The Gut Microbiome and Butyrate DifferentiateClostridioides difficileColonization and Infection in Children

Background and Aims

SymptomaticClostridioides difficileinfection (CDI) can cause significant morbidity and mortality. Conversely, patients can be colonized with toxigenicC. difficilein the absence of symptoms, termed asymptomatic colonization. We previously demonstrated that the presence and function ofC. difficiletoxins do not differentiate between asymptomatic colonization and CDI in children, suggesting the influence of other factors. This study aimed to interrogate the intestinal microbiome and butyrate in stool samples from children with CDI and asymptomatic colonization.

Methods

Design: Case-control study

Setting: Tertiary care children’s hospital

Participants and measures: Asymptomatic children had stool tested forC. difficileby nucleic-acid amplification-based testing (NAAT) and were considered colonized if positive (N=50). Residual stool was also obtained from symptomatic children who tested positive forC. difficileby NAAT (N=55). The microbiome was assessed via 16S rRNA sequencing and butyrate via liquid chromatography-mass spectrometry.

Results

Compared to clinical co-variates and comorbidities,C. difficilesymptom status (i.e., asymptomatic colonization versus symptomatic CDI) demonstrated the strongest differential abundance association on gut microbes. Symptomatic CDI was associated with increased abundance ofEscherichia/Shigella(Benjamini-Hochberg adjusted q=3.94×10⁻⁵),Haemophilus(q=0.022), andGemella(q=0.085), and depleted abundance of gut commensals such asFaecalibacterium(q=0.041),Blautia(q=0.041), andBifidobacterium(q=0.063). We also observed depletion in the abundance of microbial butyrate producers and fecal butyrate in participants with symptomatic CDI versus asymptomatic colonization.

Conclusion

The gut microbiota and butyrate differ between participants with asymptomaticC. difficilecolonization and symptomatic CDI, suggesting their potential role in symptom development.