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

Aguas del Iténez o Guaporé

Bolivia y Brasil comparten una de las cuencas más atractivas y preservadas de la te-giuri amazônica: la cuenca del rio llénez o Guaporé, que escurre tanto sobre el lecho rocoso del Escudo Precámbrico Brasilefto como sobre las Hanuras del Beni. Estas influencias hacen que la cuenca del iténez tenga una elevada heterogeneidad de habitats, una fauna acuálica peculiar y un alto valor de conservation. Este patrimo­nio binacional posée un potencial importante para la conservación de la diversidad regional y cl dcsar rollo sostcniblc participativo de las comunidades locales. El libro contiene un resumen del conotimìento de la cuenca y sus recursos, generado en los últimos 10 anos por un equipo de investigadores bolivianos, brasilefios y de otras nacionalidades. Se presenta una descripeión del medio fisico, así como resultados relevantes sobre la biodiversidad acuática, con énfasis en algas, peces, reptiles y mamíferos. El aporte más notable del libro, adernas de la descripeión ecológica del ecosistema, son las lecciones aprendidas que surgieron de experiências locales sobre la élaboration participativa de herramientas para la gestion de los recursos hidrobiológicos.A Bolívia e o Brasil compartilham uma das bacias hidrográficas mais atrativas e preservadas da região amazônica: a bacia do Rio Iténez ou Guaporé. A combinação das influências do escudo pré-cambriano brasileiro e da planícies do Beni é uma das razões pela qual existem na região elevada heterogeneidade de habitats, fauna aquática peculiar e alto grau valor dc conservação. Eslc patrimônio binacional possui potencial significativo para a conservação da diversidade regional e desenvolvimento sustentável participativo das comunidades locais. O livro contém um resumo do conhecimento da bacia e seus recursos, gerado nos últimos dez anos por uma equipe de pesquisadores bolivianos, brasileiros e de outras nacionalidades. Apresentamos uma descrição do meio físico, bem como resultados relevantes da biodiversidade aquática, com ênfase em algas, peixes, répteis e mamíferos. A contribuição mais notável do livro, além da descrição ecológica do ecossistema, é a descrição das lições aprendidas que surgiram a partir de experiências locais sobre elaboração participativa de ferramentas para a gestão dos recursos aquáticos presentes nesta bacia

Alteraciones Biomecánicas Articulares en la Obesidad

Osteoarthrosis of joints that support body weight in the obese are very common, having altered biomechanics and having to withstand high weights above the normal resistance of the tissues. Previous pathologies and/or associated with obesity, produce structural joint alterations, causing a rapid evolution to articular cartilage destruction, leading to aggravation of osteoarthritis, limiting the functionality of the affected body segment. Treatment of overweight decreases the tensional forces at the articular cartilage and therefore improves the clinical symptoms, which can be inferred that should always be treated initially the problem of obesity, and the plan the appropriate surgical treatment. We consider that proper management of these patients should always be multidisciplinary. In this review we aim to prove the harmful effects of excess weight-bearing joints in the body weight: lumbosacral spine, hips, knees and ankles.La osteoartrosis en el obeso a nivel de las articulaciones que soportan el peso del cuerpo, es frecuente, por alterarse su biomecánica y tener que soportar grandes tensiones por encima de la resistencia normal de los tejidos. Patologías previas y/o asociadas a la obesidad, producen mala estructuración de las articulaciones estudiadas, lo que provocaría una acelerada evolución de la destrucción del cartílago articular, con el consiguiente agravamiento de la artrosis, limitando la funcionalidad del segmento corporal afectado. El tratamiento del sobrepeso disminuye las fuerzas de tensión a nivel del cartílago articular y por consiguiente mejora la sintomatología clínica, lo que permite inferir que debe siempre tratarse inicialmente la obesidad, para después planificar el tratamiento quirúrgico que corresponda. Debemos considerar que el manejo adecuado de éste tipo de pacientes debe ser siempre multidisciplinario. En la presente revisión pretendemos demostrar el efecto nocivo del sobrepeso en las articulaciones que soportan el peso corporal: columna lumbo-sacra, caderas, rodillas y tobillos

Prediction of enteric methane emissions by sheep using an intercontinental database

Enteric methane (CH4) emissions from sheep contribute to global greenhouse gas emissions from livestock. However, as already available for dairy and beef cattle, empirical models are needed to predict CH4 emissions from sheep for accounting purposes. The objectives of this study were to: 1) collate an intercontinental database of enteric CH4 emissions from individual sheep; 2) identify the key variables for predicting enteric sheep CH4 absolute production (g/d per animal) and yield [g/kg dry matter intake (DMI)] and their respective relationships; and 3) develop and cross-validate global equations as well as the potential need for age-, diet-, or climatic region-specific equations. The refined intercontinental database included 2,135 individual animal data from 13 countries. Linear CH4 prediction models were developed by incrementally adding variables. A universal CH4 production equation using only DMI led to a root mean square prediction error (RMSPE, % of observed mean) of 25.4% and an RMSPE-standard deviation ratio (RSR) of 0.69. Universal equations that, in addition to DMI, also included body weight (DMI + BW), and organic matter digestibility (DMI + OMD + BW) improved the prediction performance further (RSR, 0.62 and 0.60), whereas diet composition variables had negligible effects. These universal equations had lower prediction error than the extant IPCC 2019 equations. Developing age-specific models for adult sheep (>1-year-old) including DMI alone (RSR = 0.66) or in combination with rumen propionate molar proportion (for research of more refined purposes) substantially improved prediction performance (RSR = 0.57) on a smaller dataset. On the contrary, for young sheep (<1-year-old), the universal models could be applied, instead of age-specific models, if DMI and BW were included. Universal models showed similar prediction performances to the diet- and region-specific models. However, optimal prediction equations led to different regression coefficients (i.e. intercepts and slopes) for universal, age-specific, diet-specific, and region-specific models with predictive implications. Equations for CH4 yield led to low prediction performances, with DMI being negatively and BW and OMD positively correlated with CH4 yield. In conclusion, predicting sheep CH4 production requires information on DMI and prediction accuracy will improve national and global inventories if separate equations for young and adult sheep are used with the additional variables BW, OMD and rumen propionate proportion. Appropriate universal equations can be used to predict CH4 production from sheep across different diets and climatic conditions

Prediction of enteric methane emissions by sheep using an intercontinental database

Enteric methane (CH4) emissions from sheep contribute to global greenhouse gas emissions from livestock. However, as already available for dairy and beef cattle, empirical models are needed to predict CH4 emissions from sheep for accounting purposes. The objectives of this study were to: 1) collate an intercontinental database of enteric CH4 emissions from individual sheep; 2) identify the key variables for predicting enteric sheep CH4 absolute production (g/d per animal) and yield [g/kg dry matter intake (DMI)] and their respective relationships; and 3) develop and cross-validate global equations as well as the potential need for age-, diet-, or climatic region-specific equations. The refined intercontinental database included 2,135 individual animal data from 13 countries. Linear CH4 prediction models were developed by incrementally adding variables. A universal CH4 production equation using only DMI led to a root mean square prediction error (RMSPE, % of observed mean) of 25.4% and an RMSPE-standard deviation ratio (RSR) of 0.69. Universal equations that, in addition to DMI, also included body weight (DMI + BW), and organic matter digestibility (DMI + OMD + BW) improved the prediction performance further (RSR, 0.62 and 0.60), whereas diet composition variables had negligible effects. These universal equations had lower prediction error than the extant IPCC 2019 equations. Developing age-specific models for adult sheep (>1-year-old) including DMI alone (RSR = 0.66) or in combination with rumen propionate molar proportion (for research of more refined purposes) substantially improved prediction performance (RSR = 0.57) on a smaller dataset. On the contrary, for young sheep (<1-year-old), the universal models could be applied, instead of age-specific models, if DMI and BW were included. Universal models showed similar prediction performances to the diet- and region-specific models. However, optimal prediction equations led to different regression coefficients (i.e. intercepts and slopes) for universal, age-specific, diet-specific, and region-specific models with predictive implications. Equations for CH4 yield led to low prediction performances, with DMI being negatively and BW and OMD positively correlated with CH4 yield. In conclusion, predicting sheep CH4 production requires information on DMI and prediction accuracy will improve national and global inventories if separate equations for young and adult sheep are used with the additional variables BW, OMD and rumen propionate proportion. Appropriate universal equations can be used to predict CH4 production from sheep across different diets and climatic conditions

Prediction of enteric methane emissions by sheep using an intercontinental database

Enteric methane (CH4) emissions from sheep contribute to global greenhouse gas emissions from livestock. However, as already available for dairy and beef cattle, empirical models are needed to predict CH4 emissions from sheep for accounting purposes. The objectives of this study were to: 1) collate an intercontinental database of enteric CH4 emissions from individual sheep; 2) identify the key variables for predicting enteric sheep CH4 absolute production (g/d per animal) and yield [g/kg dry matter intake (DMI)] and their respective relationships; and 3) develop and cross-validate global equations as well as the potential need for age-, diet-, or climatic region-specific equations. The refined intercontinental database included 2,135 individual animal data from 13 countries. Linear CH4 prediction models were developed by incrementally adding variables. A universal CH4 production equation using only DMI led to a root mean square prediction error (RMSPE, % of observed mean) of 25.4% and an RMSPE-standard deviation ratio (RSR) of 0.69. Universal equations that, in addition to DMI, also included body weight (DMI + BW), and organic matter digestibility (DMI + OMD + BW) improved the prediction performance further (RSR, 0.62 and 0.60), whereas diet composition variables had negligible effects. These universal equations had lower prediction error than the extant IPCC 2019 equations. Developing age-specific models for adult sheep (>1-year-old) including DMI alone (RSR = 0.66) or in combination with rumen propionate molar proportion (for research of more refined purposes) substantially improved prediction performance (RSR = 0.57) on a smaller dataset. On the contrary, for young sheep (<1-year-old), the universal models could be applied, instead of age-specific models, if DMI and BW were included. Universal models showed similar prediction performances to the diet- and region-specific models. However, optimal prediction equations led to different regression coefficients (i.e. intercepts and slopes) for universal, age-specific, diet-specific, and region-specific models with predictive implications. Equations for CH4 yield led to low prediction performances, with DMI being negatively and BW and OMD positively correlated with CH4 yield. In conclusion, predicting sheep CH4 production requires information on DMI and prediction accuracy will improve national and global inventories if separate equations for young and adult sheep are used with the additional variables BW, OMD and rumen propionate proportion. Appropriate universal equations can be used to predict CH4 production from sheep across different diets and climatic conditions

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