| Summary: | <p> <i>Clostridium difficile</i> is an anaerobic, gram-positive bacterium that is responsible for the majority of hospital-associated gastrointestinal infections. It has been recognized as a pathogen since the 1970s but more recently has become an urgent threat to public health. <i>C. difficile </i> produces two powerful toxins that disrupt the integrity of the colonic epithelium and induce a strong inflammatory response. Susceptible individuals experience symptoms that range from mild, self-limiting diarrhea to fulminant pseudomembranous colitis and even death. However, most healthy individuals are protected from <i>C. difficile</i> infections so long as they are able to maintain a diverse population of commensal bacteria in their gut. Disruptions to these commensals, often from antibiotic therapy, provide the niche <i>C. difficile</i> spores need to germinate, produce toxins, and cause disease. Current first-line therapy for infections is additional antibiotics that lead to a high risk of relapse. In fact, we found that short course antibiotic therapy leaves mice susceptible to additional infections in the days and weeks that the commensal microbiota spends recovering to pre-antibiotic levels. Beyond requiring disruptions to the microbiota before colonization, <i>C. difficile</i> is composed of hundreds of different strain subtypes. The variability in disease severity induced by each of these different subtypes has been hampered by diverse sources of human patient data and has confused the literature for years. We found that the mouse model could be used successfully to quantify the differences in disease burden of phylogenetically diverse <i>C. difficile</i> clinical isolates. Our results demonstrate that differences in observed virulence have less to do with the amount of toxin each isolate produces and more to do with its tolerance to secondary bile acids like lithocholic acid. In addition, whole genome sequencing allows us to identify groups of genes that are associated with highly lethal strains. This work emphasizes the need to evaluate the impact of antibiotic therapy and infecting strain when assessing and treating <i>C. difficile</i> infections.</p><p>
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