Letter to the editor : Is there a need for special treatment of refugees at hospital admission ?

To the editor: Two recent publications by Reinheimer et al. and Heudorf et al. in Eurosurveillance, provided data on multidrug-resistant bacteria obtained from screening of different refugee populations and concluded that additional screening or surveillance for refugees at hospital admission in Germany should be undertaken [1,2]. The high number of people currently migrating to Europe from disaster areas has sparked a debate, whether or not refugees should be screened at hospital admission for colonisation with multidrug-resistant bacteria to limit spread of antibiotic resistance within Europe. The possible negative consequences of screening and lacking data make this a more complex issue than it may seem at first.

To the editor: Two recent publications by Reinheimer et al. and Heudorf et al. in Eurosurveillance, provided data on multidrug-resistant bacteria obtained from screening of different refugee populations and concluded that additional screening or surveillance for refugees at hospital admission in Germany should be undertaken [1,2].The high number of people currently migrating to Europe from disaster areas has sparked a debate, whether or not refugees should be screened at hospital admission for colonisation with multidrug-resistant bacteria to limit spread of antibiotic resistance within Europe.The possible negative consequences of screening and lacking data make this a more complex issue than it may seem at first.

The advantages of screening seem obvious.
There is evidence that in some countries with a high emigration the prevalence of antimicrobial resistance in healthcare settings is high.In addition, international travel and migration are discussed as factors promoting the global spread of resistance [3].One could also speculate that resistant pathogens may spread during the journey or within refugee camps, where hygiene is often poor and turnover of persons is high.However, evidence to base a decision for or against microbiological screening in refugees is largely lacking.
Little can be done in terms of decolonisation in case of multidrug-resistant Gram-negative bacteria (MDRGN), because they can colonise the human gut and become part of the intestinal flora.Therefore, good adherence to infection control precautions is essential to prevent the transmission of MDRGN in hospitals.In addition to standard precautions, isolation and barrier nursing are possible intervention strategies.However, these measures may be associated with poorer patient care [4] and higher cost.In the context of refugees it is also perceivable that targeted screening will result in stigmatisation.
Given the scarcity of available data in the scientific literature, the recently published articles by Reinheimer et al. and Heudorf et al. [1,2] are highly interesting.They show that in a sample of 143 adult refugees presenting at a German hospital as well as among 119 unaccompanied refugee minors, colonisation with extended spectrum beta-lactamase (ESBL)-producing bacteria is more frequent than in patients from general German population.Both articles suggest additional screening or surveillance for refugees at hospital admission in Germany.The Robert Koch Institute on the other hand does not recommend screening particularly for refugees in addition to what is recommended for everyone at hospital admission in Germany: if a patient had recent contact to the healthcare system of countries with high prevalence of antimicrobial resistance, screening for carbapenem-resistant bacteria and meticillin-resistant Staphylococcus aureus (MRSA) is recommended [5].Reinheimer et al. calculated that according to current German guidelines [6], 32.9% of refugees in contrast to 10.9% of non-refugee patients would qualify for isolation in especially vulnerable settings, such as intensive care units (ICUs).This is misleading since not all of the patients in their sample had to be admitted to such settings.
While the high rate of colonisation with ESBL-producing bacteria among refugees is certainly worrisome and while current guidelines indeed recommend isolation in certain settings, such as in ICUs, screening for these pathogens is not recommended for any patient group in Germany [6].In addition, colonisation with ESBLproducing bacteria may also be high in some German populations.For example a study among travellers returning to Germany showed colonisation with ESBLproducing Escherichia coli in 30% [3], which is similar to that seen among refugee minors [2].Screening is, however, not recommended for travellers returning to Germany.
As described above screening for carbapenem-resistant bacteria is recommended for high risk groups [6].Fortunately, carbapenem resistance was low in both studies, so that the need for targeted screening in this population under current German guidelines does not seem to be warranted.If, however, the proposal of an extension of current screening criteria was intended, Germans at high risk for colonisation with ESBLproducing bacteria needed to be included too.In the meantime strengthening standard hospital hygiene and providing translators for refugees to ensure good patient care and to identify those patients, who qualify for isolation and screening under current guidelines, may be more urgent.