{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T00:08:46Z","timestamp":1792454926173,"version":"4.5.0"},"reference-count":41,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2019,12,24]],"date-time":"2019-12-24T00:00:00Z","timestamp":1577145600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"funder":[{"DOI":"10.13039\/100000060","name":"National Institute of Allergy and Infectious Diseases","doi-asserted-by":"publisher","award":["R56AI126881"],"award-info":[{"award-number":["R56AI126881"]}],"id":[{"id":"10.13039\/100000060","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000060","name":"National Institute of Allergy and Infectious Diseases","doi-asserted-by":"publisher","award":["R01AI139261"],"award-info":[{"award-number":["R01AI139261"]}],"id":[{"id":"10.13039\/100000060","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000060","name":"National Institute of Allergy and Infectious Diseases","doi-asserted-by":"publisher","award":["R01AI116610"],"award-info":[{"award-number":["R01AI116610"]}],"id":[{"id":"10.13039\/100000060","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Texas A&M Health Science Center"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,4,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Objectives<\/jats:title>\n                  <jats:p>To describe, for the first time (to the best of our knowledge), the genetic mechanisms of vancomycin resistance in clinical isolates of Clostridioides difficile ribotype 027.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Clinical isolates and laboratory mutants were analysed: genomically to identify resistance mutations; by transcriptional analysis of vanGCd, the vancomycin resistance operon encoding lipid II d-alanine-d-serine that is less bound by vancomycin than native lipid II d-alanine-d-alanine; by imaging of vancomycin binding to cell walls; and for changes in vancomycin bactericidal activity and autolysis.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Vancomycin-resistant laboratory mutants and clinical isolates acquired mutations to the vanSR two-component system that regulates vanGCd. The substitutions impaired VanSR\u2019s function, resulting in constitutive transcription of vanGCd. Resistance was reversed by silencing vanG, encoding d-alanine-d-serine ligase in the vanGCd operon. In resistant cells, vancomycin was less bound to the cell wall septum, the site where vancomycin interacts with lipid II. Vancomycin\u2019s bactericidal activity was reduced against clinical isolates and laboratory mutants (64 and \u22651024\u2009mg\/L, respectively) compared with WT strains (4\u2009mg\/L). Truncation of the potassium transporter TrkA occurred in laboratory mutants, which were refractory to autolysis, accounting for their survival in high drug concentrations.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Ribotype 027 evolved first-step resistance to vancomycin by constitutively expressing vanGCd, which is otherwise silent. Experimental evolutions and bactericidal assays show that ribotype 027 can acquire mutations to drastically enhance its tolerance to vancomycin. Thus, further epidemiological studies are warranted to examine the extent to which vancomycin resistance impacts clinical outcomes and the potential for these strains to evolve higher-level resistance, which would be devastating.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/jac\/dkz513","type":"journal-article","created":{"date-parts":[[2019,12,9]],"date-time":"2019-12-09T20:09:41Z","timestamp":1575922181000},"page":"859-867","source":"Crossref","is-referenced-by-count":68,"title":["Constitutive expression of the cryptic vanGCd operon promotes vancomycin resistance in Clostridioides difficile clinical isolates"],"prefix":"10.1093","volume":"75","author":[{"given":"Wan-Jou","family":"Shen","sequence":"first","affiliation":[{"name":"Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX 77030, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aditi","family":"Deshpande","sequence":"first","affiliation":[{"name":"Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX 77030, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kirk E","family":"Hevener","sequence":"first","affiliation":[{"name":"Department of Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN 38105, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bradley T","family":"Endres","sequence":"first","affiliation":[{"name":"Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, Houston, TX 77204, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin W","family":"Garey","sequence":"first","affiliation":[{"name":"Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, Houston, TX 77204, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelli L","family":"Palmer","sequence":"first","affiliation":[{"name":"Department of Biological Sciences, University of Texas at Dallas, Richardson, TX 75080, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian G","family":"Hurdle","sequence":"first","affiliation":[{"name":"Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, TX 77030, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2019,12,24]]},"reference":[{"key":"2020031310474009800_dkz513-B1","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1093\/cid\/cis386","article-title":"The roles of Clostridium difficile and norovirus among gastroenteritis-associated deaths in the United States, 1999\u20132007","volume":"55","author":"Hall","year":"2012","journal-title":"Clin Infect Dis"},{"key":"2020031310474009800_dkz513-B2","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1056\/NEJMoa1408913","article-title":"Burden of Clostridium difficile infection in the United States","volume":"372","author":"Lessa","year":"2015","journal-title":"N Engl J Med"},{"key":"2020031310474009800_dkz513-B3","doi-asserted-by":"crossref","first-page":"235","DOI":"10.15585\/mmwr.mm6509e1","article-title":"Vital signs: preventing antibiotic-resistant infections in hospitals \u2013 United States, 2014","volume":"65","author":"Weiner","year":"2016","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"2020031310474009800_dkz513-B4","doi-asserted-by":"crossref","first-page":"1224.","DOI":"10.1186\/s40064-016-2825-x","article-title":"A multi-center study of fidaxomicin use for Clostridium difficile infection","volume":"5","author":"Shah","year":"2016","journal-title":"Springerplus"},{"key":"2020031310474009800_dkz513-B5","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1086\/651706","article-title":"Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)","volume":"31","author":"Cohen","year":"2010","journal-title":"Infect Control Hosp Epidemiol"},{"key":"2020031310474009800_dkz513-B6","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1093\/cid\/ciu313","article-title":"Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials","volume":"59","author":"Johnson","year":"2014","journal-title":"Clin Infect Dis"},{"key":"2020031310474009800_dkz513-B7","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1016\/j.eimc.2016.07.013","article-title":"A scoring system for prescribing fidaxomicin in Clostridium difficile infection","volume":"36","author":"Vivancos-Gallego","year":"2018","journal-title":"Enferm Infecc Microbiol Clin"},{"key":"2020031310474009800_dkz513-B8","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1093\/cid\/ciy149","article-title":"Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)","volume":"66","author":"McDonald","year":"2018","journal-title":"Clin Infect Dis"},{"key":"2020031310474009800_dkz513-B9","doi-asserted-by":"crossref","first-page":"1601","DOI":"10.3389\/fmicb.2016.01601","article-title":"Molecular events for promotion of vancomycin resistance in vancomycin intermediate Staphylococcus aureus","volume":"7","author":"Hu","year":"2016","journal-title":"Front Microbiol"},{"key":"2020031310474009800_dkz513-B10","doi-asserted-by":"crossref","first-page":"730","DOI":"10.1002\/anie.200390202","article-title":"Vancomycin assembly: nature's way","volume":"42","author":"Hubbard","year":"2003","journal-title":"Angew Chem Int Ed Engl"},{"key":"2020031310474009800_dkz513-B11","doi-asserted-by":"crossref","first-page":"4214","DOI":"10.1128\/AAC.02775-13","article-title":"Strain types and antimicrobial resistance patterns of Clostridium difficile isolates from the United States, 2011 to 2013","volume":"58","author":"Tickler","year":"2014","journal-title":"Antimicrob Agents Chemother"},{"key":"2020031310474009800_dkz513-B12","doi-asserted-by":"crossref","first-page":"6437","DOI":"10.1128\/AAC.00845-15","article-title":"U.S.-based national sentinel surveillance study for the epidemiology of Clostridium difficile-associated diarrheal isolates and their susceptibility to fidaxomicin","volume":"59","author":"Snydman","year":"2015","journal-title":"Antimicrob Agents Chemother"},{"key":"2020031310474009800_dkz513-B13","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1016\/j.diagmicrobio.2015.05.015","article-title":"A national survey of the molecular epidemiology of Clostridium difficile in Israel: the dissemination of the ribotype 027 strain with reduced susceptibility to vancomycin and metronidazole","volume":"83","author":"Adler","year":"2015","journal-title":"Diagn Microbiol Infect Dis"},{"key":"2020031310474009800_dkz513-B14","doi-asserted-by":"crossref","first-page":"3943","DOI":"10.1128\/AAC.00191-12","article-title":"Characterizations of clinical isolates of Clostridium difficile by toxin genotypes and by susceptibility to 12 antimicrobial agents, including fidaxomicin (OPT-80) and rifaximin: a multicenter study in Taiwan","volume":"56","author":"Liao","year":"2012","journal-title":"Antimicrob Agents Chemother"},{"key":"2020031310474009800_dkz513-B15","doi-asserted-by":"crossref","first-page":"248.e9","DOI":"10.1016\/j.cmi.2014.09.017","article-title":"Pan-European longitudinal surveillance of antibiotic resistance among prevalent Clostridium difficile ribotypes","volume":"21","author":"Freeman","year":"2015","journal-title":"Clin Microbiol Infect"},{"key":"2020031310474009800_dkz513-B16","doi-asserted-by":"crossref","first-page":"363.","DOI":"10.1186\/1471-2334-10-363","article-title":"Faecal pharmacokinetics of orally administered vancomycin in patients with suspected Clostridium difficile infection","volume":"10","author":"Gonzales","year":"2010","journal-title":"BMC Infect Dis"},{"key":"2020031310474009800_dkz513-B17","doi-asserted-by":"crossref","first-page":"e0118791.","DOI":"10.1371\/journal.pone.0118791","article-title":"Vancomycin tolerant, methicillin-resistant Staphylococcus aureus reveals the effects of vancomycin on cell wall thickening","volume":"10","author":"Cazares-Dominguez","year":"2015","journal-title":"PLoS One"},{"key":"2020031310474009800_dkz513-B18","doi-asserted-by":"crossref","first-page":"S13","DOI":"10.1086\/491710","article-title":"Microbiological features of vancomycin in the 21st century: minimum inhibitory concentration creep, bactericidal\/static activity, and applied breakpoints to predict clinical outcomes or detect resistant strains","volume":"42","author":"Jones","year":"2006","journal-title":"Clin Infect Dis"},{"key":"2020031310474009800_dkz513-B19","doi-asserted-by":"crossref","first-page":"612","DOI":"10.1111\/mmi.12299","article-title":"The functional vanGCd cluster of Clostridium difficile does not confer vancomycin resistance","volume":"89","author":"Ammam","year":"2013","journal-title":"Mol Microbiol"},{"key":"2020031310474009800_dkz513-B20","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1016\/0966-842X(96)10063-9","article-title":"Glycopeptide resistance in enterococci","volume":"4","author":"Arthur","year":"1996","journal-title":"Trends Microbiol"},{"key":"2020031310474009800_dkz513-B21","doi-asserted-by":"crossref","first-page":"931","DOI":"10.1046\/j.1365-2958.2003.03737.x","article-title":"The vanG glycopeptide resistance operon from Enterococcus faecalis revisited","volume":"50","author":"Depardieu","year":"2003","journal-title":"Mol Microbiol"},{"key":"2020031310474009800_dkz513-B22","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1139\/w2012-002","article-title":"Distribution of the vanG-like gene cluster in Clostridium difficile clinical isolates","volume":"58","author":"Ammam","year":"2012","journal-title":"Can J Microbiol"},{"key":"2020031310474009800_dkz513-B23","doi-asserted-by":"crossref","first-page":"550","DOI":"10.1111\/j.1365-2958.2005.04706.x","article-title":"Binding sites of VanRB and \u03c370 RNA polymerase in the vanB vancomycin resistance operon of Enterococcus faecium BM4524","volume":"57","author":"Depardieu","year":"2005","journal-title":"Mol Microbiol"},{"key":"2020031310474009800_dkz513-B24","doi-asserted-by":"crossref","first-page":"1069","DOI":"10.1046\/j.1365-2958.2003.03771.x","article-title":"A six amino acid deletion, partially overlapping the VanSB G2 ATP-binding motif, leads to constitutive glycopeptide resistance in VanB-type Enterococcus faecium","volume":"50","author":"Depardieu","year":"2003","journal-title":"Mol Microbiol"},{"key":"2020031310474009800_dkz513-B25","doi-asserted-by":"crossref","first-page":"e00648-18","DOI":"10.1128\/mBio.00648-18","article-title":"Cwp19 is a novel lytic transglycosylase involved in stationary-phase autolysis resulting in toxin release in Clostridium difficile","volume":"9","author":"Wydau-Dematteis","year":"2018","journal-title":"MBio"},{"key":"2020031310474009800_dkz513-B26","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1021\/acsinfecdis.8b00205","article-title":"The fatty acid synthesis protein enoyl-ACP reductase II (FabK) is a target for narrow-spectrum antibacterials for Clostridium difficile infection","volume":"5","author":"Marreddy","year":"2019","journal-title":"ACS Infect Dis"},{"key":"2020031310474009800_dkz513-B27","doi-asserted-by":"crossref","first-page":"24442.","DOI":"10.1038\/srep24442","article-title":"Structural basis of DNA sequence recognition by the response regulator PhoP in Mycobacterium tuberculosis","volume":"6","author":"He","year":"2016","journal-title":"Sci Rep"},{"key":"2020031310474009800_dkz513-B28","year":"2018"},{"key":"2020031310474009800_dkz513-B29","doi-asserted-by":"crossref","first-page":"1060","DOI":"10.1128\/AAC.49.3.1060-1066.2005","article-title":"Transcriptional analysis of the vanC cluster from Enterococcus gallinarum strains with constitutive and inducible vancomycin resistance","volume":"49","author":"Panesso","year":"2005","journal-title":"Antimicrob Agents Chemother"},{"key":"2020031310474009800_dkz513-B30","doi-asserted-by":"crossref","first-page":"3892","DOI":"10.1128\/AAC.48.10.3892-3904.2004","article-title":"VanD-type vancomycin-resistant Enterococcus faecium and Enterococcus faecalis","volume":"48","author":"Depardieu","year":"2004","journal-title":"Antimicrob Agents Chemother"},{"key":"2020031310474009800_dkz513-B31","doi-asserted-by":"crossref","first-page":"4186","DOI":"10.1128\/JB.185.14.4186-4194.2003","article-title":"Structural analysis of the domain interface in DrrB, a response regulator of the OmpR\/PhoB subfamily","volume":"185","author":"Robinson","year":"2003","journal-title":"J Bacteriol"},{"key":"2020031310474009800_dkz513-B32","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1016\/S0969-2126(01)00706-7","article-title":"Evidence of intradomain and interdomain flexibility in an OmpR\/PhoB homolog from Thermotoga maritima","volume":"10","author":"Buckler","year":"2002","journal-title":"Structure"},{"key":"2020031310474009800_dkz513-B33","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1046\/j.1365-2958.1996.00617.x","article-title":"Quantitative analysis of the metabolism of soluble cytoplasmic peptidoglycan precursors of glycopeptide-resistant enterococci","volume":"21","author":"Arthur","year":"1996","journal-title":"Mol Microbiol"},{"key":"2020031310474009800_dkz513-B34","doi-asserted-by":"crossref","first-page":"5057","DOI":"10.1021\/bi00070a013","article-title":"Purification and characterization of VanR and the cytosolic domain of VanS: a two-component regulatory system required for vancomycin resistance in Enterococcus faecium BM4147","volume":"32","author":"Wright","year":"1993","journal-title":"Biochemistry"},{"key":"2020031310474009800_dkz513-B35","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1093\/jac\/dkt302","article-title":"In vitro selection, via serial passage, of Clostridium difficile mutants with reduced susceptibility to fidaxomicin or vancomycin","volume":"69","author":"Leeds","year":"2014","journal-title":"J Antimicrob Chemother"},{"key":"2020031310474009800_dkz513-B36","doi-asserted-by":"crossref","first-page":"e00177-16","DOI":"10.1128\/mSphere.00177-16","article-title":"A phenotypically silent vanB2 operon carried on a Tn1549-like element in Clostridium difficile","volume":"1","author":"Knight","year":"2016","journal-title":"mSphere"},{"key":"2020031310474009800_dkz513-B37","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1016\/j.ijantimicag.2015.03.016","article-title":"Impact of vancomycin faecal concentrations on clinical and microbiological outcomes in Clostridium difficile infection","volume":"46","author":"Thabit","year":"2015","journal-title":"Int J Antimicrob Agents"},{"key":"2020031310474009800_dkz513-B38","doi-asserted-by":"crossref","first-page":"297","DOI":"10.7326\/0003-4819-117-4-297","article-title":"Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole. A randomized, placebo-controlled trial","volume":"117","author":"Johnson","year":"1992","journal-title":"Ann Intern Med"},{"key":"2020031310474009800_dkz513-B39","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1111\/j.1574-6976.2002.tb00598.x","article-title":"Bacterial osmoadaptation: the role of osmolytes in bacterial stress and virulence","volume":"26","author":"Sleator","year":"2002","journal-title":"FEMS Microbiol Rev"},{"key":"2020031310474009800_dkz513-B40","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1007\/BF00408306","article-title":"Transient accumulation of potassium glutamate and its replacement by trehalose during adaptation of growing cells of Escherichia coli K-12 to elevated sodium chloride concentrations","volume":"150","author":"Dinnbier","year":"1988","journal-title":"Arch Microbiol"},{"key":"2020031310474009800_dkz513-B41","doi-asserted-by":"crossref","first-page":"3261","DOI":"10.1128\/AAC.02352-14","article-title":"Discovery of novel cell wall-active compounds using PywaC, a sensitive reporter of cell wall stress, in the model gram-positive bacterium Bacillus subtilis","volume":"58","author":"Czarny","year":"2014","journal-title":"Antimicrob Agents Chemother"}],"container-title":["Journal of Antimicrobial Chemotherapy"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/jac\/article-pdf\/75\/4\/859\/32903464\/dkz513.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/jac\/article-pdf\/75\/4\/859\/32903464\/dkz513.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,3,13]],"date-time":"2020-03-13T14:48:01Z","timestamp":1584110881000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jac\/article\/75\/4\/859\/5686405"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,12,24]]},"references-count":41,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2019,12,24]]},"published-print":{"date-parts":[[2020,4,1]]}},"URL":"https:\/\/doi.org\/10.1093\/jac\/dkz513","relation":{},"ISSN":["0305-7453","1460-2091"],"issn-type":[{"value":"0305-7453","type":"print"},{"value":"1460-2091","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2020,4]]},"published":{"date-parts":[[2019,12,24]]}}}