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

Evaluation of 25-hydroxy vitamin d3 levels in patients with small uterine myomas

Background; Uterine fibroid are the most frequent benign pelvic tumors between women in reproductive period group that has multifactorial pathogenesis. Modern ideas of uterine fibroid pathogenesis have included vitamin D as a vital component. Aim and objectives; was to study the link between 25-hydroxy vitamin D3 levels in cases having small uterine myomas. Subjects and methods; This is a case-control study, was conducted at the Gynecology and Obstetrics department outpatient clinic at Al Zahraa University Hospitals, on 60 women divided into two groups: (Study group); included Thirty cases having fibroid uterus, (Control group); included Thirty women who had no fibroid uterus. Result; When compared to controls, vitamin D3 levels in cases were considerably lower. Conclusion; Vitamin D looks to be a promising and valuable anti-UF treatment. More large, well-designed randomized clinical trials are needed to look into the effectiveness of vitamin D in females with UFs of all ethnicities, especially those of color who are at higher risk of vitamin D deficiency. As a result, vitamin D may become a viable treatment choice for UF, with the added benefit of its pleiotropic impact

Evaluation of risk factors of ventilator associated pneumonia on outcome of acute exacerbation of chronic obstructive pulmonary disease

Background: Ventilator associated pneumonia (VAP) remains an area of active clinical research with little data about effect of (VAP) on outcome among patients with acute exacerbation of chronic obstructive pulmonary disease. Materials and methods: A prospective study included patients with COPD exacerbation requiring endotracheal intubation for more than 48 h. Clinical assessment and Quantitative culture done for all patients for the occurrence of VAP. Results: Out of one hundred fifty two patients 92 patients (60.5%) were with VAP diagnosis. Their mean age was 56.1 ± 15.02 (38 cases developed early while 54 cases developed late VAP). Forty eight cases were discharged (54%) while 44 cases (46%) died. In comparing mean age of both groups 45.08 ± 15.52 and 57.41 ± 16.34 with P value 0.003. Prolonged use of antibiotics, re-intubation and steroid use are possible risk factors for VAP with significant P values 0.03, 0.001, 0.05 respectively. Age above vs. below 60 showed adjusted odds ratio 5.33; 95% confidence interval 1.59–7.83 with P value 0.007. Early vs. late VAP, and prolonged use of antibiotics vs. none showed significant odds ratio 0.32; 95% CI 0.13–0.76, odds ratio 2.85; 95% CI 1.07–7.59 with P values 0.01, 0.04 respectively. Conclusions: Old age, late onset VAP, re-intubation and prolonged use of antibiotics were predictors of mortality in VAP patients with AECOPD

Ultrasonographic evaluation of lower uterine segment thickness in pregnant women with previous cesarean section

Objective: To evaluate the accuracy of prenatal sonography (U/S) in determining the lower uterine segment (LUS) thickness in women with previous cesarean section (CS) and to assess its usefulness in predicting the risk of uterine rupture during a trial of vaginal birth. Design: Prospective controlled study. Setting: Suzan Mubarak University Hospital. Subjects: One hundred and fifty pregnant women with singleton pregnancies, with the gestational age between 37 and 40weeks were recruited for the study during the period from October 2007 to June 2008. The recruited patients were allocated into three equal groups. Group I included those with previous one low transverse CS and with the history of successful VBAC. Group II included those without the history of successful VBAC. Group III included those without the previous history of CS (control group). Interventions: The recruited patients were subjected to clinical and U/S evaluations. The LUS thickness was evaluated by both transabdominal (TA) and transvaginal (TV) U/S. Women were categorized for the mode of delivery into either trial of VBAC or elective repeated CS (ERCS). All the intraoperative findings were correlated with U/S findings. Main outcome measures: Accuracy of US in predicting uterine dehiscence. Results: Mean LUS thickness was lower among the study groups than in the control group. The present study reported 14 (28%) cases of dehiscent scar. Mean LUS thickness was significantly lower among the dehiscence groups (1.7±0.7mm) than in the non-dehiscence groups (2.6±0.8mm) (P⩽0.01). At a cutoff value of 2.5mm, the sensitivity, specificity, and positive and negative predictive values were 90.9%, 84%, 71.4%, and 95.5%, respectively, using (TA) U/S and 81.8%, 84%, 69.2%, and 91.3%, respectively, using (TV) U/S. At LUS thickness ⩽2.5mm, there was a higher risk for dehiscence than those with a thickness of more than 2.5mm. Conclusions: If the thickness of the LUS is more than 2.5mm, the possibility of dehiscence during the subsequent trials of labor is very small and a safe vaginal delivery can be achieved. Further large studies are recommended

Prevalence of childhood and adolescence epilepsy in Upper Egypt (desert areas)

Abstract Background A high prevalence of epilepsy in children is frequently found in developing countries. Objective This study aimed to determine the prevalence and clinical pattern of childhood and adolescence epilepsy in Upper Egypt. Methods This is a door-to-door study conducted on all inhabitants < 18 years in Al Kharga district and Al Qusier city (36,195 subjects). The study was conducted through two stages; every stage consisted of two phases (screening and diagnostic). Results Lifetime prevalence of childhood and adolescence epilepsy (children < 18 years) in Upper Egypt was 9.7/1000, with higher prevalence among children < 12 years (10.8/1000) than adolescents (7.2/1000). The age-specific prevalence was highest in early childhood (12.01/1000) and least at adolescence (7.2/1000). More than half of the patients (59.4%) had idiopathic epilepsy. The most frequent etiology for structural/metabolic epilepsy was perinatal complications, particularly in infancy, followed by central nervous system (CNS) infections, in childhood, and post-traumatic epilepsy in adolescence. Partial seizures were more frequent in infancy, while generalized seizures were more frequent in late childhood and adolescence. Generalized tonic-clonic seizures (GTCS) were the most frequent type of seizures. Conclusion Prevalence of childhood and adolescence epilepsy in Upper Egypt was not so much different from other developing countries. Idiopathic epilepsy was more prevalent than structural/metabolic cases. Perinatal complications, CNS infections, and head injury were the most frequent etiologies, and generalized tonic-clonic seizures were the most frequent seizure type

Colonoscopy screening for colorectal cancer in Egypt: a nationwide cross-sectional study

Abstract Background Current guidelines advocate for colorectal cancer (CRC) screening in adults who are at risk by using direct visualization methods such as colonoscopy. However, in Egypt, there is a paucity of data regarding the current practice of colonoscopy screening. Moreover, more information is needed about the knowledge and attitudes of potential participants regarding the procedure and possible barriers that can limit their participation. Methods We conducted a nationwide cross-sectional study using an interview-based survey of patients aged 45 years or above who presented to outpatient clinics of nine university hospitals throughout Egypt. Participants were surveyed to assess their compliance with CRC colonoscopy screening guidelines, their knowledge of and attitude towards colonoscopy screening, and their perspective on potential barriers to colonoscopy screening. Results A total of 1,453 participants responded to our survey in the nine study centers. Only a minority of participants (2.3%) were referred for CRC screening. Referral rates were higher among those who knew someone with a history of CRC (5.3% vs 1.5%, p < 0.001) or had a discussion with their physician about CRC (25.8% vs 0.7%, p < 0.001). Few responders (3.2%) had good knowledge regarding CRC screening. After introducing the concept of CRC screening to all participants, most patients (66.7%) showed a positive attitude towards having the procedure. Financial burden and fear of results were the two most frequently cited barriers to undergoing CRC screening (81.1%; and 60.1%, respecteively). Conclusions Despite the positive attitude, there is insufficient knowledge about CRC screening among eligible participants in Egypt. This has probably contributed to low compliance with current CRC screening guidelines and needs to be addressed at the national level