RT176 Emerging in Slovakia, Leading to C Difficile Outbreak

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There were also 9 RT176 strains that carried the cfr(E)gene and one RT001 strain carried the cfr(C) gene. However, they were without a linezolid resistance.

A new analysis of a recent Clostridioides difficile infections (CDI) outbreak in Slovakia show the prevalence of certain ribotypes of C difficile have emerged in recent years.1

A team, led by Adriana Plankaova, Department of Clinical Microbiology, Unilabs Inc., identified CDI epidemiology in Slovakian hospitals following the emergence of ribotype 176 in 2016.

CDI Outbreaks

Over the years, the prevalence of certain ribotypes may have changed.

“Ribotyping data from Slovak C. difficile isolates from 2011 to 2013 showed a low diversity of ribotypes and clear predominance of RT001; C. difficile RT176 has not been identified at that time,” the authors wrote. “Later, in 2016, a large outbreak of 75 RT176 CDI cases have been reported in a tertiary-care center in the northern part of Slovakia. In the same year, 36 hospitals in Slovakia participated in a national CDI surveillance and 12 hospitals submitted also C. difficile isolates for characterization.”

The Data

In the study, the investigators applied the ECDC CDI surveillance protocol v2.3 to 14 hospitals between 2018-2019. The team collected additional data on recent antimicrobial use and the characterization of C difficile isolates.

The results show a mean CDI incidence per hospital of 4.1 cases per 10,000 patient bed-days with an in-hospital fatal outcome of 27.6% (n = 105) of the 381 cases. For the previous 4 weeks antimicrobial treatment was recorded in 90.5% (n = 333) of cases.

In 50% of cases (n = 185; 14 hospitals) ribotype 176 was detected, while RT001 was detected in 34.6% (n = 128; 13 hospitals) of the cases with ribotype data.The investigators also found 86% (n = 318) of isolates were moxifloxacin-resistant Thr82Ile in GyrA (99.7%).

The investigators conducted a Multilocus Variable Tandem Repeat Analysis and found clonal relatedness of predominant RTs within and between hospitals.

Half of the 14 hospitals sequenced RT176 isolates, while 5 of the 13 RT001 isolated showed only 0-3 allele differences by wgMLST.

Most of the sequenced isolates—24 of 27—carried the erm(B) gene. In addition 16 sequenced isolates also carried aac(6′)-aph(2′') gene with the corresponding antimicrobial susceptibility phenotypes.

There were also 9 RT176 strains that carried the cfr(E)gene and one RT001 strain carried the cfr(C) gene. However, they were without a linezolid resistance.

“The newly-predominant RT176 and endemic RT001 drive CDI epidemiology in Slovakia,” the authors wrote. “In addition to fluoroquinolones, the use of macrolide–lincosamide–streptogramin B group of antibiotics can represent another driving force for the spread of these epidemic lineages. In C. difficile, linezolid resistance should be confirmed phenotypically in strains with detected cfr-gene(s).”


Plankaova, A., Brajerova, M., Capek, V., Novotna, G. B., Kinross, P., Skalova, J., Soltesova, A., Drevinek, P., & Krutova, M. (2023). Clostridioides difficile infections were predominantly driven by fluoroquinolone-resistant C. difficile ribotypes 176 and 001 in Slovakia in 2018-2019. International Journal of Antimicrobial Agents, 106824.