High-Level Resistance of Toxigenic Clostridioides difficile Genotype to Macrolide-Lincosamide- Streptogramin B in Community Acquired Patients in Eastern China

Figures & data

Table 1 Clinical Information of Diarrheal Patients Involved in This Study

Characteristics	Diarrheal Patients at HFPH (n=1053)	Diarrheal Patients at LSPH (n=197)
Male	513 (48.7%)	96 (48.7%)
Age (Median [range])	51 (5–101)	76 (20–102)
Inpatients	536 (50.9%)	149 (75.6%)
CDI	141 (13.4%)	49 (24.9%)
Ward type
Gastroenterology	439 (41.7%)	0
Psychiatry and neurology	27 (2.6%)	36 (18.3%)
Infectious disease	155 (14.7%)	109 (55.3%)
Blood and cardiology	68 (6.5%)	33 (16.8%)
Pediatrics	181 (17.2%)	0
Surgery	63 (6.0%)	4 (2.0%)
rehabilitation	23 (2.2%)	0
Others ^a	97 (9.2%)	15 (7.6%)

Notes: ^aOther ward types included urology, gynecology, obstetrics, oncology, transplantation, respiratory medicine, bone and joint, and etc.

Figure 1 Flow diagram of data collected during the study.

Table 2 Molecular Characteristics of Toxigenic C. difficile Isolates in HFPH and LSPH

Characteristics	No. (%) of CDI Patients		Analysis Results
	HFPH (n=141)	LSPH (n=49)	value	P value
CDI severity score ^a			χ^2=3.16	0.206
2 (n=126)	92 (65.2%)	34 (69.4%)
3 (n=49)	35 (24.8%)	14 (28.6%)
4 (n=15)	14 (9.9%)	1(2.0%)
Toxin gene pattern
A^+B^+(n=102)			χ^2=2.72	0.436
MLST type
ST3 (n=24)	19 (13.5%)	5 (10.2%)
ST35 (n=15)	9 (6.4%)	6 (12.2%)
ST54 (n=31)	23 (16.3%)	8 (16.3%)
Others (n=32)	26 (18.4%)	6 (12.2%)
A^–B^+(n=88)			χ^2=6.02	0.049
MLST type
ST37 (n=58)	38 (27.0%)	20 (40.8%)
ST39 (n=11)	11 (7.8%)	0 (0.0%)
ST81 (n=19)	15 (10.6%)	4 (8.2%)
Antibiotic resistance rate ^b
MLSB			χ^2=3.13	0.077
S (n=12)	12 (8.5%)	0 (0.0%)
R (n=178)	129 (91.5%)	49(100%)
Clindamycin			χ^2=8.65	0.005
S (n=9)	9 (6.4%)	0 (0.0%)
I (n=13)	13 (9.2%)	0 (0.0%)
R (n=168)	119 (84.4%)	49 (100%)
Erythromycin			χ^2=0.54	0.464
S (n=42)	33 (23.4%)	9 (18.4%)
R (n=148)	108 (76.6%)	40 (81.6%)
Metronidazole			N/A^c
S (n=190)	141 (100.0%)	49 (100.0%)
Vancomycin			N/A
S (n=190)	141 (100.0%)	49 (100.0%)

Notes: ^aCDI Severity: 2, mild CDI; 3, mild to moderate CDI; 4, moderate CDI. ^bS: susceptible; R: resistant; I: intermediate. ^cN/A: not applicable.

Figure 2 Relationship of toxigenic C. difficile isolates susceptible or resistant to MLS_B by minimal spanning tree.

Table 3 Differences of Clinical Characteristics Between A⁺B⁺ and A⁻B⁺ C. difficile with Resistance to MLS_B

Characteristics^a	NO. (%) of Diarrheal Patients		Analysis Results
	Patients with C. difficile Isolates with Resistance to MLSB		Bivariate			Multivariate Logistic
	A^+B^+ (n=90)	A^−B^+ (n=88)	OR	95%Cl	P value	OR	95%Cl	P value
Gender, male	48(53.3%)	51(58.0%)	1.21	0.67–2.18	0.535
Years of age, >55	46(51.1%)	48(54.6%)	1.15	0.64–2.07	0.646
CDI severity score, >2 (n=54)	14(15.6%)	40(45.5%)	4.52	2.23–9.18	<0.001	7.43	2.31–23.87	0.001
Stool
S-RBC Positive (n=9)	5 (5.6%)	4 (4.6%)	0.81	0.21–3.12	0.759
S-WBC Positive (n=39)	22 (24.4%)	17 (19.3%)	0.74	0.36–1.51	0.409
OB Positive (n=43)	20 (22.2%)	23 (26.1%)	1.24	0.62–2.46	0.542
Blood
CRP (mg/L) >10 (n=82)	38 (42.2%)	44(50.0%)	0.73	0.41–1.32	0.298
WBC (cells ×10^9/L) >10 (n=50)	18 (20.0%)	32 (36.4%)	2.29	1.16–4.49	0.016	0.58	0.18–1.89	0.368
Neutrophils > 70% (n=79)	34 (37.8%)	45(48.9%)	0.64	0.35–1.15	0.136
Lymphocyte > 40% (n=139)	23 (25.6%)	16 (18.2%)	1.55	0.75–3.17	0.236
Monocyte > 10% (n=20)	10 (11.1%)	10 (11.4%)	0.88	0.34–2.28	0.788
Eosinophils > 8% (n=6)	2 (2.2%)	4 (4.5%)	2.10	0.37–11.74	0.400
Basophils > 1% (n=1)	1 (1.1%)	0	N/A^b	N/A	N/A
Hb (g/L) < 120 (n=95)	45 (50.00%)	50 (56.8%)	0.76	0.42–1.37	0.362
PLT (cells ×10^9/L) <100 (n=19)	4 (4.4%)	15 (17.0%)	4.42	1.40–13.90	0.011	5.19	1.58–17.04	0.007
Creatinine (umol/L) > 111 (n=20)	9 (10.0%)	11 (12.5%)	0.78	0.31–1.98	0.598
Glucose (mmol/L) >6.1 (n=40)	22 (24.4%)	18 (20.5%)	1.26	0.62–2.55	0.524
Kalium (mmol/L) >5.5 (n=5)	1 (1.1%)	4 (4.5%)	0.47	0.04–5.30	0.543

Notes: ^aS-RBC: stool-red blood cell; S-WBC: stool-white blood cell; OB: occult blood; CRP: C-reactive protein; Hb: haemoglobin; PLT: platelets. ^bN/A: not applicable.

Table 4 Comparison of CDI Severity Scores in MLS_B Resistant C. difficile Between with and Without ermB Genes

Toxin Gene Pattern	CDI Severity Score		Nonparametric Tests
	Positive to ermB	Negative to ermB	Z value	P value
A^+B^+	2.17±0.41 (n=78)	2.25±0.62 (n=12)	−0.21	P= 0.836
A^−B^+	2.63±0.72 (n=81)	2.00 (n=7)	−2.41	P= 0.016

Table 5 Correlation Among CDI Severities, Genotypes and ermB of C. difficile with Resistance to MLS_B

Characteristics^a	Positive to ermB					Negative to ermB
	CDI Severity Score			Trend Chi-square test		CDI Severity Score			Trend Chi-square Test
	2(n=107)	3(n=40)	4(n=12)	x^2 value	P value	2(n=17)	3(n=1)	4(n=1)	x^2 value	P value
Toxin gene pattern
A^+B^+(n=90)	66(61.7%)	11(27.5%)	1(8.3%)^b	21.62	<0.001	10(58.8%)	1(100.0%)	1(100.0%)	1.10	0.509
A-B^+(n=88)	41(38.3%)	29(72.5%)	11(91.7%)^b			7(41.2%)	0(0.0%)	0(0.0%)
ST types^c
3(n=20)	13(2.1%)	4(10.0%)	0(0.0%)	1.35	0.311	2(11.8%)	0(0.0%)	1(100%)	3.67	0.158
35(n=14)	8(7.5%)	4(10.0%)	1(8.3%)	0.13	0.818	1(5.9%)	0(0.0%)	0(0.0%)	0.11	1.000
54(n=29)	21(19.6%)	2(5.0%)	0(0.0%)	6.80	0.010	5(29.4%)	1(100.0%)	0(0.0%)	<0.01	1.000
37(n=58)	21(19.6%)	22(55.0%)	9(75.0%)	26.38	<0.001	6(35.3%)	0(0.0%)	0(0.0%)	0.87	0.772
39(n=11)	7(6.5%)	3(7.5%)	0(0.0%)	0.29	0.632	1(5.9%)	0(0.0%)	0(0.0%)	0.11	1.000
81(n=19)	13(12.1%)	4(10.0%)	2(16.7%)	0.02	1.000	0(0.0%)	0(0.0%)	0(0.0%)	N/A^d	N/A
Other STs(n=27)	24(22.4%)	1(2.5%)	0(0.0%)	9.90	0.001	2(11.8%)	0(0.0%)	0(0.0%)	0.22	1.000

Notes: ^aIsolates with resistance to MLS_B. ^bThe number of A⁻B⁺ isolates was significantly more than those of A⁺B⁺ (x² = 8.61, P = 0.003). ^cThere were statistically significant differences in the CDI severity scores among different STs in ermB-positive isolates (x² = 36.77, P = 0.001). ^dN/A: not applicable.