High rate of acquisition of faecal carriage of multidrug-resistant Enterobacteriaceae after international travel

Ruppé E, Armand-Lefèvre L, Estellat C, et al.

Clin Infect Dis. 2015 Apr 22. pii: civ333. [Epub ahead of print]

In a recently published study, Ruppé et al. show that acquisition of multidrug-resistant Enterobacteriaceae is frequent among travellers returning from tropical regions, with 50.9% of the travellers carrying an average 1.8 multidrug-resistant Enterobacteriaceae isolates upon return. Travellers returning from Asia (72.4%) were more likely to be colonised than travellers returning from sub-Saharan Africa (47.7%) or Latin America (31.1%). Three (0.5%) travellers returning from India carried carbapenemase-producing Enterobacteriaceae. Although travellers returning from Asia were colonised for a longer time, faecal carriage of multidrug-resistant Enterobacteriaceae in general did not exceed three months after return. Recent travel to the tropics should be considered as a risk factor for carriage of multidrug-resistant Enterobacteriaceae and should be taken into account when prescribing empirical antibiotic therapy for infections occurring in travellers during the first three months after return.

ECDC comment

More than 30 million Europeans travel to Asia, Africa or Latin America each year. The study by Ruppé et al. is the largest study to date that confirms the high frequency of faecal carriage of multidrug-resistant Enterobacteriaceae in travellers returning from these regions. The authors had previously published detailed case descriptions of the three travellers that were colonised with a carbapenemase-producing Enterobacteriaceae. The latter is a worrisome development because of the extensive drug resistance profile of such isolates and the ensuing potential for inadequate empirical treatment, should these patients develop an infection.

According to Ruppé et al., these findings have direct implications for the management of patients with a history of recent international travel who develop an infection in the months following return, in particular if the patient had diarrhoea and/or took antibiotics during travel. In such patients with a urinary tract infection, the authors recommend taking a urine sample before initiating treatment to allow for antimicrobial susceptibility testing of the responsible bacterium.

In addition, these results may have implications for infection prevention and control in hospitals and other healthcare institutions in the EU/EEA. Current ECDC systematic reviews and risk assessment, as well as national recommendations in EU/EEA Member States, only highlight the risk of carriage of multidrug-resistant bacteria in patients being transferred between healthcare facilities across borders, and emphasize the need for early implementation of active screening for these bacteria and isolation measures for positive patients. Extension of these precautions to patients with a history of recent travel to the tropics would require further consideration.