title: Skin and soft tissue infections in intercontinental travellers and the import of multi-resistant Staphylococcus aureus to Europe.
abstract: Staphylococcus aureus is emerging globally. Treatment of infections is complicated by increasing antibiotic resistance. We collected clinical data and swabs of returnees with skin and soft tissue infections (SSTI) at 13 travel-clinics in Europe (www.staphtrav.eu). Sixty-two percent (196/318) SSTI patients had S. aureus-positive lesions, of which almost two-thirds (122/196) were Panton-Valentine leukocidin (PVL) positive. PVL was associated with disease severity, including hospitalization for SSTI (OR 5.2, 95% CI 1.5-18.2). In returnees with SSTI, longer travel and more intense population contact were risk factors for nasal colonization with PVL-positive S. aureus. Imported S. aureus frequently proved resistant to trimethoprim-sulfamethoxazole (21%), erythromycin (21%), tetracycline (20%), ciprofloxacin (13%), methicillin (12%) and clindamycin (8%). Place of exposure was significantly (p < 0.05) associated with predominant resistance phenotypes and spa genotypes: Latin America (methicillin; t008/CC24/304), Africa (tetracycline, trimethoprim-sulfamethoxazole; t084/CC84, t314/singleton, t355/CC355), South Asia (trimethoprim-sulfamethoxazole, ciprofloxacin; t021/CC21/318), South-East Asia (clindamycin; t159/CC272). USA300-like isolates accounted for 30% of all methicillin-resistant S. aureus imported to Europe and were predominantly (71%) acquired in Latin America. Multi-resistance to non-β-lactams were present in 24% of imports and associated with travel to South Asia (ORcrude 5.3, 95% CI 2.4-11.8), even after adjusting for confounding by genotype (ORadjusted 3.8, 95% 1.5-9.5). Choosing randomly from compounds recommended for the empiric treatment of severe S. aureus SSTI, 15% of cases would have received ineffective antimicrobial therapy. These findings call for the development of regionally stratified guidance on the antibiotic management of severe imported S. aureus disease and put the infected and colonized traveller at the centre of interventions against the global spread of multi-resistant S. aureus.
authors.affiliation: Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany; Institute of Tropical Medicine, Eberhard Karls Universität, Tübingen, Germany.
authors.forename: D
authors.initials: D
authors.lastname: Nurjadi
authors.affiliation: Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, Spandauer Damm, Berlin, Germany.
authors.forename: B
authors.initials: B
authors.lastname: Friedrich-Jänicke
authors.affiliation: Tropenklinik, Paul-Lechler-Krankenhaus, Tübingen, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Schäfer
authors.affiliation: Instituut voor Tropische Ziekten, Havenziekenhuis, TG Rotterdam, The Netherlands.
authors.forename: P J J
authors.initials: PJ
authors.lastname: Van Genderen
authors.affiliation: Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: A
authors.initials: A
authors.lastname: Goorhuis
authors.affiliation: Service de Maladies Infectieuses et Tropicales, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
authors.forename: A
authors.initials: A
authors.lastname: Perignon
authors.affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: A
authors.initials: A
authors.lastname: Neumayr
authors.affiliation: Missionsärztliche Klinik, Würzburg, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Mueller
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland.
authors.forename: A
authors.initials: A
authors.lastname: Kantele
authors.affiliation: Abteilung für Infektions- und Tropenmedizin der Ludwig-Maximilians-Universität, München, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Schunk
authors.affiliation: ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
authors.forename: J
authors.initials: J
authors.lastname: Gascon
authors.affiliation: Missionsärztliche Klinik, Würzburg, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Stich
authors.affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zürich, Switzerland.
authors.forename: C
authors.initials: C
authors.lastname: Hatz
authors.affiliation: Service de Maladies Infectieuses et Tropicales, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
authors.forename: E
authors.initials: E
authors.lastname: Caumes
authors.affiliation: Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: M P
authors.initials: MP
authors.lastname: Grobusch
authors.affiliation: Tropenklinik, Paul-Lechler-Krankenhaus, Tübingen, Germany.
authors.forename: R
authors.initials: R
authors.lastname: Fleck
authors.affiliation: Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, Spandauer Damm, Berlin, Germany.
authors.forename: F P
authors.initials: FP
authors.lastname: Mockenhaupt
authors.affiliation: Institute of Tropical Medicine, Eberhard Karls Universität, Tübingen, Germany; Institute of Public Health, Unit of Epidemiology and Biostatistics, Heidelberg University Hospital, Heidelberg, Germany. Electronic address: philipp.zanger@uni-heidelberg.de.
authors.forename: P
authors.initials: P
authors.lastname: Zanger
mesh_terms: D000328:Adult; D000349:Africa; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D001210:Asia, Southeastern; D001427:Bacterial Toxins / Q000235:genetics; D002353:Carrier State / Q000453:epidemiology / Q000382:microbiology; D024901:Drug Resistance, Multiple, Bacterial; D005060:Europe / Q000453:epidemiology; D005098:Exotoxins / Q000235:genetics; D005260:Female; D005838:Genotype; D006801:Humans; D007843:Latin America; D007956:Leukocidins / Q000235:genetics; D008297:Male; D008875:Middle Aged; D058889:Molecular Typing; D009297:Nasal Mucosa / Q000382:microbiology; D011446:Prospective Studies; D018461:Soft Tissue Infections / Q000453:epidemiology* / Q000382:microbiology* / Q000473:pathology; D013205:Staphylococcal Protein A; D013207:Staphylococcal Skin Infections / Q000453:epidemiology* / Q000382:microbiology* / Q000473:pathology; D013211:Staphylococcus aureus / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification; D014195:Travel; D037521:Virulence Factors / Q000235:genetics; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D001427:Bacterial Toxins; D005098:Exotoxins; D007956:Leukocidins; C078284:Panton-Valentine leukocidin; D013205:Staphylococcal Protein A; D037521:Virulence Factors
keywords: Drug resistance; Panton–Valentine leukocidin; emerging communicable diseases; methicillin-resistant Staphylococcus aureus; molecular epidemiology; risk factors; sentinel surveillance; staphylococcal skin infections; travel medicine; trimethoprim-sulfamethoxazole combination