Microbiology, Metagenomics and Bioinformatics

Johan Bengtsson-Palme, University of Gothenburg

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In the most recent issue of the Medicine Maker (#0416), there is a short opinion piece by me and Joakim Larsson, in which we argue for that pharmaceutical companies should live up to their ethical responsibilities, and may actually benefit from doing so (1). We were invited to write for the Medicine Maker based on our recent papers on proposed limits for antibiotic discharges into the environment (2) and minimal selective concentrations (3).

We argue that now as PNECs for resistance selection are available, they should be applied in regulatory contexts. The recent O’Neill report on antimicrobial resistance (commissioned by the British Government) specifically highlighted the urgent need for enforceable regulations on antibiotic discharges (4). The concentrations we reported in our Environment International paper (2) can be used by local, national and international authorities to define emission limits for antibiotic-producing factories, but also for pharmaceutical companies to assess and manage risks for resistance selection associated with their own discharges.

The Medicine Maker can be read for free, but requires registration to access its full content. The full opinion piece can be found here.

References

  1. Bengtsson-Palme J, Larsson DGJ: Time to limit antibiotic pollution. The Medicine Maker, 0416, 302, 17–18 (2016). [Paper link]
  2. Bengtsson-Palme J, Larsson DGJ: Concentrations of antibiotics predicted to select for resistant bacteria: Proposed limits for environmental regulation. Environment International, 86, 140–149 (2016). doi: 10.1016/j.envint.2015.10.015 [Paper link]
  3. Lundström S, Östman M, Bengtsson-Palme J, Rutgersson C, Thoudal M, Sircar T, Blanck H, Eriksson KM, Tysklind M, Flach C-F, Larsson DGJ: Minimal selective concentrations of tetracycline in complex aquatic bacterial biofilms. Science of the Total Environment, 553, 587–595 (2016). doi: 10.1016/j.scitotenv.2016.02.103 [Paper link]
  4. Review on Antimicrobial Resistance: Antimicrobials in agriculture and the environment: Reducing unnecessary use and waste (J O’Neill, Ed,) (2015). [Link].

Yesterday, Ecological Informatics put our paper describing Metaxa2 Diversity Tools online (1). Metaxa2 Diversity Tools was introduced with Metaxa2 version 2.1 and consists of

  • metaxa2_dc – a tool for collecting several .taxonomy.txt output files into one large abundance matrix, suitable for analysis in, e.g., R
  • metaxa2_rf – generates resampling rarefaction curves (2) based on the .taxonomy.txt output
  • metaxa2_si – species inference based on guessing species data from the other species present in the .taxonomy.txt output file
  • metaxa2_uc – a tool for determining if the community composition of a sample is significantly different from others through resampling analysis

At the same time as I did this update to the web site, I also took the opportunity to update the Metaxa2 FAQ to better reflect recent updates to the Metaxa2 software.

Metaxa2 Diversity Tools
One often requested feature of Metaxa2 (3) has been the ability to make simple analyses from the data after classification. The Metaxa2 Diversity Tools included in Metaxa2 2.1 is a seed for such an effort (although not close to a full-fledged community analysis package comparable to QIIME (4) or Mothur (5)). It currently consist of four tools.

The Metaxa2 Data Collector (metaxa2_dc) is the simplest of them (but probably the most requested), designed to merge the output of several *.level_X.txt files from the Metaxa2 Taxonomic Traversal Tool into one large abundance matrix, suitable for further analysis in, for example, R. The Metaxa2 Species Inference tool (metaxa2_si) can be used to further infer taxon information on, for example, the species level at a lower reliability than what would be permitted by the Metaxa2 classifier, using a complementary algorithm. The idea is that is if only a single species is present in, e.g., a family and a read is assigned to this family, but not classified to the species level, that sequence will be inferred to the same species as the other reads, given that it has more than 97% sequence identity to its best reference match. This can be useful if the user really needs species or genus classifications but many organisms in the studied species group have similar rRNA sequences, making it hard for the Metaxa2 classifier to classify sequences to the species level.

The Metaxa2 Rarefaction analysis tool (metaxa2_rf) performs a resampling rarefaction analysis (2) based on the output from the Metaxa2 classifier, taking into account also the unclassified portion of rRNAs. The Metaxa2 Uniqueness of Community analyzer (metaxa2_uc), finally, allows analysis of whether the community composition of two or more samples or groups is significantly different. Using resampling of the community data, the null hypothesis that the taxonomic content of two communities is drawn from the same set of taxa (given certain abundances) is tested. All these tools are further described in the manual and the recent paper (1).

The latest version of Metaxa2, including the Metaxa2 Diversity Tools, can be downloaded here.

References

  1. Bengtsson-Palme J, Thorell K, Wurzbacher C, Sjöling Å, Nilsson RH: Metaxa2 Diversity Tools: Easing microbial community analysis with Metaxa2. Ecological Informatics, 33, 45–50 (2016). doi: 10.1016/j.ecoinf.2016.04.004 [Paper link]
  2. Gotelli NJ, Colwell RK: Quantifying biodiversity: procedures and pitfalls in the measurement and comparison of species richness. Ecology Letters, 4, 379–391 (2000). doi:10.1046/j.1461-0248.2001.00230.x
  3. Bengtsson-Palme J, Hartmann M, Eriksson KM, Pal C, Thorell K, Larsson DGJ, Nilsson RH: Metaxa2: Improved Identification and Taxonomic Classification of Small and Large Subunit rRNA in Metagenomic Data. Molecular Ecology Resources (2015). doi: 10.1111/1755-0998.12399 [Paper link]
  4. Caporaso JG, Kuczynski J, Stombaugh J et al.: QIIME allows analysis of high-throughput community sequencing data. Nature Methods, 7, 335–336 (2010).
  5. Schloss PD, Westcott SL, Ryabin T et al.: Introducing mothur: open-source, platform-independent, community-supported software for describing and comparing microbial communities. Applied and Environmental Microbiology, 75, 7537–7541 (2009).

Metaxa2 has been updated again today to version 2.1.3. This update adds a few features to the Metaxa2 Diversity Tools (metaxa2_uc and metaxa2_rf). The core Metaxa2 programs remain the same as for the previous Metaxa2 versions. The new features were suggested as part of the review process of a Metaxa2-related manuscript, and we thank the anonymous reviewers for their great suggestions!

New features and bug fixes in this update:

  • Added the Chao1, iChao1 and ACE estimators in addition to the original species abundance (“Bengtsson-Palme”) model in metaxa2_rf
  • Added the Raup-Crick dissimilarity method to the metaxa2_uc tool
  • Added a warning message when data is highly skewed for metaxa2_uc
  • Improved robustness of the ‘model’ mode of metaxa2_uc for highly skewed sample groups
  • Fixed a bug causing miscalculation of Euclidean distances on binary data in metaxa2_uc

The updated version of Metaxa2 can be downloaded here.

Happy barcoding!

After a long wait (1) Sara Lundström’s paper establishing minimal selective concentrations (MSCs) for the antibiotic tetracycline in complex microbial communities (2), of which I am a co-author, has gone online. Personally, I think this paper is among the finest work I have been involved in; a lot of good science have gone into this publication. Risk assessment and management of antibiotics pollution is in great need of scientific data to underpin mitigation efforts (3). This paper describes a method to determine the minimal selective concentrations of antibiotics, and investigates different endpoints for measuring those MSCs. The method involves a testing system highly relevant for aquatic communities, in which bacteria are allowed to form biofilms in aquaria under controlled antibiotic exposure. Using the system, we find that 1 μg/L tetracycline selects for the resistance genes tetA and tetG, while 10 μg/L tetracycline is required to detect changes of phenotypic resistance. In short, the different endpoints studied (and their corresponding MSCs) were:

  • CFU counts on R2A plates with 20 μg/mL tetracycline – MSC = 10 μg/L
  • MIC range – MSC ~ 10-100 μg/L
  • PICT, leucine uptake after short-term TC challenge – MSC ~ 100 μg/L
  • Increased resistance gene abundances, metagenomics – MSC range: 0.1-10 μg/L
  • Increased resistance gene abundances, qPCR (tetA and tetG) – MSC ≤ 1 μg/L
  • Changes to taxonomic diversity – no significant changes detected
  • Changes to taxonomic community composition – MSC ~ 1-10 μg/L

This study confirms that the estimated PNECs we reported recently (4) correspond well to experimentally determined MSCs, at least for tetracycline. Importantly, the selective concentrations we report for tetracycline overlap with those that have been reported in sewage treatment plants (5). We also see that tetracycline not only selects for tetracycline resistance genes, but also resistance genes against other classes of antibiotics, including sulfonamides, beta-lactams and aminoglycosides. Finally, the approach we describe can be used for improved in risk assessment for (also other) antibiotics, and to refine the emission limits we suggested in a recent paper based on theoretical calculations (4).

References and notes

  1. Okay, seriously: how can a journal’s production team return the proofs for a paper within 24 hours of acceptance, and then wait literally five weeks before putting the final proofs online? Nothing against STOTEN, but I honestly wonder what was going on beyond the scenes here.
  2. Lundström SV, Östman M, Bengtsson-Palme J, Rutgersson C, Thoudal M, Sircar T, Blanck H, Eriksson KM, Tysklind M, Flach C-F, Larsson DGJ: Minimal selective concentrations of tetracycline in complex aquatic bacterial biofilms. Science of the Total Environment, 553, 587–595 (2016). doi: 10.1016/j.scitotenv.2016.02.103 [Paper link]
  3. Ågerstrand M, Berg C, Björlenius B, Breitholtz M, Brunstrom B, Fick J, Gunnarsson L, Larsson DGJ, Sumpter JP, Tysklind M, Rudén C: Improving environmental risk assessment of human pharmaceuticals. Environmental Science and Technology (2015). doi:10.1021/acs.est.5b00302
  4. Bengtsson-Palme J, Larsson DGJ: Concentrations of antibiotics predicted to select for resistant bacteria: Proposed limits for environmental regulation. Environment International, 86, 140-149 (2016). doi: 10.1016/j.envint.2015.10.015
  5. Michael I, Rizzo L, McArdell CS, Manaia CM, Merlin C, Schwartz T, Dagot C, Fatta-Kassinos D: Urban wastewater treatment plants as hotspots for the release of antibiotics in the environment: a review. Water Research, 47, 957–995 (2013). doi:10.1016/j.watres.2012.11.027

Yesterday was an intensive day for typesetters apparently, since they put two of my papers online on the same day. This second paper was published in Environment International, and focuses on predicting minimal selective concentrations for all antibiotics present in the EUCAST database (1).

Today (well, up until yesterday at least), we have virtually no knowledge of which environmental concentrations that can exert a selection pressure for antibiotic resistant bacteria. However, experimentally determining minimal selective concentrations (MSCs) in complex ecosystems would involve immense efforts if done for all antibiotics. Therefore, efforts to theoretically determine MSCs for different antibiotics have been suggested (2,3). In this paper we therefore estimate upper boundaries for selective concentrations for all antibiotics in the EUCAST database, based on the assumption that selective concentrations a priori must be lower than those completely inhibiting growth. Data on Minimal Inhibitory Concentrations (MICs) were obtained for 122 antibiotics and antibiotics combinations, the lowest observed MICs were identified for each of those across all tested species, and to compensate for limited species coverage, we adjusted the lowest MICs for the number of tested species. We finally assessed Predicted No Effect Concentrations (PNECs) for resistance selection using an assessment factor of 10 to account for the differences between MICs and MSCs. Since we found that the link between taxonomic similarity between species and lowest MIC was weak, we have not compensated for the taxonomic diversity that each antibiotic was tested against – only for limited number of species tested. In most cases, our PNECs for selection of resistance were below available PNECs for ecotoxicological effects retrieved from FASS. Also, concentrations predicted to be selective have, for some antibiotics, been detected in regular sewage treatment plants (4), and are greatly exceeded in environments polluted by pharmaceutical pollution (5-7), often with drastic consequences in terms of resistance gene enrichments (8-10). This is a central issue since in principle a transfer event of a novel resistance determinant from an environmental bacteria to an (opportunistic) human pathogen only need to occur once to become a clinical problem (11). Once established, the gene could then spread through human activities, such as trade and travel (7,13). Importantly, this paper:

The paper is available under open access here. We hope, and believe, that the data will be of great use in environmental risk assessments, in efforts by industries, regulatory agencies or purchasers of medicines to define acceptable environmental emissions of antibiotics, in the implementation of environmental monitoring programs, for directing mitigations, and for prioritizing future studies on environmental antibiotic resistance.

References:

  1. Bengtsson-Palme J, Larsson DGJ: Concentrations of antibiotics predicted to select for resistant bacteria: Proposed limits for environmental regulation. Environment International, 86, 140-149 (2016). doi: 10.1016/j.envint.2015.10.015 [Paper link]
  2. Ågerstrand M, Berg C, Björlenius B, Breitholtz M, Brunstrom B, Fick J, Gunnarsson L, Larsson DGJ, Sumpter JP, Tysklind M, Rudén C: Improving environmental risk assessment of human pharmaceuticals. Environmental Science and Technology (2015). doi:10.1021/acs.est.5b00302
  3. Tello A, Austin B, Telfer TC: Selective pressure of antibiotic pollution on bacteria of importance to public health. Environmental Health Perspectives, 120, 1100–1106 (2012). doi:10.1289/ehp.1104650
  4. Michael I, Rizzo L, McArdell CS, Manaia CM, Merlin C, Schwartz T, Dagot C, Fatta-Kassinos D: Urban wastewater treatment plants as hotspots for the release of antibiotics in the environment: a review. Water Research, 47, 957–995 (2013). doi:10.1016/j.watres.2012.11.027
  5. Larsson DGJ, de Pedro C, Paxeus N: Effluent from drug manufactures contains extremely high levels of pharmaceuticals. Journal of Hazardous Materials, 148, 751–755 (2007). doi:10.1016/j.jhazmat.2007.07.008
  6. Fick J, Söderström H, Lindberg RH, Phan C, Tysklind M, Larsson DGJ: Contamination of surface, ground, and drinking water from pharmaceutical production. Environmental Toxicology and Chemistry, 28, 2522–2527 (2009). doi:10.1897/09-073.1
  7. Larsson DGJ: Pollution from drug manufacturing: review and perspectives. Philosophical Transactions of the Royal Society London, Series B Biological Sciences, 369 (2014). doi:10.1098/rstb.2013.0571
  8. Bengtsson-Palme J, Boulund F, Fick J, Kristiansson E, Larsson DGJ: Shotgun metagenomics reveals a wide array of antibiotic resistance genes and mobile elements in a polluted lake in India. Frontiers in Microbiology, Volume 5, Issue 648 (2014). doi: 10.3389/fmicb.2014.00648 [Paper link]
  9. Kristiansson E, Fick J, Janzon A, Grabic R, Rutgersson C, Weijdegård B, Söderström H, Larsson DGJ: Pyrosequencing of antibiotic-contaminated river sediments reveals high levels of resistance and gene transfer elements. PLoS ONE, Volume 6, e17038 (2011). doi:10.1371/journal.pone.0017038.
  10. Marathe NP, Regina VR, Walujkar SA, Charan SS, Moore ERB, Larsson DGJ, Shouche YS: A Treatment Plant Receiving Waste Water from Multiple Bulk Drug Manufacturers Is a Reservoir for Highly Multi-Drug Resistant Integron-Bearing Bacteria. PLoS ONE, Volume 8, e77310 (2013). doi:10.1371/journal.pone.0077310
  11. Bengtsson-Palme J, Larsson DGJAntibiotic resistance genes in the environment: prioritizing risks. Nature Reviews Microbiology, 13, 369 (2015). doi: 10.1038/nrmicro3399-c1 [Paper link]
  12. Bengtsson-Palme J, Angelin M, Huss M, Kjellqvist S, Kristiansson E, Palmgren H, Larsson DGJ, Johansson A: The human gut microbiome as a transporter of antibiotic resistance genes between continents. Antimicrobial Agents and Chemotherapy, 59, 10, 6551-6560 (2015). doi: 10.1128/AAC.00933-15 [Paper link]

Yesterday, a paper I co-authored with my colleagues Chandan Pal, Erik Kristiansson and Joakim Larsson on the co-occurences of resistance genes against antibiotics, biocides and metals in bacterial genomes and plasmids became published in BMC Genomics. In this paper (1) we utilize the publicly available, fully sequenced, genomes and plasmids in GenBank to investigate the co-occurence network of resistance genes, to better understand risks for co-selection for resistance against different types of compounds. In short, the findings of the paper are that:

  • ARGs are associated with BMRG-carrying bacteria and the co-selection potential of biocides and metals is specific towards certain antibiotics
  • Clinically important genera host the largest numbers of ARGs and BMRGs and those also have the highest co-selection potential
  • Bacteria isolated from human and domestic animal origins have the highest co-selection potential
  • Plasmids with co-selection potential tend to be conjugative and carry toxin-antitoxin systems
  • Mercury and QACs are potential co-selectors of ARGs on plasmids, however BMRGs are common on chromosomes and could still have indirect co-selection potential
  • 14 percent of bacteria and more than 70% of the plasmids completely lacked resistance genes

This analysis was possible thanks to the BacMet database of antibacterial biocide and metal resistance genes, published about two years ago (2). The visualization of the plasmid co-occurence network we ended up with can be seen below. Note the strong connection between the mercury resistance mer operon and the antibiotic resistance genes to the right.

On a side note, it is interesting to note that the underrepresentation of detoxification systems in marine environments we noted last year (3) still seems to hold for genomes (and particularly plasmids), supporting the genome streamlining hypothesis (4).

References:

  1. Pal C, Bengtsson-Palme J, Kristiansson E, Larsson DGJ: Co-occurrence of resistance genes to antibiotics, biocides and metals reveals novel insights into their co-selection potential. BMC Genomics, 16, 964 (2015). doi: 10.1186/s12864-015-2153-5 [Paper link]
  2. Pal C, Bengtsson-Palme J, Rensing C, Kristiansson E, Larsson DGJ: BacMet: Antibacterial Biocide and Metal Resistance Genes Database. Nucleic Acids Research, 42, D1, D737-D743 (2014). doi: 10.1093/nar/gkt1252 [Paper link]
  3. Bengtsson-Palme J, Alm Rosenblad M, Molin M, Blomberg A: Metagenomics reveals that detoxification systems are underrepresented in marine bacterial communities. BMC Genomics, 15, 749 (2014). doi: 10.1186/1471-2164-15-749 [Paper link]
  4. Giovannoni SJ, Cameron TJ, Temperton B: Implications of streamlining theory for microbial ecology. ISME Journal, 8, 1553-1565 (2014).

I am very happy to announce that our paper on the metagenomes of periphyton communities (1) have been accepted in Frontiers in Microbiology (Aquatic Microbiology section). This project has been one of my longest running, as it started as my master thesis in 2010 and has gone through several metamorphoses before hitting its final form.

Briefly, our main findings are that:

  1. Periphyton communities harbor an extraordinary diversity of organisms, including viruses, bacteria, algae, fungi, protozoans and metazoans
  2. Bacteria are by far the most abundant
  3. We find functional indicators of the biofilm form of life in periphyton involve genes coding for enzymes that catalyze the production and degradation of extracellular polymeric substances
  4. Genes encoding enzymes that participate in anaerobic pathways are found in the biofilms suggesting that anaerobic or low-oxygen micro-zones within the biofilms exist

Most of this work has been carried out by my colleague Kemal Sanli, who have been doing a wonderful job pulling this together, with the help of Henrik Nilsson and Martin Eriksson. It also deserves to be noted that this work was the starting point for the Metaxa software (2,3), which recently reached version 2.1.1.

References

  1. Sanli K, Bengtsson-Palme J, Nilsson RH, Kristiansson E, Alm Rosenblad M, Blanck H, Eriksson KM: Metagenomic sequencing of marine periphyton: Taxonomic and functional insights into biofilm communities. Frontiers in Microbiology, 6, 1192 (2015). doi: 10.3389/fmicb.2015.01192 [Paper link]
  2. Bengtsson J, Eriksson KM, Hartmann M, Wang Z, Shenoy BD, Grelet G, Abarenkov K, Petri A, Alm Rosenblad M, Nilsson RH: Metaxa: A software tool for automated detection and discrimination among ribosomal small subunit (12S/16S/18S) sequences of archaea, bacteria, eukaryotes, mitochondria, and chloroplasts in metagenomes and environmental sequencing datasets. Antonie van Leeuwenhoek, 100, 3, 471-475 (2011). doi:10.1007/s10482-011-9598-6. [Paper link]
  3. Bengtsson-Palme J, Hartmann M, Eriksson KM, Pal C, Thorell K, Larsson DGJ, Nilsson RH: Metaxa2: Improved identification and taxonomic classification of small and large subunit rRNA in metagenomic data. Molecular Ecology Resources, 15, 6, 1403–1414 (2015). doi: 10.1111/1755-0998.12399 [Paper link]

The paper we published in August on travelers carrying resistance genes with them in their gut microbiota has now been typeset and got proper volume and issue numbers assigned to it in Antimicrobial Agents and Chemotherapy. Take a look at it, I personally think it’s quite good-looking.

Also, if you understand Swedish, here is an interview with me broadcasted on Swedish Radio last month about this study and the consequences of it.

The new citation for the paper is:

  • Bengtsson-Palme J, Angelin M, Huss M, Kjellqvist S, Kristiansson E, Palmgren H, Larsson DGJ, Johansson A: The human gut microbiome as a transporter of antibiotic resistance genes between continents. Antimicrobial Agents and Chemotherapy, 59, 10, 6551-6560 (2015). doi: 10.1128/AAC.00933-15 [Paper link]

There have been quite a lot of buzz this week around the travel paper we published earlier this month. Twitter aside, the findings of the paper has also been covered by a range of news outlets, both in Sweden and internationally. Today, I was on Swedish radio talking resistance problems for about ten minutes (listen here; in Swedish). Here’s a few takes on the story I gathered around the web:

Science Daily
Business Standard
Z News
Englemed Health News
Läkemedelsvärlden (in Swedish)
Sveriges Radio (in Swedish)
Göteborgs-Posten (in Swedish)

Earlier today, my most recent paper (1) became available online, describing resistance gene patterns in the gut microbiota of Swedes before and after travel to the Indian peninsula and central Africa. In this work, we have used metagenomic sequencing of the intestinal microbiome of Swedish students returning from exchange programs to show that the abundance of antibiotic resistance genes in several classes are increased after travel. This work reiterates the findings of several papers describing uptake of resistant bacteria (2-8) or resistance genes (9-11) after travel to destinations with worse resistance situation.

Our paper is important because it:

  1. Addresses the abundance of a vast range of resistance genes (more than 300).
  2. Finds evidence for that the overall relative abundance of antibiotic resistance genes increased after travel, without any intake of antibiotics.
  3. Shows that the sensitivity of metagenomics was, despite very deep sequencing efforts, not sufficient to detect acquisition of the low-abundant (CTX-M) resistance genes responsible for observed ESBL phenotypes.
  4. Reveals a “core resistome” of resistance genes that are more or less omnipresent, and remain relatively stable regardless of travel, while changes seem to occur in the more variable part of the resistome.
  5. Hints at increased abundance of Proteobacteria after travel, although this increase could not specifically be linked to resistance gene increases.
  6. Uses de novo metagenomic assembly to physically link resistance genes in the same sample, giving hints of co-resistance patterns in the gut microbiome.

The paper was a collaboration with Martin Angelin, Helena Palmgren and Anders Johansson at Umeå University, and was made possible by bioinformatics support from SciLifeLab in Stockholm. I highly recommend reading it as a complement to e.g. the Forslund et al. paper (12) describing country-specific antibiotic resistance patterns in the gut microbiota.

Taken together, this study offers a broadened perspective on how the antibiotic resistance potential of the human gut microbiome changes after travel, providing an independent complement to previous studies targeting a limited number of bacterial species or antibiotic resistance genes. Understanding how resistance genes travels the globe is hugely important, since resistance in principle only need to appear in a pathogen once; improper hygiene and travel may then spread novel resistance genes across continents rapidly (13,14).

References

  1. Bengtsson-Palme J, Angelin M, Huss M, Kjellqvist S, Kristiansson E, Palmgren H, Larsson DGJ, Johansson A: The human gut microbiome as a transporter of antibiotic resistance genes between continents. Antimicrob Agents Chemother Accepted manuscript posted online (2015). doi: 10.1128/AAC.00933-15 [Paper link]
  2. Gaarslev K, Stenderup J: Changes during travel in the composition and antibiotic resistance pattern of the intestinal Enterobacteriaceae flora: results from a study of mecillinam prophylaxis against travellers’ diarrhoea. Curr Med Res Opin 9:384–387 (1985).
  3. Paltansing S, Vlot JA, Kraakman MEM, Mesman R, Bruijning ML, Bernards AT, Visser LG, Veldkamp KE: Extended-spectrum β-lactamase-producing enterobacteriaceae among travelers from the Netherlands. Emerging Infect. Dis. 19:1206–1213 (2013).
  4. Ruppé E, Armand-Lefèvre L, Estellat C, El-Mniai A, Boussadia Y, Consigny PH, Girard PM, Vittecoq D, Bouchaud O, Pialoux G, Esposito-Farèse M, Coignard B, Lucet JC, Andremont A, Matheron S: Acquisition of carbapenemase-producing Enterobacteriaceae by healthy travellers to India, France, February 2012 to March 2013. Euro Surveill. 19 (2014).
  5. Kennedy K, Collignon P: Colonisation with Escherichia coli resistant to “critically important” antibiotics: a high risk for international travellers. Eur J Clin Microbiol Infect Dis 29:1501–1506 (2010).
  6. Tham J, Odenholt I, Walder M, Brolund A, Ahl J, Melander E: Extended-spectrum beta-lactamase-producing Escherichia coli in patients with travellers’ diarrhoea. Scand. J. Infect. Dis. 42:275–280 (2010).
  7. Östholm-Balkhed Å, Tärnberg M, Nilsson M, Nilsson LE, Hanberger H, Hällgren A, Travel Study Group of Southeast Sweden: Travel-associated faecal colonization with ESBL-producing Enterobacteriaceae: incidence and risk factors. J Antimicrob Chemother 68:2144–2153 (2013).
  8. Kantele A, Lääveri T, Mero S, Vilkman K, Pakkanen SH, Ollgren J, Antikainen J, Kirveskari J: Antimicrobials increase travelers’ risk of colonization by extended-spectrum betalactamase-producing enterobacteriaceae. Clin Infect Dis 60:837–846 (2015).
  9. von Wintersdorff CJH, Penders J, Stobberingh EE, Oude Lashof AML, Hoebe CJPA, Savelkoul PHM, Wolffs PFG: High rates of antimicrobial drug resistance gene acquisition after international travel, The Netherlands. Emerging Infect. Dis. 20:649–657 (2014).
  10. Tängdén T, Cars O, Melhus A, Löwdin E: Foreign travel is a major risk factor for colonization with Escherichia coli producing CTX-M-type extended-spectrum beta-lactamases: a prospective study with Swedish volunteers. Antimicrob Agents Chemother 54:3564–3568 (2010).
  11. Dhanji H, Patel R, Wall R, Doumith M, Patel B, Hope R, Livermore DM, Woodford N: Variation in the genetic environments of bla(CTX-M-15) in Escherichia coli from the faeces of travellers returning to the United Kingdom. J Antimicrob Chemother 66:1005–1012 (2011).
  12. Forslund K, Sunagawa S, Kultima JR, Mende DR, Arumugam M, Typas A, Bork P: Country-specific antibiotic use practices impact the human gut resistome. Genome Res 23:1163–1169 (2013).
  13. Bengtsson-Palme J, Larsson DGJ: Antibiotic resistance genes in the environment: prioritizing risks. Nat Rev Microbiol 13:396 (2015).
  14. Larsson DGJ: Antibiotics in the environment. Ups J Med Sci 119:108–112 (2014).