{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T14:48:25Z","timestamp":1780930105528,"version":"3.54.1"},"reference-count":58,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,2,25]],"date-time":"2026-02-25T00:00:00Z","timestamp":1771977600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Medical University, Sofia, Bulgaria","award":["136\/14.06.2022"],"award-info":[{"award-number":["136\/14.06.2022"]}]},{"name":"Medical University, Sofia, Bulgaria","award":["N 7305\/17.11.2021"],"award-info":[{"award-number":["N 7305\/17.11.2021"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Microorganisms"],"abstract":"<jats:p>The aim of the study was to investigate the MLST types and genes encoding Clostridioides difficile toxins from fecal clinical samples of patients from two large Bulgarian cities. Overall, 100 toxigenic isolates were obtained during a 10-year period from five hospitals in Sofia and Varna, Bulgaria. Toxin gene patterns of the isolates were determined with conventional polymerase chain reaction, and multilocus sequence typing (MLST) types were determined according to Griffith\u2019s scheme. The evolutionary relatedness of ST types was analyzed through PHYLOViZ. Binary toxin-positive isolates accounted for 35% (35\/100), and the most prevalent sequence type (ST) type was ST1 (clade2) with 34%. One binary toxin-positive isolate belonged to ST11 (clade5). The cdt-negative isolates were of two clades: clade 4 (ST37), with 1 tcdA-tcdB+ isolate, and clade 1, with 64 isolates. All the cdt-positive isolates showed 18 bp deletions of tcdC, except a ST11 isolate exhibiting a 39 bp deletion. Importantly, there was more than a 6-fold increase in ST1 isolates in the 2020\u20132023 period versus 2014\u20132019. The main cdt-negative isolates were ST3 (14%), ST2 (6%), ST42 (5%), and ST92 (5%). They were tcdA+tcdB+. Four main clonal complexes (with one allele difference) were found. The first one encompassed 19 isolates and included ST3 and ST42; the second included ST8, ST16, ST52, ST92 and ST36 (11 isolates); the third consisted of 13 isolates (ST2, ST49, ST13 and ST110 clones); and the fourth included ST10 and ST44 (5 isolates). The significance of our work is the detection of a high frequency of hypervirulent isolates during the COVID-19 pandemic period, which we attribute to the national consumption of systemic antibiotics, which increased during the second period, unlike the trend in other European countries. The results highlight the need for enhanced infection control measures and strict compliance with antibiotic stewardship programs.<\/jats:p>","DOI":"10.3390\/microorganisms14030532","type":"journal-article","created":{"date-parts":[[2026,2,25]],"date-time":"2026-02-25T12:35:17Z","timestamp":1772022917000},"page":"532","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Molecular Epidemiology of Toxigenic Clostridioides difficile Isolated from Bulgarian Patients and the Prevalence of Hypervirulent ST1 Clone"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1634-8768","authenticated-orcid":false,"given":"Rumyana","family":"Markovska","sequence":"first","affiliation":[{"name":"Department of Medical Microbiology, Medical University of Sofia, 1431 Sofia, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-1028-4245","authenticated-orcid":false,"given":"Georgi","family":"Dimitrov","sequence":"additional","affiliation":[{"name":"Department of Medical Microbiology, Medical University of Sofia, 1431 Sofia, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3666-3802","authenticated-orcid":false,"given":"Denis","family":"Niyazi","sequence":"additional","affiliation":[{"name":"Department of Microbiology and Virology, University Multiprofile Hospital for Active Treatment \u201cSaint Marina\u201d, Medical University of Varna, 9002 Varna, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6202-4532","authenticated-orcid":false,"given":"Temenuga","family":"Stoeva","sequence":"additional","affiliation":[{"name":"Department of Microbiology and Virology, University Multiprofile Hospital for Active Treatment \u201cSaint Marina\u201d, Medical University of Varna, 9002 Varna, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5657-9443","authenticated-orcid":false,"given":"Kalina","family":"Mihova","sequence":"additional","affiliation":[{"name":"Molecular Medicine Centre, Medical University of Sofia, 1431 Sofia, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9622-0873","authenticated-orcid":false,"given":"Lyudmila","family":"Boyanova","sequence":"additional","affiliation":[{"name":"Department of Medical Microbiology, Medical University of Sofia, 1431 Sofia, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"970","DOI":"10.1038\/s41467-022-28196-w","article-title":"Structure and assembly of the S-layer in C. difficile","volume":"13","author":"Banerji","year":"2022","journal-title":"Nat. Commun."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1001\/archpedi.1935.01970020105010","article-title":"Intestinal flora in newborn infants with description of a new pathogenic anaerobe","volume":"49","author":"Hall","year":"1935","journal-title":"Am. J. Dis. Child"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1016\/j.anaerobe.2016.06.008","article-title":"Reclassification of Clostridium difficile as Clostridioides difficile (Hall and O\u2019Toole 1935) Preevot 1938","volume":"40","author":"Lawson","year":"2016","journal-title":"Anaerobe"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1211","DOI":"10.1007\/s10096-019-03539-6","article-title":"Clostridium difficile infection: Review","volume":"38","author":"Czepiel","year":"2019","journal-title":"Eur. J. Clin. Microbiol. Infect. Dis"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2150452","DOI":"10.1080\/21505594.2022.2150452","article-title":"Pathogenicity and virulence of Clostridioides difficile","volume":"14","author":"Buddle","year":"2023","journal-title":"Virulence"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"353","DOI":"10.1016\/j.resmic.2015.02.002","article-title":"Genomic diversity of Clostridium difficile strains","volume":"166","author":"Janezic","year":"2015","journal-title":"Res. Microbiol."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Mart\u00ednez-Mel\u00e9ndez, A., Cruz-L\u00f3pez, F., Morfin-Otero, R., Maldonado-Garza, H.J., and Garza-Gonz\u00e1lez, E. (2022). An Update on Clostridioides difficile Binary Toxin. Toxins, 14.","DOI":"10.3390\/toxins14050305"},{"key":"ref_8","first-page":"828","article-title":"Health care resource utilization and costs of recurrent Clostridioides difficile infection in the elderly: A real-world claims analysis","volume":"27","author":"Nelson","year":"2021","journal-title":"J. Manag. Care Spec. Pharm."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Feuerstadt, P., Theriault, N., and Tillotson, G. (2023). The burden of CDI in the United States: A multifactorial challenge. BMC Infect. Dis., 23.","DOI":"10.1186\/s12879-023-08096-0"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Sholeh, M., Beig, M., Kouhsari, E., Rohani, M., Katouli, M., and Badmasti, F. (2025). Global insights into the genome dynamics of Clostridioides difficile associated with antimicrobial resistance, virulence, and genomic adaptations among clonal lineages. Front. Cell. Infect. Microbiol., 14.","DOI":"10.3389\/fcimb.2024.1493225"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2427804","DOI":"10.1080\/22221751.2024.2427804","article-title":"Distribution of Clostridioides difficile ribotypes and sequence types across humans, animals and food in 13 European countries","volume":"13","author":"Rupnik","year":"2024","journal-title":"Emerg. Microbes Infect."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Blau, K., Berger, F.K., Mellmann, A., and Gallert, C. (2023). Clostridioides difficile from Fecally Contaminated Environmental Sources: Resistance and Genetic Relatedness from a Molecular Epidemiological Perspective. Microorganisms, 11.","DOI":"10.3390\/microorganisms11102497"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Stabler, R.A., Dawson, L.F., Valiente, E., Cairns, M.D., Martin, M.J., Donahue, E.H., Riley, T.V., Songer, J.G., Kuijper, E.J., and Dingle, K.E. (2012). Macro and micro diversity of Clostridium difficile isolates from diverse sources and geographical locations. PLoS ONE, 7.","DOI":"10.1371\/journal.pone.0031559"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"103028","DOI":"10.1016\/j.anaerobe.2026.103028","article-title":"Clostridioides difficile infection in animals: A literature review","volume":"97","author":"Uzal","year":"2026","journal-title":"Anaerobe"},{"key":"ref_15","unstructured":"Centers for Disease Control and Prevention (2026, January 05). Antibiotic Resistance Threats in the United States, 2019, Available online: https:\/\/www.cdc.gov\/antimicrobial-resistance\/media\/pdfs\/2019-ar-threats-report-508.pdf?CDC_AAref_Val=https:\/\/www.cdc.gov\/drugresistance\/pdf\/threats-report\/2019-ar-threats-report-508.pdf."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e1029","DOI":"10.1093\/cid\/ciab549","article-title":"Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults","volume":"73","author":"Johnson","year":"2021","journal-title":"Clin. Infect. Dis."},{"key":"ref_17","first-page":"114","article-title":"Bezlotoxumab for prevention of Clostridioides difficile recurrence in patients with inflammatory bowel disease: A retrospective multicenter experience","volume":"39","author":"Karime","year":"2026","journal-title":"Ann. Gastroenterol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"20381","DOI":"10.2807\/ese.18.04.20381-en","article-title":"Current application and future perspectives of molecular typing methods to study Clostridium difficile infections","volume":"18","author":"Knetsch","year":"2013","journal-title":"Eurosurveillance"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"770","DOI":"10.1128\/JCM.01796-09","article-title":"Multilocus sequence typing of Clostridium difficile","volume":"48","author":"Griffiths","year":"2010","journal-title":"J. Clin. Microbiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1703","DOI":"10.7546\/CRABS.2025.11.14","article-title":"Toxigenic Clostridioides difficile and their antibiotic susceptibility in Bulgarian patients during and post-COVID-19 pandemic","volume":"78","author":"Boyanova","year":"2025","journal-title":"C. R. Acad. Bulg. Sci."},{"key":"ref_21","unstructured":"EUCAST (2025, August 05). The European Committee on Antimicrobial Susceptibility Testing. Breakpoint Tables for Interpretation of MICs and Zone Diameters. Version 14.0. Available online: http:\/\/www.eucast.org."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1058","DOI":"10.1111\/j.1469-0691.2007.01793.x","article-title":"Characteristics and incidence of Clostridium difficile-associated disease in The Netherlands, 2005","volume":"13","author":"Paltansing","year":"2007","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"33","DOI":"10.1128\/jcm.29.1.33-37.1991","article-title":"Identification of toxigenic Clostridium difficile by the polymerase chain reaction","volume":"29","author":"Kato","year":"1991","journal-title":"J. Clin. Microbiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2178","DOI":"10.1128\/JCM.36.8.2178-2182.1998","article-title":"Identification of toxin A-negative, toxin B-positive Clostridium difficile by PCR","volume":"36","author":"Kato","year":"1998","journal-title":"J. Clin. Microbiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1057","DOI":"10.1111\/j.1469-0691.2008.02092.x","article-title":"New multiplex PCR method for the detection of Clostridium difficile toxin A (tcdA) and toxin B (tcdB) and the binary toxin (cdtA\/cdtB) genes applied to a Danish strain collection","volume":"14","author":"Persson","year":"2008","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_26","unstructured":"European Centre for Disease Prevention and Control (2022). Clostridioides (Clostridium) difficile infections. Annual Epidemiological Report for 2016\u20132017, ECDC."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2200244","DOI":"10.2807\/1560-7917.ES.2022.27.49.2200244","article-title":"Sentinel surveillance and epidemiology of Clostridioides difficile in Denmark, 2016 to 2019","volume":"27","author":"Persson","year":"2022","journal-title":"Eurosurveillance"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Dingle, K.E., Griffiths, D., Didelot, X., Evans, J., Vaughan, A., Kachrimanidou, M., Stoesser, N., Jolley, K.A., Golubchik, T., and Harding, R.M. (2011). Clinical Clostridium difficile: Clonality and pathogenicity locus diversity. PLoS ONE, 6.","DOI":"10.1371\/journal.pone.0019993"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"16020","DOI":"10.1038\/nrdp.2016.20","article-title":"Clostridium difficile infection","volume":"2","author":"Smits","year":"2016","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1111\/j.1469-0691.2006.01580.x","article-title":"ESCMID Study Group for Clostridium difficile; EU Member States; European Centre for Disease Prevention and Control. Emergence of Clostridium difficile-associated disease in North America and Europe","volume":"12","author":"Kuijper","year":"2006","journal-title":"Clin. Microbiol. Infect."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Mengoli, M., Barone, M., Fabbrini, M., D\u2019Amico, F., Brigidi, P., and Turroni, S. (2022). Make It Less difficile: Understanding genetic evolution and global spread of Clostridioides difficile. Genes, 13.","DOI":"10.3390\/genes13122200"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"102926","DOI":"10.1016\/j.anaerobe.2024.102926","article-title":"Clostridioides difficile hypervirulent strain ST1 isolated from clinical stool specimens obtained from three Provinces in South Africa","volume":"91","author":"Shirinda","year":"2025","journal-title":"Anaerobe"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"30294","DOI":"10.2807\/1560-7917.ES.2016.21.29.30294","article-title":"Diversity of Clostridium difficile PCR ribotypes in Europe: Results from the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID), 2012 and 2013","volume":"21","author":"Davies","year":"2016","journal-title":"Eurosurveillance"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1035","DOI":"10.1093\/cid\/ciy252","article-title":"EUCLID Study Group. Two distinct patterns of Clostridium difficile diversity across europe indicating contrasting routes of spread","volume":"67","author":"Eyre","year":"2018","journal-title":"Clin. Infect. Dis."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1007\/s10096-019-03708-7","article-title":"Five-year Pan-European, longitudinal surveillance of Clostridium difficile ribotype prevalence and antimicrobial resistance: The extended ClosER study","volume":"39","author":"Freeman","year":"2020","journal-title":"Eur. J. Clin. Microbiol. Infect. Dis."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Aptekorz, M., Sacha, K., Gofron, Z., Kaba\u0142a, M., Harmanus, C., Kuijper, E., and Martirosian, G. (2022). Antibiotic resistance profile of RT 027\/176 versus other Clostridioides difficile isolates in Silesia, Southern Poland. Pathogens, 11.","DOI":"10.3390\/pathogens11080949"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"106824","DOI":"10.1016\/j.ijantimicag.2023.106824","article-title":"Clostridioides difficile infections were predominantly driven by fluoroquinolone-resistant Clostridioides difficile ribotypes 176 and 001 in Slovakia in 2018\u20132019","volume":"62","author":"Plankaova","year":"2023","journal-title":"Int. J. Antimicrob. Agents"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1007\/s12223-022-01021-z","article-title":"Ribotyping of Clostridioides difficile in the Liberec Regional Hospital: A tertiary health care facility","volume":"68","year":"2023","journal-title":"Folia Microbiol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"102252","DOI":"10.1016\/j.anaerobe.2020.102252","article-title":"An outbreak of Clostridioides difficile infections due to a 027-like PCR ribotype 181 in a rehabilitation centre: Epidemiological and microbiological characteristics","volume":"65","author":"Kachrimanidou","year":"2020","journal-title":"Anaerobe"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"990","DOI":"10.1016\/S1473-3099(17)30325-0","article-title":"Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: A systematic review and meta-analysis","volume":"17","author":"Baur","year":"2017","journal-title":"Lancet Infect. Dis."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"151507","DOI":"10.1016\/j.ijmm.2021.151507","article-title":"Molecular epidemiology and antimicrobial resistance of Clostridioides difficile in Germany, 2014\u20132019","volume":"311","author":"Abdrabou","year":"2021","journal-title":"Int. J. Med. Microbiol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"102548","DOI":"10.1016\/j.anaerobe.2022.102548","article-title":"German C. difficile surveillance group. Implementation of a Clostridioides difficile sentinel surveillance system in Germany: First insights for 2019\u20132021","volume":"77","author":"Abdrabou","year":"2022","journal-title":"Anaerobe"},{"key":"ref_43","unstructured":"European Centre for Disease Prevention and Control (2024). Antimicrobial Consumption in the EU\/EEA (ESAC-Net)\u2014Annual Epidemiological Report 2023, ECDC."},{"key":"ref_44","unstructured":"European Centre for Disease Prevention and Control (2023). Antimicrobial Consumption in the EU\/EEA (ESAC-Net)\u2014Annual Epidemiological Report 2022, ECDC."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1428","DOI":"10.1099\/jmm.0.058149-0","article-title":"Advances in molecular surveillance of Clostridium difficile in Bulgaria","volume":"62","author":"Dobreva","year":"2013","journal-title":"J. Med. Microbiol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"116703","DOI":"10.1016\/j.diagmicrobio.2025.116703","article-title":"Whole genome sequencing characterization of Clostridioides difficile from Bulgaria during the COVID-19 pandemic","volume":"111","author":"Dobreva","year":"2025","journal-title":"Diagn. Microbiol. Infect. Dis."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1080\/13102818.2023.2169194","article-title":"Study on patients with Clostridioides difficile infection during the COVID-19 pandemic in Bulgaria","volume":"37","author":"Velev","year":"2023","journal-title":"Biotechnol. Biotechnol. Equip."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"102669","DOI":"10.1016\/j.anaerobe.2022.102669","article-title":"Community-onset Clostridioides difficile infection in south Serbia","volume":"79","author":"Stojanovic","year":"2023","journal-title":"Anaerobe"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"102050","DOI":"10.1016\/j.anaerobe.2019.06.003","article-title":"Changes in molecular epidemiology and antimicrobial resistance profiles of Clostridioides (Clostridium) difficile strains in the United States between 2011 and 2017","volume":"60","author":"Tickler","year":"2019","journal-title":"Anaerobe"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"796","DOI":"10.1080\/22221751.2019.1621670","article-title":"Clostridium difficile ribotype 017\u2014Characterization, evolution and epidemiology of the dominant strain in Asia","volume":"8","author":"Imwattana","year":"2019","journal-title":"Emerg. Microbes Infect."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"925","DOI":"10.1080\/17512433.2023.2252331","article-title":"Clostridioides difficile resistance to antibiotics, including post-COVID-19 data","volume":"16","author":"Boyanova","year":"2023","journal-title":"Expert Rev. Clin. Pharmacol."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Schwartz, O., Azrad, M., and Peretz, A. (2025). In vitro susceptibility of clinical Clostridioides difficile isolates in Israel to metronidazole, vancomycin, fidaxomicin, ridinilazole and ibezapolstat. BMC Gastroenterol., 25.","DOI":"10.1186\/s12876-025-03800-7"},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"Knight, D.R., and Riley, T.V. (2019). Genomic Delineation of Zoonotic Origins of Clostridium difficile. Front. Public Health, 7.","DOI":"10.3389\/fpubh.2019.00164"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"20954","DOI":"10.2807\/1560-7917.ES2014.19.45.20954","article-title":"Whole genome sequencing reveals potential spread of Clostridium difficile between humans and farm animals in the Netherlands, 2002 to 2011","volume":"19","author":"Knetsch","year":"2014","journal-title":"Eurosurveillance"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1331","DOI":"10.1080\/22221751.2021.1943538","article-title":"Genomic evolution and virulence association of Clostridioides difficile sequence type 37 (ribotype 017) in China","volume":"10","author":"Xu","year":"2021","journal-title":"Emerg. Microbes Infect."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"e13846","DOI":"10.1016\/j.heliyon.2023.e13846","article-title":"The effect of different C. difficile MLST strains on viability and activity of macrophages","volume":"9","author":"Saad","year":"2023","journal-title":"Heliyon"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"2408322","DOI":"10.1080\/22221751.2024.2408322","article-title":"Genomic epidemiology of Clostridioides difficile sequence type 35 reveals intraspecies and interspecies clonal transmission","volume":"13","author":"Luo","year":"2024","journal-title":"Emerg. Microbes Infect."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"e01259-19","DOI":"10.1128\/AAC.01259-19","article-title":"Antimicrobial susceptibility and molecular characterisation using whole-genome sequencing of Clostridioides difficile collected in 82 hospitals in Japan between 2014 and 2016","volume":"63","author":"Aoki","year":"2019","journal-title":"Antimicrob. Agents Chemother."}],"container-title":["Microorganisms"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-2607\/14\/3\/532\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,25]],"date-time":"2026-02-25T13:01:47Z","timestamp":1772024507000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-2607\/14\/3\/532"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,25]]},"references-count":58,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["microorganisms14030532"],"URL":"https:\/\/doi.org\/10.3390\/microorganisms14030532","relation":{},"ISSN":["2076-2607"],"issn-type":[{"value":"2076-2607","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,25]]}}}