title: Clostridium difficile infection in returning travellers.
abstract: There is increasing recognition of the contribution of community-acquired cases to the global burden of Clostridium difficile infection (CDI). The epidemiology of CDI among international travellers is poorly understood, and factors associated with international travel, such as antibiotic use and changes in gut microbiota, could potentially put travellers at higher risk.
  
  
  
  We summarized demographic, travel-associated and geographic characteristics of travellers with CDI in the GeoSentinel database from 1997 to 2015. We also surveyed GeoSentinel sites to compare various testing indications, approaches, and diagnostic modalities.
  
  
  
  We identified 260 GeoSentinel records, including 187 that satisfied criteria for analysis (confirmed cases in non-immigrant travellers aged >2 years, seen <12 weeks post-travel). CDI was reported in all age groups and in travellers to all world regions; the largest proportions of cases having destinations in Asia (31%), Central/South America or the Caribbean (30%) and Africa (24%). Our site survey revealed substantial heterogeneity of testing approaches between sites; the most commonly used test was the C. difficile toxin gene PCR.
  
  
  
  CDI is encountered in returning international travellers, although there is considerable variability in testing practices. These data underscore the importance of awareness of C. difficile as a potential cause of travel-associated diarrhoea.
authors.affiliation: International Travel Clinic, Division of Infectious Diseases, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT, USA.
authors.forename: A
authors.initials: A
authors.lastname: Michal Stevens
authors.affiliation: Travelers' Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
authors.forename: Douglas H
authors.initials: DH
authors.lastname: Esposito
authors.affiliation: Travelers' Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
authors.forename: Rhett J
authors.initials: RJ
authors.lastname: Stoney
authors.affiliation: Department of Global Health, and Center for Global Health and Development, Boston University School of Public Health (BUSPH), Boston, MA, USA.|Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA.
authors.forename: Davidson H
authors.initials: DH
authors.lastname: Hamer
authors.affiliation: JM Research, Cuernavaca, Mexico.
authors.forename: Jose
authors.initials: J
authors.lastname: Flores-Figueroa
authors.affiliation: Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Bottieau
authors.affiliation: Weill Medical College of Cornell University, New York, NY, USA.
authors.forename: Bradley A
authors.initials: BA
authors.lastname: Connor
authors.affiliation: Department of Infectious Diseases, Cambridge University Hospitals, Cambridge, UK.|Medical Research Council Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK.
authors.forename: Effrossyni
authors.initials: E
authors.lastname: Gkrania-Klotsas
authors.affiliation: Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Abraham
authors.initials: A
authors.lastname: Goorhuis
authors.affiliation: Geographic Medicine Center, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Noreen A
authors.initials: NA
authors.lastname: Hynes
authors.affiliation: J.D. MacLean Centre for Tropical Diseases, McGill University, Montreal, Québec, QC, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Libman
authors.affiliation: National Referral Unit for Tropical Diseases, Department of Infectious Diseases, Ramón y Cajal University Hospital, Madrid, Spain.
authors.forename: Rogelio
authors.initials: R
authors.lastname: Lopez-Velez
authors.affiliation: Tropical Medicine and International Health Clinic, Division of Infectious Diseases, Ottawa Hospital and the University of Ottawa, Ottawa, ON, Canada.
authors.forename: Anne E
authors.initials: AE
authors.lastname: McCarthy
authors.affiliation: Department of Infectious Diseases and Tropical Medicine, Ludwig-Maximilian's University of Munich, Munich, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: von Sonnenburg
authors.affiliation: Center for Geographic Medicine, Department of Medicine C, Sheba Medical Center, Tel Hashomer, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Eli
authors.initials: E
authors.lastname: Schwartz
authors.affiliation: Institute for Tropical Diseases, Harbor Hospital, Rotterdam, The Netherlands.
authors.forename: Perry J J
authors.initials: PJ
authors.lastname: van Genderen
authors.affiliation: International Travel Clinic, Division of Infectious Diseases, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT, USA.
authors.forename: L
authors.initials: L
authors.lastname: Scott Benson
authors.affiliation: International Travel Clinic, Division of Infectious Diseases, University of Utah School of Medicine, 30 North 1900 East, Salt Lake City, UT, USA.
authors.forename: Daniel T
authors.initials: DT
authors.lastname: Leung
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control; D005260:Female; D014943:Global Health; D006801:Humans; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D057236:Travel Medicine; D055815:Young Adult
keywords: Clostridium difficile; diarrhoea; travellers