Does evidence support the surveillance of carbapenem-resistant bacteria?

Antibiotic resistance is a significant threat to public health. Carbapenem-resistant gram-negative bacteria are “priority pathogens” according to the World Health Organization.

In this systematic review from the Pan American Health Organization (PAHO) [1] we found that the implementation of active surveillance strategies to detect these bacteria can induce a decline in infection or colonization rates. However, the observed effect could be substantially different from the real effect, since studies reported that active surveillance cultures were implemented as part of a bundle intervention, which precludes determining the independent effect.

Resistance to carbapenem antibiotics in gram-negative bacteria has been increasing due to the proliferation of different resistance mechanisms, resulting in a serious public health threat of international concern due to the current absence of effective therapeutic alternatives, which translates into a mortality rate between 34% to 70% [2,3].

The World Health Organization published in 2019 the first ever global guidelines for the prevention and control of carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities [3] which includes recommendations on surveillance policies.

In order to assist evidence-based decision-making on the effect of surveillance strategies in health care facilities, the Antimicrobial Resistance Special Program, Communicable Diseases and Environmental Determinants of Health from PAHO led a systematic review conducted by the Methodology Team of Epistemonikos Foundation [1]. Existing evidence may favor the use of surveillance culture to carbapenem-resistant gram-negative bacteria, which results in a decline in the prevalence of both infection and colonization rates. But at the same time, some studies suggest screening strategies may result in little to no difference in the risk of all-cause mortality and the length of hospital stay.

PRISMA Flowchart.

Authors warn that the certainty of the evidence was assessed as low, mainly due to serious risk of bias of the included studies and the presence of co-interventions since active surveillance cultures were implemented as part of a bundle intervention which precludes determining the independent effect of active surveillance in these studies. Well-conducted randomized trials or high-quality quasi-experimental studies are needed to improve the certainty of the existing evidence. Authors add that these studies should assess the effect of the addition of screening strategies as a single intervention and measure clinically important outcomes such as infection, length of hospital stay, and mortality.


[1] Verdugo-Paiva F, Otaiza F, Roson-Rodríguez P, Rojas-Gomez AM, Galas M, El Omeiri N, Fuentes Y, Rada G, Ramón-Pardo P. Effects of screening strategies to detect carbapenem-resistant gram-negative bacteria: A systematic review. American Journal of Infection Control 2022: 1-8.

[2] Nordmann P, Poirel L. Epidemiology and Diagnostics of Carbapenem Resistance in Gram-negative Bacteria. Clin Infect Dis. 2019;69(Suppl 7):S521-S528. doi: 10.1093/cid/ciz824.

[3] Guidelines for the Prevention and Control of Carbapenem-Resistant Enterobacteriaceae, Acinetobacter Baumannii and Pseudomonas Aeruginosa in Health Care Facilities. World Health Organization; 2017. Disponible en:

The first evidence map for acupunture identified promising therapies

The first evidence map for acupunture identified promising therapies

We combined evidence mapping and an overview approach to provide the first evidence map for acupuncture therapies across all therapeutic areas. An evidence map is considered to be a particularly useful tool for evidence-based decision-making and evidence-based policy development.

Our Methodology Team assessed 120 systematic reviews (SRs) published in the last 5 years, addressing acupuncture therapies across 77 diseases and conditions. The SRs included 138.995 participants from 1.402 randomized control trials (RCTs).

Acupuncture is one of the most accepted alternative therapies among clinicians and patients. In the last 30 to 40 years, its application has extended to treat a wide variety of diseases and conditions. According to a World Health Organization 2013 report, acupuncture use was recognized in 103 of the 194 member states.

Along with the increase in the practice of acupuncture, clinical research on the therapeutic effects of this traditional chinese medicine has also grown. In order to summarize the existing evidence on acupuncture, we partnered with the Guangzhou University of Chinese Medicine, the Guang’anmen Hospital, the Academy of Chinese Medical Sciences, The University of Nottingham Ningbo, the Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine and the Department of Health Research Methods, Evidence, and Impact from McMaster University. The purpose of our work was to identify both promising acupuncture therapies that require further investigation and therapies with demonstrated substantial benefits that may require more assertive evidence dissemination.

Effective interventions at risk of underutilisation:

  • Lactation within 24 hours after delivery
  • Poststroke aphasia
  • Myofascial pain (pain relief)
  • Vascular dementia
  • Neck, shoulder, and non-specific low-back pain
  • Fibromyalgia syndrome
  • Allergic rhinitis.

Promising but unproven interventions warranting further research:

  • Peptic ulcer
  • Urinary infection
  • Smoking cessation
  • Lactation within 24 and 72 hours after delivery.

Plenty of evidence but of poor quality

Our initial query resulted in 3.427 articles about acupuncture therapies, that we screened on title and abstract. Next, we assessed the full text of 614 of them. Following the selection criteria, we included 120 systematic reviews (SRs) to perform the analysis. It is noteworthy that 119 of the 120 SRs are rated as having ‘low’ or ‘critically low’ quality.

We detected the following therapeutic areas with high or moderate certainty of evidence:

  • Improvement in functional communication of patients who had poststroke aphasia
  • Reduction in myofascial pain
  • Increased lactation success rate within 24 hours postdelivery
  • Relief of neck pain and shoulder pain
  • Reduction in the severity of vascular dementia symptoms
  • Relief of fibromyalgia-related pain and non-specific low back pain
  • Improvement of allergic rhinitis nasal symptoms.

On the other hand, we identified areas with low or very low certainty of evidence:

  • Reduction in the length of first flatus and defecation in postoperative ileus after abdominal surgery
  • Reduction in pain of poststroke shoulder–hand syndrome
  • Increase in motor function and reduction in spasm symptoms of patients who had poststroke spastic hemiplegia
  • Improvement in sleep quality of patients with insomnia disorder, patients with haemodialysis and menopausal women
  • Reduction in neurogenic pain
  • Improvement in the symptoms of autism spectrum disorder in children
  • Reduction in the severity of migraine pain
  • Improvement in quality of life of migraine patients
  • Reduction in the severity of carpal tunnel syndrome pain and tic symptoms in patients with tic disorder
  • Reduction in sciatica pain
  • Improvement in quality of life and constipation symptoms of patients with functional dyspepsia
  • Reduction in the severity of pain and voiding symptoms
  • Rmprovement in quality of life of patients with chronic prostatitis
  • Increase in abstinence rate for smoking in short and long terms
  • Reduction in severity of opioid craving and depression in opioid use disorder
  • Reduction in body mass index in patients with obesity
  • Improvement in success rate of lactation within 24 and 72 hours after delivery
  • Improvement in the overall symptoms of chronic pelvic pain syndrome
  • Reduction in severity of pain and menstrual symptoms of dysmenorrhoea
  • Improvement in pregnancy rate among infertile women.

Then, we selected the best SR to provide the most up-to-date effect estimate and its corresponding certainty of evidence. For the best SRs, we used a bubble plot to display therapeutic areas, their corresponding SRs, RCTs and the type of acupuncture tested. Of the 77 reviews, neurology is the content area most frequently represented (33.8%), with a number of areas in the vicinity of 10% (oncology, connective tissue diseases, gastrointestinal disorders, mental health, obstetrics, gynaecology and women’s health), and others 5.2% or less (periprocedural care, genitourinary disorders, eye disorders, ear, nose, and throat disorders, nutrition and metabolic disorders, pregnancy or intended pregnancy).

Bubble plot. Each pie represents a therapeutic area. The number of RCTs included in each of the 77 SRs ranges from 1 to 40. RCTs in only three areas (neurology, connective tissue diseases, mental health) enrol more than 16 000 participants. Manual acupuncture proves the most frequently used intervention (54.1%), followed by electroacupuncture (20.2%) and body needling (5.5%).

To date, no other evidence maps or overview of SRs summarising evidence regarding acupuncture therapies exist. Evidence mapping is a relatively novel method for the overview of SRs and is particularly suitable for areas where a large number of SRs exist and overlap across diseases and conditions because it helps to define future research and knowledge dissemination priorities.

Presenter, Gonzalo Cansino, Pablo Alonso Coello, Iván Solá, Xavier Bonfill (Director Centro Cochrane Iberoamericano), Gerard Urrutia, Javier Ballesteros, María Ximena Rojas (Living Evidence Framework), Francisca Verdugo (Epistemonikos).

Cochrane Library Day

The Cochrane Library in the health evidence ecosystem Day took place last June 7th in Madrid and Epistemonikos was part of a dozen of international exponents and collaborators. The event was organized by the Health Ministry of Spain and Centro Cochrane Iberoamericano.

The program for the day.

Our Chief Scientific Innovation Officer, Francisca Verdugo, was invited to present about the applications developed by the Epistemonikos Foundation at the Ernest Lluch lounge at the Health Ministry of Spain in Madrid.

The program included diverse resources for knowledge generation and transference to health professionals, researchers, health policy developers and the general public, to make informed decisions on the field of medicine.

Some photographs of the day:

The event was presented by Pilar Aparicio, general director of Public Health in Spain, and Xavier Bonfill, Director of Centro Cochrane Iberoamericano. The record will be available soon.