title: Colonization with extended-spectrum beta-lactamase-producing and carbapenemase-producing Enterobacteriaceae in international travelers returning to Germany.
abstract: Two hundred and twenty-five healthy German volunteers traveling to 53 different countries (mostly in Asia, Africa and South America) were enrolled in a prospective cohort study. Stool samples and data on potential travel-associated risk factors (such as type of travel, nutritional habits, occurrence of gastroenteritis) were collected before and after traveling. Screening for extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) and carbapenemase-producing Enterobacteriaceae (CPE) was performed using selective media (CHROMagar™ ESBL/CPE plates). Isolates with confirmed ESBL-phenotype were examined for the presence of blaCTX-M, blaTEM, blaSHV, and blaVIM, blaIMP, blaNDM, blaKPC, blaOXA-48 genes by PCR amplification and sequencing. Antimicrobial susceptibility testing was performed using conventional microbroth dilution. Pre-travel analysis of 205 fully evaluable participants revealed an ESBL-PE prevalence rate of 6.8% (14/205). Among 191 participants that were ESBL-negative before travel, 58 (30.4%) were colonized by ESBL-producing Escherichia coli, and 5 (8.6%) additionally carried ESBL-producing Klebsiella pneumoniae upon return. However, no carbapenem-resistant Enterobacteriaceae were detected. ESBL-genotyping revealed that 52/54 (96.6%) E. coli and 4/4 (100%) K. pneumoniae strains available for sequencing produced CTX-M enzymes, mostly CTX-M-15 (33/56, 58.9%), and 2/54 (3.7%) E. coli strains produced SHV-12 enzymes. Travel to India was associated with the highest ESBL-PE acquisition rate (11/15, 73.3%; p=0.015), followed by South East Asia (22/46, 47.8%; p=0.038). Evaluation of travel-associated risk factors demonstrated significance for the occurrence of gastroenteritis (p=0.011). Strictly practiced hand hygiene and exclusive consumption of packaged beverages showed no protective effect. The ESBL-PE persistence rate after 6 months was 8.6% (3/35). We conclude that global efforts are needed to address the further spread of ESBL-PE in the community. Active surveillance and contact isolation precautions may be recommended at admission to medical facilities especially for patients who traveled to India and South East Asia in the previous 6 months.
authors.affiliation: Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany. Electronic address: christoph.luebbert@medizin.uni-leipzig.de.
authors.forename: Christoph
authors.initials: C
authors.lastname: Lübbert
authors.affiliation: Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.
authors.forename: Laurentia
authors.initials: L
authors.lastname: Straube
authors.affiliation: Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, D-07740 Jena, Germany.
authors.forename: Claudia
authors.initials: C
authors.lastname: Stein
authors.affiliation: Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, D-07740 Jena, Germany.
authors.forename: Oliwia
authors.initials: O
authors.lastname: Makarewicz
authors.affiliation: Division of Infectious Diseases and Tropical Medicine, Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Schubert
authors.affiliation: Department of Gastroenterology and Rheumatology, Leipzig University Hospital, Liebigstr. 20, D-04103 Leipzig, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Mössner
authors.affiliation: Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, D-07740 Jena, Germany.
authors.forename: Mathias W
authors.initials: MW
authors.lastname: Pletz
authors.affiliation: Institute for Medical Microbiology and Epidemiology of Infectious Diseases, Leipzig University Hospital, Liebigstr. 21, D-04103 Leipzig, Germany.
authors.forename: Arne C
authors.initials: AC
authors.lastname: Rodloff
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001431:Bacteriological Techniques; D002353:Carrier State / Q000453:epidemiology* / Q000382:microbiology; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003470:Culture Media / Q000737:chemistry; D004755:Enterobacteriaceae / Q000201:enzymology* / Q000235:genetics / Q000302:isolation & purification*; D004756:Enterobacteriaceae Infections / Q000453:epidemiology* / Q000382:microbiology; D005243:Feces / Q000382:microbiology; D005260:Female; D005798:Genes, Bacterial; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D016133:Polymerase Chain Reaction; D015995:Prevalence; D011446:Prospective Studies; D017422:Sequence Analysis, DNA; D014195:Travel; D055815:Young Adult; D018440:beta-Lactam Resistance; D001618:beta-Lactamases / Q000235:genetics / Q000378:metabolism*
chemical_list: D003470:Culture Media; D001618:beta-Lactamases
keywords: Active surveillance, Community; Antimicrobial resistance; CPE; CTX-M; ESBL