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Risk factors for colonization with extended-spectrum beta-lactamase producing Enterobacteriaceae in healthcare students on clinical assignment abroad: A prospective study
Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Infectious Diseases.
Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Clinical Bacteriology.
Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Clinical Bacteriology.
Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Infectious Diseases.
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2015 (English)In: Travel Medicine and Infectious Disease, ISSN 1477-8939, E-ISSN 1873-0442, Vol. 13, no 3, 223-229 p.Article in journal (Refereed) Published
Abstract [en]

Background: The increase of antibiotic resistance in clinically important bacteria is a worldwide threat, especially in healthcare environments. International travel is a risk factor for gut colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). The risk for healthcare students of being colonized with ESBL-PE when participating in patient-related work abroad has not been previously investigated. Methods: Swedish healthcare students travelling for pre-clinical and clinical courses outside Scandinavia submitted faecal samples and survey data before and after travel. The faecal samples were screened for ESBL-PE and carbapenemase-producing Enterobacteriaceae (CPE). Screening results and survey data were analysed to identify risk factors for colonization. Results: In the 99 subjects who submitted a full set of samples, 35% were colonized with a new ESBL-PE strain during travel. No CPE was found. The most important risk factor for ESBL-PE colonization was travel destination, and the highest colonization rate was found in the South East Asia region. Antibiotic treatment during travel was an independent risk factor for ESBL-PE colonization but patient-related work was not significantly associated with an increased risk. Conclusions: Patient-related work abroad was not a risk factor for ESBL-PE suggesting that transmission from patients is uncommon. Pre-travel advice on avoiding unnecessary antibiotic treatment during travel is recommended.

Place, publisher, year, edition, pages
2015. Vol. 13, no 3, 223-229 p.
Keyword [en]
Anti-bacterial agents, Drug resistance, Beta-lactamases, Enterobacteriaceae, Travel
National Category
Infectious Medicine
URN: urn:nbn:se:umu:diva-106613DOI: 10.1016/j.tmaid.2015.04.007ISI: 000357348200005PubMedID: 25982453OAI: diva2:843252
Available from: 2015-07-28 Created: 2015-07-24 Last updated: 2015-11-09Bibliographically approved
In thesis
1. Travel – a risk factor for disease and spread of antibiotic resistance
Open this publication in new window or tab >>Travel – a risk factor for disease and spread of antibiotic resistance
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

As international travel is rapidly increasing, more people are being exposed to potentially more antibiotic resistant bacteria, a changed infectious disease epidemiology, and an increased risk of accidents and crime. Research-based advice is needed to adequately inform travellers about these risks. We studied travellers who sought advice from the Travel Medicine Clinic at the Department of Infectious Diseases, Umeå University Hospital, as well as university students from Umeå, Stockholm, and Gothenburg travelling abroad for study, research, and clinical exchange programs.

From retrospective data at the Travel Medicine Clinic, we found that pre-existing health problems were rare among travellers from Umeå seeking pre- travel health advice and vaccinations. In addition, we found that the travel destination and the sex of the traveller affected vaccination levels. Although hepatitis A is endemic to both Thailand and Turkey, compared to travellers to Thailand few travellers to Turkey visited the clinic for hepatitis A vaccination. The data also revealed that more women than men were vaccinated against Japanese encephalitis despite comparable trips.

A prospective survey study showed that travellers felt that the pre-travel health advice they received was helpful. Two-thirds of the travellers followed the advice given although they still fell ill to the same extent as those who were not compliant with the advice. Factors outside the control of travellers likely affect the travel-related morbidity. Compared to older travellers, younger travellers were less compliant with advice, fell ill to a greater extent, and took greater risks during travel.

In a prospective survey study, we found that healthcare students had higher illness rates and risk exposure when abroad compared to students from other disciplines. This difference was mainly due to the fact that healthcare students more often travelled to developing regions during their study period abroad. When abroad, half of all students increased their alcohol consumption and this was linked to an increased risk of theft and higher likelihood of meeting a new sex partner.

The healthcare students participating in the survey study also submitted stool samples before and after travel. These samples were tested for the presence of antibiotic resistance, both by selective culturing for ESBL-PE (Extended-Spectrum Beta-Lactamase Producing Enterobacteriaceae) as well as by metagenomic sequencing. About one-third (35%) of the students became colonised by ESBL-PE following their study abroad. The strongest risk factor for colonisation was travel destination; for example, 70% of students who had travelled to India became colonised. Antibiotic treatment during travel was also a significant risk factor for colonisation.

The stool samples from a subset of study subjects were analysed using metagenomic sequencing. From this we learned that although the majority of resistance genes in the gut microbiome remained unchanged following travel, several clinically important resistance genes increased, most prominently genes encoding resistance to sulphonamide, trimethoprim, and beta-lactams. Overall, taxonomic changes associated with travel were small but the proportion of Proteobacteria, which includes several clinically important bacteria (e.g., Enterobacteriaceae), increased in a majority of the study subjects.

Clearly, there are risks associated with international travel and these risks include outside factors as well as the personal behaviour of travellers. We believe our results can be used to develop better pre-travel advice for tourists as well as university students studying abroad resulting in safer travel.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2015. 66 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1754
Accident Prevention; Alcohol Drinking; Anti-Bacterial Agents; Antimalarials; Beta-Lactamases; Drug-Resistance, Bacterial; Enterobacteriaceae; Health Knowledge, Attitudes, Practice; High-Throughput Nucleotide Sequencing; Medication Adherence; Metagenome; Metagenomics; Patient Compliance; Proteobacteria; Risk Reduction Behaviour; Risk-Taking; Safe Sex; Travel medicine; Travel; Vaccination
National Category
Infectious Medicine Microbiology in the medical area
Research subject
Infectious Diseases; Microbiology
urn:nbn:se:umu:diva-111057 (URN)978-91-7601-348-9 (ISBN)
Public defence
2015-11-27, Sal A5, byggnad 6A, Norrlands universitetssjukhus, Umeå, 09:00 (English)
The Kempe Foundations
Available from: 2015-11-06 Created: 2015-11-02 Last updated: 2015-12-11Bibliographically approved

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Angelin, MartinForsell, JoakimGranlund, MargaretaEvengård, BirgittaPalmgren, HelenaJohansson, Anders
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