Severe infection with Clostridium difficile PCR ribotype 027 acquired in Melbourne, Australia

Michael Richards, James Knox, Briony Elliott, Kate Mackin, Dena Lyras, Lynette J Waring and Thomas V Riley
Med J Aust 2011; 194 (7): 369-371.

We report the first recognised case of infection with Clostridium difficile PCR ribotype 027 acquired in Australia. This pathogen has caused significant morbidity and mortality in widespread hospital-based outbreaks in the northern hemisphere. Clinicians need to be aware of the clinical picture, limitations of diagnostic tests, availability of further testing for epidemic strains, new therapeutic approaches, and in-hospital control strategies for this infection. (MJA 2011; 194: 369-371)

An 83-year-old Latvian man underwent an aortic valve replacement for aortic stenosis in late January 2010 at a hospital in Melbourne, Australia. He had a history of hypertension and chronic renal failure. He lived alone in his own home, and had not travelled outside Australia since September 2009 when he returned from a 3-month trip to Latvia. Between his return to Australia and the surgery, he had not received any antibiotics except for a single preoperative dose of cephalothin. His regular medications included various supplements, but no proton-pump inhibitor. He was admitted to the hospital the day before surgery. Two days after the surgery, he developed severe sepsis from a urinary tract infection, for which he received ticarcillin–clavulanate and a noradrenaline infusion. A coagulase-negative Staphylococcus was isolated from blood cultures, and he was given vancomycin. He later developed an infiltrate at the left lung base, but no change was made to his therapy.

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  • Michael Richards1
  • James Knox2,3
  • Briony Elliott3
  • Kate Mackin4
  • Dena Lyras5
  • Lynette J Waring6
  • Thomas V Riley4,6

  • 1 Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, VIC.
  • 2 Department of Infectious Diseases, Monash Medical Centre, Melbourne, VIC.
  • 3 Melbourne Pathology, Melbourne, VIC.
  • 4 University of Western Australia, Perth, WA.
  • 5 Monash University, Melbourne, VIC.
  • 6 PathWest Laboratory Medicine, Perth, WA.


Thanks to Grant Jenkin of the Department of Infectious Diseases, Monash Medical Centre for his assistance with collation of laboratory data.

Competing interests:

Thomas Riley has undertaken contract research for Cepheid.

  • 1. O’Neill GL, Ogunsola FT, Brazier JS, Duerden BI. Modification of a PCR-ribotyping method for application as a routine typing scheme for Clostridium difficile. Anaerobe 1996; 2: 205-209.
  • 2. Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005; 353: 2442-2449.
  • 3. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005; 353: 2433-2441.
  • 4. Clements CAA, Soares Magalhães RJ, Tatem AJ, et al. Clostridium difficile polymerase chain reaction ribotype 027: assessing the risks of further global spread. Lancet Infect Dis 2010; 10: 395-404.
  • 5. Warny M, Pepin J, Fang A, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 2005; 366: 1079-1084.
  • 6. Pepin J, Saheb N, Coulombe M-A, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis 2005; 41: 1254-1260.
  • 7. Riley TV, Thean S, Hool G, Golledge CL. First Australian isolation of epidemic Clostridium difficile PCR ribotype 027. Med J Aust 2009; 190: 706-708. <MJA full text>
  • 8. Aksenoka K, Balode A, Grope I, et al. Clostridium difficile associated disease clinical and molecular data. Acta Chirurgica Latviensis 2009; 9: 56-61.
  • 9. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31: 431-455.
  • 10. Zar FA, Bakkanagari SR, Moorthi KM, et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007; 45: 302-307.
  • 11. Apisarnthanarak A, Razavi B, Mundy LM. Adjunctive intracolonic vancomycin for severe Clostridium difficile colitis: case series and review of the literature. Clin Infect Dis 2002; 35: 690-696.
  • 12. Bolton RP, Culshaw MA. Faecal metronidazole concentrations during oral and intravenous therapy for antibiotic associated colitis due to Clostridium difficile. Gut 1986; 27: 1169-1172.
  • 13. Miller MA. Clinical management of Clostridium difficile-associated disease. Clin Infect Dis 2007; 45 Suppl 2: S122-S128.
  • 14. Lamontagne F, Labbe AC, Haeck O, et al. Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain. Ann Surg 2007; 245: 267-272.
  • 15. Thomas C, Stevenson M, Williamson DJ, Riley TV. Clostridium difficile-associated diarrhoea: epidemiological data from Western Australia following a change in antibiotic policy. Clin Infect Dis 2002; 35: 1457-1462.
  • 16. Planche T, Aghaizu A, Holliman R, et al. Diagnosis of Clostridium difficile infection by toxin detection kits: a systematic review. Lancet Infect Dis 2008; 8: 777-784.
  • 17. Wilcox MH, Planche T, Fang FC. What is the current role of algorithmic approaches for diagnosis of Clostridium difficile infection? J Clin Microbiol 2010; 48: 4347-4353.
  • 18. Cheng AC, Ferguson JK, Richards MJ, et al. Australasian Society for Infectious Diseases guidelines for the diagnosis and treatment of Clostridium difficile infection. Med J Aust 2011; 194: 000-000. <MJA full text>
  • 19. Stuart RL, Marshall C, McLaws ML, et al. ASID/AICA position statement: infection control guidelines for patients with Clostridium difficile infection in health care settings. Healthcare Infect 2011. In press.


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