Global travel and Gram-negative bacterial resistance; implications on clinical management

ABSTRACT

Introduction

Antimicrobial resistance (AR) is escalating worldwide with the potential for dire consequences, global travel contributes to the dissemination of resistant pathogens from one region to another. The World Health Organization identified the rapid emergence and prevalence of carbapenem-resistant Gram-negative species, including Enterobacterales, Acinetobacter baumannii, and Pseudomonas aeruginosa, as an international crisis due to treatment challenges, poor health outcomes, increased mortality, and high economic costs caused by these pathogens.

Areas covered

This review describes key carbapenem-resistant (CR) Gram-negative species, changes in current global and regional trends, AR surveillance and reporting, and identifies drivers of change, specifically travel. Finally, we review clinical implications and challenges of treating CR infections which exist due to widespread dissemination of CR bacteria. A literature search was conducted using PubMed, Google Scholar, Ebsco, and ProQuest (from 2000 to December 2019).

Expert opinion

The level of global travel is increasing, and antimicrobial resistance continues to disseminate worldwide. Healthcare providers risk assessment for AR needs to consider a patient’s recent travel history, including pre-travel and intra-travel antimicrobial prescription, and potential exposure based on geography. Patient education, healthcare provider awareness, and access to data and surveillance resources are critical to inform antimicrobial selection and improve health outcomes.

KEYWORDS:

• Gram-negative
• antibiotic resistance
• travel-related
• surveillance
• carbapenem-resistant

Article highlights

• Antimicrobial-resistant (AMR) Gram-negative bacteria (GNB), specifically Klebsiella pneumoniae and other ESBL producing and carbapenem-resistant (CR) Enterobacterales, can rapidly develop resistance to various classes of antimicrobials, leaving limited effective treatment options for infections such as pneumonia, sepsis, and urinary tract infections, which has led to increased morbidity and mortality due to GNB infections.

• These GNB and have disseminated globally, with bacteria type and prevalence varying greatly between countries and global regions, and as international travel among people has increased, so too has their exposure to these pathogens and their risk of AMR infections.

• Travel is an often-overlooked risk factor for acquisition of resistant or multidrug-resistant bacteria, and the clinical challenge occurs when healthcare provider selects antibiotics without knowing or considering a patient’s travel-related risks, which can result in treatment failure and poor health outcomes.

• Healthcare providers need increased education and awareness of travel-related risk factors, such as use of prophylactic antibiotics for traveler’s diarrhea, prolonged hospitalization (>20 days) while traveling, prior antimicrobial administration (particularly carbapenems), frequent healthcare contact, and travel to certain geographic regions (e.g. China and Southeast Asia, Brazil).

• Additionally, improved global AMR surveillance programs (with standardized data collection, analysis, and data repository) integrated with digital platforms are needed to provide healthcare providers with resources so they can access resistance data in real-time to guide antibiotic choice and improve patient outcomes.

Authorship contributions

All authors had a role in study design, conceiving, and writing the manuscript. According to the guidelines of the International Committee of Medical Journal Editors (ICMJE, www.icmje.org), all authors met the criteria for authorship and no deserving authors have been omitted.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.