Carriage of multi-drug resistant bacteria among foreigners seeking medical care

Abstract

Medical tourism has a potential of spreading multi-drug resistant bacteria (MDR). The Hadassah Medical Center serves as a referral center for global medical tourists and for Palestinian Authority residents. In order to assess whether patients of these groups are more likely to harbor MDR bacteria than local residents, we reviewed data from all patients admitted to our institution between 2009 and 2014. We compared MDR rates between countries of residency, controlling for gender, age, previous hospitalization and time from admission to MDR detection. Overall, among 111,577 patients with at least one microbiological specimen taken during hospitalization, there were 3,985 (3.5%) patients with at least one MDR-positive culture. Compared to Israeli patients, tourists and patients from the Palestinian Authority had increased rates of MDR positivity (OR, 95%CI): 2.3 (1.6 to 2.3) and 8.0 (6.3 to 10.1), respectively. Our data show that foreign patients seeking advanced medical care are more likely to carry MDR bacteria than the resident population. Strategies to minimize MDR spread, such as pre-admission screening or pre-emptive isolation should be considered in this population.

Figure 1

Flowchart of patient selection, exclusion and multi drug resistant (MDR) rates. The study period extended from July 1^st 2009 to December 31^st 2014. Only patients admitted at least once and from whom at least one microbiological specimen was obtained were included in the study. Patients were classified into three groups and in each, the rate of MDR bacteria was calculated twice, once excluding and once including carbapenem-resistant Pseudomonas aeruginosa (CR-PA) and extended-spectrum-beta-lactamase producing Enterobacteriaceae (ESBL-PE) (see text).

Figure 2

Multi drug resistant (MDR) prevalence per age group and source population. Each panel depicts MDR prevalence per age group. Columns depict the cumulative MDR rate in each age group, per patient nationality. The color specifications depict the time from hospital admission to first identification of MDR bacteria. Palestinian patients were found to have the highest rates of MDR bacteria in all age groups. Among patients up to 40 years old, foreign tourists had higher MDR rates than Israeli patients. In the older age groups, MDR rates were lower among foreign tourists. In most age groups about half of MDR bacteria were identified in the first 96 hours after admission.