Clostridium difficile: A healthcare-associated infection of unknown significance in adults in sub-Saharan Africa

Abstract

Background: Clostridium difficile infection (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 have higher prevalences, and antibiotic usage is less restricted. This article reviews published literature on CDI in sub-Saharan Africa, highlighting areas for future research.

Methods: 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”.

Results: Ten relevant studies were identified. There was considerable variation in methodology to assess for carriage of toxigenic C. difficile and its associations. Eight studies reported carriage of toxigenic C. 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 toxigenic C. difficile and diarrhoeal illness.

Conclusions: While the carriage of toxigenic C. difficile is well described in sub Saharan Africa, the impact of CDI in the region remains poorly understood and warrants further research.