Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Blastocystis SPP. infection prevalence and associated patient characteristics as predictors among a cohort of symptomatic and asymptomatic Egyptians

Blastocystis species (spp.) is a large unicellular intestinal protozoan parasite that has a worldwide distribution. It has unclear pathogenicity and is linked to many clinical disorders. The study purpose was to determine the prevalence of Blastocystis spp. molecularly in a cohort of symptomatic and asymptomatic individuals and to assess the association of Blastocystis spp. with the patient characteristics as possible predictors of the occurrence of Blastocystis spp. Fecal specimens were collected from 139 Egyptians of both sexes, aged from 5 months to 74 years. All fecal specimens were examined coproscopically for detection of gut parasites and cultured on Modified Jones’ medium for detection of Blastocystis spp. Molecular assay using nested PCR (nPCR) was performed for cultured Blastocystis. The association between detection of Blastocystis spp. and patient demographics and clinical data was determined. Prevalence of parasitic infections was 62 (44.6%) using coproscopy. Blastocystis spp. was the most prevalent parasite (21.6%) in both symptomatic and asymptomatic individuals, followed by E. histolytica complex (13.7%) and Giardia intestinalis (10.8%). Cryptosporidium spp. (2.2%) and E. coli (2.1%) were the least detected parasites. Among studied patient characteristics, only age showed statistical significance in association with detection of Blastocysitis spp.

Growth performance, liver and kidney functions, blood hormonal profile, and economic efficiency of broilers fed different levels of threonine supplementation during feed restriction

ABSTRACT: The objective of the existing investigation was to determine the effect of dietary inclusion of threonine amino acid at different levels during feed restriction on growth indices, liver and kidney function parameters, and some hormonal profiles along with economic indicators in broiler chickens. A total of 1,600 from 2 different breeds (800 Ross 308 and 800 Indian River) at 21-day-old age were incorporated. Chicks were randomly assigned into 2 main groups, control and feed-restricted (8 h/d), during the fourth week of age. Each main group was subdivided into 4 groups. The first group was fed a basal diet without adding extra threonine (100%), the second, third, and fourth groups were fed a basal diet with extra threonine levels of 110, 120, and 130%, respectively. Each subgroup consisted of 10 replicates of 10 birds. We noticed that the dietary inclusion of threonine at extra levels in the basal diets significantly enhanced final body weight, body weight gain, and better feed conversion ratio. This was mainly due to the enhanced levels of growth hormone (GH), insulin-like growth factor (IGF1), triiodothyronine (T3), and thyroxine (T4). Moreover, the lowest feed cost per kilogram body weight gain and improved return parameters were reported in control and feed-restricted birds fed higher levels of threonine than other groups. Also, a significant increase in alanine aminotransferase (ALT), aspartate aminotransferase (AST), and urea levels was observed in feed-restricted birds supplemented with 120 and 130% levels of threonine. Hence, we recommend supplementing threonine at levels of 120 and 130% in the diet of broilers to promote growth and profitability

Biomarkers of acute kidney injury in children with congenital heart disease after cardiopulmonary bypass

Background: Acute kidney injury (AKI) is a serious postoperative complication after cardiac surgery in children and is a major contributor to patient outcome. This study aims to identify the incidence of AKI in children undergoing cardiac surgery and the role of Interleukin 18 (IL-18) and Kidney Injury Molecule 1 (KIM-1) in diagnosis of AKI in comparison to creatinine. Methods: Forty-four children who underwent open heart surgery using cardiopulmonary bypass) for congenital heart disease were assessed for AKI diagnosis according the KDIGO criteria, urinary IL-18 and KIM-1 were determined by Enzyme Linked Immunosorbent Assay in addition to the assessment of length of stay in PICU and outcome and the effect of AKI on these parameters. Results: twenty three percent of the patient developed AKI, there were no statistical correlation between AKI and the factors (Age, gender, CBP and Risk adjustment for congenital heart surgery (RACHS-1) complexity score). Eight of our patients needed peritoneal dialysis (PD), seven of them developed AKI and the 8th patient didn’t develop due to the early initiation of PD. There was strong correlation between the development of AKI and the Length of stay in ICU