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International Clostridium difficile Symposium 2010 – Special Issue
The Third International Clostridium
difficile Symposium took place from 22 to
24 September 2010 and was once again
held in Slovenia (www.mf.uni-mb.si/
mikro/icds2010). This time the location
was the picturesque alpine resort of Bled.
The meeting followed the previous two
successful meetings held in Kranjska Gora
in May 2004 and Maribor in June 2007.
Approximately 210 delegates from 29
countries in five continents attended the
Although the massive increase in
worldwide awareness of C. difficile
infections took place several years ago, the
infection continues to hit the headlines
and is a real cause for concern in many
countries. The programme kicked off with
a presentation by Mark Miller – with the
subtitle ‘There is so much we don’t know’.
The following two-and-a-bit days tried to
attempt to address some of these
unknowns, and achieved some success.
However, there remain many questions
without good answers and there will be
many opportunities in future meetings to
The seven sessions each began with an
invited lecture, and a further 22 oral
presentations were selected from the
offered papers. Also just over 100 posters
were presented in two day-long sessions.
The programme covered all of the
important aspects of C. difficile research:
clinical and molecular epidemiology in
man and domestic animals; toxins and
their action at the cellular and molecular
levels; other virulence factors; the host
response to CDI; spores of C. difficile: their
structures and susceptibilities to cleaning
agents; and prevention and control of CDI,
including novel antibiotic and non-
antibiotic therapies. Diagnosis also
featured largely with discussions on the
new generation of PCR-based diagnostics.
All authors who presented papers at the
meeting, either oral or poster, were invited
to submit their work for this special issue
of the Journal of Medical Microbiology. The
submissions were handled by the editorial
team of the journal and subjected to the
normal peer review process. The papers in
this special issue are the 25 that were
accepted. These represent the spectrum of
those presented at the meeting.
Papers on molecular epidemiology, an
extremely active area of research, account
for the majority of accepted papers.
Solomon et al. (2011) described an Irish
study investigating the diversity of
ribotypes 027 and 078 by repetitive-
extragenic palindromic PCR. Eckert et al.
(2011) described the more commonly used
multilocus variable-number tandem repeat
analysis (MLVA) to subtype French
C. difficile 027 isolates, and Broukhanski
et al. (2011) also employed MLVA to
investigate an outbreak of NAP1 and
defined criteria to interpret the results.
Janezic et al. (2011) used different
molecular typing methods to study
heterogeneity within toxinotypes V and III.
Elliott et al. (2011) identified new types of
toxin A-negative, toxin B-positive strains
among clinical isolates of C. difficile in
Australia. Rousseau et al. (2011) assessed
the prevalence and diversity of C. difficile
strains in infants.
Three papers are included on molecular
diagnostics: Avbersek et al. (2011)
compared real-time PCR methods with
enrichment culture, while the use of loop-
mediated isothermal amplification
(LAMP) technology was employed for the
identification of PCR ribotype 027 strains
(Kato & Arakawa, 2011). Zidaric et al.
(2011) compared two commercial
molecular tests for the detection of
C. difficile in the routine diagnostic
Pathogenesis, especially the host response
to infection, continues to be one of the
most difficult areas to study and is poorly
understood. Two review articles cover very
different aspects of this field: the molecular
action of clostridial toxins (Popoff & Geny,
2011) and the host response to C. difficile
infections (Kelly & Kyne, 2011). Metcalf &
Weese (2011) compared the full binary
toxin loci sequences from different
C. difficile ribotypes in an effort to further
the understanding of the regulation of the
binary toxin and its putative regulator.
Medeiros et al. (2011) have investigated
the role of the haem oxygenase/carbon
monoxide pathway in C. difficile toxin
A-induced enteritis in mice. The
importance of adherence in the
pathogenesis of CDI continues to be
debated, and a French group (Barketi-Klai
et al., 2011) have investigated the role of
fibronectin-binding protein A in C. difficile
intestinal colonization. The more
intensively researched non-toxin virulence
factors, the S-layer proteins (SLPs), are the
basis of two studies. The first demonstrated
that the SLPs obtained from epidemic and
hypervirulent C. difficile strains have
2011) and the second that 027 and 001
strains share common immunogenic
properties of the low-molecular-weight SLP
(Spigaglia et al., 2011). Buckley et al. (2011)
described the hamster model of CDI in
studies on an outbreak strain of 027 from
the UK. Passive immunity for CDI is not a
new idea but Mulvey et al. (2011) took an
interesting new slant on this approach,
using animal and cell adhesion assays to
determine the therapeutic potential of egg
yolk antibodies raised against putative
colonization factors for treating C. difficile
Although several papers were presented at
the meeting on C. difficile in animals, only
two have been included in this special
issue. Thean et al. (2011) showed that
C. difficile is much more common in
Australian horses than previously thought,
with the previously mentioned paper on
molecular detection (Avbersek et al., 2011)
employing animal isolates.
Although several genomes of C. difficile
have now been fully sequenced, it is useful
to go back to the originally sequenced
strain (630) and reannotate it to maintain
the accuracy and relevance of the
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information it contains. This has been
done here by Monot et al. (2011).
Three papers have been included on
antibiotics. Two are traditional
susceptibility studies: one from Poland
investigated the susceptibility of hospital
isolates from adult patients with diarrhoea
to some commonly used antibiotics as well
as some of the newer fluoroquinolones
(Pituch et al., 2011); the other looked
specifically at the disc diffusion test for
testing in vitro susceptibility to rifaximin
(Huhulescu et al., 2011). The final paper
on antibiotics investigated the killing
kinetics of fidaxomicin and its major
metabolite (OP-1118) (Babakhani et al.,
2011). This antibiotic is showing great
promise and may soon become an
important agent for treatment of CDI.
Removal/killing of spores of C. difficile by
disinfectants is a crucial measure in
infection control required to prevent CDI.
One paper addresses this issue but targeted
the decontamination of the laboratory
rather than the environment of the patient
and demonstrated the importance of
chlorine-releasing agents (Vohra &
Finally, as the result of discussions that
took place at the meeting between
interested attendees, a paper summarizing
the names of the cell wall proteins has been
written in an attempt to standardize
nomenclature (Fagan et al., 2011).
We look forward to the next (fourth)
International C. difficile Symposium
scheduled for autumn 2012, again in Bled,
Ian R. Poxton1and Maja Rupnik2
1Medical Microbiology, Centre for
Infectious Diseases, University of
Edinburgh College of Medicine and
Veterinary Medicine, The Chancellor’s
Building, 49 Little France Crescent,
Edinburgh EH16 4SB, UK
2University of Maribor, Faculty of
Medicine; Center of Excellence
CIPKEBIP, Ljubljana; Institute of Public
Health Maribor, Centre for Microbiology,
Prvomajska 1, 2000 Maribor, Slovenia
Correspondence: Ian R. Poxton
Avbersek, J., Cotman, M. & Ocepek, M. (2011).
Detection of Clostridium difficile in animals:
comparison of real-time PCR assays with the
culture method. J Med Microbiol 60, 1119–1125.
Babakhani, F., Gomez, A., Robert, N. & Sears, P.
(2011). Killing kinetics of fidaxomicin and its
major metabolite, OP-1118, against Clostridium
difficile. J Med Microbiol 60, 1213–1217.
Barketi-Klai, A., Hoys, S., Lambert-Bordes, S.,
Collignon, A. & Kansau, I. (2011). Role of
fibronectin-binding protein A in Clostridium
difficile intestinal colonization. J Med Microbiol
Bianco, M., Fedele, G., Quattrini,A., Spigaglia, P.,
Barbanti, F., Mastrantonio, P. & Ausiello, C. M.
(2011). Immunomodulatory activities of surface-
layer proteins obtained from epidemic and
hypervirulent Clostridium difficile strains. J Med
Microbiol 60, 1162–1167.
Broukhanski, G., Simor, A. & Pillai, D. R. (2011).
Defining criteria to interpret multilocus
variable-number tandem repeat analysis to aid
Clostridium difficile outbreak investigation.
J Med Microbiol 60, 1095–1100.
Buckley, A. M., Spencer, J., Candlish, D., Irvine,
J. J. & Douce, G. R. (2011). Infection of hamsters
with the UK Clostridium difficile ribotype 027
outbreak strain R20291. J Med Microbiol 60,
Eckert, C., Vromman, F., Halkovich, A. &
Barbut, F. (2011). Multilocus variable-number
tandem repeat analysis: a helpful tool for
subtyping French Clostridium difficile PCR
ribotype 027 isolates. J Med Microbiol 60, 1088–
Elliott, B., Squire, M. M., Thean, S., Chang, B. J.,
Brazier, J. S., Rupnik, M. & Riley, T. V.(2011). New
types of toxin A-negative, toxin B-positive strains
among clinical isolates of Clostridium difficile in
Australia. J Med Microbiol 60, 1108–1111.
Fagan, R. P., Janoir, C., Collignon, A.,
Mastrantonio, P., Poxton, I. R. & Fairweather,
N. F. (2011). A proposed nomenclature for cell
wall proteins of Clostridium difficile. J Med
Microbiol 60, 1225–1228.
Huhulescu, S., Sagel, U., Fiedler, A., Pecavar, V.,
Blaschitz, M., Wewalka, G., Allerberger, F. &
Indra, A. (2011). Rifaximin disc diffusion test for
in vitro susceptibility testing of Clostridium
difficile. J Med Microbiol 60, 1206–1212.
Janezic,S., Indra,A.,Allerberger,F. & Rupnik,M.
(2011). Use of different molecular typing
methods for the study of heterogeneity within
Clostridium difficile toxinotypes V and III. J Med
Microbiol 60, 1101–1107.
Kato, H. & Arakawa, Y. (2011). Use of the loop-
mediated isothermal amplification method for
identification of PCR ribotype 027 Clostridium
difficile. J Med Microbiol 60, 1126–1130.
Kelly, C. P. & Kyne, L. (2011). The host immune
response to Clostridium difficile. J Med Microbiol
Medeiros, C. A., Warren, C. A., Freire, R., Vieira,
C. A., Lima, B. B., Vale, M. L., Ribeiro, R. A.,
Souza, M. H. & Brito, G. A. (2011). Role of the
haem oxygenase/carbon monoxide pathway in
Clostridium difficile toxin A-induced enteritis in
mice. J Med Microbiol 60, 1146–1154.
Metcalf, D. S. & Weese, J. S. (2011). Binary
toxin locus analysis in Clostridium difficile.
J Med Microbiol 60, 1137–1145.
Monot, M., Boursaux-Eude, C., Thibonnier, M.,
Vallenet, D., Moszer, I., Medigue, C., Martin-
Verstraete, I. & Dupuy, B. (2011). Reannotation
of the genome sequence of Clostridium difficile
strain 630. J Med Microbiol 60, 1193–1199.
Mulvey, G. L., Dingle, T. C., Fang, L., Strecker, J.
& Armstrong, G. D. (2011). Therapeutic
potential of egg yolk antibodies for treating
Clostridium difficile infection. J Med Microbiol
Pituch, H., Obuch-Woszczatyn ´ski, P.,
Wultan ´ska, D., Nurzyn ´ska, G., Harmanus, C.,
Banaszkiewicz, A., Radzikowski, A., Łuczak, M.,
van Belkum, A. & Kuijper, E. (2011).
Characterization and antimicrobial susceptibility
of Clostridium difficile strains isolated from adult
patients with diarrhoea hospitalized in two
university hospitals in Poland, 2004–2006. J Med
Microbiol 60, 1200–1205.
Popoff, M. R. & Geny, B. (2011). Rho/Ras-
GTPase-dependent and -independent activity of
clostridial glucosylating toxins. J Med Microbiol
Rousseau, C., Leme ´e, L., Le Monnier, A.,
Poilane, I., Pons, J.-L. & Collignon, A. (2011).
Prevalence and diversity of Clostridium difficile
strains in infants. J Med Microbiol 60, 1112–
Solomon, K., Murray, S., Scott,L., McDermott, S.,
Drudy, D., Martin, A., O’Donoghue, C., Skally, M.,
Burns, K. & other authors (2011). An
investigation of subtype diversity of clinical
isolates of Irish Clostridium difficile ribotypes 027
and 078 by repetitive-extragenic palindromic
PCR. J Med Microbiol 60, 1080–1087.
Spigaglia, P., Galeotti, C. L., Barbanti, F.,
Scarselli, M., Van Broeck, J. & Mastrantonio, P.
(2011). The LMW surface-layer proteins of
Clostridium difficile PCR ribotypes 027 and 001
share common immunogenic properties. J Med
Microbiol 60, 1168–1173.
Thean, S., Elliott, B. & Riley, T. V. (2011).
Clostridium difficile in horses in Australia – a
preliminary study. J Med Microbiol 60, 1188–1192.
Vohra, P. & Poxton, I. R. (2011). Efficacy of
decontaminants and disinfectants against
Clostridium difficile. J Med Microbiol 60, 1218–
Zidaric ˇ, V., Kotnik Kevorkijan, B., Oresic, N.,
Janezic, S. & Rupnik, M. (2011). Comparison of
two commercial molecular tests for the
detection of Clostridium difficile in the routine
diagnostic laboratory. J Med Microbiol 60, 1131–
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