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

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 &lt; 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

Heterogeneity in patterns of survival of the invasive species Ipomoea carnea in urban habitats along the Egyptian Nile Delta

Plant traits are critical for understanding invasion success of introduced species, yet attempts to identify universal traits that explain invasion success and impact have been unsuccessful because environmenttrait- fitness relationships are complex, potentially context dependent, and variation in traits is often unaccounted for. As introduced species encounter novel environments, their traits and trait variability can determine their ability to grow and reproduce, yet invasion biologists do not often have an understanding of how novel environments might shape traits. To uncover which combination of traits are most effective for predicting invasion success, we studied three different urban habitat types along the Nile Delta in Egypt invaded by the Pink Morning Glory, Ipomoea carnea Jacq. (Family: Convolvulaceae). Over two years, we measured ten plant traits at monthly intervals along an invasion gradient in each habitat. No single trait sufficiently explained survival probability and that traits linked to invasion success were better predicted by the characteristics of the invaded habitat. While the measured traits did influence survival of I. carnea, the importance of specific traits was contingent on the local environment, meaning that local trait-environment interactions need to be understood in order to predict invasion

Heterogeneity in patterns of survival of the invasive species Ipomoea carnea in urban habitats along the Egyptian Nile Delta

Plant traits are critical for understanding invasion success of introduced species, yet attempts to identify universal traits that explain invasion success and impact have been unsuccessful because environment-trait-fitness relationships are complex, potentially context dependent, and variation in traits is often unaccounted for. As introduced species encounter novel environments, their traits and trait variability can determine their ability to grow and reproduce, yet invasion biologists do not often have an understanding of how novel environments might shape traits. To uncover which combination of traits are most effective for predicting invasion success, we studied three different urban habitat types along the Nile Delta in Egypt invaded by the Pink Morning Glory, Ipomoea carnea Jacq. (Family: Convolvulaceae). Over two years, we measured ten plant traits at monthly intervals along an invasion gradient in each habitat. No single trait sufficiently explained survival probability and that traits linked to invasion success were better predicted by the characteristics of the invaded habitat. While the measured traits did influence survival of I. carnea, the importance of specific traits was contingent on the local environment, meaning that local trait-environment interactions need to be understood in order to predict invasion

Encrypted network traffic classification based on machine learning

Encrypted traffic is an essential part of maintaining the security and privacy of data transmission. It plays an important role in keeping our networks secure by preventing attackers from intercepting confidential information, which they may access without authorization; However, its effectiveness relies heavily on accurate classification techniques being applied correctly, so we can differentiate between legitimate users' activities versus those attempting malicious activity within the networks’ boundaries. Encrypted network traffic is becoming increasingly common in modern communication systems, presenting a challenge for effective network management and security. To address this challenge, machine learning models have been employed to classify encrypted traffic but with limited success due to the lack of clear visibility into packet contents and an inability to inspect their content. For the sake of tackling this issue, more effective research has begun on developing machine learning models for classifying encrypted payloads without relying on inspecting their contents directly. This research will investigate how features like packet length, time stamps or transport layer security (TLS) and encrypted payload information can be used as input features when attempting classification tasks, instead of analyzing unencrypted content directly from packets themselves which would otherwise be impossible given the current technology constraints. The evaluation process will focus on assessing different model architectures, as well as feature selection techniques that yield improved results over the existing approaches. In this paper, we proposed three approaches to identify encrypted traffic and classify different applications such as browsing, VOIP, file transfer and video streaming. The first two techniques consist of two stages: the first stage is either a neural network or a bi-directional LSTM, and the second stage is a selection of different classification techniques, namely Random Forest, Support vector machine, Linear regression, and K-nearest neighbor. The final result is achieved using an ensemble voting technique. As for the third technique, the network packets are grouped together by Source IP, destination IP and session time before feeding them into three different combinations of LSTM networks; either coupled with convolution 1D or 2D layers, or without. Like the first two techniques, the final result is achieved by means of ensemble voting. Through extensive comparison between the three approaches, The first approach yielded the highest accuracy. However, the performance of the second and third techniques in terms of time complexity was superior. The achieved accuracies were 96.8%, 95.2% and 96.5% for the proposed techniques, respectively

Richness, phylogenetic diversity, and abundance all have positive effects on invader performance in an arid ecosystem

In search of generalities in biological invasions, it is sometimes forgotten that invader success can be a function of both the diversity of the invaded community and the relatedness of the invader relative to community residents. Both qualities are likely to be especially important in stressful ecosystems, and identifying the species and community attributes that influence biological invasions can help direct management efforts in a sensitive ecosystem like those in arid regions. Pink Morning Glory, Ipomoea carnea Jaq. (Family: Convolvulaceae), is an annual vine native to Central and South America and is invasive in Egypt. We examined the performance of I. carnea at different densities in assembled communities of Egyptian annual native species. The native plant communities were manipulated to represent gradients of species richness and phylogenetic diversity and relatedness to I. carnea . We quantified the performance of I. carnea in these communities and examined the contribution of resident species richness, phylogenetic diversity, and phylogenetic relatedness to invader resistance. Our findings revealed that there was a positive relationship between invader performance and its mean phylogenetic distance to the resident species. Furthermore, species‐rich communities with more distantly related species positively contributed to invader performance in contrast to the classic biotic resistance hypothesis. Beyond these positive relationships, a positive density‐dependent effect of I. carnea on its performance was observed. We conclude that facilitative interactions are potentially important drivers promoting the successful invasion of the nonnative species I. carnea in water‐limited and harsh ecosystems. These results suggest that perhaps contrary to understanding from temperate systems, communities with a higher diversity of species could be more likely to be invaded by arid‐adapted species that are distantly related to natives. Thus, policy and management in arid regions should carefully consider reviewing the importation of nonnative species that are phylogenetically distinct and adapted to arid conditions and prioritizing their control once they are established

Synergistic effect of potential alpha-amylase inhibitors from Egyptian propolis with acarbose using in silico and in vitro combination analysis

Abstract Background Type 2 Diabetes mellitus (DM) is an affliction impacting the quality of life of millions of people worldwide. An approach used in the management of Type 2 DM involves the use of the carbohydrate-hydrolyzing enzyme inhibitor, acarbose. Although acarbose has long been the go-to drug in this key approach, it has become apparent that its side effects negatively impact patient adherence and subsequently, therapeutic outcomes. Similar to acarbose in its mechanism of action, bee propolis, a unique natural adhesive biomass consisting of biologically active metabolites, has been found to have antidiabetic potential through its inhibition of α-amylase. To minimize the need for ultimately novel agents while simultaneously aiming to decrease the side effects of acarbose and enhance its efficacy, combination drug therapy has become a promising pharmacotherapeutic strategy and a focal point of this study. Methods Computer-aided molecular docking and molecular dynamics (MD) simulations accompanied by in vitro testing were used to mine novel, pharmacologically active chemical entities from Egyptian propolis to combat Type 2 DM. Glide docking was utilized for a structure-based virtual screening of the largest in-house library of Egyptian propolis metabolites gathered from literature, in addition to GC–MS analysis of the propolis sample under investigation. Thereafter, combination analysis by means of fixed-ratio combinations of acarbose with propolis and the top chosen propolis-derived phytoligand was implemented. Results Aucubin, identified for the first time in propolis worldwide and kaempferol were the most promising virtual hits. Subsequent in vitro α-amylase inhibitory assay demonstrated the ability of these hits to significantly inhibit the enzyme in a dose-dependent manner with an IC50 of 2.37 ± 0.02 mM and 4.84 ± 0.14 mM, respectively. The binary combination of acarbose with each of propolis and kaempferol displayed maximal synergy at lower effect levels. Molecular docking and MD simulations revealed a cooperative binding mode between kaempferol and acarbose within the active site. Conclusion The suggested strategy seems imperative to ensure a steady supply of new therapeutic entities sourced from Egyptian propolis to regress the development of DM. Further pharmacological in vivo investigations are required to confirm the potent antidiabetic potential of the studied combination

Combating Bacterial Biofilm Formation in Urinary Catheter by Green Silver Nanoparticle

Urinary catheters are commonly associated with urinary tract infections. This study aims to inhibit bacterial colonisation and biofilm of urinary tract catheters. Silicon catheter pieces were varnished with green silver nanoparticles (AgNPs) using Pistacia lentiscus mastic to prevent bacterial colonisation. Pomegranate rind extract was used to synthesize AgNPs. AgNPs were characterized by UV-Vis spectroscopy, X-ray crystallography, and transmission electron microscopy (TEM). Results obtained revealed that the size of most AgNPs ranged between 15–25 nm and they took crystallised metal and oxidised forms. The amounts of released silver ions from 1 cm pieces of catheters coated with AgNPs were estimated for five days and ranged between 10.82 and 4.8 µg. AgNPs coated catheters significantly inhibited the colonisation of catheters by antibiotic-resistant clinical Gram-positive (Staphylococcus epidermidis and Staphylococcus aureus) and Gram-negative (Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa) bacteria. AgNPs-varnish was more active against Gram-negative bacteria than Gram-positive bacteria. The significant inhibitory effect of coated catheters lasted for 72 h for both Gram-positive and Gram-negative bacteria. Varnishing catheters with AgNPs may help to prevent bacterial colonisation and infections