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

Furen gong (福仁宮)

Exterior front of 福仁宮, Furen gong temple, founded in 1966 [1]. Name plaque of temple [2]. Interior of temple [3]. Postal address marker of temple [4]. Panorama of temple's exterior [5]. Panorama of temple's interior [6]. 360-degree video of temple's interior [7].Non UBCUnreviewedAuthor Affiliations: National Taiwan Normal University 國立臺灣師範大學, Temple University, Independent Scholar, Duke Kunshan University 昆山杜克大学FacultyGraduateUndergraduateOthe

Ziyun gong (紫雲宮)

Exterior front of 紫雲宮, Ziyun gong temple, located on the roof of a residential block [1]. Postal address marker of temple [2]. Exterior front of temple [3]. Name plaque of temple [4]. Interior of temple, with lanterns hanging from the ceiling [5]. Certificate of temple's membership in a Quan Zhen Taoist Association [6]. Name plaque of temple, featuring the year of founding in 癸酉 [7, 8]. Panorama of residential building where the temple is located [9]. Panorama of temple's exterior [10]. Panorama of temple's interior [11]. 360-degree of temple's interior [12].Non UBCUnreviewedAuthor Affiliations: National Taiwan Normal University 國立臺灣師範大學, Temple University, Independent Scholar, Duke Kunshan University 昆山杜克大学FacultyGraduateUndergraduateOthe

Unnamed tudi gong 6 (土地公)

Exterior front view [1]. Primary altar interior view [2]. Exterior panorama view [3]. Interior panorama view [4]. Interior 360 view [5].Non UBCUnreviewedAuthor Affiliations: National Taiwan Normal University 國立臺灣師範大學, Temple University, Independent Scholar, Duke Kunshan University 昆山杜克大学FacultyGraduateUndergraduateOthe

Wumufanci gong (伍母樊慈宮)

Founded in 2007. Exterior front view of 伍母樊慈宮, WuMuFanCiGong temple [1]. Primary altar of temple with a Cun Ti Bodhisattva [2]. Stone inscription of temple [3, 4]. Secondary altar of temple to the left [5]. Secondary altar of temple to the right [6]. Exterior panorama view of temple [7]. Interior panorama view of temple [8]. Interior 360 video of temple [9].Non UBCUnreviewedAuthor Affiliations: National Taiwan Normal University 國立臺灣師範大學, Temple University, Independent Scholar, Duke Kunshan University 昆山杜克大学FacultyGraduateUndergraduateOthe

Tianhedafashi gongmiao (天和大法師公廟)

Founded 2012. Exterior front of 天和大法師公廟, Tianhedafashi gongmiao Temple [1]. Name plaque of temple regards to the term of 九霄寶殿 [2]. Primary altar of temple with a Taoist deity [3]. Interior decoration of temple, with specific year of 2005 [4]. Exterior panorama of temple [5]. Interior panorama of temple [6]. Interior 360 video of temple [7].Non UBCUnreviewedAuthor Affiliations: National Taiwan Normal University 國立臺灣師範大學, Temple University, Independent Scholar, Duke Kunshan University 昆山杜克大学FacultyGraduateUndergraduateOthe

Jinbaoshan denglijun jinian gongyuan (金寶山鄧麗君紀念公園)

Exterior front view of 金寶山鄧麗君紀念公園, Jinbaoshan denglijun Jinian gongyuan site. Dedicated in 1995 [1]. Exterior view of site with stone inscription [2]. Exterior front view of site with primary altar [3]. Exterior front view of site, with oversized playable piano [4]. Exterior panoramic view of site [5, 6]. Exterior 360 view of site [7].Non UBCUnreviewedAuthor Affiliations: National Taiwan Normal University 國立臺灣師範大學, Temple University, Independent Scholar, Duke Kunshan University 昆山杜克大学FacultyGraduateUndergraduateOthe

Chengtian gong (承天宮)

Exterior front view of 承天宮, Chengtian gong temple with dragons. Founded in 1953 [1]. Exterior front view of temple with stone inscriptions [2]. Address marker of temple with dragons [3]. Exterior view of temple with stage [4]. Exterior front view of temple with dragons and stone reliefs on walls [5]. Exterior front view of temple with name sign [6]. Interior view of temple with Taoist deities and intricate carvings [7]. Interior view of temple primary altar with Taoist deities and intricate carvings [8]. Exterior front view of temple with stone inscriptions [9]. Interior panoramic view of temple with Taoist deities and intricate carvings [10]. Exterior panoramic view of temple with dragons and stone reliefs on walls [11]. Interior 360 view of temple [12].Non UBCUnreviewedAuthor Affiliations: National Taiwan Normal University 國立臺灣師範大學, Temple University, Independent Scholar, Duke Kunshan University 昆山杜克大学FacultyGraduateUndergraduateOthe

Futan gong (福潭宮)

Exterior front of 福潭宮, Futan gong temple. Founded in 1982 [1]. Stone inscription of temple on the wall [2]. Stone inscription of temple recording the donation list [3]. Interior of temple with the main deity Earth God [4]. Stone inscription of temple recording the donation list [5]. Exterior panorama view of temple [6]. Interior panorama view of temple [7]. Interior 360 Video of temple [8].Non UBCUnreviewedAuthor Affiliations: National Taiwan Normal University 國立臺灣師範大學, Temple University, Independent Scholar, Duke Kunshan University 昆山杜克大学FacultyGraduateUndergraduateOthe