Multiple studies have determined the effect of travel on ESBL acquisition, and highlighted the importance of improved screening and efforts to reduce import (4). However, information on acquisition of HRMO during travel of patients is scarce; even more because other studies focused on people in settings outside hospitals, such as travel clinics. We found an overall carriage rate of 6.1%; 6.2% for non-travelers and 6.0% for traveling patients, which is comparable to the normal carriage rate of ESBL-producing Enterobacterales in the Netherlands (8). However, the majority of patients travelled within Europe. While the prevalence of HRMO is higher in Southern European countries compared to the Netherlands and countries in the Northern part of Europe, research has shown that travelling to countries in especially South East Asia is a risk factor (4). We showed that patients that did travel outside of Europe had higher carriage rates upon admission, compared to patients travelling in Europe, and compared to patients that did not travel (13.3% vs. 3.4% vs. 6.2%). With regard to patients that did travel, experiencing diarrhea or vomiting during travel were rare, as was being admitted to a hospital abroad (i.e. less than 7%). Out of six patients using antibiotics abroad, only one carried an HRMO upon admittance. This in contrast to the study by Wuerz et al. that described that the risk of acquiring ESBL-producing Enterobacterales increases substantially when using antibiotics during travel (9). Overall, more than 50% of patients used antibiotics in the year before admission. This could be considered as high, especially higher compared to the study by Reuland et al, who took a representative sample of the general adult Dutch population and found rates between 14% and 26% (10). The difference between our findings and the findings by Reuland et al. could be explained by different populations included; in our study this population included patients of a tertiary care hospital. Additionally, the median age of included patients was 64 years old, ranging from 20 to 91, which is considerably older compared to the study by Reuland et al. (i.e. median age of cases 48 and controls 50 years old) and by Arcilla et al., (i.e. 51 years old, range 33 to 61). We assume that our older, tertiary-care hospital patients were less likely travelers outside of Europe. We identified that two out of seven travelers carrying an ESBL-producing E. coli carried E. coli ST131, a common strain in the world, including in the Dutch community, and no carbapenemase-producing isolates were identified. In the study by Arcilla et al., and Peirano et al., blaCTX-M-15 was the most frequently acquired ESBL-gene in travelers (>50%), as was in our study (6 out of 12 ESBL-producing E. coli, 50%; 4 travelling patients and 2 in nontravelling patients) (3, 11). CTX-M-15 (CTX-M-1 group) and CTX-M-27 (CTX-M-9 group) were previously identified as prevalent in the Netherlands, including in long-term care facilities, while CTX-M-14/65 (CTX-M-9 group and CTX-M-55 (CTX-M-1 group) are less present in the Dutch population (10, 12-14). In three patients, blaOXA-1 was found, in combination with blaCTX-M-15 and aac(6’)-Ib-cr, which was also described as being a frequent combination in the UK (15). Of these, the aac(6’)-Ib-cr is most worrisome, as this enzyme also confers resistance to ciprofloxacin and norfloxacin and its gene is known to be plasmid-mediated. 62 Chapter 2.2
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