A significant obstacle to the control of CDI within hospitals in low-income countries is the lack of laboratory tests for diagnosing CDI in many such institutions. A multitude of diagnostic tests for CDI exist, BIBW2992 supplier and this issue is beyond the scope of this article. In general, a screening test with a sensitive method (such as the glutamate dehydrogenase) and a confirmatory test

(such as a cytotoxicity test) are optimal. In a resource-limited setting, an enzyme immunoassay detecting the C difficile toxins can be used despite its lower sensitivity. However, empiric treatment for presumed bacterial pathogens and intestinal parasites is frequently administered to patients with diarrhea without using any diagnostic tool. This approach results in an unrestricted use of antibiotics and the delay of treatment for CDI. Such use of antibiotics creates ideal conditions for the proliferation of C difficile. Ultimately, excess morbidity, mortality, and increased transmission of CDI to other patients may ensue. As previously mentioned, several potential reservoirs of C difficile have been recognized (eg, soil, farm animals, water). In addition, Natural Product Library solubility dmso infants and healthy adults are occasionally asymptomatic carriers of these bacteria. In low-income countries, these reservoirs may play a more prominent

role in the spread of community-acquired CDI. Throughout Bay 11-7085 much of the developing world clean water is not universally available, sewage infrastructure is suboptimal, and drinking water is frequently contaminated with human or animal excretions. Whether transmission of C difficile is enhanced by such unfortunate circumstances is unknown. In addition, the close proximity of humans to domestic animals known to carry pathogenic strains of

C difficile and the higher number of persons per household may also pose additional risks of contracting the bacteria. Thus, although the incidence of community-acquired CDI in low-income countries is unknown, it is likely to be high. An association between human immunodeficiency virus (HIV) infection and CDI has been long observed in the United States.[51] A study conducted in Peru demonstrates that this important association is also evident in low-income countries.[52] In this study, the most common pathogen causing persistent diarrhea in HIV-positive patients was C difficile, and CDI was associated with increased mortality, even after adjustment for coinfection, CD4 lymphocyte count, and weight loss. Similar findings were reported in Africa.[42] One would expect to find a high incidence of CDI in hospitals within some developing countries in which a large proportion of the patients are infected with HIV.