d contact with farm or domestic animals more than 3 times a week, more than 1 hour each day e numbers do not add up because 20 patients had contact with multiple animals f two patients with missing information about which animal g one patient with missing information about which animal h one patient reported domestic animal contact but missing information about which animal. Behavior during travel Overall, more than half of the travelling patients consumed ice cream and/or pastries during travel (Table 3). Traveling patients carrying HRMO at hospital admission experienced, with low numbers of patients however, more often diarrhea (14.3% vs. 4.6%), and used more often antibiotics during travel (14.3% vs. 4.6%) compared to patients not carrying HRMO at admission (Table 3). Vomiting during travel and the use of malaria prophylaxis were only described in HRMO-negative patients. Additionally, only HRMO-negative patients reported that they ate meals at street food stalls. HRMO carriage rates were higher for patients travelling outside of Europe, compared to patients travelling in Europe (13.3% vs. 3.4%, Table 3). Fig. 2 Regions visited by patients admitted to the Erasmus MC University Medical Center. HRMO; highly resistant microorganism Genomic analysis WGS results confirmed the presence of beta-lactamases in the isolates from the 12 patients identified with an ESBL-producing E. coli (Additional Figure 3: Fig. 1, Additional file 4: Fig. 2). The beta-lactamases distribution in isolates was not associated with patient travelling (Additional Figure 3: Fig. 1). In two traveling and one non-traveling patient (patients 1, 2 and 3) blaOXA-1 was detected. These three isolates also contained an blaCTX-M-15 and aac(6’)-Ib-cr gene. Additionally, multiple other aminoglycoside-modifying enzymes (AMEs) were present 2 59 Pre-COVID-19 international travel and addmission to hospital back home
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