Virulence and genomic diversity among clinical isolates of ST1 (BI/NAP1/027) Clostridioides difficile .

, a leading cause of nosocomial infection, produces toxins that damage the colonic epithelium and results in colitis that varies from mild to fulminant. Variation in disease severity is poorly understood and has been attributed to host factors (age, immune competence and intestinal microbiome composition) and/or virulence differences between strains, with some, such as the epidemic BI/NAP1/027 (MLST1) strain, being associated with greater virulence. We tested 23 MLST1(ST1) clinical isolates for virulence in antibiotic-treated C57BL/6 mice. All isolates encoded a complete Tcd pathogenicity locus and achieved similar colonization densities in mice. Disease severity varied, however, with 5 isolates causing lethal infections, 16 isolates causing a range of moderate infections and 2 isolates resulting in no detectable disease. The avirulent ST1 isolates did not cause disease in highly susceptible Myd88 or germ-free mice. Genomic analysis of the avirulent isolates revealed a 69 base-pair deletion in the N-terminus of the gene, which encodes a response regulator for binary toxin (CDT) expression. Genetic deletion of the 69 base-pair sequence in the highly virulent ST1 R20291 strain rendered it avirulent and reduced toxin gene transcription in cecal contents. Our study demonstrates that a natural deletion within attenuates virulence in the epidemic ST1 strain without reducing colonization and persistence in the gut. Distinguishing strains on the basis of may enhance the specificity of diagnostic tests for colitis.