Clostridium difficile fecal toxin level is associated with disease severity and prognosis

Background: Antibiotic-associated colitis caused by Clostridium difficile (C. difficile) is the most common cause of hospital-acquired diarrhea. The pathogenesis of C. difficile colitis is mediated by bacterial toxins. C. difficile infection (CDI) severity may be determined by the fecal level of these toxins. Objective: The objective of this article is to determine whether fecal C. difficile toxin (CDT) levels are associated with disease severity and prognosis. Methods: A cross-sectional study of patients admitted with CDI in a tertiary center between 2011 and 2015 was conducted. Fecal CDT levels were determined by quantitative ELISA. Severe CDI was defined as a leukocyte count of > 15 × 10³ cells/μl, creatinine levels that deteriorated by > 1.5 times the baseline level, or albumin levels < 3 g/dl. Results: Seventy-three patients were recruited for this study. Patients with severe CDI (n = 47) had significantly higher toxin levels compared to patients with mild to moderate CDI (n = 26) (651 ng/ml (IQR 138–3200) versus 164 ng/ml (IQR 55.2–400.1), respectively; p = 0.001). A high toxin level (>2500 ng/ml) was associated with an increased mortality rate (odds ratio 11.8; 95% confidence interval 2.5–56). Conclusions: The fecal CDT level is associated with disease severity and mortality rate. Measuring CDT levels may be an objective and accurate way to define the severity of CDI.