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

The impact of maternal body mass index on pelvic floor during labor and after childbirth, and a new anesthetic approach for repair of perineal lacerations

Objectives: This thesis aimed to assess the impact of maternal body mass index (BMI) on pelvic floor during labor and focusing on pelvic floor function following an anal sphincter injury (OASI). Additionally, the objective was to design a study protocol for a randomized controlled trial (RCT) with the objective to evaluate the impact of supplementary anesthesia during the examination and repair of obstetric perineal lacerations. Material and Methods: Study I was an observational prospective cohort study, conducted at the maternity ward Linköping University Hospital, including 207 primiparous women in the active phase of labor. Transperineal ultrasound was used for measurement of the anovaginal distance (AVD) during active phase of labor, with AVD measurements analyzed in relation to the women's BMI groups. Study II and III were nationwide Swedish register studies, including 6595 women with a first time vaginal birth complicated by an OASI. Data was sourced from the Swedish Perineal Laceration Register (PLR), based on medical records and patient reported outcome measurements (PROM). Women were categorized by BMI, and analyses were performed on PROM data at the 8 week follow-up (Study II), and at the 12 month follow-up (Study III), after an OASI. Study IV, a study protocol for a RCT, with parallel groups. Women who undergo examination and repair of obstetric perineal lacerations (grade I and II) are randomized into two arms (1:1); analgesia with pudendal nerve block (PNB) with Ropivacaine®-the PNB group or analgesia with PNB in combination with patient-controlled sedation (PCS) with propofol, the PCS group. Results: Obese women exhibited a higher AVD compared to normal weight women. The mean AVD was 25 mm for primiparous women in the active phase of labor. Overweight and obese women reported fewer wound complications than normal weight women at 8 weeks postpartum. Additionally, overweight and obese women had a lower risk of anal incontinence (AI) at 8 weeks after an OASI compared to normal weight counterparts. However, at 12 months after an OASI, the risk of AI was comparable across BMI groups. Urinary incontinence (UI) was more prevalent among overweight and obese women, with a higher risk of UI both at 8 weeks and 12 months after an OASI compared to normal weight women. Overweight and obese women had a lower risk of reporting dyspareunia at 12 months after an OASI compared to normal weight women. Results from the ongoing RCT are pending. Conclusions: Differences in the AVD during active phase of labor were observed between women with normal weight and those who were overweight or obese. The higher AVD in obese women compared to normal weight women may indicate a valuable anatomical distinction that could be protective for pelvic floor muscles vulnerable during labor. Furthermore, women sustaining an OASI after their first vaginal birth reported distinct complications at 8 weeks and 12 months postpartum based on BMI. Various explanations may underlie these differences in reported complications, including the hypothesis that women with overweight and obesity may experience less extensive involvement of other pelvic floor muscles and nerves, leading to a reduced risk of AI and dyspareunia during the initial postpartum year. Overweight and obese women demonstrated a lower risk of AI and wound complications at 8 weeks, as well as a lower risk of dyspareunia 12 months after a first time vaginal delivery complicated by an OASI. However, the risk of UI was higher among overweight and obese women at both 8 weeks and at 12 months after a first-time vaginal delivery complicated by an OASI. The divergence in complications and symptoms among women in different BMI groups during the initial postpartum year following an OASI underscores the importance of tailored postpartum care, necessitating to individualize advice and follow-ups

Maternal Body Mass Index and Anovaginal Distance in Active Phase of Term Labor

Introduction. To evaluate if there was a difference in the anovaginal distance (AVD) measured by transperineal ultrasound between obese and normal weight women. Material and Methods. A prospective observational study including 207 primiparous women at term in first stage of labor. Transperineal ultrasound with a vaginal probe was used to measure the AVD. Maternal, pregnancy, and delivery characteristics potentially associated with perineal thickness were extracted from womans medical records. The participants were divided into three BMI groups based on maternal weight in early pregnancy: normal weight (BMI amp;lt; 25), overweight (BMI 25-29.9), and obesity (BMI amp;gt;= 30). Obese and overweight women were compared with normal weight women regarding the AVD. Results. The mean AVD was 24.3, 24.9, and 27.0 mm in the normal weight, overweight, and obesity group, respectively. There were no group differences in background characteristics. The AVD was significantly longer in obese women compared with normal weight women (p = 0.018). Conclusions. The observed longer AVD in obese women might be protective of the anal sphincter complex, explaining lower rates of anal sphincter injuries in this group. Further studies are indicated to evaluate whether the length of the AVD plays a role in the risk assessment of obstetric anal sphincter injury

Interobserver agreement in perineal ultrasound measurement of the anovaginal distance : a methodological study

Objective outcome measures of the extent of laceration at delivery are needed. In this study we evaluated and describe here a method for learning perineal ultrasound measurement of the anovaginal distance (AVD). The learning period needed for examiners proficient in vaginal ultrasound examination and the interobserver agreement after reaching proficiency in AVD measurement were determined. The hypothesis was that the method is feasible to learn and reproducible for use in further research. The method was taught by an examiner experienced in perineal ultrasonography. The distance between the mucosal margin of the internal anal sphincter was measured with a vaginal probe. The studied examiners measured the AVD until similar results (+/- 5 mm) were achieved. The AVD in 40 women was then measured and documented by two examiners who were blinded to each others results. Interobserver agreement was calculated using the kappa score. Examiners with previous experience in vaginal ultrasonography had learned the method after performing five sets of comeasurements. The AVD measurements after the learning period showed almost perfect agreement (kappa = 0.87) between the examiners. The method for perineal ultrasound measurement of AVD was learned quickly with high interobserver agreement. The method is feasible to learn and reproducible for use in further research

Body mass index and complications after obstetric anal sphincter injury, 8 weeks postpartum

Introduction and hypothesis The impact of body mass index (BMI) on pelvic floor recovery after an obstetric anal sphincter injury (OASI) is unclear. The aim of this study was to evaluate the hypothesis that urinary incontinence (UI) and anal incontinence (AI) are more common in overweight and obese women than in normal-weight women 8 weeks postpartum in women with OASI. Methods A population-based cohort study including 6,595 primiparous women, with an OASI, delivered between 2014 and 2019. Exposure and questionnaire data were retrieved from the Swedish Perineal Laceration Registry. Uni- and multivariate analyses were used to compare normal-weight (BMI &amp;lt;= 24.9, reference), overweight (25.0-29.9), and obese (&amp;gt;= 30) women with regard to UI and AI at 8 weeks post-partum. Results Multivariate analyses showed an increased risk for urinary incontinence (OR 1.54, 95% CI 1.27-1.87) among overweight women as well as among obese women (OR 1.72, 95% CI 1.32-2.24). In contrast to our hypothesis, both overweight women (OR 0.68, 95% CI 0.56-0.83) and obese women (OR 0.65, 95% CI 0.49-0.87) were at a decreased risk for any gas and/or faecal incontinence after adjustment to possible confounding factors. The absolute rate of AI was 40.1% among normal-weight women, 34.2% among overweight women, and 29.1% in the obese group. Conclusions Urinary incontinence is more common, whereas AI is less common among overweight and obese women than in primiparous women with a BMI &amp;lt;24.9, 8 weeks after an OASI. The new finding, that overweight women report less AI than normal-weight women, merits further study.Funding Agencies|Linkoping University; County Council of Ostergotland; Linkoping University, Sweden (ALF grants, Region Ostergotland)</p

Complications 8 weeks after an obstetric second-degree perineal laceration in relation to body mass index

Introduction and hypothesisHow body mass index (BMI) affects pelvic floor function after a second-degree perineal laceration is unknown. The hypothesis of this study is that pelvic floor dysfunction and complications after an obstetric second-degree perineal laceration are more common in women with a higher BMI 8 weeks postpartum.MethodsThis register-based cohort study includes 10,876 primiparous women with an obstetric second-degree perineal laceration between 2014 and 2021. Data were retrieved from the Swedish Perineal Laceration Registry. Outcomes in relation to maternal BMI were urinary incontinence (UI), anal incontinence (AI) and common complications attributable to the laceration. Uni- and multivariate logistic regressions were used for comparison between normal weight (BMI &amp;lt; 24.9, reference), overweight (25.0-29.9) and obese (&amp; GE; 30) women.ResultsMultivariate analyses showed an increased risk for UI in both overweight and obese women compared to normal-weight women 8 weeks after a second-degree perineal laceration with an adjusted odds ratio (aOR) of 1.21 (CI 1.02-1.44) and 1.27 (CI 1.13-1.58) respectively. Overweight and obese women had a decreased risk for AI (aOR 0.81, CI 0.68-0.96; aOR 0.72, CI 0.57-0.90 respectively) compared with normal-weight women. No significant differences were found in the univariate analyses over BMI strata concerning complications after perineal laceration.ConclusionsPrimiparous overweight and obese women report less AI and more UI than normal-weight women 8 weeks after a second-degree perineal laceration. No differences were found regarding complications. These findings are new and merit further study to find potential preventive factors and interventions after a second-degree perineal laceration.Funding Agencies|Linkoping University; Region Ostergotland, ALF grants, Region Ostergotland, Sweden</p

A step towards better audit : The Robson Ten Group classification system for outcomes other than cesarean section

Introduction The Robson Ten Group Classification System is widely used for the audit of cesarean section (CS) rates. However, CS rate alone is a poor quality indicator and should be balanced with other obstetric endpoints. The aim of this study was to evaluate whether Swedish national data on obstetric outcomes other than CS, stratified by the Robson classification, could be analyzed in a useful way. Material and methods All births in Sweden from 2017 through 2020 recorded in the nationwide Swedish Pregnancy Register were categorized using the Robson classification with subdivision of some groups. Five outcomes were explored: CS, operative vaginal delivery, postpartum hemorrhage, obstetric anal sphincter injury (OASIS) and Apgar score The largest Robson groups were nulliparous and multiparous women with single-term cephalic pregnancies, unscarred uterus and spontaneous labor. Intrapartum CS rates were highest for multiple pregnancies, women with induced labor after previous CS, and nulliparous women with induced labor. Nulliparous women and multiparous women with a previous CS with attempted vaginal birth had the highest operative vaginal delivery and OASIS rates. The postpartum hemorrhage rate was highest for multiple pregnancies and transverse lie, followed by prelabor CS in nulliparous and multiparous women with single-term cephalic pregnancies and unscarred uterus. The highest rates of Apgar score &amp;lt;7 at 5 minute were observed in preterm deliveries, multiple pregnancies, transverse lie and breech presentation. The largest contribution to the total CS rate was made by women with previous CS delivered by prelabor CS, and nulliparous women with induced or spontaneous labor. The largest contribution to all other outcomes was made by nulliparous women with spontaneous or induced labor and, notably, multiparous women with spontaneous labor and unscarred uterus. Conclusions The Robson classification provides a useful framework for analyzing CS rates along with rates of operative vaginal delivery, OASIS, postpartum hemorrhage and low Apgar score. Parallel interpretation of several outcomes allows a systematic and multidimensional audit, helpful for families and healthcare professionals, and can be used for comparisons, assessment of trends and subpopulations