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Multidrug-resistant bacteria in unaccompanied refugee minors arriving in Frankfurt am Main, Germany, October to November 2015 U Heudorf 1 , B Krackhardt 1 , M Karathana 1 , N Kleinkauf 1 , C Zinn 2
1. Public Health Department, Frankfurt, Germany 2. Center for Hygiene and Infection Prevention, Ingelheim, Germany
Correspondence: Ursel Heudorf ([email protected])
Citation style for this article:
Heudorf U, Krackhardt B, Karathana M, Kleinkauf N, Zinn C. Multidrug-resistant bacteria in unaccompanied refugee minors arriving in Frankfurt am Main, Germany, October to November 2015. Euro Surveill. 2016;21(2):pii=30109. DOI: http://dx.doi.org/10.2807/1560-7917.ES.2016.21.2.30109 Article submitted on 17 December 2015 / accepted on 14 January 2016 / published on 14 January 2016 Many refugees arriving in Germany originate or have surrogate substance) were part of 3MDR GNB, while travelled through countries with high prevalence bacteria characterised as 4MDR GNB had additional of multidrug-resistant Gram-negative organisms. resistance against carbapenems, with imipenem and/ Therefore, all unaccompanied refugee minors (<18 or meropenem as surrogate substance [1]. MDR GNB years-old) arriving in Frankfurt am Main between 12 detection was performed by plating stools on ESBL October and 6 November 2015, were screened for mul- and Klebsiel a pneumoniae carbapenemase (KPC) tidrug-resistant Enterobacteriaceae in stool samples. chromagar selective media (Mast, Reinfeld, Germany). Enterobacteriaceae with extended spectrum beta-lac- For identification and susceptibility testing of resist- tamases (ESBL) were detected in 42 of 119 (35%) indi- ant colonies, matrix-assisted laser desorption ioni- viduals, including nine with additional resistance to zation (MALDI), Biotyper mass spectrometry (Bruker fluoroquinolones (8% of total screened), thus exceed- Daltonics, Bremen, Germany) and VITEK 2 (BioMerieux, ing the prevalences in the German population by far. Nürtingen, Germany) with Clinical and Laboratory Standards Institute (CLSI) interpretative standards We report multidrug-resistant Enterobacteriaceae in were used [2,3]. ESBL phenotypes were confirmed stool samples of unaccompanied refugee minors (<18 using double disk synergy testing [4]. Decreased car- years-old) arriving in Frankfurt am Main, Germany, bapenem susceptibility in Enterobacteriaceae was con- between 12 October and 6 November 2015. Of 119 firmed using Etest and carbapenemase detection was individuals screened in this study, extended spectrum performed using a modified Hodge test [2].
beta-lactamase (ESBL)-producing Enterobacteriaceae were found in 42 (35%), including nine with additional resistance to fluoroquinolones (8% of total screened), Of a total of 119 individuals screened, ESBL-producing i.e. 3-multidrug-resistant Gram-negative bacteria (MDR Enterobacteriaceae were detected in 42 (35%), includ- ing nine 3MDR GNB (8% of total screened). No 4MDR GNB was observed. Six (5%) of the 119 refugees reported having a prior antimicrobial therapy, and two All unaccompanied refugee minors arriving without their (2%) reported a hospital admission during the preced- parents and families in Frankfurt am Main, Germany, ing six months. Among the 42 with ESBL-producing from 12 October to 6 November 2015 were screened for bacteria, two had received prior antimicrobial treat- multidrug-resistant Enterobacteriaceae in stool sam- ment in the past six months and one had been hospi- ples with informed consent of their legal caregivers. talised, whereas one of nine refugees colonised with The enterobacteria were classified as 3MDR GNB or 3MDR GNB reported an antimicrobial treatment, with 4MDR GNB according to the phenotypic definition of the no hospital stay in this group.
German commission on hospital hygiene and infection prevention (Kommission für Krankenhaushygiene und In total, 37 Escherichia coli (thereof 9 3MDR GNB) and Infektionsprävention), i.e. Enterobacteriaceae resist- five K. pneumoniae (non-3MDR GNB) were detected. ant against three of four antibiotic groups (penicillins Whereas ESBL-producing bacteria were detected in per- with piperacillin as surrogate substance, cephalospor- sons from nearly all of the countries of origin (except ins with cefotaxime and/or ceftazidime as surrogate Iraq, Iran, Libya, Senegal), 3MDR GNB were found only substance, and fluoroquinolones with ciprofloxacin as www.eurosurveil ance.org Table
Detection of extended spectrum beta-lactamase-producing Enterobacteriaceae and thereof multidrug-resistant Gram-
negatives in unaccompanied refugee minors arriving in Frankfurt am Main, Germany, 12 October–6 November 2015 Country of origin Number of persons tested Number of individuals with ESBL- Number of individuals with Number of individuals Total n (%)
ESBL: extended spectrum beta-lactamase; GNB: Gram-negative bacteria; MDR: multidrug-resistant. a 29 Escherichia coli, 5 Klebsiella pneumoniae.
b 7 E. coli. c Iran, Libya, Senegal. in persons coming from Afghanistan, Pakistan, and population, between 2009 and 2012, Valenza et al. had Somalia (Table).
tested 3,344 persons residing in the southern part of Germany, with 6.3% exhibiting ESBL, including 3MDR Discussion and conclusion
GNB, which occurred in 1.8% of those tested [12]. The There is a dramatic influx of refugees to the European MDR GNB prevalence in the young refugees exceeded Union under way, with more than 600,000 applica- these values by four- to fivefold. tions for asylum during the first nine months of 2015 in Germany [5]. Many refugees are coming from countries In the Rhine-Main region, Germany, in the 2012 to with high prevalence of multidrug-resistant organisms 2015 period, prevalences for ESBL-producing bacteria (MDRO) in hospital and community settings, such as and for 3MDR GNB were respectively 7.5% and 3.8% in Afghanistan, the Near and Middle East and the North dialysis outpatients, and 7.7% and 3.8% in patients of African countries [6]. Additionally, many of the refu- rehabilitation clinics, i.e. only slightly exceeding the gees coming from the Near and Middle East have been MDR GNB prevalences in the general population [13,14]. travelling through countries with high prevalences of Patients depending on ambulatory care or residing MDROs, such as Turkey or Greece [7-9], whereas those in elderly care homes however, were more frequently coming from Africa are travelling via the ‘West-Route', colonised with bacteria having an ESBL phenotype or i.e. via Libya and Italy. A current European Centre for 3MDR GNB, with, in outpatients, 14.4% ESBL-producing Disease Prevention and Control (ECDC) report showed bacteria and 7.6% 3MDR GNB, and in nursing home high prevalence of carbapenem resistance and other residents, 17.8 to 26.7% ESBL-producing bacteria and antimicrobial resistances in Turkey and Greece in the 12.3 to 21.3% 3MDR GNB [15-17]. Hence, colonisation period from 2013 to 2014 [7-9]. On that account, the with ESBL-producing Enterobacteriaceae in the unac- Robert Koch Institute, Germany, has recommended in companied refugee minors was also exceeding rates October 2015, screening refugees for MDRO on hospital of bacteria with ESBL in all other patient groups tested admission in Germany [10]. Preliminary work on screen- in the Rhine-Main region recently, and 3MDR GNB colo- ing of 143 refugees admitted to the University Clinic of nisation rates were exceeding those in haemodialysis Frankfurt, Germany has been undertaken [11], however and rehabilitation patients with regular contact to the no data have so far been available on MDR GNB preva- German medical system as well. lences in young healthy refugees. Prevalence of ESBL-producing Enterobacteriaceae in Here we report the first data on prevalence of 3MDR unaccompanied minors was higher than prevalence GNB and ESBL-producing bacteria in unaccompa- rates of patients transferred from hospitals abroad nied refugee minors arriving in the country. ESBL- to the University Hospital Zurich, Switzerland, from 1 producing Enterobacteriaceae were found in 35% of January 2009 to 30 September 2011: of them, 13.9% the individuals included in our study and among these, were found with ESBL-producing bacteria, while 3MDR 3MDR GNB were found in 8% of the total individuals GNB prevalence was comparable (7.6% refugees com- screened. To compare with estimates for the German pared with 8.1% patients transferred to the university www.eurosurveil ance.org clinic) [18]. However, prevalence of 3MDR GNB in the 8. European Survey of Carbapenemase-Producing Enterobacteriaceae (EuSCAPE) working group,Albiger unaccompanied minors was still low compared with B, Glasner C, Struelens MJ, Grundmann H, Monnet DL. the data obtained by Reinheimer et al., who tested Carbapenemase-producing Enterobacteriaceae in Europe: assessment by national experts from 38 countries, May 2015.
143 refugee patients on admission to the University Euro Surveill. 2015;20(45):30062.PMID: 26675038 Hospital Frankfurt, Frankfurt/Main, Germany from June 9. European Centre for Disease Prevention and Control (ECDC). Communicable disease risks associated with the movement of to December 2015 and compared the results to data on refugees in Europe during the winter season – 10 November 1,489 non-refugee patients screened on admission as 2015. Stockholm: ECDC; 2015. Available from: http://ecdc.
well. Prevalence of MDR GNB (ESBL-producing bacteria, 3MDR GNB, and 4MDR GNB) in refugee patients was 10. Robert Koch-institute (RKI). Screening von Asylsuchenden auf 60.8%, and thus exceeding the prevalence of MDR GNB Multiresistente Erreger (MRE). [Screening of refugees for multi- drug resistant bacteria]. Berlin: RKI; Oct 2015. [Accessed 5 Dec in non-refugees (16.7%) fourfold [11]. Our sample, how- 2015]. German. Available from: http://www.rki.de/DE/Content/ ever, encompassed only young people, most of them healthy, having fled on their own without their parents or families. This might explain the lower prevalence of 11. Reinheimer C, Kempf V, Göttig S, Hogardt M, Wichelhaus T, MDR GNB in this group compared with that of the refu- O´Rourke F, et al. Multidrug-resistant organisms detected in refugee patients admitted to a University Hospital, Germany gees on hospital admission. Nevertheless, both data June–December 2015.Euro Surveill. 2016;21(2):30110. DOI: support the demand for surveillance in refugees, not 12. Valenza G, Nickel S, Pfeifer Y, Eller C, Krupa E, Lehner-Reindl V, only for communicable disease [19] but also for MDRO et al. Extended-spectrum-β-lactamase-producing Escherichia coli as intestinal colonizers in the German community. Antimicrob Agents Chemother. 2014;58(2):1228-30. DOI: 10.1128/AAC.01993-13 PMID: 24295972 13. Dawson A, Mischler D, Petit C, Klein R, Heudorf U, Herrmann Conflict of interest
M. Prevalence of Methicillin-resistent Staphylococcus aureus in end stage renal failure patients in Saarland and Hessen.Int J None declared.
Med Microbiol. 2012;302:87.
14. Heudorf U, Färber D, Mischler D, Schade M, Zinn C, Cuny C, et al. [Multidrug-Resistant Organisms (MDRO) in Rehabilitation Clinics in the Rhine-Main-District, Germany, 2014: Prevalence and Risk Factors]. Rehabilitation (Stuttg). 2015;54(5):339-45.
DOI: 10.1007/s00103-013-1927-7 PMID: 24658671 Prof. Heudorf and Dr. Niels Kleinkauf wrote and finalised 15. Hogardt M, Proba P, Mischler D, Cuny C, Kempf VA, Heudorf the paper, Dr. Krackhardt and Mrs. Karathana organised the U. Current prevalence of multidrug-resistant organisms in study. Dr. Zinn was responsible for the analytical results.
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