Travel-Related Antimicrobial Resistance: A Systematic Review

Abstract

There is increasing evidence that human movement facilitates the global spread of resistant bacteria and antimicrobial resistance (AMR) genes. We systematically reviewed the literature on the impact of travel on the dissemination of AMR. We searched the databases Medline, EMBASE and SCOPUS from database inception until the end of June 2019. Of the 3052 titles identified, 2253 articles passed the initial screening, of which 238 met the inclusion criteria. The studies covered 30,060 drug-resistant isolates from 26 identified bacterial species. Most were enteric, accounting for 65% of the identified species and 92% of all documented isolates. High-income countries were more likely to be recipient nations for AMR originating from middle- and low-income countries. The most common origin of travellers with resistant bacteria was Asia, covering 36% of the total isolates. Beta-lactams and quinolones were the most documented drug-resistant organisms, accounting for 35% and 31% of the overall drug resistance, respectively. Medical tourism was twice as likely to be associated with multidrug-resistant organisms than general travel. International travel is a vehicle for the transmission of antimicrobial resistance globally. Health systems should identify recent travellers to ensure that adequate precautions are taken.

Keywords: antimicrobial resistance; enteric bacteria; medical traveller; multidrug resistance; travel.

Figure 1

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram for the current systematic review: the methods used for search, identification, screening and the selection process for our review.

Figure 2

Travel-related antimicrobial resistance for unspecified enteric organisms’ movement, 2007–2019: data are shown by arrows representing antimicrobial resistant isolate movements, where the arrowhead represents the destination and the base of the arrow represents the source. Thus, double-headed arrows represent movements between the same regions. Different regions are represented by different shades.

Figure 3

Travel-related antimicrobial resistant typhoidal Salmonella spp. movements, 1984–2019: data are shown by arrows representing antimicrobial resistant isolate movements, where the arrowhead represents the destination and the base of the arrow represents the source. Thus, double-headed arrows represent movements between the same regions. Different regions are represented by different shades.

Figure 4

Travel-related antimicrobial resistant nontyphoidal Salmonella spp. movements, 1990–2019: data are shown by arrows representing antimicrobial resistant isolate movements, where the arrowhead represents the destination and the base of the arrow represents the source. Thus, double-headed arrows represent movements between the same regions. Different regions are represented by different shades.

Figure 5

Travel-related antimicrobial resistant Escherichia coli transmission, 1987–2019: data are shown by arrows representing antimicrobial resistant isolate movements, where the arrowhead represents the destination and the base of the arrow represents the source. Thus, double-headed arrows represent movements between the same regions. Different regions are represented by different shades.

Figure 6

Travel-related antimicrobial resistant Shigella spp. movements, 1967–2019: data are shown by arrows representing antimicrobial resistant isolate movements, where the arrowhead represents the destination and the base of the arrow represents the source. Thus, double-headed arrows represent movements between the same regions. Different regions are represented by different shades.

Figure 7

Traveling antimicrobial resistance transmission events for Staphylococcus aureus, 2000–2019: data are shown by arrows representing antimicrobial resistant isolate movements, where the arrowhead represents the destination and the base of the arrow represents the source. Thus, double-headed arrows represent movements between the same regions. Different regions are represented by different shades.