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

Clinical characteristics and health related quality of life (HRQoL) in Egyptian patients with systemic lupus erythematosus

Aim of the work: To study the clinical characteristics and health related quality of life (HRQoL) in systemic lupus erythematosus patients. Patients and methods: 94 adult SLE patients were included from those attending Zagazig University Hospitals. SLE disease activity index (SLEDAI) and Systemic Lupus International Collaborative Clinics damage Index (SLICC/DI) were recorded. The health-related quality of life (HRQoL) was assessed using the lupus-QoL (LQoL) questionnaire. Results: The mean age of the patients was 36.9 ± 14.1 years and disease duration 5.8 ± 4 years. All LqoL domains were reduced. LQoL was significantly related to the gender, SLEDAI, SLICC/DI, erythrocyte sedimentation rate (ESR), anti-nuclear antibody (ANA) and anti-double stranded deoxyribonucleic acid (ds-DNA) (p < 0.0001, p < 0.0001, p = 0.03, p = 0.002, p = 0.02, p < 0.0001 respectively). The LQoL was not related to the age, disease duration and level of education. All 8 domains significantly correlated with SLEDAI and SLICC/DI. Mucocutaneous manifestations lowered emotional health (43.3 ± 5.7), body image (45.3 ± 6.9) and fatigue (47.3 ± 9.3) domains; neuropsychiatric manifestation lowered the emotional health (43.4 ± 9.7), planning (47.3 ± 8.8) and intimate relationship (49.2 ± 11.7); musculoskeletal manifestations mainly worsened burden to others (31.3 ± 10.5), pain (47.6 ± 10.4) and physical health (50.3 ± 11.3) while lupus nephritis mainly decreased physical health (60.4 ± 11.4), fatigue (61.2 ± 5.7), burden to others (62.4 ± 11.4) and emotional health (67.4 ± 20.3). Conclusions: SLE is a condition associated with high unmet need and considerable burden to patients. To our knowledge, no previous study has systematically examined the clinical features as well as HRQoL of SLE patients in Sharkia Governorate, Eastern Egypt. HRQoL is a multidimensional concept that encompasses physical, emotional and social components associated with SLE manifestations. Keywords: SLE, Clinical characteristics, SLEDAI, SLICC/DI, HRQo

Prevalence of low back pain in working nurses in Zagazig University Hospitals: an epidemiological study

Background Nursing is one of the occupations with a high risk for back injuries. The etiology of low back pain (LBP) among nurses is usually multifactorial, probably because job demands in nursing is a mixture of physically demanding and mentally demanding tasks. Objective The aim of this study was to identify the prevalence of and risk factors for chronic LBP in nursing personnel working in Zagazig University Hospitals. Materials and methods This study is a quantitative, retrospective, analytical, cross-sectional one. It included 150 female nurses who are currently working in Zagazig University Hospitals. All participants completed a self-administered Oswestry Low Back Disability Questionnaire. Data for risk factors of LBP (age, height, weight, BMI, marital state, parity) and working conditions (duration of employment in the current work, average working hours per week, work demands, duration of absence from work in the last year) were collected. Results LBP prevailed in 79.3% of the studied group of working nurses. The highest percentage was found among nurses working in the ICU (95.0%) and the least among those working in the outpatient clinics (64.0%). There was a highly significant association between LBP and body mass index (BMI) (P < 0.001). A higher incidence of LBP was associated with lifting heavy loads, followed by twisting, prolonged standing, prolonged sitting, walking for long distances, and bending forward. Conclusion Prevalence of LBP is high among nurses, resulting in significant medical and socioprofessional consequences. Risk factors necessitate multidisciplinary involvement to reduce the incidence of LBP and related costs

Musculoskeletal disorders in hemodialysis patients and its impact on physical function (Zagazig University Nephrology Unit, Egypt)

Background A number of musculoskeletal disorders have been reported in hemodialysis (HD) patients and they exert an impact on their functional status. Objectives This study was designed to determine the most common musculoskeletal system involvement in chronic HD patients and to show its effect on physical function (disability). Patients and methods This study was carried out on HD patients at the Nephrology Unit in Zagazig University Hospitals, Egypt. Pain intensity was measured using a 100-mm pain visual analogue scale. Physical disability was measured using the Health Assessment Questionnaire. A blood sample was obtained to measure calcium, phosphorus, alkaline phosphatase, parathyroid hormone, serum uric acid, serum albumin, serum iron, serum ferritin, and transferrin. Radiography of the symptomatic joints was performed. Dual-energy x-ray absorptiometry was performed at the femoral neck and the lumbar spine. Results Of the 144 HD patients, 87 patients (60.4%) had musculoskeletal manifestations. The most common musculoskeletal disorder was joint pain (arthralgia) (25.3%), followed by osteoarthritis (17.2%), carpal tunnel syndrome (14.9%), and osteoporosis (13.7%). The Results of dual-energy x-ray absorptiometry showed that the median T-score was −1.43 of the hip and −2.76 at the lumbar spine. There were highly significant positive correlations between the duration of HD and parathyroid hormone (P < 0.02). Higher Health Assessment Questionnaire scores were significantly associated with shoulder pain (P < 0.02), wrist pain (P < 0.03), small joint pain (P < 0.01), knee pain (P < 0.04), hip pain (P < 0.04), osteoarthritis (P < 0.02), and osteoporosis (P < 0.00). Conclusion Musculoskeletal system involvement remains a common problem that limits the physical function of patients with renal failure, in particular, those treated with long-term maintenance dialysis

Vascular endothelial growth factor and colour Doppler ultrasonography in knee osteoarthritis: Relation to pain and physical function

Aim of the work: To investigate the vascular endothelial growth factor (VEGF) levels in serum and synovial fluid of patients with knee osteoarthritis (KOA) and to determine the relationship of VEGF levels with clinical manifestation, physical function, radiographic grading and ultrasonography (US) findings. Patients and methods: 45 patients with KOA and 15 matched control subjects were enrolled. Western Ontario McMaster Osteoarthritis index (WOMAC) was scored, knee X-rays assessed using Kellgren and Lawrence (KL) scale and superficial gray scale and colour Doppler US were done. Serum and synovial VEGF levels were analyzed. Results: The 45 patients mean age was 56.5 ± 11.2 years; 39 females and 6 males (F:M 6.5:1). 30 (66.7%) patients had bilateral symptomatic KOA. Knee effusion was mild in 4, moderate in 26 and severe in 21. The mean WOMAC score was 70.9 ± 10.7; pain (14.7 ± 3.4); stiffness (6.2 ± 1.4) and disability (49.2 ± 12.4). The serum VEGF level was 0.29 ± 1.02 pg/ml and the synovial 0.48 ± 0.1 pg/ml both significantly increased compared to the control (0.14 ± 0.7 pg/ml and 0.33 ± 0.1 respectively, p < 0.0001). Levels in grade 3 KL were significantly increased compared to those with grades 1 or 2 (p < 0.0001) and between colour Doppler US grades 1 and 2 (p < 0.0001). A strong correlation was present between serum and synovial VEGF with X-ray and colour Doppler US grading as well as the WOMAC index (p < 0.0001). Conclusion: Serum and synovial VEGF correlated with clinical, functional, radiographic and US severity in KOA patients. Both VEGF and musculoskeletal ultrasound may serve as promising potential tools for evaluating disease severity in KOA. Keywords: VEGF, Knee OA, WOMAC, Doppler ultrasonograph

Damage in rheumatic diseases: Contemporary international standpoint and scores emerging from clinical, radiological and machine learning

In rheumatic diseases, damage is a major concern and reflects irreversible organ scarring or tissue degradation. Quantifying damage or measuring its severity is an indispensable concern in determining the overall outcome. Damage considerably influences both longterm prognosis and quality of life. Rheumatic diseases (RD) represent a significant health burden. Organ damage is consistently associated with increased mortality. Monitoring damage is critical in the evaluation of patients and in appraising treatment efficacy. Proper assessment and early detection of damage paves way for modifying the disease course with effective medications and regimens may reduce organ damage, improve outcomes and decrease mortality. With the exception of systemic lupus erythematosus and vasculitis, most RDs lack an established damage index making it an ongoing demand to develop effective scores and prediction models for damage accrual early in the disease course. A better understanding of machine learning with the increasing availability of medical large data may facilitate the development of meaningful precision medicine for patients with RDs. An updated spectrum of clinical and radiological damage scores and indices as well as the role of machine learning are presented in this review for the key RDs

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially