title: International travel is a risk factor for extended-spectrum β-lactamase-producing Enterobacteriaceae acquisition in children: A case-case-control study in an urban U.S. hospital.
abstract: BACKGROUND
  Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL) infections are increasing in both adults and children. The aim of this study was to describe the epidemiology of children with ESBL in an ethnically-diverse population, to determine what proportion of these infections were community-onset, and to identify risk factors predisposing children to ESBL acquisition.
  
  
  METHODS
  A case-case-control study of children aged 0-18 years was conducted from 2012 to 2014. Patients with ESBL (detected via VITEK2) were matched 1:1:5 (based on age, sex, specimen source, and healthcare setting) with non-ESBL and uninfected controls. Data on prior antibiotic and healthcare exposure, international travel, prior urinary tract infection (UTI), comorbid gastrointestinal (GI), genitourinary (GU), neurologic, and immunocompromising conditions were collected and compared.
  
  
  RESULTS
  Seventy-six patients were identified with 85 ESBL infections, of which 77 (91%) were E. coli. ESBL was isolated most frequently from urine (n = 72, 85%). Most infections were community-onset (n = 76, 89%) and were managed in the ambulatory setting (n = 47, 62%). On multivariate analysis, international travel (p < 0.001, OR 8.93; CI 2.92-27.78), comorbid GI condition (p = 0.002, OR 2.65, CI 1.36-5.15), Asian race (p = 0.005, OR 2.56, CI 1.34-4.89) and prior UTI (p < 0.001, OR 8.06, CI 3.47-18.87) were significant risk factors for ESBL.
  
  
  CONCLUSIONS
  Most ESBL infections in this study were community-onset. To our knowledge, this is the first description of international travel as a risk factor for ESBL acquisition in children in the United States.
authors.affiliation: Department of Pediatrics, Maimonides Infants & Children's Hospital of Brooklyn, Brooklyn, NY, USA. Electronic address: strysko@gmail.com.
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Strysko
authors.affiliation: Department of Pediatrics, Maimonides Infants & Children's Hospital of Brooklyn, Brooklyn, NY, USA; Division of Pediatric Infectious Diseases, Maimonides Infants & Children's Hospital of Brooklyn, Brooklyn, NY, USA.
authors.forename: Vidya
authors.initials: V
authors.lastname: Mony
authors.affiliation: Department of Pediatrics, Maimonides Infants & Children's Hospital of Brooklyn, Brooklyn, NY, USA; Division of Pediatric Hospitalist Medicine, Maimonides Infants & Children's Hospital of Brooklyn, Brooklyn, NY, USA.
authors.forename: Jeremiah
authors.initials: J
authors.lastname: Cleveland
authors.affiliation: Department of Pediatrics, Maimonides Infants & Children's Hospital of Brooklyn, Brooklyn, NY, USA.
authors.forename: Hanna
authors.initials: H
authors.lastname: Siddiqui
authors.affiliation: Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Homel
authors.affiliation: Department of Pediatrics, Maimonides Infants & Children's Hospital of Brooklyn, Brooklyn, NY, USA; Division of Pediatric Infectious Diseases, Maimonides Infants & Children's Hospital of Brooklyn, Brooklyn, NY, USA; Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.
authors.forename: Christina
authors.initials: C
authors.lastname: Gagliardo
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D017714:Community-Acquired Infections / Q000453:epidemiology / Q000382:microbiology; D024901:Drug Resistance, Multiple, Bacterial; D004755:Enterobacteriaceae / Q000201:enzymology / Q000235:genetics / Q000302:isolation & purification*; D004756:Enterobacteriaceae Infections / Q000453:epidemiology* / Q000208:ethnology / Q000382:microbiology*; D004926:Escherichia coli / Q000302:isolation & purification; D004927:Escherichia coli Infections / Q000453:epidemiology / Q000382:microbiology; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D038622:Internationality; D008297:Male; D008826:Microbial Sensitivity Tests; D015995:Prevalence; D012307:Risk Factors; D014195:Travel; D014481:United States / Q000453:epidemiology; D001618:beta-Lactamases / Q000096:biosynthesis*
chemical_list: D000900:Anti-Bacterial Agents; D001618:beta-Lactamases
keywords: Enterobacteriaceae; Extended-spectrum β-lactamase; Gram-negative organisms; International travel; Multidrug-resistant organisms; Pediatrics