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Clostridium  [ Clostridioides ]  difficile  infection (CDI) is one of the leading causes of diarrhea associated with medical care worldwide, and up to 60% of patients with CDI can develop a recurrent infection (R-CDI). A multi-species microbiota biofilm model of  C .  difficile  was designed to evaluate the differences in the production of biofilms, sporulation, susceptibility to drugs, expression of sporulating ( sigH ,  spo0A) , quorum sensing ( agrD   1  , and  luxS) , and adhesion-associated ( slpA  and  cwp84)  pathway genes between selected  C .  difficile  isolates from R-CDI and non-recurrent patients (NR-CDI). We obtained 102  C .  difficile  isolates from 254 patients with confirmed CDI (66 from NR-CDI and 36 from R-CDI). Most of the isolates were biofilm producers, and most of the strains were ribotype 027 (81.374%, 83/102). Most  C .  difficile  isolates were producers of biofilm (100/102), and most were strongly adherent. Sporulation was higher in the R-CDI than in the NR-CDI isolates (p = 0.015). The isolates from R-CDI patients more frequently demonstrated reduced susceptibility to vancomycin than isolates of NR-CDI patients (27.78% [10/36] and 9.09% [6/66], respectively, p = 0.013). The minimum inhibitory concentrations for vancomycin and linezolid against biofilms (BMIC) were up to 100 times and 20 times higher, respectively, than the corresponding planktonic MICs. Expression of  sigH ,  spo0A ,  cwp84 , and  agrD   1   was higher in R-CDI than in NR-CDI isolates. Most of the  C .  difficile  isolates were producers of biofilms with no correlation with the ribotype. Sporulation was greater in R-CDI than in NR-CDI isolates in the biofilm model of  C .  difficile . The R-CDI isolates more frequently demonstrated reduced susceptibility to vancomycin and linezolid than the NR-CDI isolates in both planktonic cells and biofilm isolates. A higher expression of sporulating pathway ( sigH ,  spo0A ), quorum sensing ( agrD   1  ), and adhesion-associated ( cwp84 ) genes was found in R-CDI than in NR-CDI isolates. All of these factors can have effect on the recurrence of the infection.

plos one

High sporulation and overexpression of virulence factors in biofilms and reduced susceptibility to vancomycin and linezolid in recurrent Clostridium [Clostridioides] difficile infection isolates