title: Clostridium difficile: A healthcare-associated infection of unknown significance in adults in sub-Saharan Africa.
abstract: Clostridium difficileinfection (CDI) causes a high burden of disease in high-resource healthcare systems, with significant morbidity, mortality, and financial implications. CDI is a healthcare-associated infection for which the primary risk factor is antibiotic usage, and it is the leading cause of bacterial diarrhoea in HIV-infected patients in the United States. Little is known about the disease burden of CDI in sub-Saharan Africa, where HIV and healthcare-associated infections are more prevalent and antibiotic usage is less restricted. This article reviews published literature on CDI in sub-Saharan Africa, highlighting areas for future research.
  
  
  
  English language publications since 1995 were identified from online databases (PubMed, Medline, Google Scholar, and SCOPUS), using combinations of keywords"C. difficile", "Africa", and "HIV".
  
  
  
  Ten relevant studies were identified. There was considerable variation in the methodologies used to assess for carriage of toxigenicC. difficileand its associations. Eight studies reported carriage of toxigenicC. difficile. Three (of three) studies found an association with antibiotic usage. One (of four) studies showed an association with HIV infection. One study showed no association with degree of immunosuppression in HIV. Two (of three) studies showed an association between carriage of toxigenicC. difficileand diarrhoeal illness.
  
  
  
  While the carriage of toxigenicC. difficileis well described in sub-Saharan Africa, the impact of CDI in the region remains poorly understood and warrants further research.
authors.affiliation: Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Keeley
authors.affiliation: Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom; National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Beeching
authors.affiliation: Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom.
authors.forename: Katharine E
authors.initials: KE
authors.lastname: Stott
authors.affiliation: Department of Infection and Immunity, Royal Liverpool University Hospital, Liverpool, United Kingdom.
authors.forename: Paul
authors.initials: P
authors.lastname: Roberts
authors.affiliation: National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, United Kingdom.
authors.forename: Alastair J
authors.initials: AJ
authors.lastname: Watson
authors.affiliation: Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Michael Bj
authors.initials: MB
authors.lastname: Beadsworth
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016360:Clostridioides difficile; D003015:Clostridium Infections / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology / Q000517:prevention & control; D003428:Cross Infection / Q000175:diagnosis / Q000188:drug therapy / Q000382:microbiology / Q000517:prevention & control; D003967:Diarrhea; D006801:Humans; D007420:Intestine, Large / Q000382:microbiology*
chemical_list: D000900:Anti-Bacterial Agents