all of the provinces in Canada, and in at least forty US states. The studies compared genomic characteristics of ribotypes 027 and 630. The results show the majority of isolates belonging to a single phylogenetic group that are distinct from other strains. Analysis of tcdB sequence showed a 2.9 kb region that is approximately 87–92% identical to the region of the strain 630 and encodes a unique amino acid sequence. These amino acids contain the binding domain of the toxin B receptors, which may facilitate binding to various receptors, and thus contribute to increased virulence in strains BI/NAP1/027.
Different approaches are applied for molecular studies involving C. difficile strains. In a study by Schneeberg [77], a test based on a DNA microarray was presented. Probes were designed to query a modularly engineered intergenic spacer region called the ISR. It is also a matrix to the conventional PCR ribotyping method using capillary electrophoresis. Forty-eight co-ribotypes were examined, resulting in the disclosure of 27 matrix profiles. The most often obtained pathogenic human ribotypes were as follows: 014/020, 001, 027 and 078/126. The study also confirmed the genetic relationship between ribotypes. PCR ribotyping was performed under the same conditions and by using the same primers as the study performed in this work.
The results of the sequential PCR ribotyping may slightly differ from the predicted ribotyping results, based on the applied strains’ genome sequences and applied methodology. Full genomes belonging to ribotype 027, e.g., CD196, differ from each other by at least one ISR length, which indicates partially spurious DNA sequencing results or an insufficient attribution of the PCR ribotype. Ribotypes 078 and 126 as well as 014 and 020 in traditional ribotyping are difficult to distinguish. With sequential PCR ribotyping, they can be made more distinctly distinguished which works better for epidemiological studies.
Of note, in 2009, 76 different isolates were sent from patients with severe CDI for testing to the national reference laboratory C. difficile in Germany [78] (Institute for Medical Microbiology, University of Mainz or Robert Koch Institute). PCR ribotyping was performed according to the Bidet protocol, and electrophoresis was also applied on 1.5% agarose gels in 1× TBE. Twenty-four isolates identified as 027, eight as 001 as well as 017, 042, 003, 066, 078 and 081 and a new one was named RKI-034.
In 2005, the European research group on C. difficile conducted studies in 38 hospitals from 14 countries over a two-month period. Out of 322, 31 toxigenic isolates were detected, 20 belonged to type 027. In January 2006 in Belgium, 896 bacterial isolates were analyzed in the reference laboratory with the ribotype 027 appearing in 158 or about 18% of them. Other common ones included ribotypes 078 (6.3%) and 031 (5.6%) [79].
In the research conducted by Lyytikäinen et al., the incidence of CDI was 1.7 per 1000 admissions; 68% of the cases appeared more than two days after admission to the hospital. The first case of the disease in Finland associated with C. difficile, for which 027 was responsible, was detected in 2007. Clinical laboratories in Helsinki and Turku, out of 268 isolates, isolated 131 belonging to the type 027, which is as much as 49%. The remaining ones were divided into more than 30 different ribotypes [80].
In Polish studies conducted by Pituch [81], the technique used for C. difficile strain typing was PCR ribotyping with a comparison of the intergenic region of 16S rRNA and 23S rRNA within strains negative for toxin A but positive for toxin B synthesis. This region is subject to frequent mutations. Materials with a deletion of the toxin A gene have been shown to exhibit genetic similarity between strains. Nine of them were used in the mentioned study on reference C. difficile strains isolated from patients with antibiotic-associated diarrhea, which produced toxin B but did not produce toxin A. PCR was performed using primers specific for the 3′ 16S rRNA gene end and the 5′ end of 23S rRNA. Then, pulse electrophoresis and DNA preparation in agarose blocks were performed; restriction enzyme digestion and agarose gel electrophoresis were also conducted. The results show that all the strains belonged to one ribotype, which is inconsistent with the results of our study. The author of the work himself emphasizes the difficulties in typing strains using pulsed field gel electrophoresis. In some strains, no ribotypes were obtained, which could have been caused by DNA degradation due to powerful bacterial nucleases, while the use of PCR ribotyping and capillary gel electrophoresis achieved ribotype profiles in a much shorter time and without having to perform a large number of laboratory steps. At the same time, the results were clearer and more accurate with the possibility of multiple samples testing at the same time. Another difference was found in the acquisition samples by the author from various medical facilities in a large interval of time. Samples used for this research came from one hospital only.
Research by Indra [55] in capillary gel electrophoresis shows 11 fragments per isolate. Each had a minimum size of 233 bp and a maximum size of 680 bp. Among the isolates of one ribotype, size differences in conventional electrophoresis agarose gel were as high as 27 bp for some fragments. Capillary electrophoresis results for individual peaks within one ribotype did not exceed deviations of more than one bp. For 146 tested strains, 47 obtained Austrian ribotype patterns. The production of enterotoxin A and cytotoxin B in vitro was additionally detected. The exception was isolate 017 and one AI-51 in which a negative result was obtained for toxin A. Binary toxin genes were found in 10 out of 141 isolates, which is about 7%. Compared to the research in this work, enterotoxin A and cytotoxin B were also detected in almost all the tested strains. Binary toxin gene was found in almost 50% of the isolates.
A database that collects information on C. difficile ribotypes and their genotypes in its analysis compares not only the lengths of the reads, but also the reaction conditions. All existing ribotypes were determined using an internal primer LIZ 1200 (for details, see Supplementary Materials). New ribotypes and possibly matching existing ones were frequently analyzed using different equipment, as well as standard and different reaction conditions. Thanks to appropriately selected algorithms and a small number of available internal standards, all the differences can be read worldwide in a few minutes to compare results from other laboratories.
Based on data from the Webribo database, the number of different ribotypes was determined in individual countries. The most different C. difficile ribotypes have been described in Austria, Poland, Czech Republic, and Great Britain. Many factors can affect the spread of C. difficile, i.e., hospital overcrowding and staff shortages, an aging population of hospital patients and the intensification of comorbidities, a high level use of antibiotics (in particular fluoroquinolones), worldwide travels (which are becoming increasingly popular) as well as hospital transfers [75].
The management of antibiotic dosing plays a crucial role in controlling and influencing C. difficile infections [82]. This was confirmed by a study conducted by Vaverková et al. [63], which investigated the effects of restricting the use of fluoroquinolone antibiotics on C. difficile infections. The study, conducted at the University Hospital in Hradec Králové, demonstrated that an effective antibiotic management strategy led to a 23.2% decrease in the incidence of CDI and a reduction in the prevalence of hypervirulent ribotypes 001 and 176. Additionally, research conducted in the United States has shown that the decreased usage of fluoroquinolones within a large healthcare system results in an uptick in the utilization of broad-spectrum cephalosporins. This shift contributes to a decline in CDI cases and enhances resistance patterns [61].
To be well acquainted with the dissemination routes, variability, and frequency occurrence of individual C. difficile strains, including relevant clinical strains, it is necessary to collect much more data from different countries and geographical regions. The ribotyping technique used in this work is a relatively cheap, quick and effective method that could be used in monitoring the spread of individual strains of this species. In summary, expanding data collection, efforts across diverse geographic locations and utilizing efficient techniques such as ribotyping are essential steps toward a better understanding of the transmission patterns and characteristics of C. difficile strains. By leveraging these methods, we can enhance surveillance capabilities and implement targeted interventions to mitigate the impact of this pathogen on public health.

3. Conclusions

  • PCR ribotyping is an effective method for the differentiation of C. difficile isolates and can be recognized as a very useful tool in epidemiological studies.
  • Due to automatic ribotype assignment in the Webribo database, the use of capillary gel electrophoresis significantly shortens the time for C. difficile strains ribotyping data analysis.
  • The results obtained are highly reproducible, independent of the used reagents’ batches or brands, which make it possible to compare data from different laboratories.
  • The most common C. difficile ribotype in the studied hospital-derived population is 027.
  • Of the remaining strains detected with toxigenic potential, all contain cytotoxin A, enterotoxin B genes or the gene encoding a binary toxin.
  • The Webribo database is a useful and an accessible database for a quick analysis of C. difficile ribotypes.

4. Materials and Methods

4.1. Bacterial Strains

The material for the study consisted of 69 samples of DNA obtained from C. difficile strains, with marked genotypes. All the strains were cultured from stool samples derived from the patients of University Hospital No. 1 in Bydgoszcz, Poland. The strains were further collected, and cultures were prepared with the DNA isolated in the Department of Microbiology of Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń.

4.2. Bacterial DNA Isolation

The DNA extraction was carried out using a Genomic Mini kit (A&A Biotechnology, Gdynia, Poland) in accordance with the manufacturer’s instructions, with the addition of lysozyme (Sigma, St. Louis, MO, USA) to improve DNA isolation efficiency from the strains. Prior to their use for the study, all the DNA samples were kept in 4 °C.

4.3. DNA Amplification and Amplicons’ Denaturation

Primers FAM-16S and 23S were applied for PCR-based strain differentiation. Their sequences were as follows: 16S 5′-GTGCGGCTGGATCACCTCCT-3 and 23S 5′-CCCTGCACCCTTAATAACTTGACC-3′, according to the ECDC procedure available on the website: https://www.ecdc.europa.eu/en/publications-data/laboratory-procedures-diagnosis-and-typing-human-clostridium-difficile-infection (accessed on 10 May 2024) [83].
The amplification reaction was carried out in a volume of 50 µL. The reaction mixture was prepared in a 1.5 mL Eppendorf tube placed on ice. In order to reduce the risk of contamination, the entire preparation process took place under a laminar flow chamber, in sterile conditions. To each tube containing 48 µL of the mixture, 2 µL of the isolated DNA sample was added.
The PCR reaction was carried out in on Applied Biosystems 9600 thermal cycler according to the following program: one cycle of pre-denaturation 95 °C for 5 min and 30 cycles of the following:
a.
Denaturation 94 °C for 1 min;
b.
Primer annealing 60 °C for 1 min;
c.
Primer elongation at 72 °C for 1 min;
d.
Final elongation at 72 °C for 30 min.
The procedure of fragment denaturation was as follows:
a.
Reagent mix was prepared for fragment denaturation.
b.
Standard size (LZ 1200) in a volume of 5 μL was dissolved in Hi-Di formamide in a volume of 100 μL.
c.
The mix prepared in this way was applied to a 96-well plate in a volume of 10 μL.
d.
One microleter of PCR product was added to each mixed well.
e.
The whole volume was centrifuged briefly.
f.
Denaturation in a thermal cycler for 2 min at 95 °C.
g.
The well was placed on ice and held for about 10 min.
h.
The whole solution was centrifuged briefly.

4.4. Fragment Analysis by Capillary Gel Electrophoresis

Electrophoresis was performed on the Applied Biosystem 3130xl Genetic Analyzer. Gel electrophoresis was performed under the following conditions:
-
Laser power: 15 mW;
-
A 36 cm capillary type;
-
working temperature: 60 °C;
-
POP7 polymer;
-
Standard-sized GeneScan™ 1200 LIZ;
-
A 1× EDTA buffer.
The obtained results were analyzed using the GeneMapper 3.2 software, which allows for determining the size of the obtained DNA fragments based on the internal standard LIZ 1200 (see Supplementary Materials). The obtained fragment size and peak height measurements were exported to a text file, which was then processed in MS Excel 2016 to prepare a batch file for ribotype similarity analysis in the Webribo database.

4.5. Assignment of Ribotypes Using the Webribo Database

A text file containing the numbers of the tested samples and the sizes of DNA fragments and peak heights, prepared in accordance with the recommendations of the database creators, was entered into the Webribo database.
The obtained ribotyping results were downloaded from the database in a text file format and imported to MS Excel for statistical analysis.

4.6. Evaluation of the Toxinogenic Potential of the Strain

Toxinogenic potential (cdtA/cdtB—binary toxin genes; tcdA—toxin A gene; tcdB—toxin B gene) of the investigated strains was evaluated according to ECDC procedure available on the following website: https://www.ecdc.europa.eu/en/publications-data/laboratory-procedures-diagnosis-and-typing-human-clostridium-difficile-infection (accessed on 10 May 2024).

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/gels10050343/s1, Figure S1: An example of a perfect ribotype match (ribotype 027); Figure S2: An example of a ribotype identified as the “most probable ribotype” (014/0); Figure S3: An example of a new ribotype.

Author Contributions

Conceptualization, T.B. and M.W.; methodology, T.B. and M.W.; software, T.B. and M.W.; validation, T.B. and M.W.; formal analysis, T.B. and M.W.; investigation, T.B., A.D. and M.W.; resources, T.B., A.M. and M.W.; data curation, T.B. and A.D.; writing—original draft preparation, T.B. and P.K.; writing—review and editing, T.B., A.M. and P.K.; visualization, T.B. and P.K.; supervision, T.B.; project administration, T.B.; funding acquisition, T.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research was financially supported by the Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, with funds for the maintenance of the research potential of the Microbiology Department (WF PDB 839).

Institutional Review Board Statement

This study was approved by the Institutional Review Board of Ludwik Rydygier Collegium Medicum in the Bydgoszcz Nicolaus Copernicus University in Toruń Ethics Committee, approval code: KB 144/2021.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Nuchtavorn, N.; Suntornsuk, W.; Lunte, S.M.; Suntornsuk, L. Recent Applications of Microchip Electrophoresis to Biomedical Analysis. J. Pharm. Biomed. Anal. 2015, 113, 72–96. [Google Scholar] [CrossRef] [PubMed]
  2. Subedi, S.; Kong, F.; Jelfs, P.; Gray, T.J.; Xiao, M.; Sintchenko, V.; Chen, S.C.-A. 16S-23S Internal Transcribed Spacer Region PCR and Sequencer-Based Capillary Gel Electrophoresis Has Potential as an Alternative to High Performance Liquid Chromatography for Identification of Slowly Growing Nontuberculous Mycobacteria. PLoS ONE 2016, 11, e0164138. [Google Scholar] [CrossRef] [PubMed]
  3. Hou, X.; Xiao, M.; Chen, S.C.-A.; Wang, H.; Zhang, L.; Fan, X.; Xu, Z.-P.; Cheng, J.-W.; Kong, F.; Zhao, Y.-P.; et al. Sequencer-Based Capillary Gel Electrophoresis (SCGE) Targeting the RDNA Internal Transcribed Spacer (ITS) Regions for Accurate Identification of Clinically Important Yeast Species. PLoS ONE 2016, 11, e0154385. [Google Scholar] [CrossRef] [PubMed]
  4. Zhao, Z.-M.; Jin, Y.; Gan, Y.; Zhu, Y.; Chen, T.-Y.; Wang, J.-B.; Sun, Y.; Cao, Z.-G.; Qian, G.-S.; Tu, H. Novel Approach to Identifying the Hepatitis B Virus Pre-S Deletions Associated with Hepatocellular Carcinoma. World J. Gastroenterol. 2014, 20, 13573–13581. [Google Scholar] [CrossRef] [PubMed]
  5. Mohamed, S.; Boulmé, R.; Sayada, C. From Capillary Electrophoresis to Deep Sequencing: An Improved HIV-1 Drug Resistance Assessment Solution Using In Vitro Diagnostic (IVD) Assays and Software. Viruses 2023, 15, 571. [Google Scholar] [CrossRef] [PubMed]
  6. Duodu, S.; Wan, X.; Tandstad, N.M.; Larsson, P.; Myrtennäs, K.; Sjödin, A.; Forsman, M.; Colquhoun, D.J. An Improved Multiple-Locus Variable-Number of Tandem Repeat Analysis (MLVA) for the Fish Pathogen Francisella noatunensis Using Capillary Electrophoresis. BMC Vet. Res. 2013, 9, 252. [Google Scholar] [CrossRef] [PubMed]
  7. Gulla, S.; Mohammad, S.N.; Colquhoun, D.J. Multi-Locus Variable-Number Tandem-Repeat Analysis of the Fish-Pathogenic Bacterium Yersinia ruckeri by Multiplex PCR and Capillary Electrophoresis. J. Vis. Exp. 2019, 148, e59455. [Google Scholar] [CrossRef] [PubMed]
  8. Pavlova, M.R.; Dobreva, E.G.; Ivanova, K.I.; Asseva, G.D.; Ivanov, I.N.; Petrov, P.K.; Velev, V.R.; Tomova, I.I.; Tiholova, M.M.; Kantardjiev, T.V. Multiplex PCR Assay for Identifi Cation and Differentiation of Campylobacter jejuni and Campylobacter coli Isolates. Folia Med. 2016, 58, 95–100. [Google Scholar] [CrossRef] [PubMed]
  9. Lin, W.-J.; Tung, C.-Y.; Yen, M.-Y.; Chan, Y.-J.; Lin, C.-H.; Hsueh, P.-R. A Novel Target Pathogen Identification and Tracking System Using Capillary Electrophoresis-Random Amplified Polymorphic DNA. Sci. Rep. 2018, 8, 15365. [Google Scholar] [CrossRef] [PubMed]
  10. Li, X.; Chen, B.; Zhang, S.; Li, X.; Chang, J.; Tang, Y.; Wu, Y.; Lu, X. Rapid Detection of Respiratory Pathogens for Community-Acquired Pneumonia by Capillary Electrophoresis-Based Multiplex PCR. SLAS Technol. 2019, 24, 105–116. [Google Scholar] [CrossRef] [PubMed]
  11. Monstein, H.-J.; Tärnberg, M.; Persis, S.; Johansson, A.G. Comparison of a Capillary Gel Electrophoresis-Based Multiplex PCR Assay and Ribosomal Intergenic Transcribed Spacer-2 Amplicon Sequencing for Identification of Clinically Important Candida Species. J. Microbiol. Methods 2014, 96, 81–83. [Google Scholar] [CrossRef] [PubMed]
  12. Alarcón, B.; García-Cañas, V.; Cifuentes, A.; González, R.; Aznar, R. Simultaneous and Sensitive Detection of Three Foodborne Pathogens by Multiplex PCR, Capillary Gel Electrophoresis, and Laser-Induced Fluorescence. J. Agric. Food Chem. 2004, 52, 7180–7186. [Google Scholar] [CrossRef] [PubMed]
  13. García-Cañas, V.; González, R.; Cifuentes, A. Sensitive and Simultaneous Analysis of Five Transgenic Maizes Using Multiplex Polymerase Chain Reaction, Capillary Gel Electrophoresis, and Laser-Induced Fluorescence. Electrophoresis 2004, 25, 2219–2226. [Google Scholar] [CrossRef] [PubMed]
  14. Villamizar-Rodríguez, G.; Fernández, J.; Marín, L.; Muñiz, J.; González, I.; Lombó, F. Multiplex Detection of Nine Food-Borne Pathogens by MPCR and Capillary Electrophoresis after Using a Universal Pre-Enrichment Medium. Front. Microbiol. 2015, 6, 1194. [Google Scholar] [CrossRef] [PubMed]
  15. Ndraha, N.; Lin, H.-Y.; Tsai, S.-K.; Hsiao, H.-I.; Lin, H.-J. The Rapid Detection of Salmonella Enterica, Listeria Monocytogenes, and Staphylococcus aureus via Polymerase Chain Reaction Combined with Magnetic Beads and Capillary Electrophoresis. Foods 2023, 12, 3895. [Google Scholar] [CrossRef] [PubMed]
  16. Du, X.-F.; Xiao, M.; Liang, H.-Y.; Sun, Z.; Jiang, Y.-H.; Chen, G.-Y.; Meng, X.-Y.; Zou, G.-L.; Zhang, L.; Liu, Y.-L.; et al. An Improved MLVF Method and Its Comparison with Traditional MLVF, Spa Typing, MLST/SCCmec and PFGE for the Typing of Methicillin-Resistant Staphylococcus aureus. Int. J. Mol. Sci. 2014, 15, 725–742. [Google Scholar] [CrossRef] [PubMed]
  17. Jian, M.-J.; Perng, C.-L.; Sun, J.-R.; Cheng, Y.-H.; Chung, H.-Y.; Cheng, Y.-H.; Lee, S.-Y.; Kuo, S.-C.; Shang, H.-S. Multicentre MDR Elizabethkingia Anophelis Isolates: Novel Random Amplified Polymorphic DNA with Capillary Electrophoresis Systems to Rapid Molecular Typing Compared to Genomic Epidemiology Analysis. Sci. Rep. 2019, 9, 1806. [Google Scholar] [CrossRef] [PubMed]
  18. Tau, N.P.; Smith, A.M.; Wain, J.R.; Tarupiwa, A.; Coulibaly, K.J.; Keddy, K.H.; GERMS-SA. Development and Evaluation of a Multiple-Locus Variable-Number Tandem-Repeats Analysis Assay for Subtyping Salmonella typhi Strains from Sub-Saharan Africa. J. Med. Microbiol. 2017, 66, 937–945. [Google Scholar] [CrossRef] [PubMed]
  19. Zhou, C.; Li, M.; Sun, C.; Zou, H.; Wu, X.; Zhang, L.; Tao, S.; Wang, B.; Li, Y. Identification of Vibrio cholerae Serotypes in High-Risk Marine Products with Non-Gel Sieving Capillary Electrophoresis. Anal. Biochem. 2016, 494, 68–75. [Google Scholar] [CrossRef] [PubMed]
  20. Zhang, B.; Sambono, J.L.; Morgan, J.A.T.; Venus, B.; Rolls, P.; Lew-Tabor, A.E. An Evaluation of Quantitative PCR Assays (TaqMan® and SYBR Green) for the Detection of Babesia bigemina and Babesia bovis, and a Novel Fluorescent-ITS1-PCR Capillary Electrophoresis Method for Genotyping B. Bovis Isolates. Vet. Sci. 2016, 3, 23. [Google Scholar] [CrossRef] [PubMed]
  21. 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, e00135-23. [Google Scholar] [CrossRef] [PubMed]
  22. Vitiello, A.; Sabbatucci, M.; Zovi, A.; Salzano, A.; Ponzo, A.; Boccellino, M. Advances in Therapeutic Strategies for the Management of Clostridioides difficile Infection. J. Clin. Med. 2024, 13, 1331. [Google Scholar] [CrossRef] [PubMed]
  23. Markantonis, J.E.; Fallon, J.T.; Madan, R.; Alam, M.Z. Clostridioides difficile Infection: Diagnosis and Treatment Challenges. Pathogens 2024, 13, 118. [Google Scholar] [CrossRef] [PubMed]
  24. Czepiel, J.; Dróżdż, M.; Pituch, H.; Kuijper, E.J.; Perucki, W.; Mielimonka, A.; Goldman, S.; Wultańska, D.; Garlicki, A.; Biesiada, G. Clostridium difficile Infection: Review. Eur. J. Clin. Microbiol. Infect. Dis. 2019, 38, 1211–1221. [Google Scholar] [CrossRef] [PubMed]
  25. Nagy, E. What Do We Know about the Diagnostics, Treatment and Epidemiology of Clostridioides (Clostridium) difficile Infection in Europe? J. Infect. Chemother. 2018, 24, 164–170. [Google Scholar] [CrossRef] [PubMed]
  26. Gourevitch, D.; Hawkey, P. Clostridium difficile Infection and Surgery. Br. J. Surg. 2009, 96, 3–4. [Google Scholar] [CrossRef] [PubMed]
  27. Shirley, D.-A.; Tornel, W.; Warren, C.A.; Moonah, S. Clostridioides difficile Infection in Children: Recent Updates on Epidemiology, Diagnosis, Therapy. Pediatrics 2023, 152, e2023062307. [Google Scholar] [CrossRef] [PubMed]
  28. Smits, W.K.; Lyras, D.; Lacy, D.B.; Wilcox, M.H.; Kuijper, E.J. Clostridium difficile Infection. Nat. Rev. Dis. Primers 2016, 2, 16020. [Google Scholar] [CrossRef] [PubMed]
  29. Orrell, K.E.; Melnyk, R.A. Large Clostridial Toxins: Mechanisms and Roles in Disease. Microbiol. Mol. Biol. Rev. 2021, 85, e0006421. [Google Scholar] [CrossRef] [PubMed]
  30. Papatheodorou, P.; Minton, N.P.; Aktories, K.; Barth, H. An Updated View on the Cellular Uptake and Mode-of-Action of Clostridioides difficile Toxins. In Updates on Clostridioides difficile in Europe: Advances in Microbiology, Infectious Diseases and Public Health Volume 18; Mastrantonio, P., Rupnik, M., Eds.; Springer International Publishing: Cham, Switzerland, 2024; pp. 219–247. ISBN 978-3-031-42108-2. [Google Scholar]
  31. Buddle, J.E.; Fagan, R.P. Pathogenicity and Virulence of Clostridioides difficile. Virulence 2023, 14, 2150452. [Google Scholar] [CrossRef] [PubMed]
  32. Heils, L.; Schneemann, M.; Gerhard, R.; Schulzke, J.-D.; Bücker, R. CDT of Clostridioides difficile Induces MLC-Dependent Intestinal Barrier Dysfunction in HT-29/B6 Epithelial Cell Monolayers. Toxins 2023, 15, 54. [Google Scholar] [CrossRef]
  33. Kuenzli, A.B.; Burri, S.; Casanova, C.; Sommerstein, R.; Buetti, N.; Seth-Smith, H.M.B.; Bodmer, T.; Egli, A.; Marschall, J. Successful Management of a Clostridioides difficile Ribotype 027 Outbreak with a Lean Intervention Bundle. J. Hosp. Infect. 2020, 106, 240–245. [Google Scholar] [CrossRef] [PubMed]
  34. Zhang, R.; Man, Y.; Bai, Y.; Shao, C.; Liu, C.; Wang, C.; Lei, Y.; Wang, Y.; Jin, Y. Molecular Characterization of Clostridioides difficile Ribotype 027 in a Major Chinese Hospital. J. Microbiol. Immunol. Infect. 2021, 54, 1179–1183. [Google Scholar] [CrossRef] [PubMed]
  35. Marujo, V.; Arvand, M. W Dużej Mierze Niezauważone Rozprzestrzenianie Się Rybotypu 027 Clostridioides difficile PCR w Niemczech Po 2010 r. Infect. Prev. Pract. 2020, 2, 100102. [Google Scholar] [CrossRef] [PubMed]
  36. Guery, B.; Galperine, T.; Barbut, F. Clostridioides difficile: Diagnosis and Treatments. BMJ 2019, 366, l4609. [Google Scholar] [CrossRef]
  37. Liu, C.; Monaghan, T.; Yadegar, A.; Louie, T.; Kao, D. Insights into the Evolving Epidemiology of Clostridioides difficile Infection and Treatment: A Global Perspective. Antibiotics 2023, 12, 1141. [Google Scholar] [CrossRef] [PubMed]
  38. van Rossen, T.M.; van Prehn, J.; Koek, A.; Jonges, M.; van Houdt, R.; van Mansfeld, R.; Kuijper, E.J.; Vandenbroucke-Grauls, C.M.J.E.; Budding, A.E. Simultaneous Detection and Ribotyping of Clostridioides difficile, and Toxin Gene Detection Directly on Fecal Samples. Antimicrob. Resist. Infect. Control 2021, 10, 23. [Google Scholar] [CrossRef] [PubMed]
  39. Lai, H.; Huang, C.; Cai, J.; Ye, J.; She, J.; Zheng, Y.; Wang, L.; Wei, Y.; Fang, W.; Wang, X.; et al. Simultaneous Detection and Characterization of Toxigenic Clostridium difficile Directly from Clinical Stool Specimens. Front. Med. 2018, 12, 196–205. [Google Scholar] [CrossRef] [PubMed]
  40. Surawicz, C.M.; Brandt, L.J.; Binion, D.G.; Ananthakrishnan, A.N.; Curry, S.R.; Gilligan, P.H.; McFarland, L.V.; Mellow, M.; Zuckerbraun, B.S. Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections. Am. J. Gastroenterol. 2013, 108, 478–498. [Google Scholar] [CrossRef] [PubMed]
  41. Mateu, L.; Fernández-Rivas, G.; Sopena, N. Diagnosis and Treatment of Clostridioides difficile Infection. Med. Clin. 2020, 155, 30–35. [Google Scholar] [CrossRef] [PubMed]
  42. Somily, A.M.; Khan, M.A.; Morshed, M. The Laboratory Diagnosis of Clostridioides difficile Infection: An Update of Current Laboratory Practice. J. Infect. Dev. Ctries. 2021, 15, 1364–1375. [Google Scholar] [CrossRef] [PubMed]
  43. Maestri, A.C.; Nogueira, K.S.; Mialski, R.; dos Santos, E.M.; Kraft, L.; Raboni, S.M. Laboratory Diagnosis of Clostridioides difficile Infection in Symptomatic Patients: What Can We Do Better? Braz. J. Microbiol. 2023, 54, 849–857. [Google Scholar] [CrossRef] [PubMed]
  44. Lee, H.S.; Plechot, K.; Gohil, S.; Le, J. Clostridium difficile: Diagnosis and the Consequence of Over Diagnosis. Infect. Dis. Ther. 2021, 10, 687–697. [Google Scholar] [CrossRef] [PubMed]
  45. Bouza, E.; Alcalá, L.; Reigadas, E. Optimizing the Diagnostic Testing of Clostridium difficile Infection. Expert Rev. Anti-Infect. Ther. 2016, 14, 801–808. [Google Scholar] [CrossRef] [PubMed]
  46. Martínez-Meléndez, A.; Morfin-Otero, R.; Villarreal-Treviño, L.; Baines, S.D.; Camacho-Ortíz, A.; Garza-González, E. Molecular Epidemiology of Predominant and Emerging Clostridioides difficile Ribotypes. J. Microbiol. Methods 2020, 175, 105974. [Google Scholar] [CrossRef] [PubMed]
  47. Zhang, X.; Zhang, W.Z.; Li, W.W.; Zhao, H.Q.; Wu, Y.H.; Li, H.; Liu, Z.J.; Wu, Y.; Lu, J.X. Standardization and application on ribotyping library of Clostridioides difficile in China. Zhonghua Liu Xing Bing Xue Za Zhi 2019, 40, 1624–1628. [Google Scholar] [PubMed]
  48. Xiao, M.; Kong, F.; Jin, P.; Wang, Q.; Xiao, K.; Jeoffreys, N.; James, G.; Gilbert, G.L. Comparison of Two Capillary Gel Electrophoresis Systems for Clostridium difficile Ribotyping, Using a Panel of Ribotype 027 Isolates and Whole-Genome Sequences as a Reference Standard. J. Clin. Microbiol. 2012, 50, 2755–2760. [Google Scholar] [CrossRef] [PubMed]
  49. Krutova, M.; Matejkova, J.; Nyc, O.C. Difficile Ribotype 027 or 176? Folia Microbiol. 2014, 59, 523–526. [Google Scholar] [CrossRef] [PubMed]
  50. Baktash, A.; Corver, J.; Harmanus, C.; Smits, W.; Fawley, W.; Wilcox, M.; Kumar, N.; Eyre, D.; Indra, A.; Mellmann, A.; et al. Comparison of Whole-Genome Sequence-Based Methods and PCR Ribotyping for Subtyping of Clostridioides difficile. J. Clin. Microbiol. 2022, 60, e01737-21. [Google Scholar] [CrossRef] [PubMed]
  51. Rizzardi, K.; Åkerlund, T.; Norén, T.; Matussek, A. Impact of Ribotype on Clostridioides difficile Diagnostics. Eur. J. Clin. Microbiol. Infect. Dis. 2020, 39, 847–853. [Google Scholar] [CrossRef] [PubMed]
  52. Lloyd, C.D.; Shah-Gandhi, B.; Parsons, B.D.; Morin, S.B.N.; Du, T.; Golding, G.R.; Chui, L. Direct Clostridioides difficile Ribotyping from Stool Using Capillary Electrophoresis. Diagn. Microbiol. Infect. Dis. 2021, 99, 115259. [Google Scholar] [CrossRef] [PubMed]
  53. Novakova, E.; Stofkova, Z.; Sadlonova, V.; Hleba, L. Diagnostic Methods of Clostridioides difficile Infection and Clostridioides difficile Ribotypes in Studied Sample. Antibiotics 2021, 10, 1035. [Google Scholar] [CrossRef] [PubMed]
  54. McDermott, L.A.; Thorpe, C.M.; Goldstein, E.; Schuetz, A.; Johnson, S.; Gerding, D.N.; Carroll, K.C.; Garey, K.W.; Lancaster, C.; Walk, S.; et al. 1669. A US Based National Surveillance Study for the Susceptibility and Epidemiology of Clostridioides difficile Associated Diarrheal Isolates with Special Reference to Ridinilazole: 2020–2021. Open Forum Infect. Dis. 2022, 9, ofac492-1299. [Google Scholar] [CrossRef]
  55. Indra, A.; Huhulescu, S.; Schneeweis, M.; Hasenberger, P.; Kernbichler, S.; Fiedler, A.; Wewalka, G.; Allerberger, F.; Kuijper, E.J. Characterization of Clostridium difficile Isolates Using Capillary Gel Electrophoresis-Based PCR Ribotyping. J. Med. Microbiol. 2008, 57, 1377–1382. [Google Scholar] [CrossRef] [PubMed]
  56. Fawley, W.N.; Knetsch, C.W.; MacCannell, D.R.; Harmanus, C.; Du, T.; Mulvey, M.R.; Paulick, A.; Anderson, L.; Kuijper, E.J.; Wilcox, M.H. Development and Validation of an Internationally-Standardized, High-Resolution Capillary Gel-Based Electrophoresis PCR-Ribotyping Protocol for Clostridium difficile. PLoS ONE 2015, 10, e0118150. [Google Scholar] [CrossRef] [PubMed]
  57. Tóth, J.; Urbán, E.; Osztie, H.; Benczik, M.; Indra, A.; Nagy, E.; Allerberger, F. Distribution of PCR Ribotypes among Recent Clostridium difficile Isolates Collected in Two Districts of Hungary Using Capillary Gel Electrophoresis and Review of Changes in the Circulating Ribotypes over Time. J. Med. Microbiol. 2016, 65, 1158–1163. [Google Scholar] [CrossRef] [PubMed]
  58. Wen, X.; Shen, C.; Xia, J.; Zhong, L.L.; Wu, Z.; Ahmed, M.A.E.G.E.S.; Long, N.; Ma, F.; Zhang, G.; Wu, W.; et al. Whole-Genome Sequencing Reveals the High Nosocomial Transmission and Antimicrobial Resistance of Clostridioides difficile in a Single Center in China, a Four-Year Retrospective Study. Microbiol. Spectr. 2022, 10, e01322-21. [Google Scholar] [CrossRef] [PubMed]
  59. Curova, K.; Novotny, M.; Ambro, L.; Kamlarova, A.; Lovayova, V.; Hrabovsky, V.; Siegfried, L.; Jarcuska, P.; Jarcuska, P.; Toporova, A. High Prevalence of Clostridioides difficile Ribotype 176 in the University Hospital in Kosice. Pathogens 2023, 12, 430. [Google Scholar] [CrossRef] [PubMed]
  60. Nyc, O.; Tejkalova, R.; Kriz, Z.; Ruzicka, F.; Kubicek, L.; Matejkova, J.; Kuijper, E.; Krutova, M. Two Clusters of Fluoroquinolone and Clindamycin-Resistant Clostridium difficile PCR Ribotype 001 Strain Recognized by Capillary Electrophoresis Ribotyping and Multilocus Variable Tandem Repeat Analysis. Microb. Drug Resist. 2017, 23, 609–615. [Google Scholar] [CrossRef] [PubMed]
  61. Wren, C.M.; Cowper, J.; Greer, N.; Goldin, L.; Perry, A. Effect of Reduced Fluoroquinolone Use on Cephalosporin Use, Susceptibilities and Clostridioides difficile Infections. Antibiotics 2022, 11, 1312. [Google Scholar] [CrossRef] [PubMed]
  62. Redmond, S.N.; Silva, S.Y.; Wilson, B.M.; Cadnum, J.L.; Donskey, C.J. Impact of Reduced Fluoroquinolone Use on Clostridioides difficile Infections Resulting From the Fluoroquinolone-Resistant Ribotype 027 Strain in a Veterans Affairs Medical Center. Pathog. Immun. 2019, 4, 251–259. [Google Scholar] [CrossRef] [PubMed]
  63. Vaverková, K.; Kracík, M.; Ryšková, L.; Paterová, P.; Kukla, R.; Hobzová, L.; Špánek, R.; Žemličková, H. Effect of Restriction of Fluoroquinolone Antibiotics on Clostridioides difficile Infections in the University Hospital Hradec Králové. Antibiotics 2021, 10, 519. [Google Scholar] [CrossRef] [PubMed]
  64. Adams, D.J.; Barone, J.B.; Nylund, C.M. Community-Associated Clostridioides difficile Infection in Children: A Review of Recent Literature. J. Pediatr. Infect. Dis. Soc. 2021, 10, S22–S26. [Google Scholar] [CrossRef] [PubMed]
  65. Marcos, P.; Whyte, P.; Burgess, C.; Ekhlas, D.; Bolton, D. Detection and Genomic Characterisation of Clostridioides difficile from Spinach Fields. Pathogens 2022, 11, 1310. [Google Scholar] [CrossRef] [PubMed]
  66. Bjöersdorff, O.G.; Lindberg, S.; Kiil, K.; Persson, S.; Guardabassi, L.; Damborg, P. Dogs Are Carriers of Clostridioides difficile Lineages Associated with Human Community-Acquired Infections. Anaerobe 2021, 67, 102317. [Google Scholar] [CrossRef]
  67. Finsterwalder, S.K.; Loncaric, I.; Cabal, A.; Szostak, M.P.; Barf, L.M.; Marz, M.; Allerberger, F.; Burgener, I.A.; Tichy, A.; Feßler, A.T.; et al. Dogs as Carriers of Virulent and Resistant Genotypes of Clostridioides difficile. Zoonoses Public Health 2022, 69, 673–681. [Google Scholar] [CrossRef] [PubMed]
  68. Marcos, P.; Whyte, P.; Burgess, C.; Bolton, D. A Small Study on Clostridioides difficile in Spinach Field Soil and the Chemical and Microbial Factors That May Influence Prevalence. Curr. Microbiol. 2023, 80, 236. [Google Scholar] [CrossRef] [PubMed]
  69. Zhang, W.-Z.; Li, W.-G.; Liu, Y.-Q.; Gu, W.-P.; Zhang, Q.; Li, H.; Liu, Z.-J.; Zhang, X.; Wu, Y.; Lu, J.-X. The Molecular Characters and Antibiotic Resistance of Clostridioides difficile from Economic Animals in China. BMC Microbiol. 2020, 20, 70. [Google Scholar] [CrossRef] [PubMed]
  70. Blau, K.; Berger, F.K.; Mellmann, A.; Gallert, C. Clostridioides difficile from Fecally Contaminated Environmental Sources: Resistance and Genetic Relatedness from a Molecular Epidemiological Perspective. Microorganisms 2023, 11, 2497. [Google Scholar] [CrossRef] [PubMed]
  71. Rodriguez-Diaz, C.; Seyboldt, C.; Rupnik, M. Non-Human Clostridioides difficile Reservoirs and Sources: Animals, Food, Environment. Adv. Exp. Med. Biol. 2024, 1435, 329–350. [Google Scholar] [CrossRef] [PubMed]
  72. Webribo. Available online: https://webribo.ages.at/ (accessed on 8 May 2024).
  73. Couturier, J.; Davies, K.; Barbut, F. Ribotypes and New Virulent Strains Across Europe. Adv. Exp. Med. Biol. 2024, 1435, 151–168. [Google Scholar] [CrossRef] [PubMed]
  74. Snydman, D.R.; McDermott, L.A.; Jenkins, S.G.; Goldstein, E.J.C.; Patel, R.; Forbes, B.A.; Johnson, S.; Gerding, D.N.; Thorpe, C.M.; Walk, S.T. Epidemiologic Trends in Clostridioides difficile Isolate Ribotypes in United States from 2011 to 2016. Anaerobe 2020, 63, 102185. [Google Scholar] [CrossRef] [PubMed]
  75. Mengoli, M.; Barone, M.; Fabbrini, M.; D’Amico, F.; Brigidi, P.; Turroni, S. Make It Less Difficile: Understanding Genetic Evolution and Global Spread of Clostridioides difficile. Genes 2022, 13, 2200. [Google Scholar] [CrossRef] [PubMed]
  76. O’Connor, J.R.; Lyras, D.; Farrow, K.A.; Adams, V.; Powell, D.R.; Hinds, J.; Cheung, J.K.; Rood, J.I. Construction and Analysis of Chromosomal Clostridium difficile Mutants. Mol. Microbiol. 2006, 61, 1335–1351. [Google Scholar] [CrossRef]
  77. Schneeberg, A.; Ehricht, R.; Slickers, P.; Baier, V.; Neubauer, H.; Zimmermann, S.; Rabold, D.; Lübke-Becker, A.; Seyboldt, C. DNA Microarray-Based PCR Ribotyping of Clostridium difficile. J. Clin. Microbiol. 2015, 53, 433–442. [Google Scholar] [CrossRef] [PubMed]
  78. Arvand, M.; Hauri, A.M.; Zaiss, N.H.; Witte, W.; Bettge-Weller, G. Clostridium difficile Ribotypes 001, 017, and 027 Are Associated with Lethal C. Difficile Infection in Hesse, Germany. Euro Surveill. 2009, 14, 19403. [Google Scholar] [CrossRef] [PubMed]
  79. Barbut, F.; Mastrantonio, P.; Delmée, M.; Brazier, J.; Kuijper, E.; Poxton, I. Prospective Study of Clostridium difficile Infections in Europe with Phenotypic and Genotypic Characterisation of the Isolates. Clin. Microbiol. Infect. 2007, 13, 1048–1057. [Google Scholar] [CrossRef] [PubMed]
  80. Lyytikäinen, O.; Mentula, S.; Kononen, E.; Kotila, S.; Tarkka, E.; Anttila, V.J.; Mattila, E.; Kanerva, M.; Vaara, M.; Valtonen, V. First Isolation of Clostridium difficile PCR Ribotype 027 in Finland. Wkly. Releases (1997–2007) 2007, 12, 3303. [Google Scholar] [CrossRef]
  81. Pituch, H.; Van Belkum, A.; Obuch-Woszczatynski, P.; Meisel-Mikolajczyk, F.; Luczak, M. Porownanie metodami AP-PCR, rybotypowania [PCR-ribotyping] oraz elektroforezy pulsacyjnej [PFGE] szczepow Clostridium difficile wytwarzajacych toksyne B i nie wytwarzajacych toksyny A. Med. Doświadczalna I Mikrobiol. 2003, 55, 53–60. [Google Scholar]
  82. Perić, A.; Rančić, N.; Dragojević-Simić, V.; Milenković, B.; Ljubenović, N.; Rakonjac, B.; Begović-Kuprešanin, V.; Šuljagić, V. Association between Antibiotic Use and Hospital-Onset Clostridioides difficile Infection in University Tertiary Hospital in Serbia, 2011–2021: An Ecological Analysis. Antibiotics 2022, 11, 1178. [Google Scholar] [CrossRef] [PubMed]
  83. Laboratory Procedures for Diagnosis and Typing of Human Clostridium difficile Infection. Available online: https://www.ecdc.europa.eu/en/publications-data/laboratory-procedures-diagnosis-and-typing-human-clostridium-difficile-infection (accessed on 10 May 2024).
Gels 10 00343 g001
Figure 1. Number of the catalogued ribotypes.
Figure 1. Number of the catalogued ribotypes.
Gels 10 00343 g001
Table 1. Summary of methods for detecting C. difficile, along with the advantages and disadvantages of each method [40].
Table 1. Summary of methods for detecting C. difficile, along with the advantages and disadvantages of each method [40].
TestMethodologyAdvantagesDisadvantages
Stool culturedetection of bacteriahigh sensitivitynecessity of a culture under anaerobic conditions,
time length for the result,
moderate specificity (lack of differentiation of toxigenic strains)
PCR testdetection of bacterial DNA (e.g., GDH, toxin genes)high sensitivity and specificitylack of specificity against toxin-producing strains if only GDH is detected
Cytotoxicity neutralization test in the cell culturetoxin detection“gold standard” in the diagnosis of C. difficile intoxication;
high sensitivity and specificity		labor-intensive,
time-consuming,
the need for constant cell culture
Immunoenzymatic tests for toxin antigenstoxin detectionspeed and simplicity of testing; low-cost methodlow sensitivity
PCR test (detection of toxin genes directly from stool sample or cultured strain)toxin detectionhigh sensitivity and specificity, can be used as a single diagnostic methodrequires appropriate equipment
GDH and toxin A/B detection testdetection of bacteria and toxin detectionfast method (2–6 h); easy to performlow sensitivity compared to PCR and cytotoxicity tests
Table 2. The detailed results obtained in the research using the Webribo database.
Table 2. The detailed results obtained in the research using the Webribo database.
Strain NumberRibotype DetectedCommentary/Interpretation
10241Existing ribotype
101027Existing ribotype
102003Existing ribotype
103027Existing ribotype
106PR09247New ribotype
111027Existing ribotype
115027Existing ribotype
12029Existing ribotype
13027Existing ribotype
14PR24695Most probable: 014/0 ribotype
15027Existing ribotype
16PR24696New ribotype
17009Existing ribotype
18027Existing ribotype
19018Existing ribotype
21027Existing ribotype
22PR2468Most probable: 076 ribotype
23PR24697New ribotype
24027Existing ribotype
25027Existing ribotype
26AI-84Existing ribotype
27PR24698Most probable: AI-61 ribotype
3081Existing ribotype
30241Existing ribotype
32005Existing ribotype
33PR24695Most probable: 014/0 ribotype
34014/0Existing ribotype
36PR24694Most probable: 006/1 ribotype
37005Existing ribotype
38241Existing ribotype
39023Existing ribotype
4002/2Existing ribotype
40020Existing ribotype
41416Existing ribotype
42027Existing ribotype
43029Existing ribotype
44403Existing ribotype
45081Existing ribotype
46027Existing ribotype
47PR24683New ribotype
48PR24699New ribotype
49PR24700Most probable: 095 ribotype
5005Existing ribotype
50046Existing ribotype
51PR24701New ribotype
52PR24702New ribotype
53014/0Existing ribotype
54PR01729New ribotype
55PR01744Most probable: 031 ribotype
56027Existing ribotype
57001Existing ribotype
58PR24684New ribotype
59012Existing ribotype
6018Existing ribotype
60AI-78Existing ribotype
7PR24685New ribotype
70PR01729New ribotype
71PR24686New ribotype
72014/0Existing ribotype
73PR24687New ribotype
74001Existing ribotype
77027Existing ribotype
78027Existing ribotype
79PR24690Most probable: 578 ribotype
8002/0Existing ribotype
9026Existing ribotype
91023Existing ribotype
92081Existing ribotype
93023Existing ribotype
Table 3. Summary of the existing ribotypes obtained in the research using the Webribo database with the observed genotypes.
Table 3. Summary of the existing ribotypes obtained in the research using the Webribo database with the observed genotypes.
Ribotype DetectedStrain NumbertcdAtcdBcdtA/cdtBRibotype DetectedStrain NumbertcdAtcdBcdtA/cdtB
02756pos.pos.pos.02040pos.pos.neg.
46pos.pos.pos.24110pos.pos.neg.
103pos.pos.pos.38pos.pos.neg.
115pos.pos.pos.30pos.pos.neg.
111pos.pos.pos.0/1259pos.pos.neg.
13pos.pos.pos.002/24pos.pos.neg.
18pos.pos.pos.0/1819pos.pos.neg.
21pos.pos.pos.6pos.pos.neg.
15pos.pos.pos.0055pos.pos.neg.
24pos.pos.pos.32pos.pos.neg.
25pos.pos.pos.37pos.pos.neg.
42pos.pos.pos.02393pos.pos.pos.
101pos.pos.pos.91pos.pos.pos.
77pos.pos.pos.39pos.pos.pos.
78pos.pos.pos.0813pos.pos.neg.
014/034pos.pos.neg.45pos.pos.neg.
53pos.pos.neg.92pos.pos.neg.
72pos.pos.neg.02943pos.pos.neg.
00174pos.pos.pos.12pos.pos.neg.
57pos.pos.pos.003102pos.pos.neg.
00917pos.pos.neg.
cdtA/cdtB—binary toxin genes; neg.—gene absence; pos.—gene presence; tcdA—toxin A gene; tcdB—toxin B gene.
Table 4. Summary of the most probable existing ribotypes obtained in the research using the Webribo database with respect to the observed genotypes.
Table 4. Summary of the most probable existing ribotypes obtained in the research using the Webribo database with respect to the observed genotypes.
Ribotype DetectedThe Most Probable RibotypeStrain NumbertcdAtcdBcdtA/cdtB
PR24695014/014pos.pos.pos.
PR2468907622pos.pos.pos.
PR24698AI-6127neg.neg.neg.
PR24694006/136pos.pos.neg.
PR2470009549pos.pos.neg.
PR0174403155pos.pos.neg.
PR2469057879pos.pos.pos.
PR24695014/033pos.pos.neg.
cdtA/cdtB—binary toxin genes; neg.—gene absence; pos.—gene presence; tcdA—toxin A gene; tcdB—toxin B gene.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Bogiel, T.; Dura, A.; Woźniak, M.; Mikucka, A.; Kanarek, P. Usefulness of Capillary Gel Electrophoresis-Based PCR for Detection of Clostridioides difficile Strains with Hypervirulent Ribotypes. Gels 2024, 10, 343. https://doi.org/10.3390/gels10050343

AMA Style

Bogiel T, Dura A, Woźniak M, Mikucka A, Kanarek P. Usefulness of Capillary Gel Electrophoresis-Based PCR for Detection of Clostridioides difficile Strains with Hypervirulent Ribotypes. Gels. 2024; 10(5):343. https://doi.org/10.3390/gels10050343

Chicago/Turabian Style

Bogiel, Tomasz, Alicja Dura, Marcin Woźniak, Agnieszka Mikucka, and Piotr Kanarek. 2024. "Usefulness of Capillary Gel Electrophoresis-Based PCR for Detection of Clostridioides difficile Strains with Hypervirulent Ribotypes" Gels 10, no. 5: 343. https://doi.org/10.3390/gels10050343

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop