Background Before the start of the SARS-CoV-2 pandemic, international tourism was on the rise worldwide. Tourism increased from 25 million tourist arrivals in 1950 to over 1.4 billion international tourist arrivals in 2019 (1). Although the number of tourist arrivals has fallen to around 380 million in 2020, it is expected that it will return to the 2019 levels within 2.5 to 4 years (2). These international travelers do pick up microorganisms that they are exposed to during travel, among which antibiotic-resistant bacteria, and bring these microorganisms back home (3). In recent years, it has been increasingly recognized that highly resistant microorganisms (HRMO) are a threat to human health, hampering antibiotic therapy, and increasing morbidity and mortality, especially in patients admitted to hospitals. Important risk factors for acquiring HRMO while travelling are exposure to healthcare abroad, experiencing travelers’ diarrhea, and/or antibiotic use during travel. Travel to certain destinations is also a risk factor, specifically to Southern Asia; which is known as a region with high HRMO prevalence (4). A recent Dutch study amongst healthy travelers showed that 34.3% of included persons acquired extended-spectrum beta-lactamase (ESBL)-producing bacteria during travel, with an astonishing 75.1% in travelers traveling to Southern Asia (3). Other known risk factors include for example ice cream consumption, and consuming meals at street food stalls (4). Protective factors, although not well established, have also been identified; such as handwashing before meals, and having a vegetarian diet (3-5). It is assumed that there is an increased risk of introducing HRMO into the hospital when people from countries with a low prevalence of HRMO are admitted to a hospital, after they have returned from travelling to countries with a high prevalence of HRMO. To contain this risk, a strategy that includes questions at admission about travel history, preemptive isolation, and screening for HRMO could be developed. However, it is unknown how many patients travel and to which destinations, and if they indeed carry HRMO at admission. Therefore, the primary aim of this study was to investigate the travel behavior of patients admitted to a large tertiary care hospital in a country with low prevalence of HRMO, and to correlate travel behavior to HRMO carriage of patients at admission. The secondary aim was to gain insight in the travel-related risk perception of patients, and about their opinion regarding measures hospitals can implement to prevent HRMO transmission due to undetected carriers. This knowledge can then be used in the future to develop policies or guidelines. Furthermore, we aimed to determine by whole genome sequencing (WGS) the sequence types and antimicrobial resistance genes in HRMO identified from traveling and non-traveling patients. Methods Study design The Erasmus MC University Medical Center (Erasmus MC) Rotterdam, the Netherlands, is a tertiary care, university hospital, with all medical specialties available. In 2018, the Erasmus MC relocated to a newly constructed hospital building (i.e. for adult patients only), which 2 53 Pre-COVID-19 international travel and addmission to hospital back home
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