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

A Comparison of Germany, Holland and Turkey Football Leagues With Cramér–Von Mises Test

Football, which is assumed to be played with more than 250 million players in more than 200 countries all around the world, is a sports activity that appeals to the masses. In this respect, football, apart from the sports structure, with its fan communities, sponsors, social media applications and social responsibility projects has turned into an inseparable part of our daily lives. Different football leagues show differences in regards to the sponsor connections and financial powers they have. In this study, Germany, Holland and Turkey premier football leagues, all of which are in European leagues, have been discussed because each have 18 teams. The competitiveness structure of the leagues has been compared by making comparisons based on the points scored throughout the season by the teams that rank among the top three in the league. The results have been interpreted by comparing the above-mentioned three leagues with the fundamental principle that the score increase rate of the teams ranking among the top three in leagues where there is less competitiveness will be high

The accuracy of earnings forecasts disclosed in IPO prospectuses: The case of the Turkish IPO companies

This paper examines the accuracy of earnings forecasts made by Turkish IPO (Initial Public Offering) companies during the period 2002-2007. It is a voluntary requirement for Turkish IPOs to furnish earnings forecasts. Their accuracy is measured by forecast errors, absolute forecast errors and squared forecast errors in this paper. A number of company specific characteristics such as size, age, forecast interval, gearing, proportion of shares retained by owners and both auditing firm and underwriter reputation are also tested. The results of this study show that like IPO forecasts disclosed in most other countries, IPO forecasts disclosed by Turkish companies do overestimate their earnings, on average, by 13.44 %. On an overall basis, the findings of this study can be intrepreted to mean that IPO forecasts disclosed by Turkish companies provide reliable information.Publisher's Versio

Molecular Epidemiology of Beta-Lactamases in Ceftazidime-Resistant Pseudomonas aeruginosa Isolates

Pseudomonas aureginosa, özellikle immün sistemin baskılandığı hastalarda, yaşlılarda ve ağır yanık durumlarında hastalık oluşturan ve daha çok hastane enfeksiyonlarına neden olabilen önemli bir fırsatçı patojendir. Bakterinin birçok antibiyotiğe karşı yüksek oranda direnç geliştirme özelliği, P.aeruginosa enfeksiyonlarının mortalite ve morbiditesini artırmaktadır. Bu çalışmada, yatan hastalardan izole edilen P.aeruginosa suşlarının antibiyotik duyarlılıklarının belirlenmesi ve PER, GES, KPC, VIM, IMP ve OXA gibi direnç enzimlerinin varlığının araştırılması amaçlanmıştır. Çalışmaya, 2010-2012 yılları arasında Afyon Kocatepe Üniversitesi Tıp Fakültesi Hastanesinde yatan 134ü erkek 61i kadın hastanın çeşitli klinik örneklerinden (29 balgam, 67 yara, 53 trakeal aspirat, 23 kan, 18 idrar, 3 beyin omurilik sıvısı, 2 plevral sıvı) izole edilen, 195 P.aeruginosa suşu dahil edilmiştir. İzolatların tanımlanmasında konvansiyonel ve otomatize sistemler (VITEK 2, BioMerieux, Fransa) kullanılmış; antibiyotik duyarlılıklarının belirlenmesi için disk difüzyon ve E-test yöntemleri uygulanmıştır. İzolatların indüklenebilir beta-laktamaz (İBL), genişlemiş spektrumlu beta-laktamaz (GSBL) ve metallo-beta-laktamaz (MBL) üretimleri, fenotipik olarak, sırasıyla çift disk indüksiyon yöntemi, çift disk sinerji testi ve E-test yöntemi ile saptanmıştır. İzolatlarda direnç enzimlerini (PER, GES, KPC, VIM, IMP ve OXA) kodlayan genlerin varlığı ise gerçek zamanlı polimeraz zincir reaksiyonu ile araştırılmış; pozitif örneklere dizi analizi uygulanmıştır. Çalışmamızda, 195 P.aeruginosa suşunun tümü (%100) seftazidime, %90.8i tazobaktam/piperasiline, %60.5i aztroenama, %50.2 si sefepime, %48.2 si imipeneme, %47.2 si meropeneme, %47.2 si ofl oksasine, %44.1 i pipe rasiline, %31.3 ü levofl oksasine, %26.2 si siprofl oksasine, %11.8 i gentamisine, %8.7 si amikasine ve %6.2 si tobramisine dirençli bulunmuştur. Fenotipik yöntemlerle, izolatların %89.2 sinde (174/195) İBL, %30.7 sinde (60/195) GSBL ve %26.7sinde (52/195) MBL pozitifl iği tespit edilmiştir. Moleküler çalış- malar sonucunda beş izolatta OXA-10, dört izolatta OXA-14, dört izolatta VIM-2, iki izolatta IMP-1, 26 izolotta GES-1 ve 87 izolatta ABC taşıyıcı permeaz (transporter permease) geni saptanmış; PER ve KPC genlerine rastlanmamıştır. Sonuç olarak, beta-laktamaz genlerini taşıyan kökenlerin saptanması ve betalaktamaz tiplerinin tanımlanmasının; antibiyotik seçiminde, tedavinin takibinde, direnç gelişiminin önlenmesinde ve enfeksiyon kontrol programlarının geliştirilmesinde yol gösterici olacağı düşünülmüştür.Pseudomonas aeruginosa is an important opportunistic pathogen that cause mainly nosocomial infections especially in the immunocompromised patients, the elderly and patients with severe burns. The bacterial feature of developing high degree of resistance against several antibiotics leads to increased morbidity and mortality of P.aeruginosa infections. The aims of this study were to investigate the antibiotic susceptibilities of P.aeruginosa strains isolated from hospitalized patients and to determine the presence of resistance enzymes namely PER, GES, KPC, VIM, IMP and OXA. A total of 195 P.aeruginosa strains isolated from different clinical samples (29 sputum, 67 wound, 53 tracheal aspirate, 23 blood, 18 urine, 3 cerebrospinal fl uid, 2 pleural fl uid) of inpatients (134 male, 61 female) in Afyon Kocatepe University School of Medicine Hospital between 2010-2012, were included in the study. The isolates were identifi ed by conventional methods and automated systems (VITEK 2, BioMerieux, France), and their antibiotic susceptibilities were detected by disk diffusion and E-test methods. Inducible beta-lactamase (IBL), extended-spectrum beta-lactamase (ESBL) and metallo-beta-lactamase (MBL) productions of the isolates were phenotypically investigated by double disk induction, double disk synergy and E-test methods, respectively. The presence of resistance genes encoding PER, GES, KPC, VIM, IMP and OXA enzymes were determined by real-time polymerase chain reaction, and sequence analysis was applied to positive samples. In our study, the antibiotic resistance rates of 195 P.aeruginosa strains were found as follows: ceftazidime 100%, tazobactam/piperacillin 90.8%, aztreonam 60.5%, cefepime 50.2%, imipenem 48.2%, meropenem 47.2%, ofl oxacin 47.2%, piperacillin 44.1%, levofl oxacin 31.3%, cipro- fl oxacin 26.2%, gentamicin 11.8%, amikacin 8.7% and tobramycin 6.2%. With the use of phenotypical methods, IBL, ESBL and MBL production rates in the isolates were detected as 89.2% (174/195), 30.7% (60/195) and 26.7% (52/195), respectively. Molecular studies showed that, fi ve strains harboured OXA- 10, four OXA-14, four VIM-2, two IMP-1, 26 GES-1 and 87 ABC transporter permease genes, while PER and KPC genes were not detected in any of the isolates. In conclusion, it was considered that the detection of beta-lactamase genes in bacteria and the identifi cation of beta-lactamase types may provide facilities in selection of antibiotics, monitorization of therapy, prevention of resistance development of infection control programs

Molecular Epidemiology of Beta-Lactamases in Ceftazidime-Resistant Pseudomonas aeruginosa Isolates

Pseudomonas aeruginosa is an important opportunistic pathogen that cause mainly nosocomial infections especially in the immunocompromised patients, the elderly and patients with severe burns. The bacterial feature of developing high degree of resistance against several antibiotics leads to increased morbidity and mortality of P.aeruginosa infections. The aims of this study were to investigate the antibiotic susceptibilities of P.aeruginosa strains isolated from hospitalized patients and to determine the presence of resistance enzymes namely PER, GES, KPC, VIM, IMP and OXA. A total of 195 P.aeruginosa strains isolated from different clinical samples (29 sputum, 67 wound, 53 tracheal aspirate, 23 blood, 18 urine, 3 cerebrospinal fluid, 2 pleural fluid) of inpatients (134 male, 61 female) in Afyon Kocatepe University School of Medicine Hospital between 2010-2012, were included in the study. The isolates were identified by conventional methods and automated systems (VITEK 2, BioMerieux, France), and their antibiotic susceptibilities were detected by disk diffusion and E-test methods. Inducible beta-lactamase (IBL), extended-spectrum beta-lactamase (ESBL) and metallo-beta-lactamase (MBL) productions of the isolates were phenotypically investigated by double disk induction, double disk synergy and E-test methods, respectively. The presence of resistance genes encoding PER, GES, KPC, VIM, IMP and OXA enzymes were determined by real-time polymerase chain reaction, and sequence analysis was applied to positive samples. In our study, the antibiotic resistance rates of 195 P.aeruginosa strains were found as follows: ceftazidime 100%, tazobactam/piperacillin 90.8%, aztreonam 60.5%, cefepime 50.2%, imipenem 48.2%, meropenem 47.2%, ofloxacin 47.2%, piperacillin 44.1%, levofloxacin 31.3%, ciprofloxacin 26.2%, gentamicin 11.8%, amikacin 8.7% and tobramycin 6.2%. With the use of phenotypical methods, IBL, ESBL and MBL production rates in the isolates were detected as 89.2% (174/195), 30.7% (60/195) and 26.7% (52/195), respectively. Molecular studies showed that, five strains harboured OXA-10, four OXA-14, four VIM-2, two IMP-1, 26 GES-1 and 87 ABC transporter permease genes, while PER and KPC genes were not detected in any of the isolates. In conclusion, it was considered that the detection of beta-lactamase genes in bacteria and the identification of beta-lactamase types may provide facilities in selection of antibiotics, monitorization of therapy, prevention of resistance development of infection control programs

Seropositivity rate for toxoplasmosis in suspected patients: Afyon experience

Amaç: Tüm dünyada yaygın bir zoonoza yol açan Toxoplasma gondii, çeşitli ülkelerde ve Türkiye’nin çeşitli bölgelerinde farklı oranlarda seropozitiviteye sahiptir. Bu çalışma ile Afyon yöresinde Toxoplasma’ya özgül antikorların yaygınlığını araştırmak amaçlanmıştır. Yöntem: Bir yıllık sürede ELISA yöntemi ile saptanmış Toxoplasma IgG ve IgM sonuçları değerlendirilmiştir. Bulgular: Toxoplasmosis şüpheli 305 hastanın 87’sinde (%28.52) IgG seropozitifliği, 2’sinde (%0.65) IgM seropozitifliği saptanmıştır. Sonuç: Sonuç olarak, Toxoplasma seroprevalansı birçok bölge ile uyumlu bulunmuştur, ancak daha sağlıklı sonuçlar için bölgede daha geniş epidemiyolojik çalışmaların yapılması gerekmektedir. Halk toxoplasmosis yönünden bilinçlendirilmeli ve bölgede bu enfeksiyonun epidemiyolojik özellikleri araştırılmalıdır.Objective: Toxoplasma gondii, causing a worldwide zoonosis, shows different seropositivity rates in different countries, even in different regions of the same country. It was aimed to determine the prevalence of Toxoplasma antibodies in Afyon. Method: Toxoplasma IgG and IgM antibodies were evaluated by ELISA in serum of suspected patients collected for one year period. Results: Of the 305 patients 87 (28.52%) were Toxoplasma IgG seropositive and 2 (0.65%) Toxoplasma IgM seropositive. Conclusion: This study suggests that people should be warned and informed about toxoplasmosis. In addition, further studies should be performed to elucidate epidemiology of mentioned toxoplasmosis in this region

Farklı post boylarının ve farklı siman kullanımının kron ile restore edilmiş dişlerin kırılma dayanımına etkisi

Amaç: Bu çalışmanın amacı post-kor ve kronla restore edilmiş dişlerde farklı simantasyon materyallerinin ve post uzunluklarının kırılma direncine etkisini değerlendirmektir.Gereç ve Yöntemler: Benzer boylara sahip 40 mandibular premolar dişin kronları uzaklaştırıldı. Kanal tedavileri yapıldıktan sonra dişler akrilik bloklara gömüldü. Örnekler ilk olarak ikiye ayrıldı. 10 mm ve 5 mm derinliklerinde sirküler post boşlukları, sırasıyla #0.5 ve #2 kodlu üretici frezleri ile hazırlandı. Post (D.T. Light-Post) simantasyonu aşamasında, her post grubundaki 10 örnek kendinden adezivli rezin siman (Rely X) ile simante edildi. Diğer 10 örnek kendinden asitli kompozit siman (Clearfill Esthetic Cement) ile simante edildi (n=10). Tüm örnekler kompozit korlar ile restore edildi ve toplamda yaklaşık 5°’lik konverjans açısıyla 6 mm boyunda (1 mm ferrule dahil) prepare edildi. Sonra, tüm dişler tam metal kronlarla, cam iyonomer simanla simante edilerek restore edildi. Termal döngü ile yorma sonrası, tüm örneklere kırılma dayanımı testi (0,5 mm/min) uygulandı. Data iki yönlü varyans analizi kullanılarak analiz edildi (α=0.05).Bulgular: Farklı tip siman kullanımı restore edilmiş dişlerin kırılma dayanımını etkilemezken (p=0.209), 10 mm derinlikte post yerleşimi 5 mm derinlikte yerleşime göre daha yüksek kırılma dayanımı göstermiştir (p &lt; 0.001).Sonuç: Çalışmanın limitasyonları dahilinde, hangi tip simanın kullanıldığına bakılmaksızın, post boşluğunun daha derin açılması post-kor destekli kron restorasyonlu dişlerin kırılma dayanımını artırmaktadır