Clinical outcome was favorable after therapy associating piperacillin–tazobactam, amikacin, and vancomycin. She was transferred to our unit on day 15, where she was diagnosed with a urinary tract infection due to A baumannii (same MDR strain as that previously found on the rectal swabbing). She was successfully treated by 7-day trimethoprim–sulfamethoxazol and 2-day tobramycin

and was discharged on day 45 for transfer to a rehabilitation center. These three aero-medically evacuated travelers were diagnosed with four MDR A baumannii infections, a ventilator-associated pneumonia in two patients and a urinary tract infection in two patients GSI-IX in vitro as patient 2 had two successive infections with the same MDR strain. In two patients (cases 1 and mTOR inhibitor 3), the strains were undoubtedly acquired in Algeria and Turkey,

respectively, as the rectal swabs were positive on admission and the day after ICU admission. However, we cannot rule out that the third patient (case 2) acquired A baumannii infection just after his arrival in France. Indeed, this patient was diagnosed with MDR A baumannii ventilator-associated pneumonia 5 days after repatriation, whereas rectal swabbing on admission was negative. Therefore, and by definitions used routinely by infection control practitioners, this patient could be considered to have a nosocomial infection more likely acquired in our hospital than in Thailand. Nonetheless, there is enough evidence to support a relationship with an overseas hospitalization. First, this infection developed within 5 days after repatriation. Furthermore, this was the only patient diagnosed with such an infection in this ICU, no other patient being identified by screening during this time period (Jerôme Robert, personal data). Therefore, hospitalization in Thailand could be Idelalisib ic50 considered in the acquisition of MDR A baumannii infection in case 2, although the relationship with travel is less solid than that in the two other cases. MDR A baumannii infection contributed to death in one of our cases (case 2). Similarly,

it has been shown that having MDR bacterial infections is a risk factor for increased duration of hospitalization, even if not directly responsible for an unfavorable outcome.3 Indeed, the additional length of stay (LOS) attributable to antibiotic-resistant health care-associated infections (HAIs) caused by gram-negative bacteria has been estimated to be 23.8% (95% CI, 11.01–36.56) higher than that attributable to HAIs caused by antibiotic susceptible bacteria. In addition, LOS may increase the risk of acquiring another nosocomial infection as illustrated by these case presentations. Travelers may be exposed to MDR bacteria when hospitalized abroad. Hospitalization for a travel-related illness has been estimated to occur in about 1% of travelers per month of travel, whereas the corresponding figure for medical evacuation was estimated to be about 1/1000 travelers per month of travel in developing countries.