Extended-Spectrum β-Lactamase–producing Enterobacteriaceae among Travelers from the Netherlands

Sunita Paltansing

, Jessica A. Vlot, Margriet E.M. Kraakman, Romy Mesman, Marguerite L. Bruijning, Alexandra T. Bernards, Leo G. Visser¹, and Karin Ellen Veldkamp¹

Author affiliations: Leiden University Medical Center, Leiden, the Netherlands

Abstract

A prospective cohort study was performed among travelers from the Netherlands to investigate the acquisition of carbapenemase-producing Enterobacteriaceae (CP-E) and extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-E) and associated risk factors. Questionnaires were administered and rectal swabs were collected and tested before and after return. Of 370 travelers, 32 (8.6%) were colonized with ESBL-E before travel; 113 (30.5%) acquired an ESBL-E during travel, and 26 were still colonized 6 months after return. No CP-E were found. Independent risk factors for ESBL-E acquisition were travel to South and East Asia. Multilocus sequence typing showed extensive genetic diversity among Escherichia coli. Predominant ESBLs were CTX-M enzymes. The acquisition rate, 30.5%, of ESBL-E in travelers from the Netherlands to all destinations studied was high. Active surveillance for ESBL-E and CP-E and contact isolation precautions may be recommended at admission to medical facilities for patients who traveled to Asia during the previous 6 months.

The effect of international travel on the spread of multidrug-resistant Enterobacteriaceae (MDR-E) became more evident during 2007–2010. Data obtained during that time from prospective studies of returning travelers from Australia, Canada, Sweden, and the United States (New York, New York) revealed high rates of extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-E) carriage, varying from 18% to 25% after foreign travel (1–4). Two of these studies also reported a pretravel ESBL-E carriage rate of 7.8%.
The identification of carbapenemase-producing Enterobacteriaceae (CP-E) produced another set of challenges. Carbapenemases, such as Klebsiella pneumoniae carbapenemases (KPC), New Delhi metallo-β-lactamase (NDM), OXA-48, VIM and IMP, are plasmid-encoded enzymes, which have emerged worldwide. The rate of acquisition of CP-E during foreign travel is unknown; no surveillance system to date tracks these rates, and such rates are included sporadically in case reports, such as the situation recently reviewed by Van der Bij and Pitout (5). In the Netherlands, CP-E were found for the first time in 2010 (6).
No data were available on the pre-and post-travel carriage rates among travelers from the Netherlands. Our objective was to investigate whether these travelers are at risk of MDR-E (ESBL-E and/or CP-E) by use of a prospective cohort study design. Because detailed microbiological data of the isolates and epidemiologic data are crucial for assessing the real public health impacts of these organisms, we also investigated the persistence of intestinal colonization and possible spread to household contacts 6 months after the travelers returned.