Fidaxomicin inhibits toxin production in Clostridium difficile

Fidaxomicin, which was recently approved for the treatment of Clostridium difficile-associated diarrhoea, demonstrates narrow-spectrum bactericidal activity via inhibition of RNA polymerase. In this study we evaluated its inhibitory activity versus C. difficile toxin gene expression and toxin production by quantifying toxin mRNA and protein. The effects of fidaxomicin, its major metabolite (OP-1118), vancomycin and metronidazole on toxin A and toxin B production were determined by assaying culture supernatants of two C. difficile isolates (ATCC 43255, a high-level toxin-producing strain, and UK-14, a NAP1/027/BI epidemic strain) using a commercial ELISA. The effects of the drugs on toxin gene expression were assessed in stationary-phase cells of C. difficile strain UK-1 (NAP1/027/BI type epidemic strain) and in the closely related non-epidemic strain CD196 by quantitative RTPCR. Subinhibitory levels (1/4 MIC) of fidaxomicin or OP-1118 (but not vancomycin or metronidazole) strongly suppressed toxin production in C. difficile (epsilon 60) through at least 1 week of culture. Additionally, transcripts from the pathogenicity loci (tcdR, tcdA and tcdB) were nearly completely inhibited by both fidaxomicin (2 MIC) and OP-1118 (2.5 MIC), but not vancomycin (2.5 MIC). Both fidaxomicin and OP-1118 are able to inhibit toxin production in vitro, which may explain prior post-treatment observations of less frequent detectable toxin in fidaxomicin-treated patients (27 subjects) than those treated with vancomycin (8 patients).