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Clinical Microbiology and Infection xxx (2016) 1.e1e1.e7
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Original article
Travel to Asia and traveller's diarrhoea with antibiotic treatment are
independent risk factors for acquiring ciprofloxacin-resistant and
extended spectrum b-lactamase-producing Enterobacteriaceaeda
prospective cohort study
E.A. Reuland 1, *, G.J.B. Sonder 2, 3, I. Stolte 2, N. al Naiemi 1, 4, 5, A. Koek 1, G.B. Linde 6,
T.J.W. van de Laar 1, C.M.J.E. Vandenbroucke-Grauls 1, A.P. van Dam 6, 7
1)
Medical Microbiology and Infection Control, VU University Medical Centre, Amsterdam
Department of Infectious Diseases, Public Health Service (GGD) Amsterdam
3)
Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam
4)
Laboratory for Medical Microbiology and Public Health, Enschede
5)
Microbiology and Infection Control, Ziekenhuisgroep Twente, Hengelo
6)
Public Health Laboratory, Division of Infectious Diseases, Amsterdam Health Service
7)
Medical Microbiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
2)
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 10 January 2014
Received in revised form
29 April 2016
Accepted 3 May 2016
Available online xxx
Travel to (sub)tropical countries is a well-known risk factor for acquiring resistant bacterial strains,
which is especially of significance for travellers from countries with low resistance rates. In this study we
investigated the rate of and risk factors for travel-related acquisition of extended spectrum b-lactamaseproducing Enterobacteriaceae (ESBL-E), ciprofloxacin-resistant Enterobacteriaceae (CIPR-E) and
carbapenem-resistant Enterobacteriaceae. Data before and after travel were collected from 445 participants. Swabs were cultured with an enrichment broth and sub-cultured on selective agar plates for ESBL
detection, and on plates with a ciprofloxacin disc. ESBL production was confirmed with the double-disc
synergy test. Species identification and susceptibility testing were performed with the Vitek-2 system. All
isolates were subjected to ertapenem Etest. ESBL and carbapenemase genes were characterized by PCR
and sequencing. Twenty-seven out of 445 travellers (6.1%) already had ESBL-producing strains and 45 of
445 (10.1%) travellers had strains resistant to ciprofloxacin before travel. Ninety-eight out of 418 (23.4%)
travellers acquired ESBL-E and 130 of 400 (32.5%) travellers acquired a ciprofloxacin-resistant strain. Of
the 98 ESBL-E, predominantly Escherichia coli and predominantly blaCTX-M-15, 56% (55/98) were resistant
to gentamicin, ciprofloxacin and co-trimoxazole. Multivariate analysis showed that Asia was a high-risk
area for ESBL-E as well as CIPR-E acquisition. Travellers with diarrhoea combined with antimicrobial use
were significantly at higher risk for acquisition of resistant strains. Only one carbapenemase-producing
isolate was acquired, isolated from a participant after visiting Egypt. In conclusion, travelling to Asia and
diarrhoea combined with antimicrobial use are important risk factors for acquiring ESBL-E and CIPR-E.
E.A. Reuland, CMI 2016;▪:1
© 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All
rights reserved.
Editor: L. Leibovici
Keywords:
Acquisition rate
Ciprofloxacin-resistance
Extended spectrum b-lactamase-producing
Enterobacteriaceae
Risk factors
Travelling
Introduction
* Corresponding author. E.A. Reuland, VU University Medical Centre, Department
of Medical Microbiology & Infection Control, PO Box 7057 1007 MB, Amsterdam,
The Netherlands.
E-mail address: [email protected] (E.A. Reuland).
Resistance of Enterobacteriaceae to several classes of antimicrobials (AB) is increasing all over the world. Carriage of extended
spectrum b-lactamase-producing Enterobacteriaceae (ESBL-E) in
healthy persons varies from 3% in Western European countries to
60% in India [1,2]. Travellers to countries with a high prevalence of
antimicrobial resistance might be at increased risk for the
http://dx.doi.org/10.1016/j.cmi.2016.05.003
1198-743X/© 2016 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Reuland EA, et al., Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk
factors for acquiring ciprofloxacin-resistant and extended spectrum b-lactamase-producing Enterobacteriaceaeda prospective cohort study,
Clinical Microbiology and Infection (2016), http://dx.doi.org/10.1016/j.cmi.2016.05.003
1.e2
E.A. Reuland et al. / Clinical Microbiology and Infection xxx (2016) 1.e1e1.e7
acquisition of antibiotic-resistant bacteria (ARB) and may facilitate
the spread to countries with relatively low antimicrobial resistance
rates. The identification of risk factors associated with the acquisition of resistant Enterobacteriaceae is crucial for developing strategies to prevent acquisition of ARB in travellers and to ensure best
choice of empirical treatment if needed, either during travel or
upon return to the country of origin, both in cases where carry-on
empirical stand-by treatment is advised and when empirical
treatment is started in returned travellers [3]. In the present study
we examined the acquisition rate and risk factors for travel-related
acquisition of Enterobacteriaceae producing ESBL (ESBL-E), carbapenemases (CR-E), or resistant to ciprofloxacin (CIPR-E).
Materials and Methods
Participants were individuals (age 18 years) attending the
vaccination clinic of the Public Health Service, Amsterdam, between April 2012 and April 2013, who intended to travel to Africa,
Asia or Latin America including the Caribbean. The Dutch LCR
guidelines do not recommend that healthy travellers carry empirical antibiotic stand-by treatment. Stand-by treatment is only recommended for travellers who are at increased risk (such as
immunocompromised persons and travellers to very remote areas).
overnight (37 C). Control plates were used to ensure proper
growth.
Selective agar plates (EbSA ESBL screening agar; Cepheid Benelux, Apeldoorn, the Netherlands) were used for detection of
cephalosporin-resistant strains, i.e. MIC >1 mg/L for cefotaxim and/
or ceftazidim. ESBL production was confirmed with the double-disc
synergy test with clavulanic acid (Rosco, Taastrup, Denmark) on
MuellereHinton agar. A positive confirmation test was defined as a
>5-mm zone difference for cephalosporins with clavulanic acid
compared with cephalosporins without this inhibitor [6]. Screening
for ciprofloxacin-resistance was carried out by plating out enrichment broth on CLED agar (cystine lactose electrolyte-deficient
medium) with a ciprofloxacin disc (concentration 5 mg), using
zone diameter <21 mm as cut-off for further testing. Colonies
growing within this zone that phenotypically resembled Enterobacteriaceae were subsequently further analysed for CIPR-E as
described below.
Species identification and susceptibility testing were performed
rieux, Marcy
with the Vitek-2 system (Vitek ID and Vitek AST; bioMe
l’Etoile, France). EUCAST criteria for resistance were used [7]. All of
these isolates were also subjected to ertapenem Etest on MuellereHinton agar to screen specifically for carbapenemases.
Molecular analysis
Study population
The study was an open, prospective, observational cohort study.
Travellers were advised according to the Dutch National guidelines
for traveller's health advice (LCR guidelines) [4]. Within each
continent, countries were categorized into distinct geographical
regions following the definition by the United Nations Department
of Economic and Social Affairs [5].
Before travel, participants were asked for their age, gender,
country of birth (participant and parents), country of destination,
duration of travel, antimicrobial use in the previous 12 months, and
whether they had been admitted to a (foreign) hospital in the last
12 months. People were not included in the analyses if their case
record forms were not filled in completely and data were missing.
Participants were given the option to take either a rectal swab or a
stool sample before departure, which they had to send by mail to
the infectious disease laboratory of the Public Health Service.
After travel, participants were asked to fill in a questionnaire
with questions about which countries they had actually visited, the
amount of time they spent in each country, whether they had been
hospitalized, whether they had traveller's diarrhoea (TD) and in
which country, or had used AB. Together with the questionnaire, we
included a transport medium to obtain a second rectal swab or
stool sample. Participants were asked to collect this sample within
2 weeks after their return. A voucher of 25 V was given for
participation.
Molecular analysis of ESBL genes was performed on all isolates
with a positive confirmation test. Isolates with an increased MIC for
for ertapenem (0.25 mg/L), meropenem (MIC 0.5 mg/L) or imipenem (MIC 2 mg/L) were selected for molecular characterization
of carbapenemases [7]. ESBL and carbapenemase genes were
characterized using PCR followed by sequencing [8,9]. Sequences
were analysed in BIONUMERICS (version 6.6; Applied Maths, SintMartens-Latem, Belgium) and compared with sequences in the
NCBI (http://www.ncbi.nlm.nih.gov/BLAST) and Lahey (http://
www.lahey.org/studies/) databases.
Statistical analyses
Written informed consent was obtained from all participants.
The study was approved by the medical ethics committee (METc,
NL29769.029.09) of the VU University Medical Centre (NTR Trial ID
NTR2453).
Potential risk factors were based on preceding literature, e.g.
antibiotic use, TD and travel to (sub)tropical areas. Risk factors for
the acquisition of ESBL-E and/or CIPR-E before and during travel
were identified by comparing travellers who did and who did not
acquire ARB during travel using univariate and multivariate logistic
regression models. Participants who were already were colonized
with ESBL-producing or ciprofloxacin-resistant Enterobacteriaceae
before travel were excluded for risk factor analysis of ESBL-E and
CIPR-E acquisition during travel, respectively. Also participants
visiting more than one region were not present in the analyses. Two
multivariable models were built following a backward procedure
starting with only variables with a univariate p-value <0.05. Final
multivariate models only included variables with a p-value <0.05.
.In addition, age was forced into the multivariate models to correct
for potential confounding. In the final models interaction between
all variables was investigated and interaction between two variables was considered present with a p-value <0.10. All statistical
analyses were performed with Statistical Package for the Social
Sciences (SPSS, version 20.0).
Phenotypic and genotypic detection
Results
Swabs in Copan transport medium (Copan Italia, Brescia, Italy)
were cultured in trypticase soy enrichment broth containing
50 mg/L ampicillin and thereafter sub-cultured. In the case of stool
samples, faeces was retrieved using a swab and thereafter treated
in the same way as rectal swabs. Broths and plates were incubated
Study population
Ethics statement
In total, 622 travellers were asked to participate in the study, of
whom 487 agreed and signed an informed consent (Fig. 1). Of these,
one was excluded because the first sample was not returned, and 41
Please cite this article in press as: Reuland EA, et al., Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk
factors for acquiring ciprofloxacin-resistant and extended spectrum b-lactamase-producing Enterobacteriaceaeda prospective cohort study,
Clinical Microbiology and Infection (2016), http://dx.doi.org/10.1016/j.cmi.2016.05.003
E.A. Reuland et al. / Clinical Microbiology and Infection xxx (2016) 1.e1e1.e7
1.e3
Approached for participation
N=622
Willing to participate
N=487
Excluded: n = 42:
(missing second sample and
form (n=42))
Included in the study
N=445
No ESBL
before travel
N=418
No ESBL
after travel
N=320
ESBL
before travel
N=27/445 (6.1 %)
ciprofloxacin-resistance
before travel
N=45/445 (10.1%)
ESBL
after travel
N=98 (23.4%)
No ciprofloxacin-resistance
before travel
N=400
ciprofloxacin-resistance
after travel
N=130 (32.5%)
No ciprofloxacin-resistance
after travel
N=270
Fig. 1. Flowchart of the study population
were excluded because they did not return their second sample and
questionnaire. Excluded participants (n ¼ 42) were not significantly
different from the final study population (see Supplementary
material, Table S1). In total 445 participants were available for
analysis to determine risk factors before travel. Almost all samples
(>95%) were received within 1 month of return. Of all 932 specimens submitted either pre- or post-travel, 352 (38%) were faecal
swabs, whereas the remainder were stool samples. The distribution
of stool samples and faecal swabs in pre- and post-travel samples
was similar among included participants. As there was no significant difference in the frequency of ESBL-E and CIPR-E between
these two sample types, the term ‘samples’ is used throughout the
manuscript. The median age of the participants was 33 years (IQR
27e48) and 58% were female. Of these travellers, 27/445 participants (6.1%, 95% CI 4.2%e8.7%) acquired ESBL-E before travel (15
only ESBL-E, and 12 ESBL-E in combination with ciprofloxacinresistance) and 45 participants (10.1%, 95% CI 7.6%e13.3%) acquired CIPR-E before travel (31 only with ciprofloxacin-resistance,
12 ESBL-E in combination with ciprofloxacin-resistance and two
isolates with a wild-type b-lactamase (TEM-1) in combination with
ciprofloxacin-resistance). After exclusion of five travellers who did
not provide information on previous travels, the only predictor for
the presence of ESBL-E before travel was a previous visit to
Northern Africa (OR 11.21, 95% CI 2.07e60.84). No predictors for
presence of CIPR-E before travel were found.
The study population for acquisition of resistant strains during
travel was 418 for ESBL and 400 for ciprofloxacin-resistance. In line
with LCR guidelines, none of these travellers was prescribed carryon AB by the vaccination clinic of the Public Health Service.
Acquisition of resistant strains
ESBL
Of the 418 participants who did not have ESBL-E before travel,
98 acquired ESBL-E (23.44%, 95% CI 19.63%e27.74%).
These 418 participants visited 79 different countries. The
continent most frequently visited was Asia (n ¼ 240), followed by
Africa (n ¼ 96) and Latin America/Caribbean (n ¼ 79). The most
visited countries were Thailand, Indonesia, India, Vietnam and
China. More than one country was visited by 32% (133/418) of the
travellers, more than one region by almost 9% (37/418) of the
travellers and more than one continent by 1.2% (5/418). On average
travellers stayed for 2 weeks, with a range from 1 to 105 days.
Molecular analysis of the 98 ESBL-E (95 Escherichia coli, two
Klebsiella pneumoniae and one Morganella morganii) yielded ESBLencoding genes for all 98 isolates.
The ESBL-encoding genes that were most frequently acquired in
our study were blaCTX-M-15 (n ¼ 54), blaCTX-M-14/18 (n ¼ 16) and
blaCTX-M-27 (n ¼ 9). Furthermore the isolates comprised one blaCTXM-3, two blaCTX-M-8, two blaCTX-M-9,one blaCTX-M-24/130,one blaCTX-M32,one blaCTX-M-55,one blaCTX-M-55/79 and one blaCTX-M-104. Two isolates harboured blaCTX-M-1, one isolate had two genes (blaCTX-M-14
and blaCTX-M-15). One gene belonging to the CTX-M family remained
unidentified, also one gene per group included members of
respectively the CTX-M-1, CTX-M-8 or CTX-M-9 family but could
not be subdivided further by sequencing. In addition, two blaSHV-12
were detected. Univariate analysis of association between the
countries visited and the four most predominant gene types
showed that blaCTX-M-15 was mainly acquired in western and south-
Please cite this article in press as: Reuland EA, et al., Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk
factors for acquiring ciprofloxacin-resistant and extended spectrum b-lactamase-producing Enterobacteriaceaeda prospective cohort study,
Clinical Microbiology and Infection (2016), http://dx.doi.org/10.1016/j.cmi.2016.05.003
1.e4
E.A. Reuland et al. / Clinical Microbiology and Infection xxx (2016) 1.e1e1.e7
central Asia, blaCTX-M-14 was acquired in eastern Asia, and blaCTX-Min South-East Asia and western Asia. In travellers visiting India
only blaCTX-M-15 was found.
In addition, co-resistance was common: 50 isolates also
comprised ciprofloxacin-resistance. Gentamicin resistance was
detected in 39% (38/98) of the isolates, and resistance to cotrimoxazole in 70% (69/98); 56% (55/98) of strains were multidrug resistant as defined by Magiorakos et al. [10].
Risk factors
27
Ciprofloxacin-resistance
In total, 130 out of 400 travellers (32.50%, 95% CI 28.09%e37.24%)
acquired CIPR-E. As the study group of 400 travellers largely overlapped with the study group for ESBL acquisition, the distribution of
continents and countries visited was highly similar (data not
shown). Of these ciprofloxacin-resistant strains 65.4% (85/130)
were resistant to ciprofloxacin only and 34.6% (45/130) also produced ESBL. A total of 126 (97%) of these strains were Escherichia
coli, two Morganella morganii, one Citrobacter freundii and one
Shigella sonnei.
Carbapenemase
Only one traveller returned with a carbapenemase (OXA-48)
producing strain. This isolate, E. coli, harbouring blaCTX-M-9, had a
reduced susceptibility to meropenem (MIC 1 mg/L), but remained
ertapenem- and imipenem-susceptible. Seven other isolates had
reduced susceptibility to ertapenem but no carbapenemaseencoding gene could be detected using PCR.
ESBL
Univariate and multivariate results for the acquisition of ESBL-E
were similar and are shown in Table 1. Participants who visited Asia
were at significantly higher risk for acquisition of ESBL-producing
strains (OR 7.53, 95% CI 3.12e18.18). Of all participants who
visited eastern Asia, 46% (10/22) acquired ESBL-E, for south-central
Asia this was 55% (27/49), for South-East Asia 23% (32/137) and for
western Asia 25% (3/12). The highest acquisition rate for ESBL-E
was in travellers visiting India, 62.5% (20/32).
Travellers with diarrhoea who did not use AB were at slightly
higher risk of acquisition of ESBL-E (OR 1.65, 95% CI 0.97e2.82)
compared with those without diarrhoea and without AB, although
this association was not statistically significant. However, risk for
ESBL-E acquisition was highly increased in those travellers that
developed TD and used antimicrobial agents (OR 9.56, 95% CI
2.64e34.57).
Age, sex, country of birth, travel history before current travel
and admission to a foreign hospital were not associated with
acquisition of ESBL-E. One of the five participants who was
admitted to a foreign hospital was colonized with an ESBL-E (CTXM-15) combined with ciprofloxacin-resistance upon return from
Togo.
Ciprofloxacin-resistance
Univariate and multivariate results for acquisition of isolates
with ciprofloxacin-resistance are shown in Table 1. Like ESBL-E, the
Table 1
Univariate and multivariable risk factors of acquisition of ESBL-E or ciprofloxacin-resistance CIPR-E during travel, among 418 and 400 travellers, respectively, attending the
vaccination clinic at the Infectious Diseases department at the Public Health Service (GGD) Amsterdam (between April 2012 and April 2013)
Risk factor
Prevalence
Univariate
Multivariate
Total
Age (years) per 10-year increase,
median (IQR)
Sex
Men
Women
Missing
Country of birth
Non-endemic countrya
Otherb
Missing
Travel history (previous 12 months,
before current travel)
Stay in a (sub)tropical country -no
Stay in a (sub)tropical country -yes
Missing
Medical history (current travel)
TDe, ABe
TDþ, ABe
TDe, ABþ
TDþ, ABþ
Missing
Admission to a foreign hospital
No
Yes
Missing
Travel destinations
Only Africac
Only Latin America/Caribbean
Only Asia
50/177 (28.2)
48/240 (20.0)
1
ESBL-E n/N (%)
OR (95% CI)
OR (95% CI)
98/418 (23.4)
33 (27-49)
(19.63e27.74)
1.06 (0.89e1.26)
1.02 (1.00e1.04)
1
0.64 (0.40e1.00)
55/172 (32.0)
75/227 (33.0)
1
1
1.05 (0.69e1.60)
85/359 (23.7)
11/52 (21.2)
7
1
0.86 (0.43e1.76)
109/340 (32.1)
18/52 (34.6)
8
1
1.12 (0.61e2.08)
8/34 (23.5)
85/361 (23.5)
23
1
1.00 (0.44e2.29)
11/32 (34.4)
110/344 (32.0)
25
1
0.90 (0.42e1.93)
38/213 (17.8)
46/175 (26.3)
2/8 (25.0)
9/14 (64.3)
9
1
1.64 (1.01e2.67)
1.54 (0.30e7.90)
8.29 (2.63e26.13)
53/203 (26.1)
62/171 (36.3)
3/8 (37.5)
7/10 (70.0)
8
1
1.61 (1.04e2.50)
1.70 (0.39e7.35)
6.60 (1.65e26.47)
95/407 (23.3)
1/5 (20.0)
6
1
0.82 (0.09e7.44)
125/390 (32.1)
2/4 (50.0)
6
1
2.12 (0.30e15.22)
7/93 (7.5)
7/77 (9.1)
81/235 (34.5)
1
1.23 (0.41e3.67)
6.46 (2.86e14.61)
18/88 (20.5)
8/70 (11.4)
102/229 (44.5)
1
0.50 (0.20e1.24)
3.12 (1.75e5.58)
1
1.65 (0.97e2.82)
1.49 (0.24e9.08)
9.56 (2.64e34.57)
1
1.36 (0.43e4.31)
7.31 (3.03e17.63)
Prevalence
Univariate
Multivariate
CIPR-E n/N (%)
OR (95% CI)
OR (95% CI)
130/400 (32.5)
33 (27e49)
(28.09-37.24)
0.97 (0.83e1.14)
1.01 (0.99e1.03)
1
1.51 (0.93e2.45)
1.35 (0.29e6.22)
5.69 (1.29e24.99)
1
0.48 (0.18e1.23)
3.14 (1.73e5.71)
Abbreviations: AB, antimicrobial use; CIPR-E, ciprofloxacin-resistant Enterobacteriaceae; ESBL-E, extended spectrum b-lactamase-producing Enterobacteriaceae; TD, traveller's
diarrhoea.
a
Country of birth and country of birth of both parents is in a non-endemic area (Europe, Oceania, Northern America).
b
Country of birth or country of birth of one of both parents is in an endemic area (Africa, Asia, Latin America/Caribbean).
c
Africa had lowest percentage of ESBL and therefore chosen as reference category.
Please cite this article in press as: Reuland EA, et al., Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk
factors for acquiring ciprofloxacin-resistant and extended spectrum b-lactamase-producing Enterobacteriaceaeda prospective cohort study,
Clinical Microbiology and Infection (2016), http://dx.doi.org/10.1016/j.cmi.2016.05.003
E.A. Reuland et al. / Clinical Microbiology and Infection xxx (2016) 1.e1e1.e7
two independent risk factors were visits to Asia and the combination of TD with antibiotic use. No other risk factors were identified.
One of the four participants was admitted to a foreign hospital in
Togo and was colonized with an ESBL-E (CTX-M-15) combined with
ciprofloxacin-resistance, and another participant was admitted to a
foreign hospital in India and was colonized with a ciprofloxacinresistant strain.
Carbapenemase
Only one carbapenemase (OXA-48) producing E. coli was acquired by a participant after a 15-day visit to Egypt; however, the
number of travellers visiting northern Africa was low (n ¼ 12). This
participant was a 50-year-old female, born in the Netherlands. No
use of AB and no admission to a hospital in the previous episode
was reported, but she did report an episode of TD.
Use of antibiotics
Twenty-two participants reported antibiotic use during travel.
Details about the type of antibiotics, the presence of TD and the
acquisition of ESBL-E and CIPR-E have been provided in Table 2.
Although the numbers of patients having received different groups
of antibiotics are low, it is remarkable that all six persons who used
quinolones during travel, who all had TD, acquired both ESBL-E and
CIPR-E. Five of these participants had visited Asia (Indonesia, India
and Nepal), one participant travelled to Africa (Malawi). In contrast,
the two persons who used doxycycline only, probably for malaria
prophylaxis, did not acquire CIPR-E or ESBL-E.
Discussion
Colonization with resistant strains after travel to (sub)tropical
areas was detected in a large proportion of Dutch travellers in the
present study. This included ESBL-E, CIPR-E and even one CR-E was
detected. Independent risk factors associated with the acquisition
of antimicrobial resistance were travel to Asia, and TD in combination with the use of AB. People with TD without AB use was
slightly at higher risk of acquisition of ARB. This confirms the recent
finding that TD and the use of AB during travel contribute to the
acquisition of ESBL-E [11]. Although a prospective study has found
that travel is a risk for the introduction of quinolone-resistance
genes, as far as we know, this is the first study that finds that
antibiotic use during travel contributes to the acquisition of CIPR-E
[12].
1.e5
The percentage of carriage of ESBL-E before travel (about 6.0%)
was comparable with 8.6% found in a study in the Dutch community and the high pre-travel ESBL-E carriage rate in another prospective cohort study among healthy travellers in the Netherlands
[13,14]. We found an even higher prevalence of colonization with
CIPR-E (10.1%) before departure; comparable with the prevalence of
quinolone resistance encoding genes found pre-travel by von
Wintersdorff et al. [12].
The percentage of ESBL acquisition during travel was similar to
that found in other studies from Sweden, Finland and the
Netherlands, where approximately one in five to one in three
travellers was colonized upon return [11,14,15]. Indeed, other
retrospective [16e18] and prospective [11,19] studies have
confirmed this issue. Import of quinolone-resistance genes by
travel was seen in one-third to one-half of travellers and recently
also import of CRE has been reported in asymptomatic travellers,
although only in 0.5% [12,20].
Overall, predominantly CTX-M-producing E. coli, mainly CTX-M15, were found, which is comparable with what has been described
in other studies [11,15,21,22]. Multidrug resistance was seen in 56%
of the ESBL-E [21,22]. The present study, where we also determined
CIPR-E besides the association of quinolone resistance with ESBL-E,
showed even more clearly that acquisition of multidrug-resistant
strains in general is a major threat.
The risk of acquiring CIPR-E during travel was even higher than
the risk of acquiring ESBL-E, comparable with other data concerning quinolone-resistance-encoding genes after travel [12]. As with
ESBL, Asia was the highest risk area for acquiring such strains.
When focusing on CIPR-E, all six participants in our study who
had taken quinolones during travel also reported TD. All six travellers treated with quinolones acquired ESBL-E as well as CIPR-E.
Also Tangden et al. reported acquisition of ESBL-E in three patients treated with ciprofloxacin [15]. We assume that antimicrobial
use is a trigger for inducing ciprofloxacin-resistance in plasmidmediated ESBL-producing strains or for selection of co-resistant
strains. However, ciprofloxacin use could also lead to horizontal
dissemination of antibiotic resistance genes between species by
inducing an SOS response [23].
In clinical studies as well as in studies among travellers, use of
AB and gastrointestinal symptoms has been reported as a risk factor
for the acquisition of ARB [11,15,24,25]. Findings from ours and
other mentioned studies suggest that routinely prescribing (standby) AB for TD should be strongly reconsidered, also because TD is
usually self-limiting [3].
Table 2
Baseline participant characteristics with the antimicrobials used
Antimicrobial
n
Amoxicillin
Amoxicillin
Augmentin
Azitromycin
Ciprofloxacin
Ciprofloxacin þ doxycycline
ofloxacin, aciloc/ranitidin, tinidazol
Cotrimoxazol
Nitrofurantoin
Doxycycline
Unspecified
Unspecified
Unspecified: bacterial infection
Unspecified: stitches after small accident
Unspecified: salmonella infection
Unspecified: cystitis
Unspecified: salmonella infection and parasite
3
1
1
4
1
1
1
1
2
2
1
1
1
1
1
TDe
TDþ
Resistance mechanism
2
None
ESBL
ESBL
ciprofloxacin-resistance only
ESBL and ciprofloxacin-resistance
ESBL and ciprofloxacin-resistance
ESBL and ciprofloxacin-resistance
ESBL and ciprofloxacin-resistance
ciprofloxacin-resistance only
none
ciprofloxacin-resistance only
ESBL and ciprofloxacin-resistance
ciprofloxacin-resistance only
none
none
ESBL and ciprofloxacin-resistance
ciprofloxacin-resistance only
1
1
1
4
1
1
1
1
2
1
1
1
1
1
1
1
abrAbbreviationsESBL, extended spectrum b-lactamase; TD, traveller's diarrhoea.
Please cite this article in press as: Reuland EA, et al., Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk
factors for acquiring ciprofloxacin-resistant and extended spectrum b-lactamase-producing Enterobacteriaceaeda prospective cohort study,
Clinical Microbiology and Infection (2016), http://dx.doi.org/10.1016/j.cmi.2016.05.003
1.e6
E.A. Reuland et al. / Clinical Microbiology and Infection xxx (2016) 1.e1e1.e7
In this study we only found one CR-E in a traveller to Egypt,
therefore the risk for acquisition of CR-E might seem low. However,
the number of travellers acquiring OXA-48 may be underestimated
because in our study only a few travellers to northern African
countries were included, known for their high endemic levels of
OXA-48-producing strains [26e28]. Several other studies also
described the introduction of CR-E by returning (asymptomatic)
travellers [13,29e31].
One limitation of our study is that data on AB use during travel
were self-reported, and that we did not ask whether the AB were
used specifically for TD. In addition, we did not provide a standardized definition of TD to travellers responding to the questionnaire. Another possible limitation of the study is that we did not
follow up participants to assess the duration of carriage. However,
other studies have already demonstrated that colonization persists
at least 6 months after return [14,32]. Also, travellers to countries
were no vaccination was needed were not included. The number of
participants who took AB during travel was small, so we cannot
draw conclusions on risk based on specific AB used. Also, because of
the enrichment broth used, quinolone-resistant but ampicillinsusceptible strains were not detected, so our screening method
might not detect all CIPR-E.
In conclusion, international travel to (sub)tropical areas, especially travel to Asia, is an important risk factor for acquiring and
importing ESBL-E and CIPR-E. A high percentage of multidrug
resistance was found among these isolates. The contribution of AB
to the high risk of acquisition of ARB is important in this era of
increasing antimicrobial resistance. It may be useful to advise
returning travellers regarding personal hygiene to decrease the risk
of transmission of acquired ARB to household members. A careful
patient's travel history asked on admission to hospital might prevent unnecessary delay of appropriate therapy and allow adequate
infection control policies.
Acknowledgements
We thank Joan Kint for enrolling participants at the vaccination
clinic and Kaoutar el Faouzi for organizing/assisting the laboratory
work at the Department of Infectious Diseases, GGD, Amsterdam,
the Netherlands. This work was presented in part at the European
Society of Clinical Microbiology and Infectious Diseases (ECCMID),
Barcelona, Spain, May 2014 (P1216).
Funding
This work was supported by Research & Development fund GGD
Amsterdam and ZonMw, the Netherlands Organisation for Health
Research and Development [grant number 125020011].
Transparency Declarations
Prof. Dr C.M.J.E. Vandenbroucke-Grauls received speakers fees
rieux.
from bioMe
Appendix A. Supporting information
Additional Supporting Information may be found in the online
version of this article at http://dx.doi.org/10.1016/j.cmi.2016.05.
003.
References
[1] Mathai D, Rhomberg PR, Biedenbach DJ, Jones RN. Evaluation of the in vitro
activity of six broad-spectrum beta-lactam antimicrobial agents tested against
recent clinical isolates from India: a survey of ten medical center laboratories.
Diagn Microbiol Infect Dis 2002;44:367e77.
[2] Struwe J, Olsson-Liljequist B. Short summary of swedres 2008, a report on
antimicrobial utilisation and resistance in humans in sweden. Euro Surveill
2009;14.
[3] Belderok SM, van den Hoek A, Kint JA, Schim van der Loeff MF, Sonder GJ.
Incidence, risk factors and treatment of diarrhoea among Dutch travellers:
reasons not to routinely prescribe antibiotics. BMC Infect Dis 2011;11:295.
[4] LCR. National Coordination Center for Travelers Health Available at: https://
www.lcr.nl/Landen.
[5] World Health Organization. United Nations, Department of Economic and
Social Affairs. Available at: http://esa.un.org/unpd/wpp/General/Files/
Definition_of_Regions.pdf.
[6] Cohen Stuart J, Leverstein van Hall M, al Naiemi N. NVMM guideline laboratory detection of highly resistant microorganisms (HRMO), version 2.0. 2012.
Available at: http://www.nvmm.nl/richtlijnen/hrmo-laboratory-detectionhighly-resistant-microorganisms.
[7] EUCAST. European committee on antimicrobial susceptibility testing Breakpoint tables for interpretation of MICs and zone diameters Available at: http://
www.eucast.org/clinical_breakpoints/.
[8] Naiemi NA, Duim B, Savelkoul PH, Spanjaard L, de Jonge E, Bart A, et al.
Widespread transfer of resistance genes between bacterial species in an
intensive care unit: implications for hospital epidemiology. J Clin Microbiol
2005;43:4862e4.
[9] Mulvey MR, Bryce E, Boyd DA, Ofner-Agostini M, Land AM, Simor AE, et al.
Molecular characterization of cefoxitin-resistant Escherichia coli from Canadian hospitals. Antimicrob Agents Chemother 2005;49:358e65.
[10] Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al.
Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012;18:268e81.
[11] Kantele A, Laaveri T, Mero S, Vilkman K, Pakkanen SH, Ollgren J, et al. Antimicrobials increase travelers' risk of colonization by extended-spectrum
betalactamase-producing Enterobacteriaceae. Clin Infect Dis 2015;60:837e46.
[12] von Wintersdorff CJ, Penders J, Stobberingh EE, Oude Lashof AM, Hoebe CJ,
Savelkoul PH, et al. High rates of antimicrobial drug resistance gene acquisition after international travel, the Netherlands. Emerg Infect Dis 2014;20:
649e57.
[13] Reuland EA, Al Naiemi N, Kaiser AM, Heck M, Kluytmans JA, Savelkoul PH,
et al. Prevalence and risk factors for carriage of ESBL-producing Enterobacteriaceae in Amsterdam. J Antimicrob Chemother 2016;71:1076e82.
[14] Paltansing S, Vlot JA, Kraakman ME, Mesman R, Bruijning ML, Bernards AT,
et al. Extended-spectrum beta-lactamase-producing Enterobacteriaceae
among travelers from the Netherlands. Emerg Infect Dis 2013;19:1206e13.
[15] Tangden T, Cars O, Melhus A, Lowdin E. Foreign travel is a major risk factor for
colonization with Escherichia coli producing ctx-m-type extended-spectrum
beta-lactamases: a prospective study with Swedish volunteers. Antimicrob
Agents Chemother 2010;54:3564e8.
[16] Laupland KB, Church DL, Vidakovich J, Mucenski M, Pitout JD. Communityonset extended-spectrum beta-lactamase (ESBL) producing Escherichia coli:
importance of international travel. J Infect 2008;57:441e8.
[17] Tham J, Odenholt I, Walder M, Brolund A, Ahl J, Melander E. Extended-spectrum beta-lactamase-producing Escherichia coli in patients with travellers'
diarrhoea. Scand J Infect Dis 2010;42:275e80.
[18] Peirano G, Laupland KB, Gregson DB, Pitout JD. Colonization of returning
travelers with CTX-M-producing Escherichia coli. J Travel Med 2011;18:
299e303.
[19] Lubbert C, Straube L, Stein C, Makarewicz O, Schubert S, Mossner J, et al.
Colonization with extended-spectrum beta-lactamase-producing and
carbapenemase-producing Enterobacteriaceae in international travelers
returning to Germany. Int J Med Microbiol 2015;305:148e56.
[20] Ruppe E, Armand-Lefevre L, Estellat C, Consigny PH, El Mniai A, Boussadia Y,
et al. High rate of acquisition but short duration of carriage of multidrugresistant Enterobacteriaceae after travel to the tropics. Clin Infect Dis
2015;61:593e600.
[21] Hawkey PM, Jones AM. The changing epidemiology of resistance. J Antimicrob
Chemother 2009;64(Suppl 1). i3e10.
[22] Rossolini GM, D'Andrea MM, Mugnaioli C. The spread of CTX-M-type
extended-spectrum beta-lactamases. Clin Microbiol Infect 2008;14(Suppl 1):
33e41.
[23] Beaber JW, Hochhut B, Waldor MK. SOS response promotes horizontal
dissemination of antibiotic resistance genes. Nature 2004;427:72e4.
[24] Woerther PL, Burdet C, Chachaty E, Andremont A. Trends in human fecal
carriage of extended-spectrum beta-lactamases in the community: toward
the globalization of ctx-m. Clin Microbiol Rev 2013;26:744e58.
[25] Kennedy K, Collignon P. Colonisation with Escherichia coli resistant to “critically important” antibiotics: a high risk for international travellers. Eur J Clin
Microbiol Infect Dis 2010;29:1501e6.
Please cite this article in press as: Reuland EA, et al., Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk
factors for acquiring ciprofloxacin-resistant and extended spectrum b-lactamase-producing Enterobacteriaceaeda prospective cohort study,
Clinical Microbiology and Infection (2016), http://dx.doi.org/10.1016/j.cmi.2016.05.003
E.A. Reuland et al. / Clinical Microbiology and Infection xxx (2016) 1.e1e1.e7
[26] Poirel L, Potron A, Nordmann P. Oxa-48-like carbapenemases: the phantom
menace. J Antimicrob Chemother 2012;67:1597e606.
[27] van der Bij AK, Pitout JD. The role of international travel in the worldwide
spread of multiresistant Enterobacteriaceae. J Antimicrob Chemother
2012;67:2090e100.
[28] Naas T, Nordmann P. Oxa-type beta-lactamases. Curr Pharm Des 1999;5:
865e79.
[29] Leverstein-Van Hall MA, Stuart JC, Voets GM, Versteeg D, Tersmette T, Fluit AC.
Global spread of New Delhi metallo-beta-lactamase 1. Lancet Infect Dis
2010;10:830e1.
1.e7
[30] Kalpoe JS, Al Naiemi N, Poirel L, Nordmann P. Detection of an ambler class
d OXA-48-type beta-lactamase in a Klebsiella pneumoniae strain in the
netherlands. J Med Microbiol 2011;60:677e8.
[31] Hashimoto A, Nagamatsu M, Ohmagari N, Hayakawa K, Kato Y, Kirikae T.
Isolation of OXA-48 carbapenemase-producing Klebsiella pneumoniae ST101
from an overseas traveler returning to Japan. Jpn J Infect Dis 2014;67:120e1.
[32] Platteel TN, Leverstein-van Hall MA, Cohen Stuart JW, Thijsen SF, Mascini EM,
van Hees BC, et al. Predicting carriage with extended-spectrum beta-lactamase-producing bacteria at hospital admission: a cross-sectional study. Clin
Microbiol Infect 2015;21:141e6.
Please cite this article in press as: Reuland EA, et al., Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk
factors for acquiring ciprofloxacin-resistant and extended spectrum b-lactamase-producing Enterobacteriaceaeda prospective cohort study,
Clinical Microbiology and Infection (2016), http://dx.doi.org/10.1016/j.cmi.2016.05.003