title: Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk factors for acquiring ciprofloxacin-resistant and extended spectrum β-lactamase-producing Enterobacteriaceae-a prospective cohort study.
abstract: 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 β-lactamase-producing 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.
authors.affiliation: Medical Microbiology and Infection Control, VU University Medical Centre, Amsterdam, The Netherlands. Electronic address: e.reuland@vumc.nl.
authors.forename: E A
authors.initials: EA
authors.lastname: Reuland
authors.affiliation: Department of Infectious Diseases, Public Health Service (GGD) Amsterdam, The Netherlands; Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre, Amsterdam, The Netherlands.
authors.forename: G J B
authors.initials: GJ
authors.lastname: Sonder
authors.affiliation: Department of Infectious Diseases, Public Health Service (GGD) Amsterdam, The Netherlands.
authors.forename: I
authors.initials: I
authors.lastname: Stolte
authors.affiliation: Medical Microbiology and Infection Control, VU University Medical Centre, Amsterdam, The Netherlands; Laboratory for Medical Microbiology and Public Health, Enschede, The Netherlands; Microbiology and Infection Control, Ziekenhuisgroep Twente, Hengelo, The Netherlands.
authors.forename: N
authors.initials: N
authors.lastname: Al Naiemi
authors.affiliation: Medical Microbiology and Infection Control, VU University Medical Centre, Amsterdam, The Netherlands.
authors.forename: A
authors.initials: A
authors.lastname: Koek
authors.affiliation: Public Health Laboratory, Division of Infectious Diseases, Amsterdam Health Service, The Netherlands.
authors.forename: G B
authors.initials: GB
authors.lastname: Linde
authors.affiliation: Medical Microbiology and Infection Control, VU University Medical Centre, Amsterdam, The Netherlands.
authors.forename: T J W
authors.initials: TJ
authors.lastname: van de Laar
authors.affiliation: Medical Microbiology and Infection Control, VU University Medical Centre, Amsterdam, The Netherlands.
authors.forename: C M J E
authors.initials: CM
authors.lastname: Vandenbroucke-Grauls
authors.affiliation: Public Health Laboratory, Division of Infectious Diseases, Amsterdam Health Service, The Netherlands; Medical Microbiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
authors.forename: A P
authors.initials: AP
authors.lastname: van Dam
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D001208:Asia / Q000453:epidemiology; D002939:Ciprofloxacin / Q000494:pharmacology*; D015331:Cohort Studies; D003967:Diarrhea / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology*; D024881:Drug Resistance, Bacterial; D004755:Enterobacteriaceae / Q000187:drug effects* / Q000235:genetics; D004756:Enterobacteriaceae Infections / Q000453:epidemiology* / Q000209:etiology* / Q000382:microbiology; D005260:Female; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D015995:Prevalence; D011446:Prospective Studies; D012307:Risk Factors; D014195:Travel; D001618:beta-Lactamases / Q000096:biosynthesis / Q000235:genetics
chemical_list: D000900:Anti-Bacterial Agents; D002939:Ciprofloxacin; D001618:beta-Lactamases
keywords: Acquisition rate; Ciprofloxacin-resistance; Extended spectrum β-lactamase-producing Enterobacteriaceae; Risk factors; Travelling