Traveling (resistant) bacteria
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1 Traveling resistant bacteria Erika Vlieghe Institute of Tropical Medicine, Antwerp University Hospital Antwerp Traveling (resistant) bacteria Colonisation - carriership rectal flora, skin Infection: mild-moderate Travelers diarrhoea, SSTI, UTI Infection: severe - life threatening Typhoid fever, pneumonia, VAP, bacteriemie, Variable ~ Infections after tropical travel Timing of presentation (during/early post/late) Region and type of travel All diseases >< only febrile Risk groups (e.g. VFR) SSTI 3-15% Travelers Diarrhoea 10-70% Rare: TB, fungal, Leishmania GU 3-9% URTI RTI 10-15% LRTI Malaria 20-30% Wilson Curr Op Infect Dis 2007; Bottieau Ann Int Med 2006; Freedman NEJM 2006; Ansart J Trav Med
2 AB use in travelers During travel Standby treatment for TD (standby treatment for SSTI, LRTI) (chemoprophylaxis for TD) After travel Empiric treatment for common (bacterial) infections TD, LRTI, SSTI, typhoid fever What is causing TD? esp. in Central/South America esp. South (East) Asia Diemert, Clin Microbiol Rev 2006 Resistance in ETEC from TD 10 year trend ( ): 4-10 x increase of MIC90 for: ceftriaxone, ciprofloxacin, levofloxacin, azithromycin NOT (yet?) for rifaximin Ouyang-Latimer, AAC
3 Resistance in Campylobacter spp. (travelers at ITM, Antwerp) Annual rates of norfloxacin resistance in Campylobacter from travelers Asia 75% Africa 37% + emerging erythromycin resistance (mean 3.1% +/- 2.8%) Vlieghe & Jacobs, J Trav Med 2008 Salmonella spp. Multi drug resistance (R to ampicillin+ SMX-TMP + chloramphenicol) Fluoroquinolones Asia 25-90% Africa 30-40% Asia: 50-90% Africa: 5-15% ESBL and other cephalosporin resistance Emerging Azithromycin Carbapenemases Non-typhoid salmonella >> S. Typhi Nalidixic acid resistance predicts decreased ciprofloxacin susceptibility 40% clinical failure when treated with ciprofloxacin 500 mg q12 x 7 d S. Typhi, nalidixin R S. Typhi, nalidixin S 3
4 Typhoid fever Paratyphoid fever France 2013, travelers returning from Cambodia : 7 cases in 10 year 2013: 35 cases in 6 months!! Tourdjman M, Eurosurveillance 2013 Cambodia 2013, local residents in Phnom Penh : 2 cases : 71 cases Vlieghe E, Eurosurveillance
5 Shigella spp. Travel as risk factor for ESBL+ E. coli colonisation 2008: travel is an independent risk factor for infections with ESBL+ E. coli (Laupland, J Infect 2008) Author Country Year n travelers % ESBL+ PRE T % ESBL+ POST T Tangdén Sweden % 24% Tham Sweden (TD)? 24% Peirano Canada ? 24% Dhanji UK ? 18% Lausch Denmark ? 12.5% Paltansing Holland % 30.5% Ostholm- Balkhed Sweden % 30% ESBL E. coli colonisation Mostly CTX-M group 1 High rates of co-resistance to FQ, AG, wide genetic variety RR if travel> 2 w diarrhoea travel to India>> Asia > Africa 5
6 Duration of colonization Health status Healthy travelers (Tangén AAC 2010, Paltansing EID 2013) 7-24% > 6 m Travelers diarrhoea (Tham, Scan J Infect Dis 2012) 24% 3-8 m 10% 3 y Use of antibiotics during travel Resistance pattern: ESBL < FQ, AG Phylogenetic group of E. coli From colonisation to infection Asia travel is a risk factor for CA-ESBL+ UTI: OR 21 (4.5-97) Soraas, Plos One 2013 Travel is a risk factor for severe sepsis after prostatic Bx: RR 2.7 ( ) Patel, BJU, 2011 From bad (ESBL) to worse (CPE) NDM-1 travel track record 6
7 If all goes wrong Colonisation/infection with MDR pathogens in repatriates KPC from Greece NDM-1 from Egypt & India PDR Acinetobacter from Iraq VRE from US Mondial assistance France: 7% of repatriates Lepelletier, J Trav Med 2011; Josseaume, J Trav Med 2012 MRSA Switserland 2004: 58 patients with community-acquired MRSA 65% travelled abroad Sweden 2009: 444 imported MRSA cases Overall risk: 6 cases/10 6 travelers N Africa & Middle east: 60 cases/ 10 6 travelers Other high risk areas: Oceania, East Asia, South America, s SAfrica, (UK, US) No info on underlying disease, hospitalisations, duration of stay, Stenhem EID 2009; Tiemersma EID 2004 Conclusion (1) Traveling (especially to South(east) Asia) is an independent risk factor for colonisation/infection with MDR pathogens Use of antibiotics (FQ, macrolides) can have additional negative impact 7
8 Conclusions (2) Empiric choices for TD? Treatment treshold for TD? Quid immune compromised travelers? Screening/isolation for seriously ill travelers to risk areas? 8
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