Cross-border differences in the prevalence and risk factors for carriage of antimicrobial resistance in children attending daycare centers: a point prevalence study in the Netherlands and Belgium
Authors: Dequeker Sara , van Hensbergen Mitch , den Heijer Casper D. J. , Dhaeze Wouter , Raven Stijn F. H. , Ewalts-Hakkoer Helen , Tolsma Paulien , Willemsen Ina , van Drunen-Kamp Karine J. , van der Slikke-Verstraten Krista , Goossens Herman , Kluytmans-van den Bergh Marjolein F. Q. , Hoebe Christian J. P. A. ,   on behalf of the i-4-1-Health Study Group, van Alphen Lieke , van den Braak Nicole , Broucke Caroline , Buiting Anton , Coorevits Liselotte , Dewulf Jeroen , Diederen Bram , Gyssens Inge , Jamin Casper , Jansingh Patricia , Kluytmans Jan , van Koeveringe Stefanie , De Koster Sien , Lammens Christine , Leroux-Roels Isabel , Masson Hanna , Nieuwkoop Ellen , van Oosten Anita , Selva Natascha Perales , Postma Merel , Saegeman Veroniek , Savelkoul Paul , Schuermans Annette , Sleeckx Nathalie , Tobias Tijs , Veenemans Jacobien , van der Vegt Dewi , Verelst Martine , Verhulst Carlo , De Waegemaeker Pascal , Weterings Veronica , Wijkmans Clementine , Willemse Smits Patricia 
Published: January 2024

Abstract
Background
Day care centres (DCCs) are ideal settings for drug-resistant bacteria to emerge. Prevalence numbers of faecal carriage of antimicrobial resistant bacteria in these settings are rare. We aimed to determine the prevalence of faecal antimicrobial resistant bacteria carriage in children attending DCCs and to assess and identify infection risk factors within DCCs in The Netherlands and Belgium.

Methods
A point-prevalence study was conducted in 28 Dutch (499 children) and 18 Belgian (448 children) DCCs. Stool samples were taken from the children’s diapers and a questionnaire was filled in by their parents. Hygiene related to stool and toilet use, hygiene related to food, environmental contamination, hand hygiene and hygiene guidelines were assessed conform a standardized questionnaire by the infection prevention and control expert visiting the DCC. Multilevel logistical regression analyses were used to define which characteristics predicted the presence of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E), carbapenemase-producing Enterobacterales (CPE), vancomycin-resistant enterococci (VRE), and ciprofloxacin-resistant Enterobacterales (CipR-E).

Results
The ESBL-E prevalence was 16% (n = 71) in Belgium and 6% (n = 30) in the Netherlands. The CipR-E prevalence was 17% (n = 78) in Belgium and 8% (n = 38) in the Netherlands. Antimicrobial use (RR: 0.30; 95% CI: 0.33–0.48) and hospital admissions (RR: 0.37; 95% CI: 0.25–0.54) were lower in the Netherlands. Children travelling to Asia were at higher risk of being an ESBL-E carrier. Children using antimicrobials were at higher risk of being a CipR-E carrier. Cleaning the changing mat after each use was found as a protective factor for CipR-E carriage.

Conclusions
We established a significant difference in ESBL-E and CipR-E carriage and antimicrobial use and hospital admissions between the Netherlands and Belgium among children attending DCCs. The differences between both countries should be further studied to improve the policy on anti-microbial use and hospital admissions in children.