May 11, 2018

Food additive to blame for C. difficulty epidemic

When Clostridium difficile infections rear their ugly head, patients are at serious risk. But no one knows what is behind the soaring number of infections. New research puts a food additive at the heart of the epidemic.

How is a common food additive linked to deadly C. difficile infections?
Clostridium difficile is a bacterium capable of causing life-threatening diarrhea , colitis, toxic megacolon, organ failure, and death.
According to the Centers for Disease Control and Prevention (CDC), C. difficile is currently "the most common microbial cause of healthcare-associated infections in U.S. hospitals and costs up to $4.8 billion each year."
In fact, C. difficile causes half a million infections and kills 15,000 people each year, the majority of whom are seniors. Yet these numbers used to be much lower.
Exactly why the past 20 years have seen a rising epidemic of C. difficile infections has remained a mystery — until now.
Writing in the journal Nature recently, researchers from Baylor College of Medicine in Houston, TX, and colleagues at the University of Oregon in Eugene, Leiden Medical Center in the Netherlands, and the Wellcome Trust Sanger Institute in Hinxton, United Kingdom, might have located the missing piece in the puzzle.
They point the finger squarely at a food additive, the simple sugar trehalose, which is widely used by the food industry.
The rise of C. difficile
The turn of the century saw the emergence of epidemic strains of C. difficile , explains Jimmy D. Ballard — a professor in the Department of Microbiology and Immunology at the University of Oklahoma in Oklahoma City — in an accompanying article in the journal Nature .
Prof. Ballard explains that most of these strains originated from a single source: a type of C. difficile known as ribotype 027 (RT027), which spread from the U.S., Canada, and Europe around the world.
In 2013, the CDC classed the threat level of C. difficile as urgent , putting the bug in the top 3 of 18 drug-resistant microbes — well above tuberculosis and MRSA.
Of particular concern has been the correlation between RT027 and a dramatic increase in deaths related to C. difficile. The mystery of why this ribotype and a second one, RT078, became so prevalent apparently out of thin air has remained largely unsolved."
Prof. Jimmy D. Ballard
Robert A. Britton — who is a professor of molecular virology and microbiology at Baylor College of Medicine — and his team have been on the hunt for the answer for a number of years.
Prof. Britton pointed me in the direction of a study that the team published back in 2014, which showed that RT027 can outcompete other C. difficile strains in laboratory and animal models.
Based on this work, they decided to delve deeper to get to the bottom of what gives RT027 this advantage.
Hunt for the missing link
"To begin to ask this question we screened [around] 200 sugars and other carbon sources for their ability to support growth of RT027 strains better than other ribotypes," Prof. Britton explained.
"Through this screen," he continued, "we found that RT027 and a second hypervirulent, epidemic ribotype (ribotype 078) were able to grow on low concentrations of trehalose that do not support the growth of other C. difficile strains."
Trehalose is a naturally occurring sugar. It is a disaccharide, meaning that it is made up of two individual sugar molecules — in this case glucose. Trehalose can be found in fungi, algae, and other plants. The food industry uses the sugar to improve the texture and stability of food products.
Prof. Britton explains in his article that the use of trehalose was somewhat limited before the turn of the century; it cost approximately $7,000 to produce just 1 kilogram. However, the discovery of an enzymatic process that allows trehalose to be extracted from corn starch brought this number down to just $3 per kilogram.
"Granted [the] 'generally recognized as safe' status by the U.S. Food and Drug Administration [FDA] in 2000 and approved for use in food in Europe in 2001," Prof. Britton reports, "reported expected usage ranges from concentrations of 2 percent to 11.25 percent for foods including pasta, ground beef, and ice cream."
The widespread adoption and use of trehalose in the diet coincides with the emergence of both RT027 and RT078 outbreaks."
Prof. Robert A. Britton
Connecting the dots
Prof. Britton and his team put the two strains of C. difficile to the test in order to find out what gives them the edge over other C. difficile strains when it comes to trehalose metabolism.
Interestingly, RT027 and RT078 achieve this in different ways. The RT027 strain has one mutation in a protein that normally represses the trehalose-metabolizing enzyme phosphotrehalase. This mutation switches off the repressor protein, allowing RT027 to use low levels of trehalose.
On the flipside, RT078 has four extra genes that support trehalose metabolism and allow it to grow much better in environments with low levels of trehalose than other strains.
Commenting on the results, Prof. Britton told me that "the most surprising finding of this work is that a dietary additive impacted the emergence of epidemic strains of C. difficile that have caused increased morbidity and mortality."
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