In this article two infectious diseases pharmacists discuss the intersection of race and antimicrobial stewardship.
Authored by: Jacinda C. Abdul-Mutakabbir PharmD, MPH, AAHIVP and Brenda Simiyu PharmD, BCPS, BCIDP
Article Posted: 4 December 2021
The Coronavirus (COVID-19) pandemic has showcased many health inequities that exist amongst racially and ethnically minoritized communities [1]. The Centers for Disease Control (CDC) has reported that individuals identify as Black, Latino/ LatinX, or Native American are two -three times more likely to perish due to COVID-19 when compared to their non-Hispanic White counterparts [2]. While the COVID-19 vaccines are poised to change this disparate outcome, systemic racism and decades of medical mistreatment give rise to a lack in vaccine confidence; especially as it relates to the United States healthcare system to use fair practices when vaccinating minoritized groups [1,3]. Furthermore, the provision and access to vaccinations within heavily minoritized communities has been lacking, thus, resulting in the continued disproportionate number of infections and deaths related to COVID-19 amongst these groups [3,4]. While dire, the ambivalence to the COVID-19 vaccines, recognized amongst minoritized groups, has been frequently reported for other respiratory immunizations, including the influenza and pneumococcal vaccines [5].
Members of minoritized groups have historically been vaccinated at lower rates than their White counterparts; therefore, being more likely to contract and expire from vaccine-preventable respiratory infections [6]. To this, the development of bacterial infections and the subsequent use of antibiotics against these infections is inevitable. Evidence of this has been shown in a retrospective study conducted at the Detroit Medical Center [7]. Investigators reported that of the 451 included patients with an Enterobacterales bloodstream infection, greater than 70% were of a minoritized group. Another report examining the incidence of invasive community-associated methicillin-resistant Staphylococcus aureus (MRSA) revealed that infection was 1.6 times higher in blacks compared to their white counterparts. This racial disparity in infection rates was largely explained by socioeconomic factors [8].
While not widely investigated, resistance amongst minoritized groups is likely common place given the aforementioned circumstances. The use of nonprescription antimicrobials, secondary to increased difficulties accessing healthcare, is an easily overlooked contributing factor to antimicrobial resistance [9]. Thus, indicating the potential impact that adequate antimicrobial stewardship interventions could have on narrowing health disparity gaps.
There is currently a paucity of literature that explicitly explores the intersection of race and antimicrobial stewardship [10]. Several studies provide conflicting reports on the prescribing patterns of antibiotics and whether individuals of minoritized races are more often prescribed antimicrobials [10,11]. Further, the data surrounding the prevalence of Clostridium difficile infections amongst minoritized groups when compared to their non-Hispanic White counterparts is also limited [12]. Nonetheless, it has been previously stated that political, economic, and social factors can influence drug prescribing patterns and presumably antibiotic usage would also be affected.
Of further note, in hospitals located in urban settings (typically inhabited by mostly minoritized individuals), resources are limited which results in the lack of infectious diseases trained professionals (physicians, pharmacists, microbiologist), and/or the availability of novel therapies for hard-to-treat organisms. Therefore, resulting in the likely continued propagation of resistant organisms and disproportionate mortalities amongst minoritized groups.
There is an incessant need to address the intersectionality between race and antimicrobial stewardship. While there is no clear pathway in doing so, there are several action points that healthcare professionals can consider to rectify this current gap in medicine. These points are as follows…
1. Acknowledge the role of preventive medicine (vaccinations) in preventing bacterial and viral infections
As mentioned, individuals of minoritized communities are less likely to be vaccinated against preventable respiratory diseases. Thus, bacterial infections and the potential of inappropriate use of antibiotics is inevitable.
2. Intentionally design research that explores the demographics associated with antimicrobial prescribing patterns and antimicrobial resistance
The availability of literature that investigates how antibiotic prescribing impacts resistance in the context of race is nearly non-existent. To properly address this potential disparity, we must properly quantify the burden.
To this end, data describing race and/or ethnicity are commonly collected as well as presented in various research projects. This includes work investigating antimicrobial stewardship interventions as well as the development of antibiotic resistance. The exploration of the nuances within minoritized groups included amongst the collected data may serve as a starting point in mitigating the disparities in antibiotic usage and collateral damage.
3. Educate minoritized communities about antibiotics and the necessity of using them appropriately
Concentrated educational measures can promote awareness about antibiotics and proper use amongst minoritized groups.
Creating and/or enhancing health literacy has been shown to be successful in addressing health inequities. Further, education mechanisms also allow for interactive opportunities to build trusting and transparent relationships with minoritized individuals that have the potential to change attitudes surrounding healthcare.
4. Advocate for an increase in funding allocated to hospitals within urbanized communities as well as equitable pricing in novel antibiotic therapeutics
The allocation of financial resources will be imperative in ensuring that the hospitals in urbanized communities are equipped to tailor their necessary antimicrobial stewardship interventions to their needs. Also, affordable drug pricing could drastically enhance treatment algorithms for resistant pathogens within the urbanized healthcare setting.
Closing Comments
Understanding the role of race when addressing and tailoring innovative antimicrobial stewardship strategies is imperative.
As infectious diseases professionals, we must holistically consider the impact that preventive medicine (e.g., vaccinations) can have in addressing the health inequities within stewardship, design research that quantifies and/ or signifies the existing disparity, promote education and the necessity in trustworthy relationships, and finally advocate for equity amongst the institutions that are responsible for allocating funding to mechanisms that could drastically improve the current predicament.
As antibiotic resistance becomes prevalent and antimicrobial stewardship becomes a top priority, we cannot disregard the health disparities that exist.
REFERENCES
1. Marcelin JR, Swartz TH, Bernice F, et al. Addressing and Inspiring Vaccine Confidence in Black, Indigenous, and People of Color (BIPOC) during the COVID-19 Pandemic. 2021:
2. Centers for Diseases Control (CDC) . COVID-19 hospitalization and death by race/ethnicity. Accessed January 26, 2021.
3. Abdul-Mutakabbir JC, Casey S, Jews V, et al. A three-tiered approach to address barriers to COVID-19 vaccine delivery in the Black community. Lancet Glob Health. Mar 10 2021;doi:10.1016/S2214-109X(21)00099-1
4. Peteet B, Belliard JC, Abdul-Mutakabbir J, Casey S, Simmons K. Community-academic partnerships to reduce COVID-19 vaccine hesitancy in minoritized communities. EClinicalMedicine. Apr 2021;34:100834. doi:10.1016/j.eclinm.2021.100834
5. Travers JL, Schroeder KL, Blaylock TE, Stone PW. Racial/Ethnic Disparities in Influenza and Pneumococcal Vaccinations Among Nursing Home Residents: A Systematic Review. Gerontologist. 2018;58(4):e205-e217. doi:10.1093/geront/gnw193
6. Center for Diseases Control . Flu Disparities Among Racial and Ethnic Minority Groups. https://www.cdc.gov/flu/highrisk/disparities-racial-ethnic-minority-groups.html
7. Cwengros LN, Mynatt RP, Timbrook TT, et al. Minimizing Time to Optimal Antimicrobial Therapy for Enterobacteriaceae Bloodstream Infections: A Retrospective, Hypothetical Application of Predictive Scoring Tools vs Rapid Diagnostics Tests. Open Forum Infectious Diseases. 2020;7(8)doi:10.1093/ofid/ofaa278
8. See I, Wesson P, Gualandi N, et al. Socioeconomic Factors Explain Racial Disparities in Invasive Community-Associated Methicillin-Resistant Staphylococcus aureus Disease Rates. Clin Infect Dis. Mar 1 2017;64(5):597-604. doi:10.1093/cid/ciw808
9. Grigoryan L, Germanos G, Zoorob R, et al. Use of Antibiotics Without a Prescription in the U.S. Population: A Scoping Review. Ann Intern Med. Aug 20 2019;171(4):257-263. doi:10.7326/m19-0505
10. Fortin-Leung K, Wiley Z. What about race and ethnicity in antimicrobial stewardship? Infection Control & Hospital Epidemiology. 2021:1-2. doi:10.1017/ice.2020.1426
11. Goyal MK, Johnson TJ, Chamberlain JM, et al. Racial and Ethnic Differences in Antibiotic Use for Viral Illness in Emergency Departments. Pediatrics. Oct 2017;140(4)doi:10.1542/peds.2017-0203
12. Yang S, Rider BB, Baehr A, Ducoffe AR, Hu DJ. Racial and ethnic disparities in health care–associated Clostridium difficile infections in the United States: State of the science. American Journal of Infection Control. 2016/01/01/ 2016;44(1):91-96. doi:https://doi.org/10.1016/j.ajic.2015.08.007
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