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

Spontaneous quenches of a high temperature superconducting pancake coil

A double-pancake coil made of Bi-2223/Ag high temperature superconducting (HTS) tape was constructed with an embedded heater and graded conductors to study the stability and quench propagation in HTS coils. The experiments were performed with liquid nitrogen and gaseous helium cooling in temperatures ranging from 5 to 77 K. The coil was very stable, and no ``normal`` zone was sustained or propagated with local pulsed heating. However, spontaneous quenches of the cod were experienced. This was found to be the result of having the coil current higher than that of the lower I{sub c} sections of the coil for a long time. This quench process took minutes to develop--much longer than would be expected in a low temperature superconducting coil. The quench behaved more like a spreading and continuous heating of an increasingly larger partially resistive section of the coil than like a sequential ``normal`` front propagation

Stability measurements on a 1-T high temperature superconducting magnet

A high temperature superconducting magnet based on Bi-2223 conductor was built at the American Superconductor Corporation. The magnet was constructed by a react and wind technique using conductors made from a metallic precursor process. It was a winding ID of 25.4 mm, OD of 87.6 mm, and height of 107.3 mm. A heater, two thermometers, and several voltage taps were built into the high field region of the magnet for stability measurements. The magnet generates 1.1 T central field at 4.2 K when operating at 1 {mu}V/cm over the entire conductor length, including all the joints. Stability measurements were performed in background fields up to 2.5 T from 4.2 K to 77 K. Stability margins more than 2 orders of magnitude higher than a low temperature superconductor were observed

Design and fabrication of a 70 kA current lead using Ag/Au stabilized Bi-2223 tapes as a demonstrator for the ITER TF-coil system

In the frame of the European Fusion Technology Programme, the Forschungszentrum Karlsruhe and the Centre de Recherches en Physique des Plasmas, CRPP, Villigen, develop a 70 kA current lead to demonstrate the feasibility of the usage of High Temperature Superconductors (HTS) for the current leads of the ITER TF coils. Design and fabrication of the conventional heat exchanger that covers the temperature range from 65 K to room temperature is done at the Forschungszentrum Karlsruhe. The HTS module connects the current feeder terminal at 4.5 K with the conventional heat exchanger and is cooled only by heat conduction from the cold end. Its design and fabrication has been performed by American Superconductor, AMSC. This module consists of Bi-2223 Ag/Au tapes embedded in stainless steel carriers with copper end caps. It is highly instrumented with voltage taps, temperature sensors and Hall probes. The integration with the heat exchanger and the current feeder terminal is carried out at the Forschungszentrum Karlsruhe. The current lead will be tested in the TOSKA facility in the first months of 2004. The paper describes the design, fabrication and results of pretests carried out at AMSC and Forschungszentrum Karlsruhe