Specific polymerase chain reaction (PCR) protocols were used to determine the prevalence of toxigenic Clostridium difficile in Vhembe, South Africa. Of 322 stool samples collected, toxigenic C. difficile was found in 23 (7.1%) cases and was significantly associated with diarrhea 20 (11.4%) compared with 3 (2%) in non-diarrheal samples (chi(2) = 426, P = 0.001), intestinal inflammation in 18 (12.1%) compared with 5 (2.9%) in lactoferrin-negative samples (chi(2) = 10.194, P = 0.001), and occult blood in 19 (16%) compared with 4 (2%) in occult blood-negative samples (chi(2) = 22.157, P < 0.001). Toxigenic C. difficile was more common among individuals > 50 years of age (20%), followed by those between 30 and 39 years of age (19%) and was not associated with HIV infections (chi(2) = 0.289, P = 0.591). Co-infection with other pathogens was common. Multivariate analysis indicated that toxigenic C. difficile was associated with E. bieneusi (P = 0.028), C. parvum (P = 0.007), and Enteroaggregative Escherichia coli (EAEC) (P = 0.007) in diarrheal samples. This study confirms the usefulness of PCR methodologies in the detection of toxigenic C. difficile and suggests that C. difficile is responsible for a small, but underappreciated, proportion of diarrheal cases in the region, and further study is warranted in this area.