International travel is a risk factor for incident colonization with extended spectrum beta-lactamase (ESBL)-producing organisms. These and other multidrug-resistant (MDR) bacteria are major pathogens in combat casualties. We evaluated risk factors for colonization with MDR bacteria in US military personnel traveling internationally for official duty.
TravMil is a prospective observational study enrolling subjects presenting to military travel clinics. We analyzed surveys, antimicrobial use data, and pre- and post-travel perirectal swabs in military travelers to regions outside the continental United States, Canada, Western or Northern Europe, or New Zealand, presenting to one clinic from 12/2015-12/2017. Recovered Gram-negative isolates underwent identification and susceptibility testing (BD Phoenix). Characteristics of trip and traveler were analyzed to determine risk factors for MDR organism colonization.
110 trips were planned by 99 travelers (74% male, median age 38 years [IQR 31, 47.25]); 72 trips with returned pre- and post-travel swabs were completed by 64 travelers. Median duration was 21 days (IQR 12.75, 79.5). 17% traveled to Mexico/Caribbean/Central America, 15% to Asia, 57% to Africa, and 10% to South America; 56% stayed in hotels and 50% in dormitories/barracks. Travelers used doxycycline (15%) for malaria prophylaxis, 11% took an antibiotic for travelers’ diarrhea (TD) treatment (fluoroquinolone 7%, azithromycin 4%). Incident MDR organism colonization occurred in 8 travelers (incidence density 3.5/1000 travel days; cumulative incidence 11% of trips [95% CI: 4%-19%]), all ESBL-producing E. coli. A higher incidence of ESBL-producing E. coli acquisition was associated with travel to Asia (36% vs 7%, P = 0.02) but not with travel to other regions, TD, or use of antimicrobials. No relationship was seen between fluoroquinolone or doxycycline exposure and resistance to those antimicrobials.
Incident colonization with MDR organisms occurs at a lower rate in this military population compared to civilian travelers, with no identified modifiable risk factors, with highest incidence of ESBL acquisition observed after South Asia travel.
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