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Molecular subtyping of Clostridium perfringens by pulsed-field gel electrophoresis to facilitate food-borne-disease outbreak investigations.

Clostridium perfringens is a common cause of food-borne illness. The illness is characterized by profuse diarrhea and acute abdominal pain. Since the illness is usually self-limiting, many cases are undiagnosed and/or not reported. Investigations are often pursued after an outbreak involving large numbers of people in institutions, at restaurants, or at catered meals. Serotyping has been used in the past to assist epidemiologic investigations of C. perfringens outbreaks. However, serotyping reagents are not widely available, and many isolates are often untypeable with existing reagents. We developed a pulsed-field gel electrophoresis (PFGE) method for molecular subtyping of C. perfringens isolates to aid in epidemiologic investigations of food-borne outbreaks. Six restriction endonucleases (SmaI, ApaI, FspI, MluI, KspI, and XbaI) were evaluated with a select panel of C. perfringens strains. SmaI was chosen for further studies because it produced 11 to 13 well-distributed bands of 40 to approximately 1,100 kb which provided good discrimination between isolates. Seventeen distinct patterns were obtained with 62 isolates from seven outbreak investigations or control strains. In general, multiple isolates from a single individual had indistinguishable PFGE patterns. Epidemiologically unrelated isolates (outbreak or control strains) had unique patterns; isolates from different individuals within an outbreak had similar, if not identical, patterns. PFGE identifies clonal relationships of isolates which will assist epidemiologic investigations of food-borne-disease outbreaks caused by C. perfringens.

Centers for Disease Control and Prevention, U.S.↗

Genotyping of enterotoxigenic Clostridium perfringens fecal isolates associated with antibiotic-associated diarrhea and food poisoning in North America.

Clostridium perfringens type A isolates producing enterotoxin (CPE) are an important cause of food poisoning and non-food-borne human gastrointestinal (GI) diseases, including antibiotic-associated diarrhea (AAD). Recent studies suggest that C. perfringens type A food poisoning is caused by C. perfringens isolates carrying a chromosomal cpe gene, while CPE-associated non-food-borne GI diseases, such as AAD, are caused by plasmid cpe isolates. Those putative relationships, obtained predominantly with European isolates, were tested in the current study by examining 34 cpe-positive, C. perfringens fecal isolates from North American cases of food poisoning or AAD. These North American disease isolates were all classified as type A using a multiplex PCR assay. Furthermore, restriction fragment length polymorphism and pulsed-field gel electrophoresis genotyping analyses showed the North American AAD isolates included in this collection all have a plasmid cpe gene, but the North American food poisoning isolates all carry a chromosomal cpe gene. Western blotting demonstrated CPE expression by nearly all of these disease isolates, confirming their virulence potential. These findings with North American isolates provide important new evidence that, regardless of geographic origin or date of isolation, plasmid cpe isolates cause most CPE-associated AAD cases and chromosomal cpe isolates cause most C. perfringens type A food poisoning cases. These findings hold importance for the development of assays for distinguishing cases of CPE-associated food-borne and non-food-borne human GI illnesses and also identify potential epidemiologic tools for determining the reservoirs for these illnesses.

Anti-Bacterial Agents↗

Molecular typing of Clostridium perfringens from a food-borne disease outbreak in a nursing home: ribotyping versus pulsed-field gel electrophoresis.

In 1998, 21 inhabitants of a German nursing home fell ill with acute gastroenteritis after consumption of minced beef heart (P. Graf and L. Bader, Epidemiol. Bull. 41:327-329, 2000). Two residents died during hospital treatment. Seventeen Clostridium perfringens strains were collected from two different dishes and from patients' stool samples and autopsy materials. A majority of these isolates was not typeable by restriction fragment length polymorphism-pulsed-field gel electrophoresis (PFGE). Subsequent ribotyping of C. perfringens distinguished four different groups. The same ribopattern was detected in a minced beef heart dish, in autopsy material from the two deceased patients, and additionally in stool samples from six further residents who had fallen ill with diarrhea. Three further ribopatterns from food and autopsy materials could be differentiated. As chromosomal macrorestriction with subsequent PFGE is generally regarded more useful than ribotyping for molecular strain analysis, four selected isolates were lysed in parallel with a standard protocol and two nucleases inhibiting modifications. Neither of these methods could differentiate all of the isolates. These results suggest that PFGE with the current standard protocols is not able to characterize all C. perfringens isolates from food-borne disease investigations and that ribotyping is still a helpful method for molecular identification of clonal relationships.

Clostridium Infections↗

Development of a duplex PCR genotyping assay for distinguishing Clostridium perfringens type A isolates carrying chromosomal enterotoxin (cpe) genes from those carrying plasmid-borne enterotoxin (cpe) genes.

About 5% of Clostridium perfringens type A isolates carry the cpe gene encoding the C. perfringens enterotoxin. Those cpe-positive type A isolates are important causes of food-poisoning and non-food-borne cases of diarrheas in humans, as well as certain veterinary cases of diarrhea. Previous studies have determined that the enterotoxigenic type A isolates causing both non-food-borne human gastrointestinal disease and veterinary disease carry their cpe genes on plasmids, while the type A isolates causing human food poisoning carry a chromosomal cpe gene. The present study reports on the successful development of a duplex PCR assay that can rapidly genotype enterotoxigenic type A isolates (i.e., determine whether those cpe-positive isolates carry a chromosomal or a plasmid-borne cpe gene). The availability of this rapid cpe genotyping assay capable of handling large numbers of samples provides a powerful new investigative tool for diagnostic, epidemiologic, and basic research purposes.

Bacterial Typing Techniques↗

Genotyping and phenotyping of beta2-toxigenic Clostridium perfringens fecal isolates associated with gastrointestinal diseases in piglets.

Although Clostridium perfringens is recognized as an important cause of clostridial enteric diseases, only limited knowledge exists concerning the association of particular C. perfringens toxinotypes (type A to E) with gastrointestinal (GI) diseases in domestic animals. Some C. perfringens isolates also produce the newly discovered beta2-toxin (CPB2). Recent epidemiological studies suggested that C. perfringens isolates carrying the gene encoding CPB2 (cpb2) are strongly associated with clostridial GI diseases in domestic animals, including necrotic enteritis in piglets and typhlocolitis in horses. These putative relationships, obtained by PCR genotyping, were tested in the present study by further genotyping and phenotyping of 29 cpb2-positive C. perfringens isolates from pigs with GI disease (pig GI disease isolates). PCR and restriction fragment length polymorphism analysis reconfirmed the presence of cpb2 gene sequences in all the disease isolates included in the study. Furthermore, genotyping by pulsed-field gel electrophoresis analyses showed that the pig GI disease isolates included in this study all carry a plasmid cpb2 gene, yet no clonal relationships were detected between the cpb2-positive pig GI disease isolates surveyed. Finally, CPB2-specific Western blotting demonstrated CPB2 expression by all of the cpb2-positive isolates surveyed. The CPB2 proteins made by five of these pig GI disease isolates were shown to have the same deduced amino acid sequences as the biologically active CPB2 protein made by the original type C isolate, CWC245. Collectively, our present results support a significant association between CPB2-positive C. perfringens isolates and diarrhea in piglets.

Animals↗

Highly conserved alpha-toxin sequences of avian isolates of Clostridium perfringens.

Clostridium perfringens causes necrotic enteritis in chickens, and alpha-toxin has been suggested to be a key virulence determinant. Analysis of the alpha-toxin of 25 chicken-derived C. perfringens strains demonstrated high homology to mammal-derived strains rather than to the only avian-derived C. perfringens alpha-toxin sequence reported previously.

Amino Acid Sequence↗

Multiplex PCR genotyping assay that distinguishes between isolates of Clostridium perfringens type A carrying a chromosomal enterotoxin gene (cpe) locus, a plasmid cpe locus with an IS1470-like sequence, or a plasmid cpe locus with an IS1151 sequence.

Clostridium perfringens type A isolates carrying the enterotoxin (cpe) gene are important causes of both food poisoning and non-food-borne diarrheas in humans. In North America and Europe, food poisoning isolates were previously shown to carry a chromosomal cpe gene, while non-food-borne gastrointestinal (GI) disease isolates from those two geographic locations were found to have a plasmid cpe gene. In this report, we describe the development of an economical multiplex PCR cpe genotyping assay that works with culture lysates to distinguish among type A isolates carrying a chromosomal cpe gene, a plasmid cpe gene with a downstream IS1470-like sequence, or a plasmid cpe gene with a downstream IS1151 sequence. When this multiplex PCR assay was applied in molecular epidemiologic studies, it was found that (i) all 57 examined type A isolates with a plasmid cpe gene have either IS1470-like or IS1151 sequences downstream of the plasmid cpe gene; (ii) an IS1470-like sequence, rather than an IS1151 sequence, is more commonly present downstream of the plasmid cpe gene (particularly in North American non-food-borne human GI disease isolates); and (iii) as previously shown in the United States and Europe, isolates carrying the chromosomal cpe gene also appear to be the major cause of C. perfringens food poisoning in Japan. The superiority of this new multiplex PCR assay over existing cpe genotyping approaches should facilitate further molecular epidemiologic investigations of C. perfringens enterotoxin-associated GI illnesses and their associated cpe-positive type A isolates.

Bacterial Typing Techniques↗

Detection of Clostridium perfringens enterotoxin in human fecal samples and anti-enterotoxin in sera.

By using counterimmunoelectrophoresis (CIEP), Clostridium perfringens enterotoxin was successfully demonstrated in fecal samples collected within 1 day of attack from sick individuals involved in a bacteriologically and epidemiologically proven outbreak of C. perfringens food poisoning. In contrast, enterotoxin was not demonstrable in fecal samples of apparently healthy individuals both at high- and low-risk exposure to the organism and enterotoxin or in fecal samples collected 4 to 5 days after a food poisoning outbreak. A 100% prevalence of C. perfringens anti-enterotoxin in sera of human volunteers at high- as well as low-risk exposure to the organism and enterotoxin was recorded with CIEP.

Allied Health Personnel↗

Clostridial toxins in neonatal necrotising enterocolitis.

Clostridium difficile cytopathic toxin was found in the faeces or gut content of five of 39 neonates with necrotising enterocolitis (NEC). Toxin concentrations were uniformly low and did not differ from those found in healthy neonates. C difficile is unlikely to be involved in the pathogenesis of NEC. Stools from 33 babies with NEC were also tested for C perfringens alpha toxin, with negative results.

Bacterial Proteins↗

Crisis in our hospital kitchens: ancillary staffing levels during an outbreak of food poisoning in a long stay hospital.

An investigation into an outbreak of food poisoning caused by Clostridium perfringens showed evidence of poor food handling by catering staff. The reasons behind this were explored by interviewing catering staff, analysing shifts and rotas, and looking at staff vacancies. Morale was low because of staff shortages resulting from a long term recruitment problem. In consequence staff were working double shifts and often for weeks on end without a day off. The reasons for the recruitment problem included the difficulty of recruiting semiskilled labour from a middle class area, low wages, lack of management support, and the poor image of the hospital as a place of work. Similar factors affect the recruitment and retention of ancillary staff nationally. The NHS has a poor record as an employer of ancillary staff, paying lower wages than other organisations for equivalent posts. Competitive tendering has further worsened the position of ancillary staff, with the result that good quality of care and service has often not been achieved. The NHS Review, with its emphasis on quality of care, makes no mention of ancillary staff. Yet high standards of ancillary provision are essential if further outbreaks of food poisoning in hospitals are to be prevented.

Clostridium Infections↗

Acute clostridial enteritis--or pig-bel?

Acute postprandial gastric dilatation and associated clostridial enteritis necroticans is a well recognised but unusual clinical condition. Non-pathological overeating, gastric distension, and clostridial enteritis, termed pig-bel, has been reported in Papua, New Guinea. A similar condition (Darmbrand) was reported from Germany after the second world war, but it is not a condition seen in our society today. Gastric dilatation alone may be seen in individuals with anorexia nervosa, who may occasionally indulge in episodes of overeating (bulimia). We wish to report a case of gastric dilatation associated with a fulminating enteritis, and discuss the similarities with enteritis necroticans (pig-bel).

Acute Disease↗

Hyaline droplet formation in the renal epithelium of patients with haemoglobinuria.

Renal hyaline droplet formation is described in two patients with haemoglobinuria. The droplets were shown to contain haemoglobin by a histochemical method. The findings are correlated with the results of recent experimental studies which have demonstrated that renal hyaline droplets are phagosomes containing absorbed protein and not products of cellular degeneration as was previously thought.

Adult↗