Aim: To investigate the effect of sub-minimum inhibitory concentration (sub-MIC) of metronidazole, ciprofloxacin and imipenem on growth and toxin production in Clostridioides difficile.
Background: C. difficile is the most common causative agent of hospital-acquired diarrhea. Toxin production in C. difficile appears to be critical process for induction of the disease. Several factors such as antibiotics can facilitate growth and toxin production in in C. difficile.
Methods: Five C. difficile strains were grown with and without sub-MIC concentrations of metronidazole; ciprofloxacin; imipenem (0.5x MIC) and bacterial growth was measured by density at OD620 nm in 0, 4, 8, 12 and 24 h after inoculation. Toxin production was detected using ELISA in culture supernatants and also in cell pellet.
Results: The five strains showed minor growth variations in the presence and absence of antibiotic sub-MIC values, except for metronidazole, in which the sub-MIC concentration decreased the growth rate of the resistant isolate in comparison with the control without antibiotic. There were no significant variations was observed in the levels of toxin production with the sub-MIC values of antibiotics examined in comparison with antibiotic-free controls. However, the amount of toxin production in the culture supernatant was greater than cell pellet.
Conclusion: The findings of this study suggested that sub-MIC concentrations of antibiotics may have little effects on bacterial growth and toxin production of C. difficile. Taken together, these findings suggest that, presence of antimicrobial agents, increased expression levels of certain genes, particularly virulence genes, may help C. difficile to survive.
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: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66 (7):e1-e48.
Farooq PD, Urrunaga NH, Tang DM, von Rosenvinge EC. Pseudomembranous colitis. Disease-a-month: DM. 2015;61 (5):181.
Smits WK, Lyras D, Lacy DB, Wilcox MH, Kuijper EJ. Clostridium difficile infection. Nature reviews Disease primers. 2016;2:16020.
Voth DE, Ballard JD. Clostridium difficile toxins: mechanism of action and role in disease. Clinical microbiology reviews. 2005;18 (2):247-63.
Schäffler H, Breitrück A. Clostridium difficile - From Colonization to Infection. Frontiers in microbiology. 2018;9:646-.
Eze P, Balsells E, Kyaw MH, Nair H. Risk factors for Clostridium difficile infections - an overview of the evidence base and challenges in data synthesis. J Glob Health. 2017;7 (1):010417-.
Balassiano I, Yates E, Domingues R, Ferreira E. Clostridium difficile: a problem of concern in developed countries and still a mystery in Latin America. Journal of medical microbiology. 2012;61 (2):169-79.
Karlsson S, Dupuy B, Mukherjee K, Norin E, Burman LG, Åkerlund T. Expression of Clostridium difficile toxins A and B and their sigma factor TcdD is controlled by temperature. Infection and immunity. 2003;71 (4):1784-93.
Deneve C, Delomenie C, Barc M-C, Collignon A, Janoir C. Antibiotics involved in Clostridium difficile-associated disease increase colonization factor gene expression. Journal of medical microbiology. 2008;57 (6):732-8.
Dubois T, Dancer-Thibonnier M, Monot M, Hamiot A, Bouillaut L, Soutourina O, et al. Control of Clostridium difficile Physiopathology in Response to Cysteine Availability. Infection and immunity. 2016;84 (8):2389-405.
Drummond LJ, Smith DG, Poxton IR. Effects of sub-MIC concentrations of antibiotics on growth of and toxin production by Clostridium difficile. Journal of medical microbiology. 2003;52 (12):1033-8.
Odenholt I, Walder M, Wullt M. Pharmacodynamic studies of vancomycin, metronidazole and fusidic acid against Clostridium difficile. Chemotherapy. 2007;53 (4):267.
Davies J, Spiegelman GB, Yim G. The world of subinhibitory antibiotic concentrations. Current opinion in microbiology. 2006;9 (5):445-53.
Azimirad M, Naderi Noukabadi F, Lahmi F, Yadegar A. Prevalence of binary-toxin genes (cdtA and cdtB) among clinical strains of Clostridium difficile isolated from diarrheal patients in Iran. Gastroenterology and hepatology from bed to bench. 2018;11 (Suppl 1):59-65.
CLSI C. M100-S25: Performance Standards for Antimicrobial Susceptibility Testing. Twenty-Fifth Informational Supplement. 2012.
Bauer MP, Notermans DW, van Benthem BHB, Brazier JS, Wilcox MH, Rupnik M, et al. Clostridium difficile infection in Europe: a hospital-based survey. The Lancet. 2011;377 (9759):63-73.
Vardakas KZ, Polyzos KA, Patouni K, Rafailidis PI, Samonis G, Falagas ME. Treatment failure and recurrence of Clostridium difficile infection following treatment with vancomycin or metronidazole: a systematic review of the evidence. International journal of antimicrobial agents. 2012;40 (1):1-8.
Pickard JM, Zeng MY, Caruso R, Nunez G. Gut microbiota: Role in pathogen colonization, immune responses, and inflammatory disease. Immunological reviews. 2017;279 (1):70-89.
Farrow KA, Lyras D, Rood JI. Genomic analysis of the erythromycin resistance element Tn5398 from Clostridium difficile. Microbiology (Reading, England). 2001;147 (Pt 10):2717-28.
Adams DA, Riggs MM, Donskey CJ. Effect of fluoroquinolone treatment on growth of and toxin production by epidemic and nonepidemic Clostridium difficile strains in the cecal contents of mice. Antimicrobial agents and chemotherapy. 2007;51 (8):2674-8.
Gerber M, Walch C, Löffler B, Tischendorf K, Reischl U, Ackermann G. Effect of sub-MIC concentrations of metronidazole, vancomycin, clindamycin and linezolid on toxin gene transcription and production in Clostridium difficile. Journal of medical microbiology. 2008;57 (6):776-83.
Baines SD, Freeman J, Wilcox MH. Effects of piperacillin/tazobactam on Clostridium difficile growth and toxin production in a human gut model. Journal of Antimicrobial Chemotherapy. 2005;55 (6):974-82.
Freeman J, O’Neill FJ, Wilcox MH. Effects of cefotaxime and desacetylcefotaxime upon Clostridium difficile proliferation and toxin production in a triple-stage chemostat model of the human gut. Journal of Antimicrobial Chemotherapy. 2003;52 (1):96-102.
Honda T, Hernadez I, Katoh T, Miwatani T. Stimulation of enterotoxin production of Clostridium difficile ny antibiotics. Lancet (London, England). 1983;1(8325):655-.
Goh E-B, Yim G, Tsui W, McClure J, Surette MG, Davies J. Transcriptional modulation of bacterial gene expression by subinhibitory concentrations of antibiotics. Proceedings of the National Academy of Sciences. 2002;99 (26):17025-30.
Yim G, Wang HH, Davies J. The truth about antibiotics. International Journal of Medical Microbiology. 2006;296 (2-3):163-70.