Rifaximin disc diffusion test for in vitro susceptibility testing of Clostridium difficile

Rifaximin is a rifampicin derivative, poorly absorbed by the gastro-intestinal tract. We studied the in vitro susceptibility to rifamixin of 1082 Clostridium difficile isolates; among these,184 isolates from a strain collection were tested by an in-house rifaximin disc (40 mu g) diffusion test, by an in-house rifaximin broth microdilution test, by rifampicin Etest and by rpoB gene sequencing. In the absence of respective CLSI or EUCAST MIC breakpoints for rifaximin and rifampicin against C. difficile we chose MIC >= 32 mu g ml(-1) as criterion for reduced in vitro susceptibility. To further validate the disc diffusion test 898 consecutive clinical isolates were analysed using the disc diffusion test, the Etest and rpoB gene sequence analysis for all resistant strains. Rifaximin broth microdilution tests of the 184 reference strains yielded rifaximin MICs ranging from 0.001 (n=1) to >= 1024 mu g ml(-1) (n=61); 62 isolates showed a reduced susceptibility (MIC >= 32 mu g ml(-1)). All of these 62 strains showed rpoB gene mutations producing amino acid substitutions; the rifampicin- and rifaximin-susceptible strains showed either a wild-type sequence or silent amino acid substitutions (19 strains). For 11 arbitrarily chosen isolates with rifaximin MICs of > 1024 mu g ml(-1), rifaximin end-point MICs were determined by broth dilution: 4096 mu g ml(-1) (n=2), 8192 mu g ml(-1) (n=6), 16 384 mu g ml(-1) (n=2) and 32 678 mu g ml(-1) (n=1). Rifampicin Etests on the 184 C. difficile reference strains yielded MICs ranging from <= 0.002 (n =117) to >= 32 mu g ml(-1) (n=59). Using a 38 mm inhibition zone as breakpoint for reduced susceptibility the use of rifaximin disc diffusion yielded 59 results correlating with those obtained by use of rifaximin broth microdilution in 98.4% of the 184 strains tested. Rifampicin Etests performed on the 898 clinical isolates revealed that 67 isolates had MICs of >= 32 mu g ml(-1). There were no discordant results observed among these isolates with reduced susceptibility using an MIC of >= 32 mu g ml(-1) as breakpoint for reduced rifampicin susceptibility and a < 38 mm inhibition zone as breakpoint for reduced rifaximin susceptibility. The prevalence of reduced susceptibility was 7.5% for all isolates tested. However, for PCR ribotype 027 the prevalence of reduced susceptibility was 26%. Susceptibility testing in the microbiology laboratory therefore could have an impact on the care and outcome of patients with infection. Our results show that rifaximin - despite its water-insolubility - may be a suitable candidate for disc diffusion testing.