Management of infections in critically ill returning travellers in the intensive care unit—I: considerations on infection control and transmission of resistance☆
Identifieur interne : 001804 ( Pmc/Corpus ); précédent : 001803; suivant : 001805Management of infections in critically ill returning travellers in the intensive care unit—I: considerations on infection control and transmission of resistance☆
Auteurs : Hakan Leblebicioglu ; Alfonso J. Rodriguez-Morales ; Gian Maria Rossolini ; Rogelio L Pez-Vélez ; Jean-Ralph Zahar ; Jordi RelloSource :
- International Journal of Infectious Diseases [ 1201-9712 ] ; 2016.
Abstract
Person-to-person transmission is the most important means of transmission. Malaria remains by far the most important cause of death. Surveillance strategies based on epidemiological data (country visited, duration of travel, and time elapsed since return) and clinical syndromes associated with a systematic search policy are usually mandatory to limit the risk of an outbreak. Hospitalization in a single-bed room and isolation according to symptoms should be the rule while awaiting laboratory test results.
Url:
DOI: 10.1016/j.ijid.2016.04.019
PubMed: 27134158
PubMed Central: 7110831
Links to Exploration step
PMC:7110831Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Management of infections in critically ill returning travellers in the intensive care unit—I: considerations on infection control and transmission of resistance<sup><xref ref-type="fn" rid="d32e930">☆</xref></sup></title><author><name sortKey="Leblebicioglu, Hakan" sort="Leblebicioglu, Hakan" uniqKey="Leblebicioglu H" first="Hakan" last="Leblebicioglu">Hakan Leblebicioglu</name><affiliation><nlm:aff id="aff0035">Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University Medical School, Samsun, Turkey</nlm:aff></affiliation></author><author><name sortKey="Rodriguez Morales, Alfonso J" sort="Rodriguez Morales, Alfonso J" uniqKey="Rodriguez Morales A" first="Alfonso J." last="Rodriguez-Morales">Alfonso J. Rodriguez-Morales</name><affiliation><nlm:aff id="aff0010">Public Health and Infection Research Group, Faculty of Health Sciences, Universidad Tecnológica de Pereira, Pereira, Risaralda, Colombia</nlm:aff></affiliation></author><author><name sortKey="Rossolini, Gian Maria" sort="Rossolini, Gian Maria" uniqKey="Rossolini G" first="Gian Maria" last="Rossolini">Gian Maria Rossolini</name><affiliation><nlm:aff id="aff0015">Department of Medical Biotechnologies, University of Siena, Siena, Italy</nlm:aff></affiliation><affiliation><nlm:aff id="aff0020">Department of Experimental and Clinical Medicine, University of Florence, and Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy</nlm:aff></affiliation></author><author><name sortKey="L Pez Velez, Rogelio" sort="L Pez Velez, Rogelio" uniqKey="L Pez Velez R" first="Rogelio" last="L Pez-Vélez">Rogelio L Pez-Vélez</name><affiliation><nlm:aff id="aff0025">National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, Madrid, Spain</nlm:aff></affiliation></author><author><name sortKey="Zahar, Jean Ralph" sort="Zahar, Jean Ralph" uniqKey="Zahar J" first="Jean-Ralph" last="Zahar">Jean-Ralph Zahar</name><affiliation><nlm:aff id="aff0030">Infection Control Unit, Université d’Angers, Centre Hospitalier Universitaire d’Angers, Angers, France</nlm:aff></affiliation></author><author><name sortKey="Rello, Jordi" sort="Rello, Jordi" uniqKey="Rello J" first="Jordi" last="Rello">Jordi Rello</name><affiliation><nlm:aff id="aff0005">CIBERES, Vall Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27134158</idno><idno type="pmc">7110831</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7110831</idno><idno type="RBID">PMC:7110831</idno><idno type="doi">10.1016/j.ijid.2016.04.019</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">001804</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001804</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Management of infections in critically ill returning travellers in the intensive care unit—I: considerations on infection control and transmission of resistance<sup><xref ref-type="fn" rid="d32e930">☆</xref></sup></title><author><name sortKey="Leblebicioglu, Hakan" sort="Leblebicioglu, Hakan" uniqKey="Leblebicioglu H" first="Hakan" last="Leblebicioglu">Hakan Leblebicioglu</name><affiliation><nlm:aff id="aff0035">Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University Medical School, Samsun, Turkey</nlm:aff></affiliation></author><author><name sortKey="Rodriguez Morales, Alfonso J" sort="Rodriguez Morales, Alfonso J" uniqKey="Rodriguez Morales A" first="Alfonso J." last="Rodriguez-Morales">Alfonso J. Rodriguez-Morales</name><affiliation><nlm:aff id="aff0010">Public Health and Infection Research Group, Faculty of Health Sciences, Universidad Tecnológica de Pereira, Pereira, Risaralda, Colombia</nlm:aff></affiliation></author><author><name sortKey="Rossolini, Gian Maria" sort="Rossolini, Gian Maria" uniqKey="Rossolini G" first="Gian Maria" last="Rossolini">Gian Maria Rossolini</name><affiliation><nlm:aff id="aff0015">Department of Medical Biotechnologies, University of Siena, Siena, Italy</nlm:aff></affiliation><affiliation><nlm:aff id="aff0020">Department of Experimental and Clinical Medicine, University of Florence, and Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy</nlm:aff></affiliation></author><author><name sortKey="L Pez Velez, Rogelio" sort="L Pez Velez, Rogelio" uniqKey="L Pez Velez R" first="Rogelio" last="L Pez-Vélez">Rogelio L Pez-Vélez</name><affiliation><nlm:aff id="aff0025">National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, Madrid, Spain</nlm:aff></affiliation></author><author><name sortKey="Zahar, Jean Ralph" sort="Zahar, Jean Ralph" uniqKey="Zahar J" first="Jean-Ralph" last="Zahar">Jean-Ralph Zahar</name><affiliation><nlm:aff id="aff0030">Infection Control Unit, Université d’Angers, Centre Hospitalier Universitaire d’Angers, Angers, France</nlm:aff></affiliation></author><author><name sortKey="Rello, Jordi" sort="Rello, Jordi" uniqKey="Rello J" first="Jordi" last="Rello">Jordi Rello</name><affiliation><nlm:aff id="aff0005">CIBERES, Vall Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain</nlm:aff></affiliation></author></analytic><series><title level="j">International Journal of Infectious Diseases</title><idno type="ISSN">1201-9712</idno><idno type="eISSN">1878-3511</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>Highlights</title><p><list list-type="simple" id="lis0005"><list-item id="lsti0005"><label>•</label><p id="par0005">Person-to-person transmission is the most important means of transmission.</p></list-item><list-item id="lsti0010"><label>•</label><p id="par0010">Malaria remains by far the most important cause of death.</p></list-item><list-item id="lsti0015"><label>•</label><p id="par0015">Surveillance strategies based on epidemiological data (country visited, duration of travel, and time elapsed since return) and clinical syndromes associated with a systematic search policy are usually mandatory to limit the risk of an outbreak.</p></list-item><list-item id="lsti0020"><label>•</label><p id="par0020">Hospitalization in a single-bed room and isolation according to symptoms should be the rule while awaiting laboratory test results.</p></list-item></list></p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Rossolini, G M" uniqKey="Rossolini G">G.M. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Int J Infect Dis</journal-id><journal-id journal-id-type="iso-abbrev">Int. J. Infect. Dis</journal-id><journal-title-group><journal-title>International Journal of Infectious Diseases</journal-title></journal-title-group><issn pub-type="ppub">1201-9712</issn><issn pub-type="epub">1878-3511</issn><publisher><publisher-name>The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27134158</article-id><article-id pub-id-type="pmc">7110831</article-id><article-id pub-id-type="publisher-id">S1201-9712(16)31036-0</article-id><article-id pub-id-type="doi">10.1016/j.ijid.2016.04.019</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Management of infections in critically ill returning travellers in the intensive care unit—I: considerations on infection control and transmission of resistance<sup><xref ref-type="fn" rid="d32e930">☆</xref></sup></article-title></title-group><contrib-group><contrib contrib-type="author" id="aut0030"><name><surname>Leblebicioglu</surname><given-names>Hakan</given-names></name><xref rid="aff0035" ref-type="aff">g</xref></contrib><contrib contrib-type="author" id="aut0010"><name><surname>Rodriguez-Morales</surname><given-names>Alfonso J.</given-names></name><xref rid="aff0010" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="aut0015"><name><surname>Rossolini</surname><given-names>Gian Maria</given-names></name><xref rid="aff0015" ref-type="aff">c</xref><xref rid="aff0020" ref-type="aff">d</xref></contrib><contrib contrib-type="author" id="aut0020"><name><surname>López-Vélez</surname><given-names>Rogelio</given-names></name><xref rid="aff0025" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="aut0025"><name><surname>Zahar</surname><given-names>Jean-Ralph</given-names></name><xref rid="aff0030" ref-type="aff">f</xref></contrib><contrib contrib-type="author" id="aut0005"><name><surname>Rello</surname><given-names>Jordi</given-names></name><email>jrello@crips.es</email><xref rid="aff0005" ref-type="aff">a</xref><xref rid="cor0005" ref-type="corresp">⁎</xref></contrib><contrib contrib-type="author"><collab><on-behalf-of>on behalf of ESGCIP and ESGITM</on-behalf-of></collab></contrib></contrib-group><aff id="aff0005"><label>a</label>CIBERES, Vall Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain</aff><aff id="aff0010"><label>b</label>Public Health and Infection Research Group, Faculty of Health Sciences, Universidad Tecnológica de Pereira, Pereira, Risaralda, Colombia</aff><aff id="aff0015"><label>c</label>Department of Medical Biotechnologies, University of Siena, Siena, Italy</aff><aff id="aff0020"><label>d</label>Department of Experimental and Clinical Medicine, University of Florence, and Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy</aff><aff id="aff0025"><label>e</label>National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, Madrid, Spain</aff><aff id="aff0030"><label>f</label>Infection Control Unit, Université d’Angers, Centre Hospitalier Universitaire d’Angers, Angers, France</aff><aff id="aff0035"><label>g</label>Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University Medical School, Samsun, Turkey</aff><author-notes><corresp id="cor0005"><label>⁎</label>Corresponding author. <email>jrello@crips.es</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>28</day><month>4</month><year>2016</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="ppub"><month>7</month><year>2016</year></pub-date><pub-date pub-type="epub"><day>28</day><month>4</month><year>2016</year></pub-date><volume>48</volume><fpage>113</fpage><lpage>117</lpage><history><date date-type="received"><day>25</day><month>1</month><year>2016</year></date><date date-type="rev-recd"><day>19</day><month>4</month><year>2016</year></date><date date-type="accepted"><day>21</day><month>4</month><year>2016</year></date></history><permissions><copyright-statement>© 2016 The Authors</copyright-statement><copyright-year>2016</copyright-year><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><related-article related-article-type="article-reference" id="d32e398" ext-link-type="doi" xlink:href="10.1016/j.ijid.2016.04.020"></related-article><abstract abstract-type="author-highlights" id="abs0005"><title>Highlights</title><p><list list-type="simple" id="lis0005"><list-item id="lsti0005"><label>•</label><p id="par0005">Person-to-person transmission is the most important means of transmission.</p></list-item><list-item id="lsti0010"><label>•</label><p id="par0010">Malaria remains by far the most important cause of death.</p></list-item><list-item id="lsti0015"><label>•</label><p id="par0015">Surveillance strategies based on epidemiological data (country visited, duration of travel, and time elapsed since return) and clinical syndromes associated with a systematic search policy are usually mandatory to limit the risk of an outbreak.</p></list-item><list-item id="lsti0020"><label>•</label><p id="par0020">Hospitalization in a single-bed room and isolation according to symptoms should be the rule while awaiting laboratory test results.</p></list-item></list></p></abstract><abstract id="abs0010"><title>Summary</title><p>Depending on their destinations and activities, international travellers are at a significant risk of contracting both communicable and non-communicable diseases. On return to their home countries, such travellers may require intensive care. The emergence of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), and more recently Ebola haemorrhagic fever, has highlighted the risks. Other well-known communicable pathogens such as methicillin-resistant <italic>Staphylococcus aureus</italic> and carbapenemase-producing <italic>Enterobacteriaceae</italic> have been described previously. However, malaria remains by far the most important cause of death. The issues related to imported antibiotic resistance and protection from highly contagious diseases are reviewed here. Surveillance strategies based on epidemiological data (country visited, duration of travel, and time elapsed since return) and clinical syndromes, together with systematic search policies, are usually mandatory to limit the risk of an outbreak. Single-bed hospital rooms and isolation according to symptoms should be the rule while awaiting laboratory test results. Because person-to-person contact is the main route of transmission, healthcare workers should implement specific prevention strategies.</p></abstract><kwd-group id="kwd0005"><title>Keywords</title><kwd>Resistance</kwd><kwd>Infection control</kwd><kwd>Traveller</kwd><kwd>ICU</kwd><kwd>Migrant</kwd></kwd-group></article-meta><notes><p id="misc0005"><bold>Corresponding Editor:</bold> Eskild Petersen, Aarhus, Denmark.</p></notes></front><body><sec id="sec0005"><label>1</label><title>Imported antibiotic resistance</title><p id="par0025">Infections caused by multidrug-resistant (MDR) pathogens are typically associated with increases in morbidity, mortality, and healthcare-associated costs, and represent an increasing public health challenge of global dimensions.<xref rid="bib0160" ref-type="bibr"><sup>1</sup></xref> The combination of a progressive loss of antibiotic efficacy due to the emergence and dissemination of resistance and the slow rates of discovery and development of new antibiotics active against MDR pathogens has led to what has been termed the ‘antibiotic resistance crisis’. The situation has been further complicated recently by the emergence and dissemination of strains that remain susceptible to only a few antibiotics (extensively drug-resistant (XDR) strains), which are difficult to treat.<xref rid="bib0165" ref-type="bibr"><sup>2</sup></xref></p><p id="par0030">The most challenging MDR pathogens include (1) methicillin-resistant <italic>Staphylococcus aureus</italic> (MRSA), (2) vancomycin-resistant enterococci (VRE), (3) <italic>Enterobacteriaceae</italic> producing extended-spectrum beta-lactamases (ESBLs) or carbapenemases (CPE), (4) XDR <italic>Pseudomonas aeruginosa</italic> that remain susceptible only to polymyxins, and (5) carbapenem-resistant Acinetobacter (CRA). Among these, CPE and CRA are currently the most problematic due to their XDR phenotypes, their propensity for epidemic diffusion in healthcare settings, and the high mortality rates associated with invasive infections.<xref rid="bib0165" ref-type="bibr"><sup>2</sup></xref></p><p id="par0035">In principle, any of these pathogens can be encountered, either as colonizers or as infecting agents, in travellers returning from areas of endemicity and in patients repatriated from foreign healthcare facilities. Acquisition may be the consequence of exposure to contaminated food or environments, of close contact with colonized individuals, or of admission to hospitals and exposure to medical practices either for unexpected reasons (e.g., trauma, acute diseases) or for medical tourism (e.g., specialized surgery, organ transplantation). As has been clearly documented, the transmission of MRSA has increased with the growth of international travel, resulting in either asymptomatic colonization or clinically significant MRSA infections.<xref rid="bib0170" ref-type="bibr">3</xref>, <xref rid="bib0175" ref-type="bibr">4</xref> Some evidence is also available for the international dissemination of VRE via transfer/repatriation of patients from hospitals located in endemic areas.<xref rid="bib0180" ref-type="bibr"><sup>5</sup></xref> Concerning Gram-negative organisms, the impact of international travel has been firmly established in the dissemination of MDR <italic>Enterobacteriaceae</italic>, including high-risk clones producing ESBLs (especially enzymes of the CTX-M type) and/or carbapenemases of various types (e.g., KPC, OXA-48, NDM, VIM).<xref rid="bib0185" ref-type="bibr">6</xref>, <xref rid="bib0190" ref-type="bibr">7</xref>, <xref rid="bib0195" ref-type="bibr">8</xref> The risk of the spread of MDR strains of <italic>Enterobacteriaceae</italic> in this situation includes not only <italic>Escherichia coli</italic>, <italic>Klebsiella spp</italic>, and <italic>Enterobacter spp</italic>, but also classical enterobacterial pathogens such as <italic>Salmonella enterica</italic> and <italic>Shigella spp</italic>, with evidence of imported cases of typhoid fever and shigellosis caused by MDR strains.<xref rid="bib0195" ref-type="bibr">8</xref>, <xref rid="bib0200" ref-type="bibr">9</xref> The transmission of MDR Acinetobacter has been documented following the international transfer of patients from intensive care units (ICUs) in countries with high-level endemicity,<xref rid="bib0205" ref-type="bibr"><sup>10</sup></xref> and the repatriation of evacuees involved in military operations in endemic areas.<xref rid="bib0210" ref-type="bibr"><sup>11</sup></xref> Less evidence is available for the travel-related dissemination of MDR/XDR <italic>P. aeruginosa</italic> strains, but this is clearly a possibility following the transfer of colonized patients from ICUs where these strains are endemic or are causing outbreaks.<xref rid="bib0215" ref-type="bibr"><sup>12</sup></xref></p><p id="par0040">The admission to the ICU of patients colonized or infected by MDR/XDR pathogens is a matter of concern, since it may be followed by cross-infections and outbreaks in the ICU setting unless suitable infection control practices are enforced immediately. Moreover, infections caused by MDR/XDR pathogens may require different antimicrobial treatments from those routinely used in the ICU, which are based on the local epidemiology; this may result in inappropriate empiric treatment and thus increased morbidity and mortality.</p><p id="par0045">Therefore, the possibility of carriage or infection by an MDR/XDR pathogen should always be considered for critically ill returning travellers admitted to the ICU. A risk assessment should be performed, considering the area of provenance, the history of the patient, and the presence of additional risk factors for carriage or infection by similar resistant pathogens.<xref rid="bib0165" ref-type="bibr">2</xref>, <xref rid="bib0215" ref-type="bibr">12</xref></p><p id="par0050">The epidemiology of MDR/XDR pathogens may vary according to geographical area. The proportion of MRSA among <italic>S. aureus</italic> isolates remains very high in some European countries, the USA, Latin America, and the Far East, but is considerably lower in other European countries such as the Netherlands and the Scandinavian countries.<xref rid="bib0220" ref-type="bibr"><sup>13</sup></xref> ESBL-producing <italic>Enterobacteriaceae</italic> are now disseminated worldwide, with very high rates detected among ICU patients in Latin America, the Asia-Pacific region, and the Middle East.<xref rid="bib0225" ref-type="bibr"><sup>14</sup></xref> For their part, CPE have achieved a notable level of endemicity in some areas of Europe (e.g., Greece and Italy), the Middle East (e.g., Turkey, Israel), South America (e.g., Colombia), and China.<xref rid="bib0230" ref-type="bibr"><sup>15</sup></xref> Travellers/patients from areas of high endemicity for MDR/XDR pathogens have a higher risk of exposure to these pathogens, and the possibility of being infected or colonized by these agents at the time of repatriation should always be considered. When consulting sources of information regarding resistance and endemicity (such as ProMED-mail, <ext-link ext-link-type="uri" xlink:href="http://www.promedmail.org/" id="intr0005">http://www.promedmail.org</ext-link>), clinicians should consider that (1) for several countries (especially low-income settings) epidemiological information is scarce or lacking, and (2) the epidemiology of MDR/XDR pathogens can change rapidly. So this information should be considered partial and should be updated regularly.</p><p id="par0055">Exposure to medical practices in facilities from endemic areas, either unanticipated or scheduled, is an additional risk factor for carriage/infection by MDR/XDR pathogens.<xref rid="bib0235" ref-type="bibr"><sup>16</sup></xref></p><p id="par0060">Recommendations for ICUs, based on the current evidence, include the following:<list list-type="simple" id="lis0010"><list-item id="lsti0025"><label>(1)</label><p id="par0065">Carrying out a risk assessment for carriage/infection by MDR/XDR pathogens for all ICU admissions of patients returning from international travel or transferred from foreign hospitals.</p></list-item><list-item id="lsti0030"><label>(2)</label><p id="par0070">Enforcing infection control precautions upon admission for all patients returning from international travel or transferred from foreign hospitals with known risk factors for carriage/infection by MDR/XDR pathogens. The infection control precautions should cover the various types of MDR/XDR pathogens for which a risk was assessed, and should be kept in place until carriage/infection by MDR/XDR pathogens has been ruled out by the proactive surveillance and clinical microbiology diagnostic workup.</p></list-item><list-item id="lsti0035"><label>(3)</label><p id="par0075">Carrying out proactive surveillance for MDR/XDR pathogens for which a risk was assessed by culture and/or molecular methods.</p></list-item></list></p></sec><sec id="sec0010"><label>2</label><title>Protection from highly contagious disease in critically ill returning travellers in the ICU</title><sec id="sec0015"><label>2.1</label><title>Introduction to potentially life-threatening travel-associated infectious diseases</title><p id="par0080">Depending on their destinations and activities, international travellers are at a significant risk of contracting both communicable and non-communicable diseases.<xref rid="bib0240" ref-type="bibr"><sup>17</sup></xref> The emergence of severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), and more recently Ebola haemorrhagic fever, has highlighted the risks. However, other well-known communicable pathogens such as MRSA<xref rid="bib0245" ref-type="bibr"><sup>18</sup></xref> and CPE<xref rid="bib0250" ref-type="bibr">19</xref>, <xref rid="bib0255" ref-type="bibr">20</xref> have been described previously. ICU patients, because of the severity of illness, the workload, and the antibiotic selection pressure, are important potential reservoirs of dangerous microorganisms. The most important challenges for ICU practitioners are first to identify admissions with the highest risk of communicable disease, and second to rapidly implement preventive measures in order to avoid nosocomial transmission.</p><p id="par0085">Surveillance strategies for the early detection of unusual infectious disease events should be the rule. Syndromic surveillance can help to reduce the identification time. All patients transferred from hospitals in high-risk countries (<xref rid="tbl0005" ref-type="table">Table 1</xref>) should be considered as potential carriers of MDR or highly drug-resistant microorganisms. All of these patients should be screened for rectal carriage at admission and a few days after any antibiotic therapy.<xref rid="bib0260" ref-type="bibr"><sup>21</sup></xref> While awaiting screening results, the patient should be hospitalized in a single-bed room. Contact and body fluid precautions should be added. All patients with fever and clinical or radiographic evidence of pneumonia or acute respiratory distress syndrome, and with a history of travel from countries in or near the Arabian Peninsula (Bahrain, Iraq, Iran, Israel, the West Bank and Gaza, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, the United Arab Emirates, and Yemen) within 14 days before symptom onset, or close contact with a symptomatic traveller who developed fever and acute respiratory illness within 14 days after travelling from countries in the region, should be considered as potentially infected by MERS-CoV.<xref rid="bib0265" ref-type="bibr"><sup>22</sup></xref> Viral haemorrhagic fever should be suspected in selected patients coming from Sub-Saharan Africa with fever and bleeding disorders, depending on the geographical origin and local epidemiological situation. A general syndromic approach to tropical infections in the ICU is described in <xref rid="tbl0010" ref-type="table">Table 2</xref>.<xref rid="bib0270" ref-type="bibr"><sup>23</sup></xref><table-wrap position="float" id="tbl0005"><label>Table 1</label><caption><p>Distribution of the most common organisms by region and reservoir</p></caption><alt-text id="at1">Table 1</alt-text><table frame="hsides" rules="groups"><thead><tr><th align="left">Infectious agents</th><th align="left">Geographical origin</th><th align="left">Reservoir</th><th align="left">Main type of transmission</th><th align="left">Main type of protection</th></tr></thead><tbody><tr><td align="left">Viruses</td><td></td><td></td><td></td><td></td></tr><tr><td align="left"> MERS-CoV</td><td align="left">Middle East</td><td align="left">Dromedary camels</td><td align="left">Droplet contact</td><td align="left">Droplet precautions</td></tr><tr><td align="left"> SARS-CoV</td><td align="left">South China</td><td align="left">Chinese horseshoe bats</td><td align="left">Droplet contact, airborne</td><td align="left">Droplet precautions</td></tr><tr><td align="left"> H7N9</td><td align="left" rowspan="2" valign="middle">Eastern China, Hong Kong, Taiwan, Malaysia</td><td align="left">Poultry, wild birds</td><td align="left">Droplet?</td><td align="left">Droplet precautions</td></tr><tr><td align="left"> Influenza virus</td><td></td><td align="left">Droplet</td><td align="left">Droplet precautions</td></tr><tr><td align="left"> Haemorrhagic fever</td><td></td><td></td><td align="left">Droplet, contact</td><td align="left">Droplet precautions</td></tr><tr><td align="left">Ebola</td><td align="left">Africa, Guinea, Sierra Leone</td><td align="left">Bats</td><td align="left">Droplet, contact</td><td></td></tr><tr><td align="left">Bacteria</td><td></td><td></td><td></td><td></td></tr><tr><td align="left"> Carbapenemase-producing <italic>Enterobacteriaceae</italic></td><td align="left">Southern Asia, India, Middle Eastern Countries; Maghreb countries, Israel, Romania, Italy, Turkey, Greece</td><td align="left">Human</td><td align="left">Contact</td><td align="left">Contact precautions</td></tr><tr><td align="left"> XDR-TB and MDR-TB</td><td align="left">Russia, eastern Europe, southern Africa</td><td align="left">Human</td><td align="left">Airborne</td><td align="left">Airborne precautions</td></tr><tr><td align="left"> Meningococci</td><td></td><td align="left">Human</td><td align="left">Droplet</td><td align="left">Droplet precautions</td></tr></tbody></table><table-wrap-foot><fn><p>MERS-CoV, Middle East respiratory syndrome coronavirus; SARS-CoV, severe acute respiratory syndrome coronavirus; XDR-TB, extensively drug-resistant tuberculosis; MDR-TB, multidrug-resistant tuberculosis.</p></fn></table-wrap-foot></table-wrap><table-wrap position="float" id="tbl0010"><label>Table 2</label><caption><p>Syndromic approach to tropical infections in the ICU</p></caption><alt-text id="at2">Table 2</alt-text><table frame="hsides" rules="groups"><thead><tr><th align="left">Syndrome</th><th align="left">Diseases</th></tr></thead><tbody><tr><td align="left">Fever and toxic appearance<break></break>Fever and rash</td><td align="left">Dengue fever, malaria, typhoid fever, early shigellosis, leptospirosis, and anicteric hepatitis. The presence of a haemorrhagic rash may indicate arboviral, rickettsial, and meningococcal aetiologies. Aetiologies of VHF that have been known to cause person-to-person transmission are Lassa virus, Ebola virus, Marburg virus, and Crimean-Congo haemorrhagic fever virus</td></tr><tr><td align="left">Fever and thrombocytopenia</td><td align="left">Malaria, dengue, leptospirosis, rickettsiosis</td></tr><tr><td align="left">Fever with eosinophilia</td><td align="left">Schistosomiasis (Katayama fever or acute neurological sequelae of myelitis or encephalitis), visceral larva migrans, tropical pulmonary eosinophilia, acute fascioliasis, acute trichinosis</td></tr><tr><td align="left">Severe pneumonia or ARDS</td><td align="left"><italic>Streptococcus pneumoniae</italic>, <italic>Legionella pneumophila</italic>, bacterial sepsis with other pathogens, tuberculosis, <italic>Burkholderia pseudomallei</italic> (melioidosis), plague, histoplasmosis, malaria, typhoid fever, leptospirosis, scrub typhus, hantaviruses, coronaviruses, highly pathogenic avian influenza A (H5N1)</td></tr><tr><td align="left">Pulmonary renal syndrome</td><td align="left">Falciparum malaria, leptospirosis, hantavirus infection, scrub typhus, severe pneumonia</td></tr><tr><td align="left">Hepatorenal dysfunction</td><td align="left">Falciparum malaria, leptospirosis, scrub typhus, hepatitis E or A with fulminant hepatic failure and the hepatorenal syndrome, yellow fever virus</td></tr><tr><td align="left">Acute abdomen</td><td align="left">Appendicitis, cholecystitis, diverticulitis, perforated peptic ulcer, enteric fever, amoebic liver abscess</td></tr><tr><td align="left">Dysentery and severe gastrointestinal fluid losses</td><td align="left">Amoebic (<italic>Entamoeba histolytica</italic>) and bacillary (<italic>Shigella spp</italic>, especially <italic>S. dysenteriae</italic> and <italic>S. flexneri</italic>, <italic>Campylobacter jejuni</italic>, non-typhoidal <italic>Salmonella spp</italic>, <italic>Yersinia enterocolitica</italic>, enteroinvasive <italic>Escherichia coli</italic>, and enterohaemorrhagic <italic>E. coli</italic> (EHEC))</td></tr><tr><td align="left">Altered sensorium</td><td align="left">Cerebral malaria, meningitis, typhoid fever, viral encephalitis (Japanese encephalitis virus, Rift Valley fever virus, Murray Valley encephalitis virus, West Nile virus, St. Louis encephalitis virus, rabies virus, Nipah virus). Eosinophilic meningoencephalitis (<italic>Angiostrongylus cantonensis</italic>, <italic>Gnathostoma spinigerum</italic>, migrating ascarids, and schistosomiasis)</td></tr></tbody></table><table-wrap-foot><fn><p>ICU, intensive care unit; VHF, viral haemorrhagic fever; ARDS, acute respiratory distress syndrome.</p></fn></table-wrap-foot></table-wrap></p><p id="par0090">Although many imported infectious diseases may require ICU admission, the most frequent ones are relatively few in number. In a descriptive analysis of acute and potentially life-threatening tropical diseases among 82 825 ill Western travellers reported to GeoSentinel from 1996 to 2011, 3655 patients (4.4%) with 13 diseases were identified; falciparum malaria (76.9%), enteric fever (18.1%), and leptospirosis (2.4%) were the most frequent. Ninety-one percent of patients had fever. The median time from travel to presentation was 16 days. Thirteen (0.4%) patients died: 10 with falciparum malaria, two with melioidosis, and one with severe dengue. Falciparum malaria was mainly acquired in West Africa, enteric fever on the Indian subcontinent, and leptospirosis, scrub typhus, and murine typhus in Southeast Asia.<xref rid="bib0275" ref-type="bibr"><sup>24</sup></xref></p></sec><sec id="sec0020"><label>2.2</label><title>Transmission risks of highly contagious tropical infectious diseases associated with healthcare settings</title><p id="par0095">Emergency departments at general hospitals are the first units to deal with an unknown highly contagious tropical infectious disease and they should be prepared for this eventuality (a heavy price was paid during the SARS outbreak). In an endemic area, MERS-CoV infection is more likely to be acquired in healthcare facilities than in the community: in the 2014 outbreak in Jeddah, Saudi Arabia, more than four out of five exposures were at healthcare facilities, mainly due to poor and insufficient isolation measures at admission.<xref rid="bib0280" ref-type="bibr"><sup>25</sup></xref></p><p id="par0100">Patients with suspected highly contagious tropical infectious diseases should be placed directly in an emergency department isolation room (if available) and should be examined and assessed as soon as possible. Standard precautions and cough and respiratory etiquette should be applied systematically. During admission, these patients should avoid any contact with other patients, and unprotected healthcare workers should avoid contact with them. If possible, point-of-care bedside laboratory tests should be used for sampling, or all analyses should be done in a biosafety level 3/4 laboratory. Samples should be inactivated (with formalin) before testing in a routine laboratory. Transfer to the ICU or to a high-level isolation unit must be carried out in a secure manner.</p><p id="par0105">Many organisms are present in the ICU, but only a few are involved in person-to-person transmission. An overview of the precautions recommended for selected tropical infections and conditions is shown in <xref rid="tbl0015" ref-type="table">Table 3</xref>.<table-wrap position="float" id="tbl0015"><label>Table 3</label><caption><p>Precautions recommended for selected tropical infections and conditions</p></caption><alt-text id="at3">Table 3</alt-text><table frame="hsides" rules="groups"><thead><tr><th align="left">Infection/condition</th><th align="left">Precautions<xref rid="tblfn0005" ref-type="table-fn">a</xref></th><th align="left">Comments</th></tr></thead><tbody><tr><td align="left">Amoebiasis</td><td align="left">Standard</td><td align="left">Person-to-person transmission is rare (care when handling diapered infants and mentally challenged persons)</td></tr><tr><td align="left">Chagas disease (<italic>Trypansoma cruzi</italic>)</td><td align="left">Standard</td><td align="left">Not transmitted from person to person (only vertical transmission and organ/blood donation)</td></tr><tr><td align="left">Coronavirus: SARS-CoV, MERS-CoV</td><td align="left">Airborne<break></break>High-level isolation unit</td><td align="left">Aerosol-generating procedures and ‘super-shedders’ present highest risk for transmission</td></tr><tr><td align="left">Dengue virus<break></break>Chikungunya virus</td><td align="left">Standard</td><td align="left">Not transmitted from person to person<break></break>Install screens in windows and doors in endemic areas; use DEET-containing mosquito repellents and clothing to cover extremities</td></tr><tr><td align="left">Echinococcosis (hydatidosis)</td><td align="left">Standard</td><td align="left">Not transmitted from person to person</td></tr><tr><td align="left">Encephalitis, arthropod-borne viral<break></break> Japanese encephalitis<break></break> Central European tick-borne<break></break> Venezuelan equine<break></break> Murray Valley encephalitis<break></break> St. Louis encephalitis<break></break> West Nile virus<break></break> Nipah virus<break></break> Hendra virus</td><td align="left">Standard</td><td align="left">Not transmitted from person to person, except rarely by transfusion and for West Nile virus by organ transplant, breast milk, or transplacentally<break></break>Install screens in windows and doors in endemic areas; use DEET-containing mosquito repellents and clothing to cover extremities<break></break>Airborne precautions for Hendra and Hendra-like virus, as human-to-human spread is unknown</td></tr><tr><td align="left">Gastroenteritis<break></break> Cholera<break></break> Enteropathogenic O157:H7 and other shiga toxin-producing strains<break></break> <italic>Salmonella</italic> species (including <italic>Salmonella</italic> Typhi)<break></break> <italic>Shigella</italic> species (bacillary dysentery)</td><td align="left">Standard</td><td align="left">Use contact precautions for diapered or incontinent persons</td></tr><tr><td align="left">Hantavirus pulmonary syndrome<break></break>Haemorrhagic fever with renal syndrome, and other Puumala, Seoul, and Sin Nombre viruses</td><td align="left">Droplet</td><td align="left">Rarely transmitted from person to person</td></tr><tr><td align="left">Histoplasmosis</td><td align="left">Standard</td><td align="left">Not transmitted from person to person</td></tr><tr><td align="left">Influenza, avian (H5N1, H7, H9 strains)</td><td align="left">Droplet</td><td></td></tr><tr><td align="left">Leptospirosis</td><td align="left">Standard</td><td align="left">Not transmitted from person to person</td></tr><tr><td align="left">Malaria</td><td align="left">Standard</td><td align="left">Not transmitted from person to person except through transfusion rarely and through a failure to follow standard precautions during patient care<break></break>Install screens in windows and doors in endemic areas; use DEET-containing mosquito repellents and clothing to cover extremities</td></tr><tr><td align="left">Melioidosis</td><td align="left">Standard</td><td align="left">Not transmitted from person to person</td></tr><tr><td align="left">Meningitis: meningococcal disease</td><td align="left">Droplet</td><td align="left">Post-exposure chemoprophylaxis for household contacts and healthcare workers exposed to respiratory secretions<break></break>Eosinophilic meningitis (<italic>Angiostrongylus cantonensis, Gnathostoma spinigerum</italic>, migrating ascarids, and schistosomiasis) is not transmitted from person to person</td></tr><tr><td align="left">Rabies</td><td align="left">Standard</td><td align="left">Person-to-person transmission is rare (has been reported in corneal, tissue, and organ transplants). If the patient has bitten another individual or saliva has contaminated an open wound or mucous membrane, wash the exposed area thoroughly and administer post-exposure prophylaxis</td></tr><tr><td align="left">Relapsing fever</td><td align="left">Standard</td><td align="left">Not transmitted from person to person</td></tr><tr><td align="left">Rickettsial fevers, tick-borne (boutonneuse fever, Rocky Mountain spotted fever, tick-borne typhus fever, scrub typhus)</td><td align="left">Standard</td><td align="left">Not transmitted from person to person</td></tr><tr><td align="left">Schistosomiasis (bilharziasis)</td><td align="left">Standard</td><td align="left">Not transmitted from person to person</td></tr><tr><td align="left">Strongyloidiasis</td><td align="left">Standard</td><td align="left">Could hypothetically be transmitted by skin contact with secretions of patients with hyperinfestation syndrome</td></tr><tr><td align="left">Viral haemorrhagic fevers<break></break> Yellow fever<break></break> Rift Valley fever virus</td><td align="left">Standard</td><td align="left">Not transmitted from person to person</td></tr><tr><td align="left">Viral haemorrhagic fevers (2)<break></break> Kyasanur Forest disease virus<break></break> Omsk haemorrhagic fever virus<break></break> Crimean-Congo haemorrhagic fever virus<break></break> Ebola virus<break></break> Marburg virus<break></break> Lassa fever virus<break></break> Junin virus (Argentine haemorrhagic fever)<break></break> Guanarito virus (Venezuelan haemorrhagic fever)<break></break> Machupo virus (Bolivian haemorrhagic fever)<break></break> Sabiá virus (Brazilian haemorrhagic fever)</td><td align="left">High-level isolation unit</td><td align="left">Crimean-Congo haemorrhagic fever virus, Ebola virus, Marburg virus, Lassa fever virus, Guanarito virus, and Machupo virus can be transmitted from person to person. Unknown for Kyasanur Forest virus, Omsk virus, Junin virus, and Sabiá virus<break></break>Emphasize: (1) use of sharp safety devices and safe work practices; (2) hand hygiene; (3) barrier protection against blood and body fluids upon entry into room (single gloves and fluid-resistant or impermeable gown, face/eye protection with masks, goggles, or face shields); and (4) appropriate waste handling. Use N95 or higher respirators when performing aerosol-generating procedures. Largest viral load in final stages of illness when haemorrhage may occur; additional PPE, including double gloves, leg and shoe coverings may be used, especially in resource-limited settings where options for cleaning and laundry are limited</td></tr></tbody></table><table-wrap-foot><fn><p>SARS-CoV, severe acute respiratory syndrome coronavirus; MERS-CoV, Middle East respiratory syndrome coronavirus; DEET, <italic>N</italic>,<italic>N</italic>-diethyl-<italic>meta</italic>-toluamide; PPE, personal protective equipment.</p></fn></table-wrap-foot><table-wrap-foot><fn id="tblfn0005"><label>a</label><p id="npar0005">Standard precautions include hand hygiene, use of PPE, prevention of needlestick injuries, environment cleaning, and the appropriate handling of waste. Droplet precautions include standard precautions and the use of a single room, surgical masks for healthcare workers when working within 1–2 m of the patient, and a surgical mask on the patient if transport is necessary. Airborne precautions include standard precautions and a single monitored negative-pressure room, closed door, special high-filtration particulate respirators (N95 or FFP2 mask) for healthcare workers, and movement of the patient, wearing a surgical mask, only when essential.</p></fn></table-wrap-foot></table-wrap></p></sec><sec id="sec0025"><label>2.3</label><title>Infection prevention and control recommendations for hospitalized patients with a suspected highly contagious tropical infectious disease in the ICU</title><p id="par0110">ICUs attend patients who are severely ill and in some way immunocompromised because of underlying diseases and the use of invasive medical devices and technology in their care. Consequently, person-to-person transmission of pathogens may be frequent. Intensive care therapy should be performed in collaboration with the infectious disease team. The unit should be subjected to negative pressure if available. The duration of manual ventilation during resuscitation procedures should be kept to a minimum. Non-invasive positive pressure ventilation should be used instead of facial mask aerosol therapy when possible. Endotracheal intubation and cardiopulmonary resuscitation have been associated with increased SARS-CoV transmission among physicians and nurses in the ICU. Endotracheal intubation should be performed with rapid sequence induction by the most skilled person available, who should wear personal protective equipment. Meticulous infection control measures must be followed.</p><p id="par0115">Invasive procedures should be avoided unless absolutely essential. Chest radiography, ultrasonography, bronchoscopy, and gastrointestinal endoscopy should be performed at the bedside, avoiding moving the patient unnecessarily; if not possible, these procedures should be performed in an air-controlled environment. Patients who require dialysis at their bedside should receive either peritoneal dialysis or haemodialysis, and dedicated haemodialysis machines and decontaminated dialysate should be designated as infectious waste.</p><p id="par0120">Detailed tutorials and guidelines have been produced by the US Centers for Disease Control and Prevention (CDC),<xref rid="bib0285" ref-type="bibr"><sup>26</sup></xref> the European Centre for Disease Prevention and Control (ECDC),<xref rid="bib0290" ref-type="bibr"><sup>27</sup></xref> and the European Network for Infectious Diseases (EUNID).<xref rid="bib0295" ref-type="bibr"><sup>28</sup></xref> There are also other guidelines focused on specific diseases such as Ebola virus disease (CDC) and Crimean-Congo haemorrhagic fever.<xref rid="bib0300" ref-type="bibr">29</xref>, <xref rid="bib0305" ref-type="bibr">30</xref></p><p id="par0125">New definitions of sepsis have different implications when applied in low-income and middle-income countries,<xref rid="bib0310" ref-type="bibr"><sup>31</sup></xref> and a new paradigm for management should be developed. A research agenda highlighting the differences in approach between high-income and poor-resource scenarios is required.</p><p id="par0130"><italic>Funding:</italic> None.</p><p id="par0135"><italic>Conflict of interest:</italic> The authors have no conflicts of interest to report.</p><p id="par0140"><italic>JR and HL designed the manuscript</italic>: ARM and GMR prepared the section on emerging resistance. RLV and JRZ wrote the section on infection control. JR wrote the final version. 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