About this Journal Submit a Manuscript Table of Contents

Volume 2014 (2014), Article ID 594014, 4 pages

Research Article

Genes Encoding Toxin of Clostridium difficile in Children with and without Diarrhea

1Anaerobe Laboratory, Department of Microbiology, Institute of Biomedical Science, University of São Paulo, São Paulo, SP, Brazil

2Veterans Affairs, West Los Angeles Medical Center, Los Angeles, CA, USA

3Department of Medicine, School of Medicine, University of California, Los Angeles, CA, USA

4Department of Microbiology, Immunology and Molecular Genetics, School of Medicine, University of California, Los Angeles, CA, USA

Received 4 February 2014; Accepted 17 April 2014; Published 29 April 2014

Academic Editor: Katsumi Doi

Copyright © 2014 Victor R. C. Merino et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


The presence of gene 16S rRNA and genes encoding toxin A (tcdA), toxin B (tcdB), and binary toxin (cdtA/cdtB) of Clostridium difficile in stool samples from children with (110) and without (150) diarrhea was determined by using a TaqMan system. Fifty-seven (21.9%) out of 260 stool samples harbored the 16S rRNA gene. The genetic profile of tcdA+/tcdB− and cdtA+/cdtB+ was verified in one C. difficile-positive diarrhea sample and of tcdA+/tcdB+ in three C. difficile-positive nondiarrhea samples. The presence of tcdA+/tcdB+ in stools obtained from children without diarrhea, suggests that they were asymptomatic carriers of toxigenic strains.

1. Introduction

Clostridium difficile is the primary etiological agent of antibiotic-associated diarrhea and pseudomembranous colitis and is recognized as a cause of nosocomial diarrhea worldwide [1]. The pathogenic effects of C. difficile are mucosal damage to the colon that is caused by the production of toxin A (308 kDa) and/or toxin B (270 kDa) [2].

Some C. difficile strains also produce a binary toxin encoded by cdtA and cdtB genes, and both genes have been observed in strains producing C. difficile-associated diarrhea (CDAD) [3]. In Brazil, few studies have shown the presence of toxigenic C. difficile harboring tcdA and/or tcdB but not the binary toxin genes in stool samples from children with acute diarrhea [4, 5].

The cytotoxic assays performed from stool samples or isolated strains for detecting toxigenic C. difficile are considered the “gold standard” [6]. Other methods such as culture and enzyme immunoassay (EIA) are not specific for the identification of these toxigenic strains, but EIA method is used in most laboratories worldwide [7].

In this study, a quantitative detection of genes encoding toxins A and B and binary toxin directly from C. difficile-positive stool samples of children with and without acute diarrhea was determined.

2. Methods

2.1. Sample Collection and DNA Extraction

Two hundred sixty stool samples were obtained from 110 children with diarrhea and from 150 children without diarrhea, aged from 1 month to 8 years old. Stool samples were collected from March 2008 through November 2010. Children did not display other illnesses or comorbidities than diarrhea, and they were not under antibiotic treatment for at least three months prior to the sample collection. Diarrhea was defined as three or more unformed stools in the 24 h prior to enrollment. The Ethics Committee of the Biomedical Science Institute at the University of Sao Paulo (number 743/CEP) approved this study. Total bacterial genomic DNA was obtained from stools by using a QIAamp DNA stool minikit (Qiagen, Germany) according to the manufacturer’s instructions.

All toxigenic C. difficile-positive stool samples were evaluated for the presence of the toxins A/B with an enzyme immunoassay (EIA) by using a commercial kit Xpect C. difficile Toxin A/B Test (Remel, USA).

2.2. PCR Amplification

Real-time PCR assays were carried out in duplicate and performed in a total volume of 25 μL, containing 2X TaqMan Universal Master Mix (Applied Biosystems, USA), 100 μM of each primer, 100 μM of TaqMan probe, and 2 ng of DNA. Amplifications were performed in a thermal cycler programmed as follows: denaturation at 95°C for 10 min, followed by 45 cycles of two steps: denaturation at 95°C for 15 s and an annealing temperature at 60°C for 1 min, for detecting C. difficile 16S rRNA gene; and annealing temperatures for different toxin-encoding genes were as follows: at 51°C for detecting tcdA and cdtA genes and at 58°C for detecting tcdB and cdtB genes. The primer/probe sets used are shown in Table 1.

Table 1: Genes and primer/probe sets used to detect C. difficile and genes encoding toxins.

Bacterial DNA amplifications were adjusted using values 0.900. A sample was considered positive for a target gene when the detected fluorescence generates a curve above the background fluorescence, which was established by Rotor Gene 6000 analytical software (Corbett Life Science, Australia).

2.3. Statistical Analysis

Mean values ± SD were calculated for each toxin gene using a Student’s -test. A difference of was considered statistically significant (GraphPad Prism Software Inc.).

3. Results

By using a commercial kit Xpect, no toxin-positive stool sample was observed. Fifty-seven (21.9%) out of 260 stool samples analyzed harbored C. difficile (20 from children with diarrhea and 37 from children without diarrhea). Twenty C. difficile-positive diarrhea samples were obtained from children between six months and 7 years old, and, among them, a 1-year-old child harbored the tcdA gene and another 1-year-old child (tcdA−/tcdB−) harbored both binary toxin genes (cdtA and cdtB). Also, the 37 (24.6%) C. difficile-positive nondiarrhea samples were obtained from 1-to-5-year old children, and, of them, three children (a 1 year old and 2 years old) harbored both genes tcdA and tcdB (Table 2). None of the C. difficile-positive nondiarrhea samples harbored the binary toxin genes.

Table 2: Quantitative detection of Clostridium difficile and target genes in diarrhea and nondiarrhea samples.

The presence of the target genes and their respective copy numbers are shown in Table 2. The tcdA was observed in diarrhea sample with a value of . Similarly, binary toxin genes were observed in (cdtA) and (cdtB). Moreover, in nondiarrhea samples tcdA was detected from to and tcdB from to . The specific primer/probe sets here used showed an accurate standard curve over a 5-log-unit linear range that permitted the copy number determination from standard amplifications and detection to a limit of the 100 copies of the target DNA in unknown samples. In this study, C. difficile was detected in diarrhea (18.2%) and nondiarrhea (24.6%) stool samples.

4. Discussion

In Brazil, there are few epidemiological studies involving this pathogen as a cause of diarrhea in children [4, 8]. Since a stool sample harbored the profile of toxigenicity tcdA+/tcdB− and another cdtA+/cdtB+, it suggested a low circulation of toxigenic C. difficile in Brazilian children, and the acute diarrhea in children could have been caused by other enteropathogens than C. difficile, like typical viral or bacterial pathogens, such as Norovirus, Rotavirus, Salmonella, or Campylobacter, and this needs to be investigated.

The presence of toxins A/B and binary toxin-producing C. difficile in diarrhea outbreak has been associated to severe CDAD processes [9]. On the other hand, it is possible that strains can harbor toxins A/B and/or binary toxin genes without any expression, and it could explain the failure to detect the presence of toxins when the EIA was used.

The quantitative PCR by using the TaqMan system provided a direct detection of tcdA/tcdB and cdtA/cdtB from diarrhea and nondiarrhea stool samples, and it could determine a rapid bacterial screening in patients with acute diarrhea, and, due to the high sensitivity to detecting C. difficile strains, this assay has been useful in surveillance of nosocomial diarrhea when required [10, 11].

The presence of toxin genes (tcdA+/tcdB+) in stool samples obtained from three children without diarrhea suggests that they were asymptomatic carriers of toxigenic strains. In addition, an asymptomatic colonization by toxigenic C. difficile was recently described in neonates, suggesting that healthy children display some tolerance to toxigenic strains, and it could play a role in the development of the intestinal immune system [1215].

Our results suggest that more studies are necessary to determine the real role of toxigenic C. difficile strains and their asymptomatic colonization in the human intestinal tract, mainly in children.

Conflict of Interests

All authors declare that they have no financial/commercial conflict of interests regarding the publication of this paper.


The authors thank Marcia Harumi Fukugaiti for her technical support and Dr. Jon E. Rosenblatt (Mayo Clinic, USA) and Lynne Sloan that kindly donated C. difficile CDC (tcdA+/tcdB+ and cdtA+/cdtB+) strain. Viviane Nakano was supported by FAPESP (Grants 2008/57330-4 and 2009/03792-0). This study was supported by Fundação de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP, Grant nos. 07/03655-7 and CAPES 2472/09).


  1. J. G. Bartlett, “Antibiotic-associated diarrhea,” Clinical Infectious Diseases, vol. 15, no. 4, pp. 573–581, 1992. View at Google Scholar · View at Scopus
  2. D. E. Voth and J. D. Ballard, “Clostridium difficile toxins: mechanism of action and role in disease,” Clinical Microbiology Reviews, vol. 18, no. 2, pp. 247–263, 2005. View at Publisher · View at Google Scholar · View at Scopus
  3. H. Pituch, M. Rupnik, P. Obuch-Woszczatyński, A. Grubesic, F. Meisel-Mikołajczyk, and M. Łuczak, “Detection of binary-toxin genes (cdtA and cdtB) among Clostridium difficile strains isolated from patients with C. difficile-associated diarrhoea (CDAD) in Poland,” Journal of Medical Microbiology, vol. 54, no. 2, pp. 143–147, 2005. View at Publisher · View at Google Scholar · View at Scopus
  4. C. E. Ferreira, V. Nakano, E. L. Durigon, and M. J. Avila-Campos, “Prevalence of Clostridium spp. and Clostridium difficile in Children with Acute Diarrhea in São Paulo City, Brazil,” Memorias do Instituto Oswaldo Cruz, vol. 98, no. 4, pp. 451–454, 2003. View at Google Scholar · View at Scopus
  5. A. P. Alcides, J. S. Brazier, L. J. F. Pinto et al., “New PCR ribotypes of Clostridium difficile detected in children in Brazil,” Antonie van Leeuwenhoek, International Journal of General and Molecular Microbiology, vol. 92, no. 1, pp. 53–59, 2007. View at Publisher · View at Google Scholar · View at Scopus
  6. P. D. Stamper, W. Babiker, R. Alcabasa et al., “Evaluation of a new commercial TaqMan PCR assay for direct detection of the Clostridium difficile toxin B gene in clinical stool specimens,” Journal of Clinical Microbiology, vol. 47, no. 12, pp. 3846–3850, 2009. View at Publisher · View at Google Scholar · View at Scopus
  7. K. C. Carroll and M. Loeffelholz, “Conventional versus molecular methods for the detection of Clostridium difficile,” Journal of Clinical Microbiology, vol. 49, pp. S49–S52, 2011. View at Publisher · View at Google Scholar · View at Scopus
  8. L. B. Garcia and M. de Uzeda, “Occurrence of Clostridium difficile in the feces of children of Rio de Janeiro, RJ, Brazil,” Revista do Instituto de Medicina Tropical de Sao Paulo, vol. 30, no. 6, pp. 419–423, 1988. View at Google Scholar · View at Scopus
  9. F. Barbut, D. Decré, V. Lalande et al., “Clinical features of Clostridium difficile-associated diarrhoea due to binary toxin (actin-specific ADP-ribosyltransferase)-producing strains,” Journal of Medical Microbiology, vol. 54, no. 2, pp. 181–185, 2005. View at Publisher · View at Google Scholar · View at Scopus
  10. S. D. Bélanger, M. Boissinot, N. Clairoux, F. J. Picard, and M. G. Bergeron, “Rapid detection of Clostridium difficile in feces by real-time PCR,” Journal of Clinical Microbiology, vol. 41, no. 2, pp. 730–734, 2003. View at Publisher · View at Google Scholar · View at Scopus
  11. R. J. van den Berg, N. Vaessen, H. P. Endtz, T. Schülin, E. R. Van Der Vorm, and E. J. Kuijper, “Evaluation of real-time PCR and conventional diagnostic methods for the detection of Clostridium difficile-associated diarrhoea in a prospective multicentre study,” Journal of Medical Microbiology, vol. 56, no. 1, pp. 36–42, 2007. View at Publisher · View at Google Scholar · View at Scopus
  12. R. P. Bolton, S. K. Tait, P. R. F. Dear, and M. S. Losowsky, “Asymptomatic neonatal colonisation by Clostridium difficile,” Archives of Disease in Childhood, vol. 59, no. 5, pp. 466–472, 1984. View at Google Scholar · View at Scopus
  13. S. Matsuki, E. Ozaki, M. Shozu et al., “Colonization by Clostridium difficile of neonates in a hospital, and infants and children in three day-care facilities of Kanazawa, Japan,” International Microbiology, vol. 8, no. 1, pp. 43–48, 2005. View at Google Scholar · View at Scopus
  14. S. Jangi and J. T. Lamont, “Asymptomatic colonization by Clostridium difficile in infants: Implications for disease in later life,” Journal of Pediatric Gastroenterology and Nutrition, vol. 51, no. 1, pp. 2–7, 2010. View at Publisher · View at Google Scholar · View at Scopus
  15. C. Rousseau, I. Poilane, L. de Pontual, A. C. Maherault, A. le Monnier, and A. Collignon, “Clostridium difficile carriage in healthy infants in the community: a potential reservoir for pathogenic strains,” Clinical Infectious Diseases, vol. 55, pp. 1209–1215, 2012. View at Google Scholar
  16. J. Penders, C. Vink, C. Driessen, N. London, C. Thijs, and E. E. Stobberingh, “Quantification of Bifidobacterium spp., Escherichia coli and Clostridium difficile in faecal samples of breast-fed and formula-fed infants by real-time PCR,” FEMS Microbiology Letters, vol. 243, no. 1, pp. 141–147, 2005. View at Publisher · View at Google Scholar · View at Scopus
  17. D. Wroblewski, G. E. Hannett, D. J. Bopp et al., “Rapid molecular characterization of Clostridium difficile and assessment of populations of C. difficile in stool specimens,” Journal of Clinical Microbiology, vol. 47, no. 7, pp. 2142–2148, 2009. View at Publisher · View at Google Scholar · View at Scopus