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Lancet Infect Dis. 2017 Jan;17(1):78-85. doi: 10.1016/S1473-3099(16)30319-X. Epub 2016 Oct 14.

Import and spread of extended-spectrum β-lactamase-producing Enterobacteriaceae by international travellers (COMBAT study): a prospective, multicentre cohort study.

Author information

1
Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, Netherlands.
2
Department of Medical Microbiology, Academic Medical Centre, Amsterdam, Netherlands.
3
Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands.
4
Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Mathematics, Faculty of Science, Utrecht University, Utrecht, Netherlands.
5
Institute for Tropical Diseases, Havenziekenhuis, Rotterdam, Netherlands.
6
Centre of Tropical Medicine and Travel Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
7
School for Public Health and Primary Care (Caphri), Department of Medical Microbiology, Maastricht University Medical Centre, Maastricht, Netherlands.
8
School for Public Health and Primary Care (Caphri), Department of Medical Microbiology, Maastricht University Medical Centre, Maastricht, Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre, Maastricht, Netherlands. Electronic address: j.penders@maastrichtuniversity.nl.

Abstract

BACKGROUND:

International travel contributes to the dissemination of antimicrobial resistance. We investigated the acquisition of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) during international travel, with a focus on predictive factors for acquisition, duration of colonisation, and probability of onward transmission.

METHODS:

Within the prospective, multicentre COMBAT study, 2001 Dutch travellers and 215 non-travelling household members were enrolled. Faecal samples and questionnaires on demographics, illnesses, and behaviour were collected before travel and immediately and 1, 3, 6, and 12 months after return. Samples were screened for the presence of ESBL-E. In post-travel samples, ESBL genes were sequenced and PCR with specific primers for plasmid-encoded β-lactamase enzymes TEM, SHV, and CTX-M group 1, 2, 8, 9, and 25 was used to confirm the presence of ESBL genes in follow-up samples. Multivariable regression analyses and mathematical modelling were used to identify predictors for acquisition and sustained carriage, and to determine household transmission rates. This study is registered with ClinicalTrials.gov, number NCT01676974.

FINDINGS:

633 (34·3%) of 1847 travellers who were ESBL negative before travel and had available samples after return had acquired ESBL-E during international travel (95% CI 32·1-36·5), with the highest number of acquisitions being among those who travelled to southern Asia in 136 of 181 (75·1%, 95% CI 68·4-80·9). Important predictors for acquisition of ESBL-E were antibiotic use during travel (adjusted odds ratio 2·69, 95% CI 1·79-4·05), traveller's diarrhoea that persisted after return (2·31, 1·42-3·76), and pre-existing chronic bowel disease (2·10, 1·13-3·90). The median duration of colonisation after travel was 30 days (95% CI 29-33). 65 (11·3%) of 577 remained colonised at 12 months. CTX-M enzyme group 9 ESBLs were associated with a significantly increased risk of sustained carriage (median duration 75 days, 95% CI 48-102, p=0·0001). Onward transmission was found in 13 (7·7%) of 168 household members. The probability of transmitting ESBL-E to another household member was 12% (95% CI 5-18).

INTERPRETATION:

Acquisition and spread of ESBL-E during and after international travel was substantial and worrisome. Travellers to areas with a high risk of ESBL-E acquisition should be viewed as potential carriers of ESBL-E for up to 12 months after return.

FUNDING:

Netherlands Organisation for Health Research and Development (ZonMw).

PMID:
27751772
DOI:
10.1016/S1473-3099(16)30319-X
[Indexed for MEDLINE]

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