Infection due to travel-related carbapenemase-producingEnterobacteriaceae, a largely underestimated phenomenon in Belgium

Abstract

Background: Carbapenemase-producing Enterobacteriaceae (CPE) are emerging worldwide, representing a major threat for public health. Early CPE detection is crucial in order to prevent infections and the development of reservoirs/outbreaks in hospitals. In 2008, most of the CPE strains reported in Belgium were imported from patients repatriated from abroad. Actually, this is no longer the case. Objectives and methods: A surveillance was set up in Belgian hospitals (2012) in order to explore the epidemiology and determinants of CPE, including the link with international travel/hospitalization. The present article describes travel-related CPE reported in Belgium. Different other potential sources for importation of CPE are discussed. Results: Only 12% of all CPE cases reported in Belgium (2012Belgium ( -2013 were travel related (with/without hospitalization). This is undoubtedly an underestimation (missing travel data: 36%), considering the increasing tourism, the immigration from endemic countries, the growing number of foreign patients using scheduled medical care in Belgium, and the medical repatriations from foreign hospitals. The free movement of persons and services (European Union) contributes to an increase in foreign healthcare workers (HCW) in Belgian hospitals. Residents from nursing homes located at the country borders can be another potential source of dissemination of CPE between countries. Moreover, the high population density in Belgium can increase the risk for CPE-dissemination. Urban areas in Belgium may cumulate these potential risk factors for import/dissemination of CPE. Conclusions: Ideally, travel history data should be obtained from hospital hygiene teams, not from the microbiological laboratory. Patients who received medical care abroad (whatever the country) should be screened for CPE at admission.

Risk factors for carbapenem-resistant Enterobacteriaceae infections: a French case-control-control study

“…All these results support the fact that travelling in Asia and having been hospitalised abroad are risk factors of CPE infection. Thus, our case-control-control study re-enforces previously suggestions provided by case reports or case series on the risk of CPE carriage or infection after travelling abroad, notably in Asia with and without hospitalisation abroad [21][22][23][24][25][26][27]. Hence, Asia, already known as a reservoir for ESBL-producing Enterobacteriaceae, appears now as a region at risk of CPE acquisition during travel [28,29].…”

Increasing proportion of carbapenemase-producing Enterobacteriaceae and emergence of a MCR-1 producer through a multicentric study among hospital-based and private laboratories in Belgium from September to November 2015

“…Additionally, the presence of other OXA-48 producing DL types (3 and 5) both in hospitals and in private laboratories that are geographically close (distance < 30 km) raised the possibility of epidemiological links between the two healthcare sectors. Although no patient history regarding travel or hospitalisation in foreign country was available in this study, data from the national surveillance programme and from the previous prevalence study in 2012 support that the proportion of travel-imported CPE cases should be limited [17]. …”

Carbapenem-ResistantEnterobacteriaceae: A Strategic Roadmap for Infection Control

“…97 The establishment of centralized surveillance for both antimicrobial resistance and antimicrobial use, as exists in many countries, is also recommended. 14,22,140,141 Apart from centralized data collection, a nationwide real-time network of communications is required to manage a large-scale countrywide CRE outbreak. 87 Unfortunately, in resource-limited settings, the capacity to perform surveillance and respond to the threat of MDROs is largely absent.…”

“…Such reference laboratories are already in place in many European countries to identify the resistance mechanisms and to confirm carbapenemase production. 20,22,93,138 International Considerations…”

“…10 Importation of CRE may occur due to returned travelers, medical repatriation of patients, and medical tourism. 22 The spread of KPC-and NDM-producing Enterobacteriaceae during the 2000s due to cross-border transfer of patients between healthcare facilities highlights the urgent need for both formalized CRE screening procedures by international and national health and travel insurance providers and global antimicrobial resistance surveillance systems. 22,27,68 Global surveillance systems incorporating molecular characterization can ensure early recognition of novel resistance mechanisms and the emergence of successful international CRE clones or sequence types.…”