Towards a guideline – part 2 In a previous study, we described knowledge gaps that needed to be filled before national and international guidelines could be developed (4). First, we described that the proportion of patients with a recent travel history is unknown. With this current study, we identified that almost 50% of admitted patients traveled abroad in the last year, of which 25.6% traveled outside of Europe. Second, we previously described that it is unknown if strains carried by travelers spread in hospitals. In this study, we did not include ward mates nor did we sample the environment to assess spread in the hospital, so this knowledge gap is still unfilled. Third, the threshold of a carriage rate after travel that warrants screening and/or isolation was also an unresolved issue. In this study, we showed that carriage rates were higher in patients that travelled to Northern Africa, Asia, North America, and to South America in the last year, than the ESBL carriage rate in the Dutch community (i.e. 5.3%- 9.9%) (8). In a study prospectively including healthy travelers, ESBL carriage rates observed among people traveling to Southeastern Asia (31.6%), followed by Southern Asia (21.5%), were higher than in the Dutch community(3). This could point to a strategy of only preemptively screening and isolating patients that have travelled to those countries. A high majority of patients support the idea to screen for HRMO upon hospital admission in case of a travel history. However, although patients support screening, it is questionable if preemptive isolation and screening for around 12% (i.e. 30 out of 247 patients) of all admitted patients because of travelling outside of Europe in the last year is cost-effective, and even feasible in many hospitals with respect to isolation capacity. A screening-only (i.e. without preemptive isolation) policy could be considered, with as draw back that a contact investigation must be performed when an HRMO-positive patient is identified. We chose to ask for traveling in the year before hospital admission, however, also different cut-offs can be used (e.g. 1 month, 2 months, 3 months), since literature shows that the median elimination time of HRMO carriage after travel is quick (16). Therefore, we calculated the percentages of HRMO carriage when selecting more focused target populations for screening, primarily focusing on travelling to Asia or Africa, as previously defined destinations with high HRMO carriage upon return (3). Percentages of HRMO carriage increased when travel was closer to hospital admission, for patients traveling outside Europe and for patients traveling to Asia or Africa (i.e. travel outside Europe: 13% [n=4/30] if traveled <1 year before hospital admission to 29% [n=2/7] if <3 months to 40% [n=2/5] if <2 months to 67% [n=2/3] if <1 month; Travel to Asia or Africa: 14% [n=2/14] if traveled <1 year before hospital admission to 33% [n=1/3] if <3 months to 50% [n=1/2] if <2 months to 100% [n=1/1] if <1 month). Additionally, the numbers of patients included in these groups decrease rapidly. Antibiotic use during the year before hospital admission was not related to HRMO carriage. Considering the results of this current study and discussed literature, we would propose to target the patients that travelled more recently (i.e. <2 months) for screening and preemptive isolation. The travel destinations to include could be any country outside Europe based on our limited data, or travel to Asia or Africa, based on the broader picture from published data in combination with our data. A strategy with a more targeted patient population will be feasible for many hospitals, and most likely be cost-effective. 2 63 Pre-COVID-19 international travel and addmission to hospital back home
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