Abstract
BackgroundInternational travel contributes to the worldwide spread of multidrug resistant Gram-negative bacteria. Rates of travel-related faecal colonization with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae vary for different destinations. Especially travellers returning from the Indian subcontinent show high colonization rates. So far, nothing is known about region-specific risk factors for becoming colonized.MethodsAn observational prospective multicentre cohort study investigated travellers to South Asia. Before and after travelling, rectal swabs were screened for third-generation cephalosporin- and carbapenem-resistant Enterobacteriaceae. Participants completed questionnaires to identify risk factors for becoming colonized. Covariates were assessed univariately, followed by a multivariate regression.ResultsHundred and seventy persons were enrolled, the largest data set on travellers to the Indian subcontinent so far. The acquired colonization rate with ESBL-producing Escherichia coli overall was 69.4% (95% CI 62.1-75.9%), being highest in travellers returning from India (86.8%; 95% CI 78.5-95.0%) and lowest in travellers returning from Sri Lanka (34.7%; 95% CI 22.9-48.7%). Associated risk factors were travel destination, length of stay, visiting friends and relatives, and eating ice cream and pastry.ConclusionsHigh colonization rates with ESBL-producing Enterobacteriaceae were found in travellers returning from South Asia. Though risk factors were identified, a more common source, i.e. environmental, appears to better explain the high colonization rates.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-528) contains supplementary material, which is available to authorized users.
Highlights
International travel contributes to the worldwide spread of multidrug resistant Gram-negative bacteria
Of the remaining 179 participants, 170 (95.0%) had a negative pre-travel screening for Extended-spectrum ß-lactamase (ESBL)-Ent, five (2.8%) had a positive screening and pre-travel data was missing for four participants (2.2%)
The highest rate was found in travellers returning from India (86.8%; 95% confidence intervals (CI) 78.5-95.0%) and the lowest in travellers returning from Sri Lanka (34.7%; 95% CI 22.9-48.7%)
Summary
International travel contributes to the worldwide spread of multidrug resistant Gram-negative bacteria. According to the Global Report on Surveillance of antimicrobial resistance of the World Health Organization (WHO), resistance rates to third-generation cephalosporins of up to 50-80% have been described for all WHO regions This increase in multidrug-resistance is associated with increased morbidity and mortality and higher cost, but with the need to use broader spectrum antibiotics to treat common infections, further facilitating resistance development [1,2]. Recent analyses showed that up to 70% of infections due to ESBL-Ec are community-acquired [3,4] The reasons for this increase in infections caused by ESBL-Ec are manifold, including: the ”classical“ risk factors such as previous antibiotic use (cephalosporins and fluoroquinolones), age, and the presence of comorbidities [2]. Investigations in recent years have shown international travel as a possible means of spreading ESBL-producing Enterobacteriaceae (ESBL-Ent), mainly ESBL-Ec, from high- to low-prevalence countries through asymptomatic travellers [8,9,10,11,12,13], thereby increasing the local prevalence and changing the local epidemiology with the import of non-autochthonous ESBL-Ent [14]
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