Strengths and limitations A strength of our study is that we included a reasonable large number of patients with information on travel history with an accompanying admission culture. However, since we did not sample the patients before and after travel but at hospital admission, we do not know whether patients were already carrying an HRMO, or acquired the HRMO during travel. A second strength is that we asked for the perception of the patients towards this subject. Potential limitations include this being a single center study in a tertiary care hospital, including a relatively older patient population with complicated medical histories who might travel less often compared to patients admitted to secondary care hospitals. Second, only a low number of HRMO were identified. This could mean that this study was underpowered and could therefore not identify meaningful differences between groups. Therefore, the results of this study should be confirmed by a larger study. Third, we could have encountered recall bias of patients with regard to questionnaire, and finally, we have introduced a language bias by providing the questionnaire in Dutch only. Conclusions With this study, we identified that half of admitted patients to a large tertiary care hospital travelled abroad in the last year, with only a small percentage outside Europe. We discussed that a strategy including screening and preemptive isolation of patients who travelled to Asia or Africa in the previous 2 months could be considered. Also, we learned that this strategy would be supported by patients. Some previously identified knowledge gaps have been filled and we are one step closer towards a guideline. However, before national or international guidelines can be developed, future research should focus on determining the burden of disease of travel-related HRMO carriage, and its transmissibility to other patients and to the environment, using a multi-center study design and taking cost-effectiveness into account. Finally, since this study was performed before the COVID-19 pandemic it is unknown if travel behavior changed because of this, and if travel destinations changed. Therefore, post-COVID studies still have to be performed, to assess the impact of the COVID19 pandemic. 64 Chapter 2.2
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