Where can you find more antimicrobial-resistant bacteria? Look in low-income zip codes.
Zanthia Wiley, M.D., FHM, FIDSA
Associate Professor of Medicine, Emory; Education Committee Chair, SHEA
Rekha Murthy, M.D., FIDSA, FSHEA
Professor of Medicine, Cedars-Sinai; DEI Committee Chair, SHEA
When a May 2023 study published in Infection Control and Hospital Epidemiology found that multidrug resistance is significantly and persistently more prevalent in samples taken from patients in low-income versus high-income ZIP codes in North Carolina, readers of the medical journal were likely not surprised.
Health inequities are persistent. Marginalized populations face barriers to healthcare access and experience worse health outcomes. Vulnerable communities, including those with lower socioeconomic status and limited access to quality healthcare, bear a disproportionate burden of infectious diseases.
To best address health inequity and combat antimicrobial resistance (AMR), antibiotic stewardship programs must focus their efforts on better understanding this relationship and implementing programs that address health disparities.
Inequality and AMR
The CDC defines antibiotic stewardship as, “the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients.” This specialized, multidisciplinary effort addresses the threat of AMR by monitoring antibiotic use (and misuse) and implementing processes to support proper use.
Historically, antibiotic stewardship has focused on the antibiotics themselves and the diseases for which they’re prescribed to treat, but how do health inequalities in our medical system compound the effects of AMR? What can practitioners, policymakers, and patients do to help address health inequity and AMR?
Racial and ethnic disparities have been well documented in many healthcare settings, and antibiotic stewardship is no different. Poor sanitation, overcrowding, and inadequate nutrition in underserved areas create environments conducive to the spread of resistant pathogens. Communities with few resources to allocate to antibiotic stewardship activities are at risk of having these disparities magnified, resulting in increased patient harm.
Without properly resourced antimicrobial stewardship programs, patients may be at risk of developing adverse antibiotic effects including allergic reactions, Clostridioides difficile infections, or bearing the burden of AMR infections later in life.
Steps to change
A critical step in addressing the health equity burden lies in acknowledging that these inequities exist. Inequitable access to healthcare and health insurance, poor health literacy, and other social determinants of health result in disparities in infections.
There is inequitable and biased antibiotic prescribing. We urge healthcare providers to be aware of their own biases and to use this awareness to inform equitable patient care practices. There is a need for more diverse healthcare providers.
Whether as a patient or as a caregiver, all individuals should feel empowered to ask questions regarding their medical care to ensure they understand why they are being prescribed antibiotics and to inquire whether they are needed. Remember, antibiotics do not work for viruses, so there is no need to take them when experiencing symptoms of the common cold, the flu, or other respiratory viruses like COVID and RSV.
We also call for broader representation of diverse patient populations in clinical trials to better align with the demographics of the United States. We need efforts to promote diversity in the clinicians who are prescribing antibiotics. Studies have shown that inequities are mitigated by diverse clinicians and teams.
Attaining equity will help build trust in healthcare, which is critical to our ability to respond to the next healthcare crisis. Additionally, we must design research that accurately quantifies and characterizes existing inequities in AMR. Race and ethnicity demographic data are often absent from studies, and we must continue to develop and implement practices to collect accurate data.
The mission of The Society for Healthcare Epidemiology (SHEA) has always been “Safe Healthcare for All.” As healthcare epidemiologists and antibiotic stewards, we are dedicated to strengthening antibiotic stewardship activities, and patient and public awareness of these issues to improve the overall quality and equity of care in our communities.
 Brown, D., Henderson, H., Ruegsegger, L., Moody, J., & Van Duin, D. (2023). Socioeconomic disparities in the prevalence of multidrug resistance in Enterobacterales. Infection Control & Hospital Epidemiology, 1-3. doi:10.1017/ice.2023.116