Clostridium difficile genotypes other than ribotype 078 that are prevalent among human, animal and environmental isolates
© Janezic et al; licensee BioMed Central Ltd. 2012
Received: 2 September 2011
Accepted: 27 March 2012
Published: 27 March 2012
Characterising the overlap of C. difficile genotypes in different reservoirs can improve our understanding of possible transmission routes of this pathogen. Most of the studies have focused on a comparison of the PCR ribotype 078 isolated from humans and animals. Here we describe for the first time a comparison of C. difficile genotypes isolated during longer time intervals from different sources including humans, animals and the non-hospital environment.
Altogether 786 isolates from time interval 2008-2010 were grouped into 90 PCR ribotypes and eleven of them were shared among all host types and the environment. Ribotypes that were most common in humans were also present in water and different animals (014/020, 002, 029). Interestingly, non-toxigenic isolates were very common in the environment (30.8%) in comparison to humans (6.5%) and animals (7.7%). A high degree of similarity was observed for human and animal isolates with PFGE. In human isolates resistance to erithromycin, clindamycin and moxifloxacin was detected, while all animal isolates were susceptible to all antibiotics tested.
Our results show that many other types in addition to PCR Ribotype 078 are shared between humans and animals and that the most prevalent genotypes in humans have the ability to survive also in the environment and several animal hosts. The genetic relatedness observed with PFGE suggests that transmission of given genotype from one reservoir to the other is likely to occur.
Intestinal diseases caused by Clostridium difficile, mainly after antibiotic treatment, ranges from mild self-limiting diarrhoea to life-threatening pseudomembranous colitis (PMC) and were until recently most commonly seen in hospitalized elderly patients . However, the incidence of community-onset C. difficile infection has increased [2–4] and C. difficile has also emerged as a pathogen or commensal in different animals such as pigs, calves and chickens [5–7]. Studies on C. difficile in the environment are sparse and describe its presence in soil and water [8–11]. For both, environmental contamination and community-associated human infections, animals have been suggested as possible reservoir [5, 12, 13].
The most prevalent PCR ribotypes differ between humans and food animals. In bovine and porcine hosts PCR ribotype 078 (corresponding to NAP7 and NAP8 by PFGE) is most often detected [14–16]. In humans approximately 300 PCR ribotypes are recognized and the most prevalent in many European countries is PCR ribotype 014/020 (toxinotype 0) . However, in both animals and humans, the distribution of ribotypes is different between countries and from setting to setting, although the heterogeneity is much lower in animals compared to humans. Two large pan-European studies have shown these geographic differences for human-associated C. difficile[17, 18]. Commonly identified PCR ribotypes for which only regional spreading is suggested are 106, the predominant strain in the UK, ribotype 053 in Austria and 018 which is predominant in Italy [19, 20]. In the United States and Canada NAP1, corresponding to PCR ribotype 027 is one of the predominant strains in humans, and in Japan and Korea PCR ribotype 017/toxinotype VIII (A-B+) strain is responsible for CDI outbreaks [21, 22].
Most of the comparative studies on C. difficile genotypes in humans and food animals have focused on ribotype 078 strain comparisons [23–25]. In addition to being the most frequently isolated strain from pigs and calves in North America and the Netherlands [14–16] it is becoming prevalent in humans in hospitals [17, 26] and in the community . It is also often the most prevalent ribotype isolated from food [13, 27]. Some other currently important human ribotypes (027, 017) are also reported from animals,  but they seem to be less well established in animal hosts. There is currently no published report comparing a large number of strains isolated in the same geographic region from different sources, including humans, animals and the environment. This study makes such a comparison of C. difficile strains isolated from three of the possible main reservoirs in a single country to show that ribotypes other than 078 are shared between host types and the environment.
Results and discussion
Distribution of PCR ribotypes in different hosts and the environment
Most prevalent PCR ribotypes in humans, animals and the environment isolated between 2008 and 2010
(n = 601)
(n = 104)
(n = 81)
014/020/0 or I
001/072/0, tox- or XXIV (CDT+)§
As already mentioned, most publications dealing with comparisons of animal and human strains focus on porcine ribotype 078 strains and suggest that pig farms can be an important emerging source of human infection or colonization [23, 24]. Our previous studies have shown that ribotype 078 can be completely absent in animals in a given country and that ribotypes other than PCR ribotype 078 (toxinotype V) are prevalent in pigs and other farm animals in Slovenia [7, 29, 30]. PCR ribotype 078 (toxinotype V) has been found only in humans in Slovenia; of six isolates identified, five came from stool specimens and one from an infected wound. PCR ribotype 126 (toxinotype V and highly related to ribotype 078) has been found in humans (7 isolates) and rivers (1 isolate).
Current epidemic strain, PCR ribotype 027/toxinotypeIII/NAP1 was reported in domestic animals and their environment mostly in Canadian studies [16, 31, 32]. Our collection did not include any animal 027 strain. First human PCR ribotype 027 strain was identified only in 2010 and this type accounted for as little as 2.7% (16/601) of all human isolates (see Additional file 1: Table S1).
Characterisation of most common PCR ribotypes found in animals and humans
Due to the large number of isolates available (n = 1078) only a subset of representative strains from the most common PCR ribotypes found in humans and animals were further characterized with PFGE and antimicrobial susceptibility testing. Selected strains belonged to 7 different PCR ribotypes: 014/020/(toxinotype 0), 010/(non-toxigenic strain; tox-), SLO 055/(tox-), 023/(toxinotype IV), 029/(toxinotype 0), 002/(toxinotype 0) and 150/(toxinotype 0). A single strain of PCR ribotype SLO 055 was included in the comparison as its PCR ribotyping profile is very similar to the profile of PCR ribotype 010.
A great focus has been given on pigs as a source of human CDI. Poultry which can harbour a variety of human associated PCR ribotypes has been so far overlooked . Two human and one poultry isolate of ribotype 023 (toxinotype IV, binary toxin positive) had indistinguishable banding pattern with Sma I and belonged to the same pulsotype with Sac II (group 5 on Figure 2). For companion animals (dogs and cats) has also been shown to harbour the same ribotypes as humans [15, 33]. In our study, one dog and one cat isolate of PCR ribotype 014/020 had identical banding pattern as the human isolates of the same PCR ribotype using Sma I restriction enzyme and belonged to the same pulsotype when Sac II restriction patterns were compared (group 4 on Figure 2).
The genetic relatedness of human and animal isolates shown in this study suggests that not only ribotype 078 strains show zoonotic potential. Other ribotypes are shared between animals and humans as well, and that alongside porcine and cattle, poultry can also be an important link for human CDI. Whether and how often the transmission from animals to humans and/or vice versa occurs have yet to be determined.
MIC ranges of most common PCR ribotypes isolated from humans and animals
002 (n = 11)
023 (n = 7)
029 (n = 4)
014/020 (n = 18)
0.38- > 256
0.38- > 256
1.5- > 256
010 (n = 6)
0.38- > 256
0.75- > 256
1- > 256
150 (n = 3)
MIC50/90 values of human and animal C.difficile isolates
Humans (n = 32)
0.38- > 256
0.50- > 256
1- > 256
Animals (n = 18)
All (n = 50)
0.38- > 256
0.19- > 256
0.023- > 256
Ribotype 078 is not the only ribotype significantly shared between humans and animals. Here we show that all genotypes that are among most prevalent in (hospitalized) humans have a tendency to prevail also in animals and in the environment (river water) and that a better environmental survival might be part of their virulence spectrum. Human and animal isolates of the same PCR ribotype clustered together with PFGE and had mostly also similar MIC values for all antibiotics tested. This genetic relatedness suggests that transmission of given genotype from one reservoir to the other is likely to occur.
Materials and methods
C. difficile isolates
Isolates included in the comparison originated from humans, animals and the non-hospital environment and are part of the strain collection at the Institute of Public Health Maribor. Altogether 1078 isolates from Slovenia were available. Isolates from all three reservoirs were sampled from the overlapping geographical locations and time periods.
Human isolates (n = 690) were recovered by routine diagnostic laboratories throughout Slovenia and submitted to our laboratory for typing between 2006 and 2010. The isolates were from hospitalized patients and from patient from other institutions (less than 1% of all isolates), and were not submitted as a part of an outbreak investigation.
Environmental isolates were from river water (n = 77) and soil (n = 4), and were isolated between 2008 and 2010. River water isolates from 17 rivers throughout Slovenia were collected as a part of the national surveillance of surface waters. Soil isolates originated from the field near the poultry farm from which poultry samples were collected. The isolates were cultured as described elsewhere .
Animal isolates (n = 307) were from piglets (n = 138), calves (n = 6), a horse (n = 1), poultry and birds (n = 150), and dogs and cats (n = 12) isolated between 2006 and 2010. Piglet isolates (including symptomatic and asymptomatic animals) were from 9 pig farms located in different parts of Slovenia. Poultry isolates were from two big facility for laying hens and three smaller farms. Dog, cat and calf isolates were from different Slovenian households and farms. Stool samples or rectal swabs collected from these animals were processed as described elsewhere [7, 29]. Due to the clustering (i.e. large number of isolates from the same animal farm), only 156 animal isolates (piglets (n = 16), poultry and birds (n = 121), dogs and cats (n = 12), calves (n = 6) and a horse) were included in the final analysis (only a single strain isolated per sampling and per farm).
The final number of isolates included in the comparison of prevalence and distribution of PCR ribotypes was 786 (601 from human, 104 from animals and 81 from the environment) from the time period 2008-10, as for this time period environmental strains were available. For the PFGE and antimicrobial susceptibility testing of human and animal strains, 50 isolates from broader time interval (2006-2010) were selected.
All isolates were characterised by toxinotyping and PCR ribotyping. Toxinotyping involved amplification and subsequent restriction of PCR fragment A3 (part of tcd A) and B1 (part of tcd B). PaLoc negative strains were confirmed by amplification of a 115 bp-long insert with primers Lok1/Lok3 . The binary toxin gene (cdt B) was detected as described previously .
PCR ribotyping was performed with the primers 16S (5'-GTGCGGCTGGATCACCTCCT) and 23S (5'-CCCTGCACCCTTAATAACTTGACC) as described by Bidet et al. (1999) . After amplification PCR products were concentrated to a final volume of 25 μl by heating at 75°C for 45 min before electrophoresis in 3% agarose gel (Bio-Rad, USA) in 1× TAE buffer for 5 h at 2.5 V/cm. BioNumerics software (Applied Maths, Belgium) version 6.10 was used to analyze the banding patterns. PCR ribotypes for which reference strains were available were designated by standard Cardiff nomenclature (002, 029...; 46 Cardiff type strains were available in our laboratory for comparisons) while others were designated by internal nomenclature (SLO and 3-digit code).
A total of 50 C. difficile isolates of the most prevalent PCR ribotypes found in humans and animals isolated between 2006 and 2010 were further analyzed with PFGE and antimicrobial susceptibility testing. Selection of the strains was made by randomly selecting human and animal strains isolated in the same time period and from the same geographic locations covering different Slovenian regions. These included 32 human isolates and 18 animal isolates from pigs (n = 3), poultry (n = 8), a cat (n = 1), calves (n = 2) and dogs (n = 4).
Pulsed field gel electrophoresis
PFGE was performed as described elsewhere . Genomic DNA was digested with 15 U of Sac II or Sma I (New England BioLabs, UK) overnight and Biometra PFGE System (Biometra, Germany) was used for electrophoresis. Dendrograms were constructed using BioNumerics software 6.10 (Applied Maths, Belgium) by the UPGMA clustering method, using the Dice coefficient with position tolerance and optimization of 1.10%. Clusters with ≥ 80% (Sma I) or ≥ 85% (Sac II) similarity were considered to be distinct pulsotypes.
Antimicrobial susceptibility testing
The same strains typed by PFGE were also tested for antibiotic resistance. Minimum inhibitory concentrations (MICs) of 6 antimicrobial agents; rifampicin (RIF), moxifloxacin (MXF), erythromycin (ERY), piperacilin/tazobactam (TZP), tetracycline (TET) and clindamycin CLI), were determined by the E-test method. An inoculum of McFarland 1.0 was swabbed on Brucella blood agar supplemented with haemin (5 μg/mL) and vitamin K1 (1 μg/ml). Plates were incubated for 48 h at 37°C in an anaerobic atmosphere. Bacteroides thetaiotaomicron ATCC 29741 was used as a quality control strain. Resistance was defined according the following breakpoints established by the CLSI guidelines: clindamycin (CLI) ≥ 8 mg/l, tetracycline (TET) ≥ 16 mg/l, piperacillin/tazobactam (TZP) ≥ 128 mg/l, moxifloxacin (MXF) ≥ 8 mg/l, erythromycin (ERY) ≥ 8 mg/l and rifampicin (RIF) ≥ 4 mg/l [38, 39]. MIC50 and MIC90 were calculated for human and animal isolates. The frequencies at which the MICs for human isolates were above the MIC50 and MIC90 values for all isolates tested were compared with Fisher's exact t test.
The research leading to these results has received funding from European Communities 7th Framework programme (FP7/2007-2011) under grant agreement No. 223585 (MR), and the Slovenian Research Agency (grant 1000-08-310144 and J4-2236). Part of this work was presented as a poster (P1408) at 20th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), 2010, Vienna, Austria.
- Rupnik M, Wilcox MH, Gerding DN: Clostridium difficile infection: new developments in epidemiology and pathogenesis. Nat Rev Microbiol. 2009, 7 (7): 526-536. 10.1038/nrmicro2164.PubMedView ArticleGoogle Scholar
- Chernak EJCC, Weltman A, McDonald LC, Wiggs L, Killgore G, Thompson A, LeMaile-Williams M, Tan E, Lewis FM: Severe Clostridium difficile-associated disease in population previously at low risk-four states, 2005. Morb Mortal Wkly Rep. 2005, 54: 1201-1205.Google Scholar
- Limbago BM, Long CM, Thompson AD, Killgore GE, Hannett GE, Havill NL, Mickelson S, Lathrop S, Jones TF, Park MM, et al.: Clostridium difficile strains from community-associated infections. J Clin Microbiol. 2009, 47 (9): 3004-3007. 10.1128/JCM.00964-09.PubMedPubMed CentralView ArticleGoogle Scholar
- Wilcox MH, Mooney L, Bendall R, Settle CD, Fawley WN: A case-control study of community-associated Clostridium difficile infection. J Antimicrob Chemother. 2008, 62 (2): 388-396. 10.1093/jac/dkn163.PubMedView ArticleGoogle Scholar
- Gould LH, Limbago B: Clostridium difficile in food and domestic animals: a new foodborne pathogen?. Clin Infect Dis. 2010, 51 (5): 577-582. 10.1086/655692.PubMedView ArticleGoogle Scholar
- Weese JS, Reid-Smith RJ, Avery BP, Rousseau J: Detection and characterization of Clostridium difficile in retail chicken. Lett Appl Microbiol. 2010, 50 (4): 362-365. 10.1111/j.1472-765X.2010.02802.x.PubMedView ArticleGoogle Scholar
- Zidaric V, Zemljic M, Janezic S, Kocuvan A, Rupnik M: High diversity of Clostridium difficile genotypes isolated from a single poultry farm producing replacement laying hens. Anaerobe. 2008, 14 (6): 325-327. 10.1016/j.anaerobe.2008.10.001.PubMedView ArticleGoogle Scholar
- al Saif N, Brazier JS: The distribution of Clostridium difficile in the environment of South Wales. J Med Microbiol. 1996, 45 (2): 133-137. 10.1099/00222615-45-2-133.PubMedView ArticleGoogle Scholar
- Al-Saif NM, O'Neill GL, Magee JT, Brazier JS, Duerden BI: PCR-ribotyping and pyrolysis mass spectrometry fingerprinting of environmental and hospital isolates of Clostridium difficile. J Med Microbiol. 1998, 47 (2): 117-121. 10.1099/00222615-47-2-117.PubMedView ArticleGoogle Scholar
- Baverud V, Gustafsson A, Franklin A, Aspan A, Gunnarsson A: Clostridium difficile: prevalence in horses and environment, and antimicrobial susceptibility. Equine Vet J. 2003, 35 (5): 465-471.PubMedView ArticleGoogle Scholar
- Zidaric V, Beigot S, Lapajne S, Rupnik M: The occurrence and high diversity of Clostridium difficile genotypes in rivers. Anaerobe. 2010, 16 (4): 371-375. 10.1016/j.anaerobe.2010.06.001.PubMedView ArticleGoogle Scholar
- Rupnik M, Songer JG: Clostridium difficile Its Potential as a Source of Foodborne Disease. Adv Food Nutr Res. 2010, 60: 53-66.PubMedView ArticleGoogle Scholar
- Weese JS: Clostridium difficile in food-innocent bystander or serious threat?. Clin Microbiol Infect. 2010, 16 (1): 3-10. 10.1111/j.1469-0691.2009.03108.x.PubMedView ArticleGoogle Scholar
- Goorhuis A, Debast SB, van Leengoed LA, Harmanus C, Notermans DW, Bergwerff AA, Kuijper EJ: Clostridium difficile PCR ribotype 078: an emerging strain in humans and in pigs?. J Clin Microbiol. 2008, 46 (3): 1157-10.1128/JCM.01536-07. author reply 1158PubMedPubMed CentralView ArticleGoogle Scholar
- Keel K, Brazier JS, Post KW, Weese S, Songer JG: Prevalence of PCR ribotypes among Clostridium difficile isolates from pigs, calves, and other species. Journal of Clinical Microbiology. 2007, 45 (6): 1963-1964. 10.1128/JCM.00224-07.PubMedPubMed CentralView ArticleGoogle Scholar
- Rodriguez-Palacios A, Stampfli HR, Duffield T, Peregrine AS, Trotz-Williams LA, Arroyo LG, Brazier JS, Weese JS: Clostridium difficile PCR ribotypes in calves, Canada. Emerg Infect Dis. 2006, 12 (11): 1730-1736. 10.3201/eid1211.051581.PubMedPubMed CentralView ArticleGoogle Scholar
- Bauer MP, Notermans DW, van Benthem BH, Brazier JS, Wilcox MH, Rupnik M, Monnet DL, van Dissel JT, Kuijper EJ: Clostridium difficile infection in Europe: a hospital-based survey. Lancet. 2011, 377 (9759): 63-73. 10.1016/S0140-6736(10)61266-4.PubMedView ArticleGoogle Scholar
- Barbut F, Mastrantonio P, Delmee M, Brazier J, Kuijper E, Poxton I: Prospective study of Clostridium difficile infections in Europe with phenotypic and genotypic characterisation of the isolates. Clin Microbiol Infect. 2007, 13 (11): 1048-1057. 10.1111/j.1469-0691.2007.01824.x.PubMedView ArticleGoogle Scholar
- Indra A, Schmid D, Huhulescu S, Hell M, Gattringer R, Hasenberger P, Fiedler A, Wewalka G, Allerberger F: Characterization of clinical Clostridium difficile isolates by PCR ribotyping and detection of toxin genes in Austria, 2006-2007. J Med Microbiol. 2008, 57 (Pt 6): 702-708.PubMedView ArticleGoogle Scholar
- Spigaglia P, Barbanti F, Dionisi AM, Mastrantonio P: Clostridium difficile isolates resistant to fluoroquinolones in Italy: emergence of PCR ribotype 018. J Clin Microbiol. 2010, 48 (8): 2892-2896. 10.1128/JCM.02482-09.PubMedPubMed CentralView ArticleGoogle Scholar
- Kim H, Jeong SH, Roh KH, Hong SG, Kim JW, Shin MG, Kim MN, Shin HB, Uh Y, Lee H, et al.: Investigation of toxin gene diversity, molecular epidemiology, and antimicrobial resistance of Clostridium difficile isolated from 12 hospitals in South Korea. Korean J Lab Med. 2010, 30 (5): 491-497. 10.3343/kjlm.2010.30.5.491.PubMedView ArticleGoogle Scholar
- MacCannell DR, Louie TJ, Gregson DB, Laverdiere M, Labbe AC, Laing F, Henwick S: Molecular analysis of Clostridium difficile PCR ribotype 027 isolates from Eastern and Western Canada. J Clin Microbiol. 2006, 44 (6): 2147-2152. 10.1128/JCM.02563-05.PubMedPubMed CentralView ArticleGoogle Scholar
- Bakker D, Corver J, Harmanus C, Goorhuis A, Keessen EC, Fawley WN, Wilcox MH, Kuijper EJ: Relatedness of human and animal Clostridium difficile PCR ribotype 078 isolates determined on the basis of multilocus variable-number tandem-repeat analysis and tetracycline resistance. J Clin Microbiol. 2010, 48 (10): 3744-3749. 10.1128/JCM.01171-10.PubMedPubMed CentralView ArticleGoogle Scholar
- Debast SB, van Leengoed LA, Goorhuis A, Harmanus C, Kuijper EJ, Bergwerff AA: Clostridium difficile PCR ribotype 078 toxinotype V found in diarrhoeal pigs identical to isolates from affected humans. Environ Microbiol. 2009, 11 (2): 505-511. 10.1111/j.1462-2920.2008.01790.x.PubMedView ArticleGoogle Scholar
- Jhung MA, Thompson AD, Killgore GE, Zukowski WE, Songer G, Warny M, Johnson S, Gerding DN, McDonald LC, Limbago BM: Toxinotype V Clostridium difficile in humans and food animals. Emerg Infect Dis. 2008, 14 (7): 1039-1045. 10.3201/eid1407.071641.PubMedPubMed CentralView ArticleGoogle Scholar
- Rupnik M, Widmer A, Zimmermann O, Eckert C, Barbut F: Clostridium difficile toxinotype V, ribotype 078, in animals and humans. J Clin Microbiol. 2008, 46 (6): 2146-10.1128/JCM.00598-08.PubMedPubMed CentralView ArticleGoogle Scholar
- Songer JG, Trinh HT, Killgore GE, Thompson AD, McDonald LC, Limbago BM: Clostridium difficile in retail meat products, USA, 2007. Emerg Infect Dis. 2009, 15 (5): 819-821. 10.3201/eid1505.081071.PubMedPubMed CentralView ArticleGoogle Scholar
- Simango C: Prevalence of Clostridium difficile in the environment in a rural comm. unity in Zimbabwe. Trans R Soc Trop Med Hyg. 2006, 100 (12): 1146-1150. 10.1016/j.trstmh.2006.01.009.PubMedView ArticleGoogle Scholar
- Avbersek J, Janezic S, Pate M, Rupnik M, Zidaric V, Logar K, Vengust M, Zemljic M, Pirs T, Ocepek M: Diversity of Clostridium difficile in pigs and other animals in Slovenia. Anaerobe. 2009, 15 (6): 252-255. 10.1016/j.anaerobe.2009.07.004.PubMedView ArticleGoogle Scholar
- Pirs T, Ocepek M, Rupnik M: Isolation of Clostridium difficile from food animals in Slovenia. J Med Microbiol. 2008, 57 (Pt 6): 790-792.PubMedView ArticleGoogle Scholar
- Weese JS, Finley R, Reid-Smith RR, Janecko N, Rousseau J: Evaluation of Clostridium difficile in dogs and the household environment. Epidemiol Infect. 2010, 138 (8): 1100-1104. 10.1017/S0950268809991312.PubMedView ArticleGoogle Scholar
- Lefebvre SL, Weese JS: Contamination of pet therapy dogs with MRSA and Clostridium difficile. J Hosp Infect. 2009, 72 (3): 268-269. 10.1016/j.jhin.2009.02.019.PubMedView ArticleGoogle Scholar
- Koene MG, Mevius D, Wagenaar JA, Harmanus C, Hensgens MP, Meetsma AM, Putirulan FF, van Bergen MA, Kuijper EJ: Clostridium difficile in Dutch animals: their presence, characteristics and similarities with human isolates. Clin Microbiol Infect. 2011, doi: 10.1111/j.1469-0691.2011.03651.xGoogle Scholar
- Rupnik M, Avesani V, Janc M, von Eichel-Streiber C, Delmee M: A novel toxinotyping scheme and correlation of toxinotypes with serogroups of Clostridium difficile isolates. J Clin Microbiol. 1998, 36 (8): 2240-2247.PubMedPubMed CentralGoogle Scholar
- Stubbs S, Rupnik M, Gibert M, Brazier J, Duerden B, Popoff M: Production of actin-specific ADP-ribosyltransferase (binary toxin) by strains of Clostridium difficile. FEMS Microbiol Lett. 2000, 186 (2): 307-312. 10.1111/j.1574-6968.2000.tb09122.x.PubMedView ArticleGoogle Scholar
- Bidet P, Barbut F, Lalande V, Burghoffer B, Petit JC: Development of a new PCR-ribotyping method for Clostridium difficile based on ribosomal RNA gene sequencing. FEMS Microbiol Lett. 1999, 175 (2): 261-266. 10.1111/j.1574-6968.1999.tb13629.x.PubMedView ArticleGoogle Scholar
- Janezic S, Rupnik M: Molecular typing methods for Clostridium difficile: pulsed-field gel electrophoresis and PCR ribotyping. Methods Mol Biol. 2010, 646: 55-65. 10.1007/978-1-60327-365-7_4.PubMedView ArticleGoogle Scholar
- CLSI: Performance Standards for Antimicrobial Susceptibility Testing; Twenty-First Informational Supplement. CLSI documnet M100-S21. 2011, Wayne, PA, USA: Clinical and Laboratory Standards InstituteGoogle Scholar
- CLSI: Methods for Antimicrobial Susceptibility Testing of Anaerobic Bacteria-Sevnth Edition: CLSI document M11-A7. 2007, Wayne, PA, USA: Clinical and Laboratory Standards InstituteGoogle Scholar
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