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

Understanding the Impact of Extracellular Polymeric Substances on Lead Release in Drinking Water Systems

Lead release in a lead (Pb, anode)–iron oxide (α-Fe2O3, cathode) galvanic system was studied under the influence of synthetic extracellular polymeric substances (sEPS). Sodium alginate, bovine serum albumin (BSA), and cytochrome c represented extracellular polysaccharides, proteins, and electrochemically active components, respectively. Microbiologically influenced corrosion was investigated using sEPS and pelleted and resuspended Pseudomonas aeruginosa cells. Relative to the anaerobic inorganic control, Pb release increased by 156, 202, and 198 μg/L when sEPS was present on the cathode side at 200 mg/L (100 mg/L alginate + 100 mg/L BSA), 400 mg/L (200 mg/L alginate + 200 mg/L BSA), and 200 mg/L with 123.84 mg/L cytochrome c, respectively, under anaerobic conditions. When the cathode was aerated, Pb release increased by 75, 260, and −71 μg/L under the aforementioned conditions, all relative to the aerated inorganic control. When sEPS was instead present on the anode side, sEPS caused localized corrosion on Pb and resulted in higher Pb release than predicted by electric current. P. aeruginosa generally enhanced corrosion; when cells were dosed in the anode side, part of the oxidized Pb was immobilized by cells or organic compounds adhered to the electrodes

Improved disinfection performance for 280 nm LEDs over 254 nm low-pressure UV lamps in community wastewater

Abstract Ultraviolet (UV) disinfection has been incorporated into both drinking water and wastewater treatment processes for several decades; however, it comes with negative environmental consequences such as high energy demands and the use of mercury. Understanding how to scale and build climate responsive technologies is key in fulfilling the intersection of UN Sustainable Development Goals 6 and 13. One technology that addresses the drawbacks of conventional wastewater UV disinfection systems, while providing a climate responsive solution, is UV light emitting diodes (LEDs). The objective of this study was to compare performance of bench-scale 280 nm UV LEDs to bench-scale low pressure (LP) lamps and full-scale UV treated wastewater samples. Results from the study demonstrated that the UV LED system provides a robust treatment that outperformed LP systems at the bench-scale. A comparison of relative energy consumptions of the UV LED system at 20 mJ cm−2 and LP system at 30 and 40 mJ cm−2 was completed. Based on current projections for wall plug efficiencies (WPE) of UV LED it is expected that the energy consumption of LED reactors will be on par or lower compared to the LP systems by 2025. This study determined that, at a WPE of 20%, the equivalent UV LED system would lead to a 24.6% and 43.4% reduction in power consumption for the 30 and 40 mJ cm−2 scenarios, respectively

Monitoring natural organic matter in drinking water treatment with photoelectrochemical oxygen demand

Conventional metrics such as total organic carbon (TOC) and ultraviolet absorbance at 254 nm (UV254) may oversee aspects of natural organic matter (NOM) reactivity in drinking water treatment. The novel photoelectrochemical oxygen demand (peCOD) analyzer indirectly measures the oxygen consumed during NOM oxidation with photo- and electrochemical methods, quantifying NOM reactivity. peCOD was valuable for tracking NOM degradation in nine drinking water treatment facilities, particularly in processes where conventional metrics failed to capture changes in NOM from partial oxidation (e.g., biofiltration and oxidation). However, peCOD exhibited moderate correlations with TOC (R2 = 0.67) and UV254 (R2 = 0.48), indicating the need for its concurrent use with conventional methods. While peCOD was not a significant predictor of disinfection by-product formation potential (R2 < 0.20), its inclusion alongside standard NOM metrics improved the performance of multivariable regression models. Thus, peCOD provided a rapid, standardized, operator-friendly, environmentally conscious, concentration-based approach for evaluating NOM characteristics in drinking water samples.Engineering and Physical Sciences Research Council (EPSRC)Natural Sciences and Engineering Research Council (NSERC) Alliance “Partnership for Innovation in Climate Change Adaptation in Water & Wastewater Treatment” (grant ALLRP 568507-21)Supporting industry organizations: Halifax Water, LuminUltra Technologies Ltd., Cape Breton Regional Municipality, Mantech Inc., City of Moncton, AquiSense Technologies, AGAT Laboratories, and CBCL Ltd

Assessing the impact of multiple ultraviolet disinfection cycles on N95 filtering facepiece respirator integrity

Abstract During the COVID-19 pandemic, N95 filtering facepiece respirators (FFRs) were recommended to protect healthcare workers when providing care to infected patients. Despite their single-use disposable nature, the need to disinfect and repurpose FFRs is paramount during this global emergency. The objectives of this study were to (1) determine if UV treatment has an observable impact on respirator integrity; (2) test the impact of UV treatment on N95 FFR user fit; and (3) test the impact of UV treatment on FFR integrity. Ultraviolet (UV) disinfection was assessed in maintaining N95 FFR integrity. Two models of FFRs were exposed to UV fluences ranging from 0 to 10,000 mJ cm−2 per side and subsequently tested for fit, respirator integrity, and airflow. Inspection of N95 FFRs before and after UV treatment via microscopy methods showed no observable or tactile abnormalities in the integrity of respirator material or straps. Tensile loading tests on UV-treated and untreated respirator straps also demonstrated no impact on breaking strength. Standardized fit test methods showed no compromise in user fit following UV treatment. Evaluation of particle penetration and airflow through N95 FFRs showed no impact on integrity, and average filtration efficiency did not fall below 95% for any of the respirator types or fluence levels. This work provides evidence that UV disinfection does not compromise N95 FFR integrity at UV fluences up to 10,000 mJ cm−2. UV disinfection is a viable treatment option to support healthcare professionals in their strategy against the spread of COVID-19

Lake Recovery Through Reduced Sulfate Deposition: A New Paradigm for Drinking Water Treatment

This study examined sulfate deposition in Nova Scotia from 1999 to 2015, and its association with increased pH and organic matter in two protected surface water supplies (Pockwock Lake and Lake Major) located in Halifax, Nova Scotia. The study also examined the effect of lake water chemistry on drinking water treatment processes. Sulfate deposition in the region decreased by 68%, whereas pH increased by 0.1–0.4 units over the 16-year period. Average monthly color concentrations in Pockwock Lake and Lake Major increased by 1.7 and 3.8×, respectively. Accordingly, the coagulant demand increased by 1.5 and 3.8× for the water treatment plants supplied by Pockwock Lake and Lake Major. Not only was this coagulant increase costly for the utility, it also resulted in compromised filter performance, particularly for the direct-biofiltration plant supplied by Pockwock Lake that was found to already be operating at the upper limit of the recommended direct filtration thresholds for color, total organic carbon and coagulant dose. Additionally, in 2012–2013 geosmin occurred in Pockwock Lake, which could have been attributed to reduced sulfate deposition as increases in pH favor more diverse cyanobacteria populations. Overall, this study demonstrated the impact that ambient air quality can have on drinking water supplies

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe