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Meta-Analysis
. 2020 May 20;9(1):71.
doi: 10.1186/s13756-020-00733-6.

Acquisition of multidrug-resistant Enterobacterales during international travel: a systematic review of clinical and microbiological characteristics and meta-analyses of risk factors

Anne F Voor In 't Holt  1 , Kees Mourik  1 , Berend Beishuizen  2 , Adriënne S van der Schoor  1 , Annelies Verbon  1 , Margreet C Vos  1 , Juliëtte A Severin  3
Affiliations
Meta-Analysis

Acquisition of multidrug-resistant Enterobacterales during international travel: a systematic review of clinical and microbiological characteristics and meta-analyses of risk factors

Anne F Voor In 't Holt et al. Antimicrob Resist Infect Control. .

Abstract

Background: International tourism increased from 25 million tourist arrivals in 1950 to over 1.3 billion in 2017. These travelers can be exposed to (multi) resistant microorganisms, may become colonized, and bring them back home. This systematic review aims to identify the carriage rates of multidrug-resistant Enterobacterales (MDR-E) among returning travelers, to identify microbiological methods used, and to identify the leading risk factors for acquiring MDR-E during international travel.

Methods: Articles related to our research question were identified through a literature search in multiple databases (until June 18, 2019) - Embase, Medline Ovid, Cochrane, Scopus, Cinahl, Web of Science, and Google Scholar.

Results: Out of 3211 potentially relevant articles, we included 22 studies in the systematic review, and 12 studies in 7 random-effects meta-analyses. Highest carriage rates of MDR-E were observed after travel to Southern Asia (median 71%), followed by travel to Northern Africa (median 42%). Carbapenemase-producing Enterobacterales (CPE) were identified in 5 out of 22 studies, from a few patients. However, in only eight out of 22 studies (36.4%) the initial laboratory method targeted detection of the presence of CPE in the original samples. The risk factor with the highest pooled odds ratio (OR) for MDR-E was travel to Southern Asia (pooled OR = 14.16, 95% confidence interval [CI] = 5.50 to 36.45), followed by antibiotic use during travel (pooled OR = 2.78, 95% CI = 1.76 to 4.39).

Conclusions: Risk of acquiring MDR-E while travelling increases depending on travel destination and if antibiotics are used during travel. This information is useful for the development of guidelines for healthcare facilities with low MDR-E prevalence rates to prevent admission of carriers without appropriate measures. The impact of such guidelines should be assessed.

Keywords: Antimicrobial resistance; Beta-lactamases; Enterobacterales; Enterobacteriaceae; Epidemiology; Meta-analysis; Microbiology; Systematic review; Travel.

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Conflict of interest statement

AFV, KM, BB, AS, AV, MV and JS declare that they have no competing interests. JS recently collaborated with employees of bioMérieux on a research project that included whole-genome sequencing of bacterial isolates, which was performed by the company.

Figures

Fig. 1
Fig. 1
Flow diagram of study selection
Fig. 2
Fig. 2
Forest plots of random-effects meta-analyses of risk factors for acquiring multidrug-resistant Enterobacterales during international travel (a to g appear from top to bottom). (a) Experienced diarrhea while travelling (i.e. TD); (b) antibiotic use during travel; c) travelled to Southern Asia; (d) behavior during travel (e.g. brought disposable gloves, consumed bottled water); (e) food consumption during travel (e.g. ice cream and pastry consumption, meals at street food stalls); (f) male gender; (g) older age
See this image and copyright information in PMC

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