No evidence of carbapenemase-producing Enterobacteriaceae in stool samples of 1,544 asylum seekers arriving in Rhineland-Palatinate, Germany, April 2016 to March, 2017

摘要

Introduction: Since 2015, increased migration from Asia and Africa to Europe has raised public health concerns about potential importation of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), specifically those producing carbapenemases (C-PE), into European hospitals.Aims: To inform infection control practices about ESBL-PE prevalence in asylum seekers and to investigate whether C-PE prevalence exceeds that in the German population.Methods: Cross-sectional study from April 2016–March 2017. Routinely collected stool samples from asylum seekers were tested for antibiotic resistant Enterobacteriaceae. Country/region of origin and demographic characteristics were explored as risk factors for faecal colonisation.Results: Of 1,544 individuals, 294 tested positive for ESBL-PE colonisation (19.0%; 95% confidence intervals (CI): 17.0–21.0). Asylum seekers originating from Afghanistan/Pakistan/Iran had a prevalence of 29.3% (95% CI: 25.6–33.2), from Syria 20.4% (95% CI: 16.1–25.2) and from Eritrea/Somalia 11.9% (95% CI: 8.7–15.7). CTX-M-15 (79%) and CTX-M-27 (10%) were the most common ESBL determinants. Highest ESBL-PE prevalences were observed in boys under 10 years and women aged 20–39 years (interaction: p?=?0.03). No individuals tested positive for C-PE. Faecal C-PE colonisation prevalence in asylum seekers was not statistically significantly different from prevalence reported in German communities.Conclusion: In absence of other risk factors, being a newly arrived asylum seeker from a region with increased faecal ESBL-PE colonisation prevalence is not an indicator for C-PE colonisation and thus not a reason for pre-emptive screening and isolation upon hospital admission. Keywords: carbapenem-resistant Enterobacteriaceae, Escherichia coli, ESBL, beta-lactamase CTX-M-27, beta-lactamase CTX-M-15, E. coli ST131, Syria, Afghanistan, Iran, Pakistan, Eritrea, Somalia, human migration, mass screening, refugees, drug resistance, microbial, communicable diseases, emerging, epidemiology, infectious disease transmission, prevalence, cross-sectional studies, plasmid mediated fluoroquinolone resistanceIntroductionAntibiotic resistance of pathogens and resulting limitations of therapeutic options increase morbidity, mortality and costs [1]. Since the beginning of this century, the number of infections caused by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) has grown rapidly. Of these, carbapenemase-producing Enterobacteriaceae (C-PE) are of particular interest, as carbapenems are considered compounds of last resort against life-threatening infections. Major steps in the spread of antibiotic resistance in Enterobacteriaceae are horizontal exchange of mobile resistance genes into different clones and their dissemination over long distances, often facilitated by travel or migration of the colonised host [2]. International travel to south/south-east Asia and Africa was found to be a risk factor for colonisation [3,4] and subsequent infection with ESBL-PE [5]. Introduction of these bacteria into unaffected hospitals is much dreaded since nosocomial outbreaks of C-PE have been reported world-wide [6].In 2015, Europe was challenged by the arrival of a large number of asylum seekers, sparked primarily by the Syrian civil war, but also by other conflicts and humanitarian crises in southern Asia, western Asia, and Africa. Reports of high ESBL-PE and C-PE colonisation prevalences in hospitalised populations and among asylum seekers from these countries/regions [7-12], together with data on increased ESBL-PE and C-PE colonisation in returning travellers [3,4] led to discussions whether such migration may increase the risk of nosocomial transmission of multidrug-resistant bacteria in European countries with low C-PE prevalence [13].In April 2016, the European Centre for Disease Prevention and Control (ECDC) recommended that individuals with recent exposure in high prevalence countries may also be considered for pre-emptive screening and isolation upon admission in European hospitals, even if they had no history of hospitalisation or antibiotic therapy before their arrival in Europe [14]. However, published studies regarding ESBL-PE/C-PE colonisation of migrants seeking asylum in the European Union are limited to research in hospitalised patients [9,10,15,16], do not stratify by country/region of origin [9,10,15,16], and lack statistical power [10,11,15]. Thus, while these studies provide rough estimates of the ESBL-PE/C-PE colonisation prevalence in populations that have a priori an increased likelihood of pre-morbidities, they do not represent newly arrived asylum seekers in general and thus cannot inform whether country/region of origin alone is a sufficient predictor for increased risk of ESBL-PE/C-PE colonisation. Therefore, research on colonisation status in sufficiently large populations recruited outside health care institutions is needed to determine whether newly arrived asylum seekers i