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Background Clostridium difficile is a major identifiable and treatable cause of antibiotic-associated diarrhea. Poor nutritional status contributes to mortality through weakened host defenses against various pathogens. The primary goal of this study was to assess the contribution of a reduced protein diet to the outcomes of C. difficile infection in a murine model. Methods C57BL/6 mice were fed a traditional house chow or a defined diet with either 20% protein or 2% protein and infected with C. difficile strain VPI10463. Animals were monitored for disease severity, clostridial shedding and fecal toxin levels. Select intestinal microbiota were measured in stool and C. difficile growth and toxin production were quantified ex vivo in intestinal contents from untreated or antibiotic-treated mice fed with the different diets. Results C. difficile infected mice fed with defined diets, particularly (and unexpectedly) with protein deficient diet, had increased survival, decreased weight loss, and decreased overall disease severity. C. difficile shedding and toxin in the stool of the traditional diet group was increased compared with either defined diet 1 day post infection. Mice fed with traditional diet had an increased intestinal Firmicutes to Bacteroidetes ratio following antibiotic exposure compared with either a 2% or 20% protein defined nutrient diet. Ex vivo inoculation of cecal contents from antibiotic-treated mice showed decreased toxin production and C. difficile growth in both defined diets compared with a traditional diet. Conclusions Low protein diets, and defined nutrient diets in general, were found to be protective against CDI in mice. Associated diet-induced alterations in intestinal microbiota may influence colonization resistance and clostridial toxin production in a defined nutrient diet compared to a traditional diet, leading to increased survival. However, mechanisms which led to survival differences between 2% and 20% protein defined nutrient diets need to be further elucidated.

Summary Although most surgeons continue to adhere to the use of direct intraductal drainage routinely after choledochotomy for a variety of reasons including fear of biliary peritonitis, we believe that this may not always be in the patients' best interest. The practice of primary closure of the common bile duct is preferred in selected cases by a number of well qualified surgeons in the present and past centuries. As a matter of fact, drainage of the common bile duct may hinder rather than help the recovery of patients. The use of a binocular surgical microscope, especially a surgical diploscope with 400 to 500 mm focal distance lenses, allows the surgeons to accurately approximate common bile duct incisions or transections without the use of stents or drainage. A nonbile leakage closure of primary type can be obtained because of excellent lighting and magnification of the surgical field and the use of fine suture material.