Clostridioides difficile colonization of Twin Patients Recovering From Infant Botulism

The prevalence of Clostridioides difficile co-colonization of 107 California patients with suspect infant botulism (IB) was studied over a two-year period. One set of twins with lab-confirmed IB and C. difficile co-colonization was followed longitudinally and their isolated C. difficile was typed by restriction endonuclease analysis (REA).

Stool specimens sent to California Department of Public Health for routine IB diagnostic testing were cultured for C. botulinum and C. difficile. After diagnostic testing identified twin IB patients, their stools collected at weekly and monthly intervals were cultured to determine duration of C. botulinum and C. difficile co-colonization until three consecutive specimens were culture negative for each organism.

Twins X and Y were colonized by C. botulinum for a duration of nearly three and four months, followed by C. difficile for eight and seven months, respectively. Continuous colonization by C. difficile was identified in each twin as C. botulinum colonization was waning. They sequentially shared four identical REA types, three toxigenic and one non-toxigenic, including epidemic strain type J9. Neither twin developed C. difficile illness and colonization ceased spontaneously in each.

C. difficile co-colonization of laboratory-confirmed IB patients is infrequently encountered. IB in both twins was followed by asymptomatic C. difficile colonization. Risk factors for their respective co-colonization remain unknown, including if previous illness with IB was a potential contributing factor. Although the environmental source of the colonizing strains was not determined, this study highlights the ability of C. difficile to spread to close contacts and persist in the infant intestinal microbiome.