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

CT angiography collateral scoring: Correlation with DWI infarct size in proximal middle cerebral artery occlusion stroke within 12 h onset

Purpose: It had been postulated that intra-cranial collateral flow can maintain penumbra and limit infarct growth in acute stroke patients. CT angiography is a frequently performed non-invasive modality for evaluation of intracranial collaterals. In this study, we sought to assess whether there is correlation between degree of collateral circulation as determined by CTA and admission DWI infarct size. Patients and methods: We analyzed thirty patients with proximal middle cerebral artery occlusion within 12 h of onset. The grade of CTA intra-cranial collaterals was evaluated using Maas system and modified Tan scale. Admission DWI infarct volumes were calculated. Spearman correlation coefficient was used to assess relationship between CTA collateral score (CS) and DWI infarct size. Results: Direct inverse correlation was found between CTA CS and infarct volume (r = −0.5, p = 0.001). ROC analysis showed CS as a good discriminator of DWI volume (AUC = 0.8, p = 0.001). Small infarct size was a significant predictor of good CS (p = 0.01). Conclusions: In patients with major acute MCA occlusion strokes, CTA collateral grading is significantly correlated with admission DWI size. This finding may be relevant for clinical practice and helpful for guiding treatment decision and predicting clinical outcome

Assessment of breast lesions using BI-RADS US lexicon in mammographically dense breasts (ACR categories 3 and 4) with histopathological correlation

Purpose: To assess the role of ultrasonography in detection, and categorization of breast lesions in patients with mammographically dense breasts with the use of the BI-RADS US lexicon. Patients and methods: This study included 60 female patients (age range from 20 to 80 years, mean 38.3 ± 11.9) complaining of mastalgia, breast lump or nipple discharge with mammographically dense breast tissue. Breast ultrasound was performed to all patients with a 12-MHz linear-array transducer. Sonographic findings of the breast lesions were described and categorized according to the BI-RADS US assessment categories. Biopsy procedures were performed for the sonographically detected breast lesions with histopathological examination of the biopsied tissue. Results: The main complaint was palpable breast mass encountered in 25 patients, 12 of mastalgia, 4 of nipple discharge, 12 patients were on screening and 7 on follow up. 36 patients were categorized as ACR 3 and 24 ACR 4 regarding the density of their breasts in mammography. Mammography revealed no abnormalities in 31 patients and abnormal in 29 patients, the commonest mammographic finding was breast mass, detected in 19 patients. Ultrasound detected breast lesions in 56 (93.3%) out of 60 patients. BI-RADS US category 2 was the most common category representing 36.7%. Ultrasonography had a diagnostic reliability for differentiating between benign and malignant breast lesions (p = 0.869) in mammographically dense breasts while mammography was diagnostically unreliable (p = 0.045). Conclusion: Ultrasound is a mandatory adjunct to mammography in detection and characterization of breast lesions in mammographically dense breasts

Magnetic resonance cholangiopancreatography (MRCP) evaluation of post-laparoscopic cholecystectomy biliary complications using breath-held 3D steady state free precession (SSFP) sequence

Purpose: To assess the role of breath-held 3D-SSFP MRCP in evaluation of post-laparoscopic cholecystectomy biliary complications. Patients and methods: This study included 29 patients with post-laparoscopic cholecystectomy symptoms like abdominal pain, vomiting or jaundice during period from March 2013 to March 2015. The ages of patients ranged from 28 to 70 years (mean 49 ± 16 year). MRCP was performed for all patients on 1.5 tesla MRI machine with breath-held multi-slice acquisition. Both 2D and 3D MRCP were done. Results: The encountered post laparoscopic biliary complications were either major injuries like complete bile duct transection in 8 cases and bile duct ligation in 4 cases or minor injuries like partial thermal tear in 4 cases, slipped clips in 2 cases and benign strictures in 5 cases. The retained biliary stones were another complication and located either intrahepatic in 2 cases or extra-hepatic in 4 cases. 13 cases were managed by ERCP with sphincterotomy, dilatation and/or T-tube insertion. Other 13 patients were managed operatively with removal of ligature or hepaticojujenostomy and the remaining 3 patients were managed conservatively. Conclusion: The use of breath-held 3D-SSFP MRCP is essential in evaluation of post-laparoscopic cholecystectomy biliary complications and in planning for management regimens

Local staging of rectal cancer: Diagnostic potential of endorectal contrast agent and MPRs with 64-MDCT compared with the pathologic staging

Purpose: To assess the diagnostic potential of endorectal contrast agent and multiplanar reconstructed images (MPRs) with MDCT in local staging of rectal cancer compared with the pathologic staging. Patients and methods: This study included 30 patients with biopsy-proven rectal cancer (age range 18–84 years, mean 46.7 ± 19). Preoperative MDCT examinations were performed to all patients using a 64-row multidetector scanner. The examination was carried out in two steps, firstly using oral contrast agent only, secondly using endorectal contrast agent. Images were reconstructed in axial, coronal, and sagittal planes. MDCT staging was compared with pathologic staging. Results: For T-staging, MDCT using endorectal contrast was more sensitive (75.8%), specific (90%) and accurate (86.7%) than using oral contrast only (43.3%, 88.1%, 74.4%) respectively (p = 0.001). The sagittal and coronal MPRs were more sensitive, specific and accurate than the axial images with diagnostic accuracy 64.4% for axial, 75.5% for coronal, and 81.1% for sagittal MPRs. There were statistically significant differences between axial and coronal MPRs (p = 0.02), and between axial and sagittal MPRs (p = 0.002). Diagnostic accuracy for N-staging was 80%. Conclusion: 64-MDCT with endorectal contrast agent and MPRs, mainly sagittal images is a reliable accurate technique for the preoperative local staging of rectal cancer

Magnetic resonance imaging for detection of non palpable undescended testes: Diagnostic accuracy of diffusion-weighted MRI in comparison with laparoscopic findings

Purpose: The purpose of this study is to assess the value of adding diffusion-weighted sequences (DW) to routine magnetic resonance imaging (MRI) in identifying and locating nonpalpable undescended testes. Materials and methods: This prospective study included 51 patients with age ranges from 2 to 15 years presenting with non-palpable undescended testes. MRI was done using1.5 MRI machine. MRI examination included axial and coronal spin-echo T1-weighted sequence, axial and coronal fat suppressed spin-echo T2-weighted sequence and axial DWI. Images were interpreted for the presence or absence and the location of the undescended testes. Testes were recognized by their elliptical shape and hyperintensity. Testes were classified into three anatomic regions: intracanalicular, low intra-abdominal, and high intra-abdominal. Laparoscopy was used as a gold standard. Results: Conventional MRI showed a sensitivity, specificity and accuracy of 87.23%, 50% and 83% respectively. DW MRI showed a sensitivity, specificity and accuracy of 91.5%, 66.7% and 88.6% respectively. The combined usage of conventional and DW MRI yielded a sensitivity, specificity and accuracy of 95.8%, 100% and 96.2%. Conclusion: DWI especially performed at a high b value improves detection of undescended testes

Whole ureteric course delineation assessment using non contrast curved sagittal oblique reformatted CT

Purpose: To develop a standardized technique to assess delineation of the whole ureter for the evaluation of symptomatizing urologic patients. Method and materials: 2500 patients are examined using 64-MDCT. Examinations were performed with oral hydration Group I (n = 834), Group II which received IV diuretics (n = 847), or Group III which received nothing (n = 819). Curved planar reformatted images were obtained manually to obtain the entire ureter in a single coronal oblique image. The ureter was divided into 3 anatomic segments for estimating the degree of its delineation where if the segment is assessed along its whole length it is graded as satisfactory delineation, otherwise it is graded as non-proper delineation. Delineation degrees for each ureteric segment were compared. Results: Satisfactory delineation obtained with group II (51.3%) was statistically higher than other groups with p value < 0.001, with a statistical significant result (p < 0.001) as regards the delineation of ureteric segments and patients’ sex; the middle and lower third segments show satisfactory delineation in group II with 86%, while the non-proper delineation is higher in females with percentage 66.1%, and the percentage of non-proper delineation among females is least recorded in group II. Conclusion: Curved sagittal oblique reformatted image with IV diuretics allows better tracing of the whole ureteric course