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Nature Genetics
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Emergence and global spread of epidemic healthcare-associatedClostridium difficile

Nature Geneticsvolume 45, pages109–113 (2013)Cite this article

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Abstract

EpidemicC. difficile (027/BI/NAP1) has rapidly emerged in the past decade as the leading cause of antibiotic-associated diarrhea worldwide. However, the key events in evolutionary history leading to its emergence and the subsequent patterns of global spread remain unknown. Here, we define the global population structure ofC. difficile 027/BI/NAP1 using whole-genome sequencing and phylogenetic analysis. We show that two distinct epidemic lineages, FQR1 and FQR2, not one as previously thought, emerged in North America within a relatively short period after acquiring the same fluoroquinolone resistance–conferring mutation and a highly related conjugative transposon. The two epidemic lineages showed distinct patterns of global spread, and the FQR2 lineage spread more widely, leading to healthcare-associated outbreaks in the UK, continental Europe and Australia. Our analysis identifies key genetic changes linked to the rapid transcontinental dissemination of epidemicC. difficile 027/BI/NAP1 and highlights the routes by which it spreads through the global healthcare system.

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Figure 1: Phylogeny ofC. difficile 027/BI/NAP1 based on the genotype at core genome SNPs.
Figure 2: Transmission events inferred for epidemicC. difficile 027/BI/NAP1.

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Acknowledgements

We are grateful to members of the European Study Group ofClostridium difficile (ESGCD), a working group of ESCMID (European Society of Clinical Microbiology and Infectious Diseases), including F. Barbut, T. Eckmanns, M.L. Lambert, F. Fitzpatrick, C. Wiuff, H. Pituch, P. Reichert, A.F. Widmer, F. Allerberger, D.W. Notermans, M. Delmée, R. Frei, O. Lyytikäinen, A. Ingebretsen and I.R. Poxton. We thank the Wellcome Trust Sanger Institute sequencing and informatics teams. This project was funded by the Wellcome Trust (grants 098051 and 086418), a Medical Research Council New Investigator Research Grant (T.D.L.; grant 93614) and the Scottish Infection Research Network. We acknowledge funding from the National Institute for Health Research (NIHR) Biomedical Research Centre in Liverpool. Both F.M. and P.R. were supported by the Liverpool BRC (Biomedical Research Centre). M.P. is an NIHR Senior Investigator.

Author information

Authors and Affiliations

  1. Wellcome Trust Sanger Institute, Hinxton, Cambridge, UK

    Miao He, Louise Ellison, Derek J Pickard, Thomas R Connor, Simon R Harris, Sharon J Peacock, Gordon Dougan, Julian Parkhill & Trevor D Lawley

  2. Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK

    Fabio Miyajima, Paul Roberts & Munir Pirmohamed

  3. University of Liverpool and Royal Liverpool and Broadgreen University Hospital National Health Service (NHS) Trust, Liverpool, UK

    Fabio Miyajima, Paul Roberts & Munir Pirmohamed

  4. Department of Pathogen Molecular Biology, London School of Hygiene and Tropical Medicine, London, UK

    Melissa J Martin & Brendan W Wren

  5. Belfast Health and Social Trust, Belfast, UK

    Derek Fairley

  6. Department of Infectious Diseases and Immunity, Imperial College London, London, UK

    Kathleen B Bamford & Stephanie D'Arc

  7. Department of Bacteriology, Imperial College Healthcare NHS Trust, London, UK

    Kathleen B Bamford & Stephanie D'Arc

  8. Anaerobic Reference Laboratory, Cardiff, UK

    Jon Brazier

  9. Scottish Salmonella, Shigella and Clostridium difficile Reference Laboratory, Glasgow, UK

    Derek Brown, John E Coia & Gill Douce

  10. Hines VA Hospital, Hines, Illinois, USA

    Dale Gerding

  11. College of Medicine, Yonsei University, Seoul, South Korea

    Hee Jung Kim

  12. Department of Pathology, Singapore General Hospital, Singapore

    Tse Hsien Koh

  13. Department of Bacteriology, National Institute of Infectious Diseases, Tokyo, Japan

    Haru Kato & Mitsutoshi Senoh

  14. Department of Microbiology, Immunology & Infectious Diseases, University of Calgary, Calgary, Alberta, Canada

    Tom Louie

  15. College of Life and Environmental Sciences, University of Exeter, Exeter, UK

    Stephen Michell & Emma Butt

  16. Department of Medicine, University of Cambridge, Cambridge, UK

    Sharon J Peacock

  17. Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

    Sharon J Peacock & Nick M Brown

  18. Health Protection Agency, London, UK

    Sharon J Peacock & Nick M Brown

  19. School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Western Australia, Australia

    Tom Riley

  20. Department of Veterinary Microbiology and Preventive Medicine, Iowa State University, Ames, Iowa, USA

    Glen Songer

  21. Healthcare Associate Infection Research Group, University of Leeds, Leeds, UK

    Mark Wilcox

  22. Department of Experimental Microbiology, Leiden University Medical Centre, Leiden, The Netherlands

    Ed Kuijper

  23. School of Immunity and Infection, University of Birmingham, Birmingham, UK

    Peter Hawkey

Authors
  1. Miao He
  2. Fabio Miyajima
  3. Paul Roberts
  4. Louise Ellison
  5. Derek J Pickard
  6. Melissa J Martin
  7. Thomas R Connor
  8. Simon R Harris
  9. Derek Fairley
  10. Kathleen B Bamford
  11. Stephanie D'Arc
  12. Jon Brazier
  13. Derek Brown
  14. John E Coia
  15. Gill Douce
  16. Dale Gerding
  17. Hee Jung Kim
  18. Tse Hsien Koh
  19. Haru Kato
  20. Mitsutoshi Senoh
  21. Tom Louie
  22. Stephen Michell
  23. Emma Butt
  24. Sharon J Peacock
  25. Nick M Brown
  26. Tom Riley
  27. Glen Songer
  28. Mark Wilcox
  29. Munir Pirmohamed
  30. Ed Kuijper
  31. Peter Hawkey
  32. Brendan W Wren
  33. Gordon Dougan
  34. Julian Parkhill
  35. Trevor D Lawley

Contributions

M.H. analyzed the data. T.D.L., M.H., G. Dougan, B.W.W. and J.P. were involved in the study design. F.M., P.R., L.E., D.J.P., M.J.M., D.F., K.B.B., S.D., J.B., D.B., J.E.C., G. Douce, D.G., H.J.K., T.H.K., H.K., M.S., T.L., S.M., E.B., S.J.P., N.M.B., T.R., G.S., M.W., M.P., E.K., P.H. and B.W.W. were involved in isolate collection and DNA extraction. T.R.C. contributed to Bayesian analysis. M.H., J.P., T.D.L., G. Dougan, T.R.C. and S.R.H. contributed to data interpretation. M.H., J.P., T.D.L. and G. Dougan wrote the manuscript.

Corresponding authors

Correspondence toJulian Parkhill orTrevor D Lawley.

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Competing interests

The authors declare no competing financial interests.

Supplementary information

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Supplementary Figures 1–8, Supplementary Tables 1–6 and Supplementary Note (PDF 1606 kb)

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He, M., Miyajima, F., Roberts, P.et al. Emergence and global spread of epidemic healthcare-associatedClostridium difficile.Nat Genet45, 109–113 (2013). https://doi.org/10.1038/ng.2478

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