Risk Factors for Colonization With Multidrug-Resistant Bacteria Among Patients Admitted to the Intensive Care Unit After Returning From Abroad

The Gordian Knot of C. auris: If You Cannot Cut It, Prevent It

Since its first description in 2009, Candida auris has, so far, resulted in large hospital outbreaks worldwide and is considered an emerging global public health threat. Exceptionally for yeast, it is gifted with a profoundly worrying invasive potential and high inter-patient transmissibility. At the same time, it is capable of colonizing and persisting in both patients and hospital settings for prolonged periods of time, thus creating a vicious cycle of acquisition, spreading, and infection. It exhibits various virulence qualities and thermotolerance, osmotolerance, filamentation, biofilm formation and hydrolytic enzyme production, which are mainly implicated in its pathogenesis. Owing to its unfavorable profile of resistance to diverse antifungal agents and the lack of effective treatment options, the implementation of robust infection prevention and control (IPC) practices is crucial for controlling and minimizing intra-hospital transmission of C. auris. Rapid and accurate microbiological identification, adherence to hand hygiene, use of adequate personal protective equipment (PPE), proper handling of catheters and implantable devices, contact isolation, periodical environmental decontamination, targeted screening, implementation of antimicrobial stewardship (AMS) programs and communication between healthcare facilities about residents' C. auris colonization status are recognized as coherent strategies for preventing its spread. Current knowledge on C. auris epidemiology, clinical characteristics, and its mechanisms of pathogenicity are summarized in the present review and a comprehensive overview of IPC practices ensuring yeast prevention is also provided.

Identifying patients at high risk for multidrug-resistant organisms after hospitalization abroad

OBJECTIVES

We quantified the percentage of multidrug-resistant organism (MDRO) carriers among repatriated patients. We identified factors associated with MDRO carriage, and we evaluated the yield of MDRO detection per screened body site.

DESIGN

Retrospective cohort study.

SETTING

A tertiary-care center in Switzerland.

PATIENTS

Adult patients after a stay in a healthcare institution abroad.

METHODS

Patients were screened for MDRO carriage. Standard sites, including nose and throat, groins, and (since mid-2018) rectum, and risk-based sites (wounds, urine, tracheal secretion) were sampled. MDROs were defined as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase (ESBL)- and carbapenemase-producing Enterobacterales (CPE), multidrug-resistant (MDR) Enterobacterales, and MDR nonfermenting gram-negative rods. Risk factors for MDRO carriage were assessed using multivariate logistic regression.

RESULTS

Between May 2017 and April 2019, 438 patients were screened and 107 (24.4%) tested positive for an MDRO, predominantly ESBL-producing and MDR Enterobacterales. Risk factors for MDRO colonization were the length of stay in hospital abroad, antibiotic treatment with 'Watch' and 'Reserve' antibiotics, and region of hospitalization abroad. Rectal swabs had the highest yield for detecting patients with MDR intestinal bacteria, but nose/throat and groins, or wound samples were more sensitive for MRSA or nonfermenting gram-negative organisms, respectively.

CONCLUSIONS

We identified risk factors for MDRO carriage and body sites with the highest yield for a specific MDRO, which might help to target screening and isolation and reduce screening costs.

The first case of clade I Candida auris candidemia in a patient with COVID-19 in Japan

Candida auris is a health hazard because of its antifungal resistance and the potential to cause healthcare-associated outbreaks. To our knowledge, no previous cases of candidemia caused by C. auris have been reported in Japan. Herein, we report the first known case of clade I C. auris candidemia in a Japanese man with coronavirus disease 2019 (COVID-19) infection who was medically evacuated from the Philippines. A 71-year-old Japanese man traveled to Cebu Island in the Philippines 5 months before admission to our hospital. He contracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the Philippines and was admitted to the intensive care unit (ICU) in a local hospital. During his medical evacuation, we implemented precautions given his history of COVID-19 and pneumonia caused by multi-drug-resistant Acinetobacter baumannii complex. His blood culture revealed that C. auris infection was treated with antifungal agents but he did not survive. No evidence of nosocomial transmission was found among other patients in the ICU. This case study determines that accurate detection of C. auris, appropriate antifungal agent selection, precautions, and patient isolation are crucial to prevent nosocomial outbreaks, especially in patients with a history of multidrug-resistant organism (MDRO) colonization or international hospitalization. Medical professionals should recognize the risk of MDROs in international medical evacuation settings, considering the recent resumption of cross-border travel after the COVID-19 pandemic.

Investigation of a vanA linezolid- and vancomycin-resistant Enterococcus faecium outbreak in the Southwest Indian Ocean (Reunion Island)

INTRODUCTION

Dual resistance to linezolid and glycopeptides is a milestone reached by certain extensively drug-resistant (XDR) enterococci. This paper describes the molecular and epidemiological investigations of a linezolid-resistant and vancomycin-resistant Enterococcus faecium (E. faecium) (LVREf) outbreak in the French overseas territory of Reunion Island (Indian Ocean).

METHODS

All vancomycin-resistant Enterococcus (VRE) isolates detected on Reunion Island between 2015 and 2019 were included in the study. The VRE isolates were phenotypically characterised and genetically explored by whole-genome sequencing (WGS).

RESULTS

Sixteen vancomycin-resistant E. faecium (VREf) isolates were retrieved between 2015 and 2019. Seven isolates obtained in 2019 were involved in the outbreak. These seven LVREf isolates from the 2019 outbreak at the University Hospital of Reunion Island (UHRI) were suspected to be related to a linezolid-susceptible VREf strain imported from India. An epidemiological link was highlighted for six of the seven outbreak cases. All the LVREf outbreak isolates were obtained from rectal swabs (colonisation) and resistant to vancomycin (MIC > 128 mg/L) and linezolid (MIC 8-32 mg/L); one isolate was also resistant to daptomycin (MIC 8 mg/L). The seven outbreak isolates were positive for the vanA and optrA genes and belonged to ST761.

CONCLUSIONS

These results argue for the strict application of control and prevention measures for VRE clones at high risk of spread, particularly in areas such as Reunion Island where the risk of importation from the Indian subcontinent is high. The regional spread of optrA linezolid-resistance genes in VRE isolates is a matter of concern, due to possibility of treatment failure.

Colonization with extended-spectrum beta-lactamase-producing Escherichia coli and traveler's diarrhea attack rates among travelers to India: a systematic review and meta-analysis

Background

India is an attractive destination for travelers. Unfortunately, numerous reports exist on traveler’s diarrhea (TD) and fecal colonization with extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) among international travelers visiting India. Here, we systematically reviewed studies published on the acquisition of ESBL-EC and TD attack rates among international visitors to India.

Methods

Design: Systematic review and meta-analysis.

A systematic search was performed using Google Scholar, PubMed, EMBASE, Web of Science, and gray literature from 2000 to December 2021, for studies containing data for ESBL-EC acquisition or TD experience related to a trip to India. Random effects models were used to compute the prevalence of ESBL-EC acquisition and TD attack.

Results

The literature search yielded a total of 5023 records. Of these, 31 met our inclusion criteria for systematic review and only 17 could be meta-analyzed (9 for TD, and 8 for ESBL-EC). The overall pooled attack rate of TD was 39% (95% confidence interval, CI: 25–53%). In studies where travelers' memory was used to diagnose TD, the pooled attack rate of TD was slightly higher (42%, 95% CI: 21–64%) compared to those where TD was objectively documented (33%, 95% CI: 17–49%). There were significant risks to be colonized with ESBL-EC among the travelers who experienced TD. The pooled rate of ESBL-EC colonization was 72% (CI: 67–78%). Most ESBL-EC produced CTX-M-15 enzyme. Furthermore, most of the travelers who acquired ESBL-EC were from highly industrialized countries recruited from travel clinics: Canada (n = 80), Germany (n = 69), Netherlands (n = 20), Sweden (n = 18), Japan (n = 10), Finland (n = 8), USA (n = 7), Spain (n = 5), and Denmark (n = 3).

Conclusions

TD pooled attack rate and ESBL-EC acquisition among international travelers visiting India were high in this study. However, we cannot make generalizations based upon this TD pooled attack rate for the current situation, due to a lack of current data. Our study highlights that travelers should be advised on TD to ensure that they do not disregard the risk of contracting TD and be better prepared as a result. It also illustrates the importance of international travel in acquiring antibiotic-resistant Escherichia coli.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40794-022-00179-1.

Clinical characteristics and risk factors for multidrug-resistant bacterial isolation in patients with international travel history

BACKGROUND

International travelers are at risk of carrying resistant bacteria. It is critical to identify risk factors associated with multidrug-resistant organism (MDRO) colonization in travelers.

METHODS

A retrospective chart review observational study was conducted at two tertiary centers in Japan for inpatients who had been hospitalized or visited an outpatient clinic overseas within the previous 12 months. These patients underwent MDRO screening upon admission. To identify independent predictors for the isolation of MDROs, multivariable analyses were performed using logistic regression.

RESULTS

In total, 76 (35%) of the 216 patients were positive for MDROs at admission. The majority of bacteria detected in stool samples were extended-spectrum beta-lactamase-producing Escherichia coli (ESBLEC) (n = 67 [89%]). ESBLEC was detected in nearly 40% of patients who traveled to Asia. Travel to Asia was an independent risk factor for any MDRO and ESBLEC isolation. For non-ESBLEC MDRO isolation, a history of surgery abroad was an independent risk factor for detection.

DISCUSSION AND CONCLUSIONS

A history of hospitalization abroad has previously been found to be associated with MDRO colonization in travelers, which was not identified as a risk factor in this study. The risk factors for MDRO colonization were different between ESBLEC and non-ESBL MDROs.

European hospitals as source of multidrug-resistant bacteria: analysis of travellers screened in Finland after hospitalization abroad

BACKGROUND

As hospitals have a high prevalence of multidrug-resistant organisms (MDRO), hospitalization abroad indicates for travellers an increased risk of acquiring MDRO-and carrying the strains home. Antimicrobial resistance (AMR) rates are highest in the (sub)tropics, whereas Europe is considered a lower risk region. Since AMR prevalences vary within Europe, we aimed to gather country-specific data on the risks for hospitalized travellers.

METHODS

At hospitals of the Helsinki and Uusimaa district in Finland, patients hospitalized abroad over the past 12 months are systematically screened for methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales (ESBL-PE), carbapenemase-producing bacteria and vancomycin-resistant Enterococcus spp. (VRE). Among patients screened 2010-19, we selected those hospitalized in Europe, recorded their MDRO findings, infections and mortality, and analysed MDRO-associated risk factors.

RESULTS

Of the 1772 patients treated in 41 European countries, 16.6% (295) carried MDRO, 12.5% (221) ESBL-PE, 7.8% (138) solely ESBL-E. coli, 2.6% (46) MRSA, 2.2% (30) of those screened VRE and 2.2% (39) carbapenem-resistant Gram-negatives. Among those colonized, 9.8% (29) had symptomatic MDRO infections and 0.3% (one) died. Colonization was most frequently recorded for those treated in eastern and southern Europe, with Bulgaria, Cyprus and the Russian Federation scoring highest. MDRO colonization was associated with antibiotic treatment and showed a negative correlation with time from discharge to screening.

CONCLUSIONS

After hospitalization in European countries, ESBL-PE carriage was relatively common (12.5%), while other MDROs proved less frequent (<5%). Antibiotic treatment and short time since hospitalization abroad increased the risk of MDRO colonization. Clear differences between countries and regions were revealed, with highest rates in the east and the south.

Mortality Risk Factors and Prognostic Analysis of Patients with Multi-Drug Resistant Enterobacterales Infection

Background

The data from the China Network Antibacterial Surveillance Center (http://www.chinets.com) showed that the prevalence of Escherichia coli (E. coli), Klebsiella pneumoniae (KP), and Enterobacter cloacae (ecl), was 18.96%, 14.12%, and 2.74% in 2022, respectively. The resistance rates of E. coli and KP to 3rd or 4th generation cephalosporins were 51.7% and 22.1%, to carbapenems was 1.7% and 3.9%, to quinolones was 55.9% in Shanxi. The generation of extended-spectrum beta-lactamases (ESBLs) is a major mechanism resulting in drug resistance in Enterobacterales. To determine the mortality risk factors of multi-drug resistant Enterobacterales (MDRE) and multi-drug resistant Klebsiella pneumoniae (MDR-KP) infection.

Methods

91 MDR strains from 91 patients were collected from 2015 to 2019 in the second hospital of Shanxi Medical University. The mortality risk factors for the MDRE infections and clinical outcomes were analyzed by univariable and multivariable analysis. The independent predictors of 30-day mortality were analyzed through the Cox regression analysis including the variables with a value <0.2.

Results

The majority of patients were admitted to ICUs. Pulmonary infection was a major infection (43.96%, 40/91). Thirty-three (36.26%, 33/91) strains of MDR-KP were only detected in 2018. The proportion of multi-drug resistant Escherichia coli (MDR E. coli) and multi-drug resistant Enterobacter cloacae (MDR ecl) were 16.48% (15/91) and 17.58% (16/91), respectively. The presence of cerebrovascular diseases (OR, 4.046; 95%Cl, 1.434–11.418; P=0.008) and central venous catheterization (OR, 4.543; 95%Cl, 1.338–15.425; P=0.015) were associated with mortality in patients with MDRE infections. Endotracheal intubation (OR, 4.654; 95%Cl, 1.5–14.438; P=0.008) was an independent mortality risk factor for patients infected with MDR-KP strains. Patients who received aminoglycoside antibiotics (P=0.057) had a higher 30-day survival rate. The β-lactam antibiotics were the major agent in the clinic.

Conclusion

This study implies that patients with cerebrovascular diseases, central venous catheterization, and endotracheal intubation are at risk of carrying MDR isolates.

Screening for Antimicrobial-Resistant Gram-negative bacteria in hospitalised patients, and risk of progression from colonisation to infection: Systematic review

BACKGROUND

Transmission of antimicrobial-resistant Gram-negative bacteria (AMR-GNB) among hospitalised patients can lead to new cases of carriage, infection and outbreaks, hence the need for early carrier identification. We aim to explore two key elements that may guide control policies for colonisation/infection in hospital settings: screening practices on admission to hospital wards and risk of developing infection from colonisation.

METHODS

We searched on PubMed, Scopus and Cochrane databases for studies published from 2010 up to 2021 reporting on adult patients hospitalised in high-income countries.

RESULTS

The search retrieved 11853 articles. After screening, 100 studies were included. Combining target patient groups and setting type, we identified six screening approaches. The most reported approach was all admitted patients to high-risk (HR) wards (49.4%). The overall prevalence of AMR-GNB was 13.8% (95%CI 9.3-19.0) with significant differences across regions and time. Risk of progression to infection among colonised patients was 11.0% (95%CI 8.0-14.3) and varied according to setting and pathogens' group (p value<0.0001), with higher values reported for Klebsiella species (18.1%; 95%CI 8.9-29.3).

CONCLUSIONS

While providing a comprehensive overview of the screening approaches, our study underlines the considerable burden of AMR-GNB colonisation and risk of progression to infection in hospitals by pathogen, setting and time.

Import of multidrug-resistant bacteria from abroad through interhospital transfers, Finland, 2010-2019

Background

While 20–80% of regular visitors to (sub)tropical regions become colonised by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), those hospitalised abroad often also carry other multidrug-resistant (MDR) bacteria on return; the rates are presumed to be highest for interhospital transfers.

Aim

This observational study assessed MDR bacterial colonisation among patients transferred directly from hospitals abroad to Helsinki University Hospital. We investigated predisposing factors, clinical infections and associated fatalities.

Methods

Data were derived from screening and from diagnostic samples collected between 2010 and 2019. Risk factors of colonisation were identified by multivariable analysis. Microbiologically verified symptomatic infections and infection-related mortality were recorded during post-transfer hospitalisation.

Results

Colonisation rates proved highest for transfers from Asia (69/96; 71.9%) and lowest for those within Europe (99/524; 18.9%). Of all 698 patients, 208 (29.8%) were colonised; among those, 163 (78.4%) carried ESBL-PE, 28 (13.5%) MDR Acinetobacter species, 25 (12.0%) meticillin-resistant Staphylococcus aureus, 25 (12.0%) vancomycin-resistant Enterococcus, 14 (6.7%) carbapenemase-producing Enterobacteriaceae, and 12 (5.8%) MDR Pseudomonas aeruginosa; 46 strains tested carbapenemase gene-positive. In multivariable analysis, geographical region, intensive care unit (ICU) treatment and antibiotic use abroad proved to be risk factors for colonisation. Clinical MDR infections, two of them fatal (1.0%), were recorded for 22 of 208 (10.6%) MDR carriers.

Conclusions

Colonisation by MDR bacteria was common among patients transferred from foreign hospitals. Region of hospitalisation, ICU treatment and antibiotic use were identified as predisposing factors. Within 30 days after transfer, MDR colonisation manifested as clinical infection in more than 10% of the carriers.

Travel-Related Antimicrobial Resistance: A Systematic Review

There is increasing evidence that human movement facilitates the global spread of resistant bacteria and antimicrobial resistance (AMR) genes. We systematically reviewed the literature on the impact of travel on the dissemination of AMR. We searched the databases Medline, EMBASE and SCOPUS from database inception until the end of June 2019. Of the 3052 titles identified, 2253 articles passed the initial screening, of which 238 met the inclusion criteria. The studies covered 30,060 drug-resistant isolates from 26 identified bacterial species. Most were enteric, accounting for 65% of the identified species and 92% of all documented isolates. High-income countries were more likely to be recipient nations for AMR originating from middle- and low-income countries. The most common origin of travellers with resistant bacteria was Asia, covering 36% of the total isolates. Beta-lactams and quinolones were the most documented drug-resistant organisms, accounting for 35% and 31% of the overall drug resistance, respectively. Medical tourism was twice as likely to be associated with multidrug-resistant organisms than general travel. International travel is a vehicle for the transmission of antimicrobial resistance globally. Health systems should identify recent travellers to ensure that adequate precautions are taken.

Global geographic trends in antimicrobial resistance: the role of international travel

BACKGROUND

Rising antimicrobial resistance (AMR) is a threat to modern medicine, and increasing international mobility facilitates the spread of AMR. Infections with resistant organisms have higher morbidity and mortality, are costlier to treat, result in longer hospital stays and place a greater burden on health systems than infections caused by susceptible organisms. Here we review the role of travel in the international dissemination of AMR and consider actions at the levels of travelers, travel medicine practitioners and policymakers that would mitigate this threat.

RESULTS

Resistant pathogens do not recognize international borders; travelers to areas with high AMR prevalence are likely to be exposed to resistant bacteria and return to their home countries colonized. Medical tourists go between health facilities with drastically different rates of AMR, potentially transmitting highly resistant strains.Drug-resistant bacteria have been found in every continent; however, differences between countries in the prevalence of AMR depend on multiple factors. These include levels of antibiotic consumption (including inappropriate use), access to clean water, adequate sanitation, vaccination coverage, the availability of quality healthcare and access to high-quality medical products.

CONCLUSIONS

Travelers to areas with high levels of AMR should have vaccines up to date, be aware of ways of treating and preventing travelers' diarrhea (other than antibiotic use) and be informed on safe sexual practices. The healthcare systems of low- and middle-income countries require investment to reduce the transmission of resistant strains by improving access to clean water, sanitation facilities and vaccines. Efforts are needed to curb inappropriate antibiotic use worldwide. In addition, more surveillance is needed to understand the role of the movement of humans, livestock and food products in resistance transmission. The travel medicine community has a key role to play in advocating for the recognition of AMR as a priority on the international health agenda.

KEY POLICY RECOMMENDATIONS

AMR is a threat to modern medicine, and international travel plays a key role in the spread of highly resistant strains. It is essential that this is addressed at multiple levels. Individual travelers can reduce antibiotic consumption and the likelihood of infection. Travelers should have up-to-date vaccines and be informed on methods of preventing and treating travelers' diarrhea, other than use of antibiotics and on safe sexual practices, such as condom use. Healthcare facilities need to be aware of the travel history of patients to provide appropriate treatment to those who are at high risk of exposure and to prevent further spread. Internationally, in countries without reliable and universal access to clean water, sanitation and hygiene, investment is needed to reduce the emergence and spread of resistance and ensure the antimicrobials available are of assured quality. High-income countries must ensure their use of antimicrobials is appropriate to reduce selection for AMR. Surveillance across all countries is needed to monitor and respond to this emerging threat.

Bringing home unwelcome souvenirs: Travel and drug-resistant bacteria

Antimicrobial resistance poses a significant threat to public health globally and in Canada. Wide regional variability in antimicrobial resistance and ongoing increases in global travel present an important risk for the acquisition and transmission of drug-resistant organisms. Travel from high-income to low- and middle-income countries, particularly the Indian subcontinent, present the greatest risks for acquiring a drug-resistant Enterobacteriaceae. Risk factors for returning from travel with drug-resistant organisms include seeking medical care while abroad, travellers' diarrhea and antibiotic use. Health care professionals can play an important role in preventing harm for travellers by counselling patients on the risks of acquiring drug-resistant organisms, appropriate antibiotic prescribing for travellers' diarrhea and tailored empiric therapy for patients presenting with infection after travel.

Travel and the Spread of Drug-Resistant Bacteria

PURPOSE OF REVIEW

The rise in antimicrobial resistance is an urgent public health threat which, in the absence of intervention, may result in a post-antibiotic era limiting the effectiveness of antibiotics to treat both common and serious infections. Globalization and human migration have profoundly contributed to the spread of drug-resistant bacteria. In this review, we summarize the recent literature on the importance of travelers in the spread of drug-resistant bacterial organisms. Our goal was to describe the importance of travel on a variety of clinically relevant drug-resistant bacterial organisms including extended-spectrum β-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus, Salmonella species, as well as other enteric infections.

RECENT FINDINGS

Travelers from high income countries, visiting low and middle income countries, frequently acquire drug-resistant bacteria, particularly extended-spectrum β-lactamase-producing Enterobacteriaceae. The highest risk is associated with travel to the Indian subcontinent. Multidrug-resistant enteric infections in travelers from Salmonella spp., Campylobacter spp., and Shigella spp. are increasing. Refugees, pilgrimages, and medical tourists are associated with considerable risk of multiple forms of drug resistance. This review highlights the importance of antimicrobial stewardship, infection control, and surveillance; particularly in low and middle income countries. International leadership with global coordination is vital in the battle against antimicrobial resistance.

Prevalence and risk factors for Extended-Spectrum Beta-Lactamase-producing- Enterobacteriaceae in French military and civilian travelers: A cross-sectional analysis

BACKGROUND

International travel is a risk factor for colonization with Extended-Spectrum Beta-Lactamase-producing- Enterobacteriaceae (ESBL-E). We describe the prevalence of and risk-factors for ESBL-E colonization in civilian and military travelers.

METHODS

Patients hospitalized in the infectious diseases department of Bégin Military Hospital (France) from May 2012 to November 2015, who had traveled abroad over the past two months, were screened for intestinal colonization with ESBL-E.

RESULTS

Forty-one out of 166 travelers (24.7%) had ESBL-E colonization, predominantly Escherichia coli. The risk factors for ESBL-E colonization in the univariate analysis were a treatment with any antibiotic in the last two months (OR 4.19, 95% CI 1.91-9.16) or with a beta-lactam in the same period (OR 3.35, 95% CI 1.44-7.82), and an hospitalization in the last two months (OR 3.96, 95% CI 1.91-9.16). The military status, military mission or military accommodation were not associated with an increased risk of ESBL-E colonization. In the multivariate analysis, a treatment with any antibiotic in the last two months was significantly associated with ESBL-E colonization (OR 6.71, 95% CI 3.36-19.08).

CONCLUSION

Antibiotic treatment in the two previous months is strongly predictive of ESBL-E colonization in international travelers, while the military status and its specific living conditions are not.

Patients hospitalized abroad as importers of multiresistant bacteria-a cross-sectional study

OBJECTIVES

The pandemic spread of multidrug-resistant (MDR) bacteria poses a threat to healthcare worldwide, with highest prevalence in indigent regions of the (sub)tropics. As hospitalization constitutes a major risk factor for colonization, infection control management in low-prevalence countries urgently needs background data on patients hospitalized abroad.

METHODS

We collected data on 1122 patients who, after hospitalization abroad, were treated at the Helsinki University Hospital between 2010 and 2013. They were screened for methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), vancomycin-resistant enterococci, carbapenemase-producing Enterobacteriaceae (CPE), multiresistant Pseudomonas aeruginosa and multiresistant Acinetobacter baumannii. Risk factors for colonization were explored by multivariate analysis.

RESULTS

MDR colonization rates were higher for those hospitalized in the (sub)tropics (55%; 208/377) compared with temperate zones (17%; 125/745). For ESBL-PE the percentages were 50% (190/377) versus 12% (92/745), CPE 3.2% (12/377) versus 0.4% (3/745) and MRSA 6.6% (25/377) versus 2.4% (18/745). Colonization rates proved highest in those returning from South Asia (77.6%; 38/49), followed by those having visited Latin America (60%; 9/16), Africa (60%; 15/25) and East and Southeast Asia (52.5%; 94/179). Destination, interhospital transfer, short time interval to hospitalization, young age, surgical intervention, residence abroad, visiting friends and relatives, and antimicrobial use proved independent risk factors for colonization.

CONCLUSIONS

Post-hospitalization colonization rates proved higher in the (sub)tropics than elsewhere; 11% (38/333) of carriers developed an MDR infection. We identified several independent risk factors for contracting MDR bacteria. The data provide a basis for infection control guidelines in low-prevalence countries.

Prevalence of multidrug-resistant organisms in refugee patients, medical tourists and domestic patients admitted to a German university hospital

BACKGROUND

Patients with contact to healthcare-system in high-prevalence countries (HPC) and refugee patients in hospital settings (REF) have previously been identified to be at risk of carrying multidrug-resistant organisms (MDRO). Comparative studies addressing the epidemiology of MDRO in patients transferred from hospitals abroad (ABROAD) and REF are lacking but are necessary to introduce refined infection control measures.

METHODS

From December 2015 to June 2016, 117 REF, 84 ABROAD and 495 patients admitted to intensive care unit, with no refugee history or pre-treatment abroad (ICU), at University Hospital Frankfurt, Germany (UHF) were screened for MDRO on day of admittance. Data within these groups were compared and set in an epidemiological context.

RESULTS

52.1% (95% confidence interval = 42.7-61.5) of REF and 41.6% (31.0-52.9) of ABROAD, were positive for at least one MDRGN, respectively. In contrast, 7.9% (5.6-10.6) of ICU were positive for MDRGN. Thereof, 0.9% (0.0-4.7) of REF, 15.5% (8.5-25.0) of ABROAD and 0% (0.0-0.7) of ICU were positive for at least one MDRGN with carbapenem resistance (CR). In total, 19 MDRGN with CR were detected in ABROAD, with the most frequent species with CR being A. baumannii with 42.1% (20.3-66.5). Regarding MRSA, 10.3% (5.4-17.2) of REF, 5.9% (1.9-13.3) of ABROAD and a significantly lower proportion 1.4% (0.6-2.9) of ICU, respectively, were tested positive.

CONCLUSIONS

Both REF and ABROAD pose a relevant hospital hygiene risk. High prevalence of MDRGN with CR in ABROAD was observed. Concise screening and infection control guidelines are needed in patient cohorts with increased risk for MDRO carriage.

Self-reported illness among Boston-area international travelers: A prospective study

BACKGROUND

The Boston Area Travel Medicine Network surveyed travelers on travel-related health problems.

METHODS

Travelers were recruited 2009-2011 during pre-travel consultation at three clinics. The investigation included pre-travel data, weekly during-travel diaries, and a post-travel questionnaire. We analyzed demographics, trip characteristics, health problems experienced, and assessed the relationship between influenza vaccination, influenza prevention advice, and respiratory symptoms.

RESULTS

Of 987 enrolled travelers, 628 (64%) completed all surveys, of which 400 (64%) reported health problems during and/or after travel; median trip duration was 12 days. Diarrhea affected the most people during travel (172) while runny/stuffy nose affected the most people after travel (95). Of those with health problems during travel, 25% stopped or altered plans; 1% were hospitalized. After travel, 21% stopped planned activities, 23% sought physician or other health advice; one traveler was hospitalized. Travelers who received influenza vaccination and influenza prevention advice had lower rates of respiratory symptoms than those that received influenza prevention advice alone (18% vs 28%, P = 0.03).

CONCLUSIONS

A large proportion of Boston-area travelers reported health problems despite pre-travel consultation, resulting in inconveniences. The combination of influenza prevention advice and influenza immunization was associated with fewer respiratory symptoms than those who received influenza prevention advice alone.

High rate of multidrug-resistant organism colonization among patients hospitalized overseas highlights the need for preemptive infection control

We performed 4 years of active screening for multidrug resistant organism (MDRO) colonization among patients with a history of overseas hospitalization. Thirteen (56.5%) of 23 cases were positive for MDROs, which highlights the importance of preemptive infection control to prevent the spread of MDROs in this population.

Epidemiology of 62 patients admitted to the intensive care unit after returning from Madagascar

BACKGROUND

To our knowledge, there is no data on the epidemiology of patients hospitalized in intensive care unit (ICU) after a stay in Madagascar or other low-income countries. It is possible that such data may improve transfer delays and care quality for these patients.

METHODS

In a retrospective study, we reviewed the charts of all patients admitted to ICU of the Reunion Island Felix Guyon University Hospital from January 2011 through July 2013. We identified all patients who had stayed in Madagascar during the 6 months prior to ICU admission.

RESULTS

Of 1842 ICU patients, 62 (3.4%) had stayed in Madagascar during the 6 months prior to ICU admission. Patients were 76% male and the median age was 60.5 (48.25-64.75) years; patients were more frequently residents of Madagascar than travellers (56.5%). In most cases, patients were not hospitalized or given antibiotics in Madagascar. The most frequent causes of hospitalization were infections including malaria (21%) and lower respiratory infection (11%). Carriage and infection with multidrug resistant (MDR) bacteria on ICU admission were frequent (37% and 9.7%, respectively). The mortality rate in ICU was 21%, and severity acute physiological Score II was 53.5 (37-68).

CONCLUSIONS

Patients admitted to ICU after a stay to Madagascar are mainly elderly patients with chronic illnesses, and often foreign residents. The admission causes are specific of the country like malaria, or specific to the population concerned such as cardiovascular accidents that could be prevented.

High carriage rate of ESBL-producing Enterobacteriaceae at presentation and follow-up among travellers with gastrointestinal complaints returning from India and Southeast Asia

BACKGROUND

International travel contributes to the spread of multidrug-resistant microorganisms including extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). We assessed the proportion of faecal carriers of ESBL-PE among 211 patients with gastrointestinal symptoms who returned to Berlin, Germany, after international travel.

METHODS

ESBL-PE were screened for on chromogenic agar, antimicrobial susceptibility testing was performed, and ESBL-genes were genotyped. Travel-related data were assessed by questionnaire.

RESULTS

Diarrhoea, abdominal pain and nausea were the main symptoms. Half of the travellers carried ESBL-PE (97% Escherichia coli); the proportion was highest for returnees from India (72%) and mainland Southeast Asia (59%), and comparatively lower for Africa (33%) and Central America (20%). Co-resistance to fluoroquinolones (particularly in isolates from India), gentamicin and cotrimoxazole was frequent but all isolates were carbapenem-susceptible. ESBL-PE carriage decreased with increasing timespan from return to presentation, and with age. At revisit of initially ESBL-PE positive patients half a year later, 28% (17/61) of the individuals were still carriers, CTX-M groups being congruent with the initial isolates. CTX-M groups 9 and 1/9, vegetarian diet and cat ownership tended to be associated with ESBL-PE carriage upon revisit.

CONCLUSIONS

Travellers, particularly those returning from India and Southeast Asia, constitute a relevant source of potential spread of ESBL-PE. Carriage declines over time but ESBL-PE persist for at least 6 months in a substantial proportion of individuals. Both genetic characteristics of the bacteria and lifestyle factors seem to contribute to persistent carriage of ESBL-PE. A recent, extra-European travel history argues for ESBL-PE screening and contact precautions for patients admitted to hospital.