B io Factsheet

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Number 180

Antibiotic Use And The Rise Of

Clostridium Difficile
This Factsheet describes the Biology of Clostridium difficile and
the problems that it is causing in hospitals around the world.

Typical Exam Question

Clostridium difficile ( C-diff) is a gram-positive anaerobic bacteria

that has, in recent years, proved fatal in hospitals in England and
caused more than 5000 cases of severe diarrhoea. In hospitals, C.
difficile is the major causative agent of colitis (inflammation of the
colon) and diarrhoea that may occur following antibiotic intake.

This is a very common question! It is usually phrased as How

do bacteria become antibiotic resistant?

Suggest why C.difficile was not killed by the antibiotics that

killed the helpful bacteria.

a population of bacteria may contain a few mutant cells that are

resistant to any antibiotic;
use of an antibiotic will create a selection pressure;
kills sensitive cells while resistant ones survive and reproduce;
antibiotics should not be used in routine / trivial / casual way;
antibiotics may become, useless / ineffective;
antibiotics should be rotated;

But dont antibiotics kill bacteria?

Yes, but the problem is that, in healthy individuals, C. difficile is
kept under control by other species of bacteria that live in our
colons. If these helpful control bacteria are killed or weakened by
antibiotics, the population of C. difficile can increase rapidly. Almost
all people whose colons are attacked by C.difficile are on, or have
recently completed, a course of antibiotics and most are elderly (Fig 1).

Basically, the more we use broad-spectrum antibiotics, the faster

antibiotic-resistant types of bacteria will develop. Fig 2 shows
the clear correlation between the use of penicillins and the
development of resistant strains of a bacterium.

Fig 1. Age specific rates of Clostridium difficile reports,

England, Wales and Northern Ireland 2004

Fig 2
50
FR

male
female

700

40

600

ES

500

Penicillin resistant S pneumoniae

Rate per 100,000 population

800

400
300
200
100

<1

1-4

5-9

10-14 15-44 45-64 65-74

75+

Age group (years)

30
PT
HU
SI

20
HR
BE

PL

UJ IE

10

FL

Although nearly all antibiotics have been implicated with the disease,
the commonest antibiotics associated with C. difficile infection are
ampicillin, amoxicillin, cephalosporins, and clindamycin.

IT
CZ

DK
AT
NLDE UK SW

The antibiotics change the normal pattern of bacteria (microbiota)

in the colon. One consequence of this is that peptides which are
not normally in the colon begin to accumulate. C. difficile prefers
peptides as a substrate and so, as peptides increase, so do the
numbers of C. difficile.

4
6
8
10
12
14 16
Outpatient use of penicillins in 2000

18

Bio Factsheet

180 Antibiotics and the rise of Clostridium difficile

www.curriculum-press.co.uk

How do antibiotics work?

Antibiotics target the major differences that exist between prokaryotic and eukaryotic cells. Thus, vancomycin and b-lactam antibiotics
interfere at different levels with the synthesis of the bacterial cell wall (peptidoglycan, murein). Quinolones inhibit bacterial enzymes
involved in the replication of DNA. Rifampicin inhibits transcription by binding to bacterial RNApolymerase.
Macrolides, tetracyclines and aminoglycosides inhibit 70S-ribosomal function thereby inhibiting protein synthesis. Sulphonamide
and trimetoprim inhibit biosynthesis of tetrahydrofolic acid and also interfere with DNA-synthesis.
There are, however, no examples of antibacterial agents against which bacteria have not been able to develop resistance. Therefore,
although there is hope for new classes of antibiotics to be developed, bacteria will certainly evolve resistance against them.

How is C.difficile acquired?

Colonisation

It is estimated that between 3-5 percent of healthy adults already

have it. In hospitals, the main way in which it enters the body is by
ingestion of contaminated fecal material. Simple failure to wash
hands properly may lead to another person becoming infected but
in any case, the spores of the bacteria which are released in the
stools of patients are resistant to many disinfectants. Any surface,
device or material (toilets, baths, electronic rectal thermometers etc)
that becomes contaminated with stool can have the C. difficile spores
present.

When C. difficile colonize the gut, they release two powerful toxins,
toxin A and toxin B, which bind to specific receptors in the lining of
the colon. The colonic mucosa becomes inflamed and colon cells
(colonocytes) are killed. Diarrhoea and colitis result. Later stages
often involve flu-like symptoms of weakness, dehydration, fever,
nausea, vomiting and in advanced stages, blood in stools. As we
have seen this year, it can prove fatal.

The spores can survive up to 70 days in the environment. Nurses,

porters or doctors who have touched a contaminated surface directly
can carry the spores to another patients room. When a patient
touches something with their hands that have the spores on them
and then touch their mouth or mucous membranes the spores enter
the body.
C-difficile produces spores when attacked by antibiotics. The spores
can live in the open air or in dirt for up to two years. Normal
disinfectants have been shown to be ineffective against the spores.
This means that even if you kill the C-diff bacteria, spores can still
be present. When the left over spores detect an attack from
conventional antibiotics, they unmask the spores and start
producing the C-dif bacteria all over again. This is why you can get
rid of the symptoms while on the medicine and it can come right
back later.

Prevention
There are three important components to the prevention and control
of C. difficile disease:
Prudent antibiotic prescribing to reduce the use of broad
spectrum antibiotics
Isolation of patients with C. difficile diarrhoea and good infection
control nursing - handwashing (not relying solely on alcohol
gel as this does not kill the spores) - wearing gloves and aprons,
especially when dealing with bed pans etc
Enhanced environmental cleaning and use of a chlorine
containing disinfectant where there are cases of C. difficile
disease to reduce environmental contamination with the spores.

Typical Exam Question

New antibiotics are being developed to try to combat C. difficile.
Apart from resistance, suggest two factors which should be
taken into account before the new antibiotics could be released
for general use.

Answers
production costs / yield;
results of clinical trials/low toxicity to cells / no side effects;
effective in conditions of use;
reasonably stable;

Treatment
With patients with mild diarrhoea, no fever, and modest lower
abdominal pain, just stopping the intake of antibiotics (if possible)
is often enough to alleviate symptoms and stop the diarrhoea.
Patients with colitis are treated with the antibiotics metronidazole
or vancomycin for 10 to 14 days. More than 95% of patients respond
very well to this treatment but a small minority require surgery.
However, the use of vancomycins has led to a rise in vancomycinresistant enterococci and it appears that new types of C. difficile
are emerging.

Bio Factsheet

180 Antibiotics and the rise of Clostridium difficile

www.curriculum-press.co.uk

Type 027 C.difficile

Over 160 types of C.difficile have been identified.Type 027 has been discovered in the most recent serious outbreaks in the UK. The same
type has caused a large outbreak of severe disease in hospitals in Canada (Quebec) and North-eastern USA since 2000. Type 027 produces
much more of the two toxins than most other types because a mutation has deleted the gene (18 base pairs) that normally restricts toxin
production (Fig 3). It causes a greater proportion of severe disease and appears to have a higher mortality. It also seems to be very capable
of spreading between patients.

Fig 3
Ribotype
027
167
168
027
034
075
080
015
020
001

101
101
101
101
101
101
101
101
101
101

110
G C T G AA G AA G
G C T G AA G AA G
G C T G AA G AA G
G C T G AA G AA G
G C T G AA G AA G
G C T G AA G AA G
G C T G AA G AA G
G C T G AA G AA G
G C T G AA G AA G
G C T G AA G AA G

120
C T AAAAA
C T AAAAA
C TAAAAAA G C
C T AAAAA
C T AAAAA
C T AAAAA
C T AAAAA
C T AAAAA
C TAAAAAA G C
C TAAAAAA G C

130

T G AA G AA G C T

T G AA G AA G C T
T G AA G AA G C T

140
GGCTG
GGCTG
AAAAA G G C T G
GGCTG
GGCTG
GGCTG
GGCTG
GGCTG
AAAAA G G C T G
AAAAA G G C T G

Typical Exam Question

A patient has been infected with C. difficile. Some of these bacteria possess genes for antibiotic resistance. When these individual cells
reproduce, these genes are replicated and passed on to the next generation
Outline how replication of the antibiotic genes occurs. (4)
Note: This is a typical synoptic question; it is asking you to apply your knowledge of DNA replication to the specific case of antibiotic
resistance. The answer is pretty straightforward, the key is not to panic and to use the technical terminology

Answers
semi-conservative replication / both strands used as templates;
hydrogen bonds break;
nucleotides align / individual nucleotides;
A and T / G and C / complementary base pairing;
DNA polymerase joins nucleotides;

Acknowledgements:
This Factsheet was researched and written by Kevin Byrne.
Curriculum Press, Bank House, 105 King Street, Wellington, Shropshire, TF1 1NU.
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