Only 5/9 of these travelers were exposed to antibacterial agents during their travel—most commonly

to ciprofloxacin. Several other reports described cases of presumed travel-related CDI: Australian travelers returning from South-East Asia and Africa,[57] aid-workers in Haiti,[58] and a traveler returning from South America.[59] The methodological limitations of case-series studies make drawing definite conclusions about travel-related CDI impossible. However, the learn more existing data, although limited, highlight several interesting aspects regarding CDI in travelers (Table 1). Although CDI was reported more often after traveling to low- and middle-income countries, ∼20% of cases occurred after returning from industrialized countries. In sharp contrast to many other pathogens that cause diarrhea in travelers, C difficile is widely prevalent both in high- and low-income countries. Patients were relatively young, probably reflecting the lower average age of travelers to low-income countries. All travelers with CDI for whom a detailed history was available acquired the infection

in the community. A sizable number of travelers with CDI had no exposure to this website antibacterial agents. When prior use of antibiotics was reported, fluoroquinolones were by far the most common agent. Fluoroquinolones are used frequently as a first-line agent for the treatment or prevention of travelers’ diarrhea.[60] In general, the use of fluoroquinolones has been strongly associated with the risk of developing CDI, and has emerged as a dominant risk factor for the acquisition of the fluoroquinolones resistant, epidemic ribotype 027 strain.[11, 61] The risk of CDI in a traveler using a short course of fluoroquinolones is unknown, but many of the cases of CDI among travelers were indeed associated with the use of this class of antimicrobials (Table 1). As fluoroquinolones are used extensively by travelers, we would have expected to find more reported cases of CDI following the use of fluoroquinolones. It is possible that the use of fluoroquinolones by a young and healthy

host is normally not sufficient to create the conditions for a clinical infection with C difficile, Coproporphyrinogen III oxidase or that many cases are simply not diagnosed and resolve spontaneously. A single case series of three Australian travelers who acquired CDI after using doxycycline for malaria chemoprophylaxis has been published in 1995.[62] On the basis of this single observation, the Centers for Disease Control and Prevention (CDC) guidelines specifically mention CDI as a potential complication of malaria chemoprophylaxis.[63] We have previously suggested that this association is not supported by available data.[59] Since 1995, no additional cases have been documented despite the widespread use of doxycycline for malaria chemoprophylaxis.