The possible implications on the management of returning travelers presenting with diarrhea are discussed. Clostridium difficile has been recognized for many years as a leading cause of health-care-associated diarrhea. Prior antibiotic therapy, prolonged

use of antibacterial agents, prolonged hospitalization, chemotherapy, enteral feeding, and the use of proton pump inhibitors JQ1 supplier have been repeatedly identified as factors associated with acquisition of CDI.[12] The epidemic NAP1/027 strain (North American pulsed-field type 1 and PCR ribotype 027) has been reported initially in Canada, but then spreading rapidly to the United States, Europe, Asia, and Australia. CDI with this epidemic strain was associated with an increased rate of complicated cases,

and a significant rise in attributable mortality.[8, 11] Following this rapid rise in the incidence, morbidity, and mortality attributed PLX4032 ic50 to C difficile, many high-income countries developed programs aimed at reducing CDI rates. These programs included various combinations of active surveillance (including, in some countries, centrally funded programs for ribotyping strains of C difficile), improved infection control measures, restrictions imposed on the use of cephalosporins and fluoroquinolones, and education of health-care workers. A subsequent decrease in rate of infections caused by the NAP1/027 ADP ribosylation factor strain, and a parallel decrease in mortality directly caused by C difficile have been reported in the United States and in several European countries.[8, 13-15] These measures, aimed at reducing CDI rates within hospitals, require enormous resources which are often not available in low-income countries. Even in patients

not exposed to any of the “classical” risk factors associated with CDI, the acquisition of the infection within the community hardly comes as a surprise, when one considers the many possible reservoirs of these bacteria outside health-care facilities. Clostridium difficile is ubiquitous in the environment and frequently colonizes newborns and some asymptomatic adults.[12, 16] The organism has also been isolated from raw vegetables, rivers, tap water, seawater, swimming pools, farm animals, and pets such as cats and dogs.[17-23] Farm animals are often treated with antibiotics, and C difficile is known to colonize asymptomatic animals, and to cause a clinical disease quite identical to human CDI.[24] Clostridium difficile has been isolated from various food products, and although food-borne CDI has not been reported, its occurrence remains theoretically possible.[18, 25, 26] Guidelines published by the Infectious Diseases Society of America suggest using strict standardized case definitions for (1) health-care facility (HCF)-onset, HCF-associated CDI, (2) community-onset, HCF-associated CDI, and (3) community-associated CDI.