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

Pediatric melioidosis in Pahang, Malaysia

Melioidosis is much less common in children than in adults. This study investigated the incidence, demographic characteristics, presenting symptoms and outcome of pediatric melioidosis in Pahang, Malaysia. This retrospective study included patients < or =18 years old with positive body fluid cultures for Burkholderia pseudomallei from January 2000 to June 2003. Data on culture results were obtained from 2 referral hospitals. The incidence of pediatric melioidosis was 0.68/100,000 population per year. Of the 13 patients identified during the study period, 10 were male; 9 were Malays, 2 were Indians and 2 were aborigines. The mean age of these patients was 9.5 +/- 5.4 years. None of the patients had a previous history of confirmed melioidosis or predisposing factors for infection. Localized melioidosis was the most common presentation (46.2%) followed by melioidosis with septic shock (38.4%). Among patients with localized melioidosis, head and neck involvement (83.3%) was the most common presentation (2 patients with cervical abscesses, 1 with submandibular abscesses and 2 with acute suppurative parotitis) and another patient had right axillary abscess. All of the patients with septic shock had pneumonia and 2 of them had multi-organ involvement. The mortality among patients with septic shock was 80% and death occurred within 24 h of admission in all cases. In contrast, no complications or death occurred among patients with localized melioidosis. Melioidosis with septic shock is less common than localized melioidosis in pediatric patients, but is associated with very high mortality

Spatiotemporal trends in the southwest monsoon wind-driven upwelling in the southwestern part of the South China Sea.

This study analyzes two wind-induced upwelling mechanisms, namely, Ekman transport and Ekman pumping that occur during the southwest monsoon. The results suggest that the coastline of the east coast of Peninsular Malaysia (ECPM) is affected by upwelling with spatiotemporal variations. Characterization of upwelling by using wind-induced upwelling indexes (UIW) indicate the existence of favorable upwelling conditions from May to September. Upwelling intensity increased in May and peaked in August before declining in September, decreasing intensity from the southern tip towards the northern tip along the coastline of the ECPM. The existence of upwelling along the ECPM has resulted in an important difference between the SSTs of the inshore and the oceanic regions. Nonetheless, the use of the SST gradient between the inshore and the oceanic SSTs to characterize upwelling (UISST) was found to be unsuitable because the SST along the ECPM was affected by water advection from the Java Sea and incessant changes in the SST. In order to indicate the major contributor of wind-induced upwelling along the ECPM in terms of the spatiotemporal scale, a comparison between Ekman transport and Ekman pumping was drawn by integrating Ekman pumping with respect to the distance where the positive wind stress curl existed. The estimation of Ekman transport and Ekman pumping indicated that Ekman pumping played a major role in contributing towards upwelling in any particular month during the southwest monsoon along the entire coastline of the ECPM as compared to Ekman transport, which contributed towards more than half of the total upwelling transport. By dividing the ECPM into three coastal sections, we observed that Ekman pumping was relatively predominant in the middle and northern coasts, whereas both Ekman transport and Ekman pumping were equally prevalent in the southern coast

Ekman pumping (unit: m s^-1) monthly climatology.

<p> (a) May, (b) June, (c) July, (d) August, and (e) September.</p

Percentage contribution of Ekman transport and Ekman pumping (unit: %).

<p> (a) May, (b) June, (c) July, (d) August, and (e) September. The calculation was based on 11 years’ average, from 2003 to 2013. N, M, and S denote the northern, middle, and southern coasts, respectively, whereas T denotes the entire coastline of the ECPM. The bars in grey and dark grey represent the Ekman pumping and Ekman transport, respectively.</p

Map and bathymetry of the SCS and the ECPM.

<p> Isobaths of 50 m, 70 m, 100 m, 1000 m, 2000 m, 3000 m, and 4000 m are presented. The rectangle on the left panel denotes the location of the ECPM. On the right panel, the asterisk points represent the latitudinal transect where Ekman transport and Ekman pumping are considered and the black circles represent the latitudinal transects where the SST data are obtained. SC denotes the southern coast (Tanjung Penyusop to Kuala Rompin); MC, the middle coast (Kuala Rompin to Dungun); and NC, the northern coast (Dungun to Tumpat). The shoreline and bathymetry data are obtained from Global Self-consistent, Hierarchical, High-resolution Geography Database (GSHHG) [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0171979#pone.0171979.ref015" target="_blank">15</a>] and 2-minute Gridded Global Relief Data (ETOPO2v2) [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0171979#pone.0171979.ref016" target="_blank">16</a>], respectively.</p

Monthly climatology of latitudinal Ekman transport (unit: m³ s^-1 m^-1) during the southwest monsoon.

<p> (a) <i>Q_x</i> and <i>(b) Q_y</i>.</p

Monthly climatology of alongshore wind-induced upwelling estimates (unit: m³ s^-1 m^-1) along the ECPM.

<p> (a) May, (b) June, (c) July, (d) August, and (e) September. The estimations were based on 11 years’ average, from 2003 to 2013. The dotted lines represent the Ekman transport, the dashed lines represent the Ekman pumping and the solid lines represent the total upwelling transport.</p

Monthly climatology of latitudinal <i>UI_SST</i> (unit: °C) during the southwest monsoon.

<p>Monthly climatology of latitudinal <i>UI_SST</i> (unit: °C) during the southwest monsoon.</p