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

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

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

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Use of Ultrasonography in Clarifying the Etiology of Anal Pain

Introduction: Anal pain is defined as pain originating from the anal canal or the perianal area that can be attributed to a variety of medical problems. The current study's aim was to evaluate the role of combined endoanal, transperineal, and in married women, transvaginal ultrasound in clarifying the etiology of anal pain among our patient study group. Methodology: A total of 180 patients presented to our radiology department complaining of anal pain and were examined using transperineal, endoanal, and in women, transvaginal ultrasound aided with three-dimensional capability. The final diagnosis was reached, according to the surgical results and the histopathology reports in cases diagnosed with anorectal neoplasms and perianal masses. Results: A total of 100 patients were diagnosed with perianal fistulas. Twenty-five cases presented with anal abscesses. In four cases, pilonidal sinus extended to the perianal spaces. Three cases had hiradenitis suppurativa, 13 cases showed occult anal sphincter defects, two cases had anorectal neoplasms, and one case was diagnosed with soft tissue ependymoma overlying the coccyx. Three cases were diagnosed with perianal soft tissue masses. One case was detected with recto vaginal fistulas, 10 cases showed thick internal anal sphincter, two cases had perianal cysts, and one case had perianal hematoma. Two cases showed hemorrhage in Douglas' pouch, and one case had pelvic collection sequelae of perforated pelvic appendicitis. Three cases had pelvic endometriosis; one case was detected with missed contraceptive device in the rectum. Three cases were diagnosed with prostatitis and two cases with prostatic abscesses. Two cases had prostatic carcinoma and one case had prostatic sarcoma. Conclusion: The combined approaches of endoanal, transperineal, and in women, transvaginal ultrasound aided with three-dimensional capability proved highly valuable in clarifying the etiology of anal pain in our study group

Significance and Impact of the Intersphincteric Plane Sepsis in the Management of the Perianal Sepsis: Ultrasound Study

Background The intersphincteric plane (ISP) is a potential space between the external and the internal anal sphincters. About 90% of the perianal sepsis is caused by an obstruction of the ducts of anal glands with subsequent secondary bacterial infection. The imaging modalities used to diagnose perianal sepsis are the ultrasound via endoanal and transperineal routes and magnetic resonance imaging. Objective  The study aimed to identify the various patterns of the ISP sepsis and their incidence among our study group and to clarify the significance of ISP in the pathogenesis of anorectal abscesses and various types of perianal fistula tracts, to optimize the surgical management. Methods Retrospective descriptive study in which 57 patients with an ISP sepsis were evaluated with full medical history, clinical exam, and ultrasound; the final diagnosis was based on combining the results of ultrasound, digital rectal examination under anesthesia, and the operative results. Results The current study showed many patterns of the ISP sepsis and estimated the incidence of each pattern among our study group; such patterns could be fistula tracts, sinus tracts, abscesses, intersphincteric abscess with supralevator extension, sinus with abscess formation, fistula with abscess formation, distension of the ISP with free pus, and other complex patterns like horse abscess, abscess with transsphincteric sinus, and ISP fistula/sinus with transsphincteric branches. Conclusion Understanding the role of the ISP in the pathogenesis of anorectal abscesses and perianal fistula tracts can help in reaching the optimum way of management

Inguinoscrotal and inguinolabial swelling in infancy: Role of ultrasound

Objectives: Inguinoscrotal and inguinolabial swellings are common findings in infancy. In this study, color Doppler ultrasonography was used to identify the different etiologies of inguinoscrotal and inguinolabial swelling, thus helping to decide on the optimal management. Patients and methods: 150 infants with a history of intermittent swelling or presenting with a palpable swelling in the inguinoscrotal or inguinolabial region were included in the study. All patients were subjected to color Doppler ultrasound examination in supine position. Results: Out of 135 male infants with inguinoscrotal swelling 119 were found to have chronic, 16 acute and 14 bilateral swelling. Out of 15 female infants, 12 were found to have chronic and 3 acute inguinolabial swelling. Conclusion: Color Doppler ultrasonography is an accurate, safe and readily available imaging modality which can be used to identify different etiologies of inguinoscrotal and inguinolabial swelling in infants

The role of three dimensional transrectal ultrasonography (3-D TRUS) and power Doppler sonography in prostatic lesions evaluation

AbstractAim of workTo evaluate the role of three dimensional (3D), two dimensional (2D) as well as power Doppler transrectal ultrasound (TRUS) in diagnosis of different prostatic lesions.Patients and methods2-D TRUS, power Doppler and Transrectal 3-D US were performed for 100 patients between April 2009 and April 2010. All patients had been examined clinically with digital rectal examination (DRE) and had serum prostatic specific antigen (PSA) level (total and free). Patient age ranges from 42 to 67years and the mean age was 55years. TRUS guided biopsies were done for 77 cases showing any of the followings: abnormal focal lesion with ultrasound, abnormal vascularity with power Doppler exam, abnormal DRE, elevated serum total PSA>4ng/ml or when the percent-free PSA is 10% or less in an outpatient setting. The results were recorded and analyzed.Results3-D TRUS was more sensitive, specific and more accurate than 2-D TRUS in detecting prostate cancer as it showed estimated sensitivity 78.9% and specificity 94.8% with total accuracy 90.9% with respect to an estimated sensitivity 63.1%, specificity 86.2% and total accuracy 80.5% with 2-D TRUS and was more accurate than 2-D ultrasound in identifying the capsular breaks with an estimated sensitivity 80% with respect to 40% with 2-D TRUS.Power Doppler showed 84.2% sensitivity in detecting prostatic cancer and was of 100% sensitivity in detecting prostatitis. 3-D TRUS was more accurate in estimating the volume of adenoma in cases of BPH with an estimated error not more than +6% with respect to an estimated error not more than +18% for 2-D TRUS.Conclusion3-D transrectal ultrasound and power Doppler sonography have specific diagnostic capabilities which added significantly to the ultrasound in detecting and staging of prostatic cancer and in the planning for management. They proved highly valuable in the diagnosis of prostatitis and 3-D TRUS was more accurate than 2-D TRUS in estimating the volume of adenomas in patients with BPH