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

Salvage surgery for recurrent or persistent tumour after radical (chemo)radiotherapy for locally advanced non-small cell lung cancer: a systematic review

Background: Once recurrent or persistent locoregional tumour after radical chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC) is identified, few curative-intent treatment options are available. Selected patients might benefit from surgical salvage. We performed a systematic review of the available literature for this emerging treatment option. Methods: A systematic literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Publications about persistent or (locoregional) recurrent disease after radical/definitive CRT for locally advanced non-small cell lung cancer were identified. Results: Eight full papers were found, representing 158 patients. All were retrospective series and data were heterogeneous: definition and indication for salvage surgery varied and the median time from radiotherapy to surgery was 4.1–33   months. Complete resection (R0) was achieved in 85–100%, with vital tumour in 61–100%. A large number of pneumonectomies were performed, and additional structures were often resected. Where reported, 90-day mortality was 0–11.4%. Reported survival metrics varied but included median overall survival 9–46   months and 5-year survival 20–75%. Conclusion: There are limited, low-level, heterogeneous data in support of salvage surgery after radical CRT. Based on this, perioperative mortality appears acceptable and long-term survival is possible in (highly) selected patients. In suitable patients (fit, no distant metastases, tumour appears completely resectable and preferably with confirmed viable tumour), this treatment option should be discussed in an experienced multidisciplinary lung cancer team

School-Based Physical Activity Interventions in Prevocational Adolescents: A Systematic Review and Meta-Analyses

Purpose: Literature detailing the effectiveness of school-based physical activity promotion in- terventions in prevocational adolescents was reviewed to identify effective intervention characteristics. Methods: The search strategy assessed studies against inclusion criteria study design, study population, school setting, language, and construct. The risk of bias of the included studies was assessed, and extractions were made of the physical activity (PA) level outcome measures and intervention characteristics regarding organizational, social, and content features. A meta-analysis was conducted to determine the overall effect of the interventions on the PA level. Identification of effective intervention characteristics was done by subgroup analyses. Meta-regression analysis was performed with PA level as dependent variable and intervention characteristics as covariates.  Results: A total of 40 eligible studies was included for meta-analyses. Among the included studies, the overall intervention effect on increasing the PA level of prevocational adolescents was weak (standardized mean difference [SMD] .19, 95% confidence interval [CI] .12e.27). Intervention characteristics that improve the effect size to a moderate level were intracurricular PA (SMD .43, 95% CI .19e.68), involving school staff in an intracurricular intervention (SMD .37, 95% CI .16e.58) and a tailored intracurricular intervention (SMD .35, 95% CI .13e.58). Meta-regression analysis confirmed PA as a positive predictor. Conclusions: The effect of a school-based PA intervention was small to moderate. A sensible choice in the assembly of a multicomponent school-based PA intervention increases the effectiveness considerably. Physical education teachers, school administrators, and policy makers should consider organizational (intracurriculum, short and medium duration), personal (tailoring, participation), social (school staff) and content (PA) determinants

Salvage surgery for local recurrence after stereotactic body radiotherapy for early stage non-small cell lung cancer: a systematic review

Introduction: Stereotactic body (or ablative) radiotherapy (SBRT/SABR) is now a guideline-recommended treatment for medically inoperable patients with peripherally-located, stage I non-small cell lung cancer (NSCLC), and for medically operable patients who decline surgery. The 5-year local failure rate after SBRT is about 10% and in highly selected patients, surgery has been used as a salvage therapy. We performed a systematic review to address the feasibility, safety, and outcome of salvage surgery for locally recurrent early stage NSCLC after SBRT. Methods: A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, Embase and Cochrane databases were searched and two authors independently assessed the articles. A total of seven eligible articles were identified. Results: All seven articles were retrospective case series, representing a total of 47 patients. Surgery was completed in all patients. Where reported in sufficient detail, morbidity (four studies) was between 29 and 50% (series of two patients) and 90-day mortality (six studies) was between 0% (four studies) and 11% ( n = 1, disease progression). Median ( n = 5)/mean ( n = 1) reported or calculated follow ups were 7–54.5/17.3 months. Median overall survival was reported in three studies and ranged between 13.6–82.7 months. Crude survival in three others was 2–35 months. Conclusion: Limited, low-level evidence prevents firm conclusions, but based on the existing data, salvage surgery after local recurrence of NSCLC following SBRT appears technically feasible, with acceptable morbidity and mortality in appropriately selected and counselled patients who are fit enough and who accept the risks (level of evidence 4, strength of recommendation C)

Appendix_1 – Supplemental material for Salvage surgery for local recurrence after stereotactic body radiotherapy for early stage non-small cell lung cancer: a systematic review

<p>Supplemental material, Appendix_1 for Salvage surgery for local recurrence after stereotactic body radiotherapy for early stage non-small cell lung cancer: a systematic review by Chris Dickhoff, Pedro M. Rodriguez Schaap, Rene H. J. Otten, Martijn W. Heymans, David J. Heineman and Max Dahele in Therapeutic Advances in Medical Oncology</p