Antimicrobial Resistant Infections in Travelers
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Background
International travel has increased substantially over the last few decades and with increases in any type of travel comes an increase in the risk of travelers’ diarrhea (TD), the most frequent health impairment among travelers to developing countries. Stand-by self-treatment antibiotics are often prescribed for travelers and are recommended for use in cases of severe and some instances of moderate diarrhea. While this can be crucial when experiencing severe TD, taking antibiotics when not needed goes against prescribing instructions and contributes to acquisition and spread of antimicrobial resistant (AMR) infections. Through a combination of increased overall international travel and increased travel to newer, potentially higher risk regions, there has been a resulting increase in acquisition and spread of AMR infections globally.Numerous studies have been conducted that have linked international travel with acquisition of AMR bacteria upon return, but these have largely been studies of smaller sample sizes, have had a focus on colonization relying on fecal swabs, or looked at travel as a risk factor beyond the main scope of the study. Despite these studies on travel and antibiotics on colonization, there exists a lack of knowledge that ties receipt of stand-by self-treatment antibiotics with post-travel AMR infections. Objectives
Receipt of a pre-travel stand-by self-treatment antibiotic was not found to be associated with an increased risk of AMR UTIs or SSTIs, or GI infections following return from travel in the cohort of travelers receiving a malaria chemoprophylaxis prescription. However, it is important to note that this lack of association may be a result of low statistical power and not a true absence of association. Antimicrobial stewardship remains as important as ever, and the trade-offs between antibiotic prescription harms and benefits should continue to be evaluated on an individual basis with clear guidance provided to the traveler. While no clear relationship between pre-travel stand-by self-treatment antibiotics and AMR UTIs or SSTIs, or GI infections following return from travel was found in this study, taking antibiotics is not without other risks and side effects and should continue to be prescribed judiciously.
To link together a modifiable practice of prescribing stand-by self-treatment antibiotics for travelers and post-travel outcomes of AMR urinary tract infections (UTI), skin and soft tissue infections (SSTI), and gastrointestinal (GI) infections to expand upon the knowledge surrounding travel medicine, to further support responsible antibiotic prescribing practices and antimicrobial stewardship, and to guide treatment decisions for tourists and service members returning from international travel. Methods
Pre-travel stand-by self-treatment prescriptions did not result in an increased risk of ESBL UTIs, MRSA SSTIs, or diarrheal pathogens. In the UTI cohort there were 2,906 instances of travel, 8.3% were prescribed pre-travel antibiotics, 8.3% had an ESBL UTI, females had 8 times the risk of an ESBL UTI compared to males. In the SSTI cohort there were 1,445 individuals, 2.1% were prescribed pre-travel antibiotics, 13.4% had a MRSA SSTI, and those with MRSA had higher levels of vancomycin resistance than those with methicillin sensitive S. aureus. Among our cohort for diarrheal pathogens, there were 372,526 instances of travel, 5.6% received a pre-travel antibiotic, and 0.05% had a diarrheal pathogen of interest. Active-duty travelers had an increased risk of diarrheal pathogens compared to non-active-duty travelers. Those receiving doxycycline as their malaria prophylaxis medication had half the risk of diarrheal pathogens compared to those receiving other forms of malaria prophylaxis. Conclusion
Three retrospective cohorts of travelers from 2012 to 2019, aged 0-64 years, using the Military Health System (MHS) Data Repository were analyzed. Travelers were defined as individuals receiving a malaria prophylaxis medication. The first cohort was limited to travelers with a UTI, the second those with a Staphylococcus aureus SSTI, and the third all individuals receiving care in the MHS, and in the 12 months following travel. Pre-travel stand-by self-treatment antibiotic receipt was the exposure of interest for all three analyses. The outcomes were extended-spectrum beta-lactamase (ESBL) positive UTIs, methicillin resistant S. aureus (MRSA) SSTIs, and diarrheal pathogens (Shigella species, Campylobacter species, and Non-Typhoidal Salmonella, toxigenic Clostridioides difficile) respectively. Cox proportional hazards regression and binomial regression modeled risk of AMR outcomes. Results
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