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

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Urbanismo-AR158-201700

El curso es de especialidad de la carrera de Arquitectura de carácter teórico-práctico dirigido a los estudiantes del sétimo ciclo busca desarrollar la competencia general de Manejo de la Información y la competencia específica de Investigación.En la ciudad observamos problemas que requieren soluciones complejas. Las ciudades del siglo 21 concentran una mayor población y actividades que las que albergaron las ciudades de siglos pasados. Son el resultado de las interacciones entre los varios sistemas que la integran ante lo cual el reto es lograr soluciones con escala humana que sean inclusivas competitivas y sostenibles. Este curso te ayudará a prepararte para identificar y diagnosticar problemas urbanos en nuestras ciudades

Urbanismo-AR158-201900

Descripción:El curso de Urbanismo realiza una reflexión sobre las ciudades del siglo 21 éstas son el resultado de la interacción entre los varios sistemas que la conforman ante lo cual el reto es lograr una ciudad con calidad humana inclusiva competitiva en un mundo globalizado y sostenible. Este curso te ayudará a prepararte para identificar y contrastar los elementos que las estructuran con el fin de analizar un espacio urbano y elaborar un diagnóstico con la metodología GEUSSA.Propósito:El curso ha sido diseñado con el propósito de permitir al futuro profesional desarrollar su capacidad de análisis a través de la identificación de los diferentes aspectos que estructuran una ciudad y el empleo de herramientas metodológicas para aplicarlas en el ejercicio profesional. El curso contribuye directamente al desarrollo de la competencia general de Ciudadanía a un nivel intermedio (nivel 2). Este curso es requisito para el curso de Gestión Urbana

Urbanismo-AR158-201800

El curso es de especialidad de la carrera de Arquitectura de carácter teórico-práctico dirigido a los estudiantes del sétimo ciclo busca desarrollar lacompetencia general de Manejo de la Información y la competencia específica de Investigación.Las ciudades del siglo 21 concentran una mayor población y actividades urbanas que las que albergaron las ciudades de siglos pasados. Son el resultadode la interacción entre los varios sistemas que la conforman ante lo cual el reto es lograr una ciudad con calidad humana inclusiva competitiva en unmundo globalizado y sostenible. Este curso te ayudará a prepararte para identificar y reconocer los elementos que estructuran nuestras ciudades en el siglo21

Urbanismo-AR158-201500

La asignatura constituye la primera del área de Urbanismo y tiene como tema principal la ciudad su estructura y morfología vista como fenómeno dinámico y complejo. Dota a los estudiantes de la capacidad de observar la realidad urbana con sensibilidad permitiéndoles analizar científicamente su desarrollo de forma integral

Urbanismo-AR158-201600

Curso de especialidad en la carrera de Arquitectura de carácter teórico-práctico dirigido a los estudiantes de séptimo ciclo que busca desarrollar la competencia general Manejo de la Información y la competencia específica Investigación.La asignatura constituye la primera del área de Urbanismo y tiene como tema principal la ciudad su estructura y morfología vista como fenómeno dinámico y complejo. Dota a los estudiantes de la capacidad de observar la realidad urbana con sensibilidad permitiéndoles analizar científicamente su desarrollo de forma integral

Urbanismo-AR158-201701

El curso es de especialidad de la carrera de Arquitectura de carácter teórico-práctico dirigido a los estudiantes del séptimo ciclo busca desarrollar la competencia general de Manejo de la Información y la competencia específica de Investigación.En la ciudad observamos problemas que requieren soluciones complejas. Las ciudades del siglo 21 concentran una mayor población y actividades que las que albergaron las ciudades de siglos pasados. Son el resultado de las interacciones entre los varios sistemas que la integran ante lo cual el reto es lograr soluciones con escala humana que sean inclusivas competitivas y sostenibles. Este curso te ayudará a prepararte para identificar y diagnosticar problemas urbanos en nuestras ciudades

Urbanismo-AR158-201802

Descripción:El curso de Urbanismo realiza una reflexión sobre las ciudades del siglo 21 éstas son el resultado de la interacción entre los varios sistemas que la conforman ante lo cual el reto es lograr una ciudad con calidad humana inclusiva competitiva en un mundo globalizado y sostenible. Este curso te ayudará a prepararte para identificar y contrastar los elementos que las estructuran con el fin de analizar un espacio urbano y elaborar un diagnóstico con la metodología GEUSSA.Propósito:El curso ha sido diseñado con el propósito de permitir al futuro profesional desarrollar su capacidad de análisis a través de la identificación de los diferentes aspectos que estructuran una ciudad y el empleo de herramientas metodológicas para aplicarlas en el ejercicio profesional. El curso contribuye directamente al desarrollo de la competencia general de Ciudadanía a un nivel intermedio (nivel 2). Este curso es requisito para el curso de Gestión Urbana