A Novel Framework to Address Antimicrobial Stewardship Disparities

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The new Equity in Antimicrobial Stewardship Efforts (EASE) is a comprehensive set of priorities designed to overcome inequities and address the challenges with prescribing practices within the minoritized populations.

Social determinants of health are large factors in determining outcomes for Individuals' acute medical issues as well as their overall health.

“When I think about the social determinants of health, I think about what the CDC [Centers for Disease Control and Prevention] has defined as important to accommodate health-related needs. So, I think about environment, health care, access to health care, resources, education, socioeconomic status,” said Jacinda Abdul-Mutakabbir, PharmD, MPH, AAHIVP, assistant professor of Clinical Pharmacy, University of California San Diego. Abdul-Mutakabbir has been studying disparities and social determinants and explains her approach in tackling such large topics.1

She takes those individual points and thinks about the deficiencies in those areas and how they might be interconnected, which can create a cascading effect that can lead to serious health consequences.1

Differing Diagnoses and Subsequent Prescribing Practices
Abdul-Mutakabbir says these inequities have existed for years and points to the mis-prescribing of antibiotics that can lead to 1 particular health care-associated infection.

“I think we see disparities in Clostridium difficile, and in antimicrobial stewardship that's often that marker of, are we using antimicrobials the way that we're supposed to?” said Abdul-Mutakabbir.

“When we see these disparities or worsening of Clostridium difficile across minoritized groups, we see an increase in comorbidities across minoritized communities that cause or may contribute to the severity of C diff and an extended hospitalization,” she said.

And she explains the COVID-19 pandemic exacerbated these issues. New data from the World Health Organization provides further evidence of widespread antimicrobial use during the pandemic, despite only a minority of overall patients needing them to fight infections. In fact, the WHO found that although only 8% of hospitalized patients with COVID-19 had bacterial co-infections requiring antibiotics, 75% of patients were treated with antibiotics ‘just in case’ they helped. 2

Conversely, there is evidence patients from minoritized communities are not getting diagnosed with certain infections and not getting the antimicrobials they need. “In one study in pediatrics, looking at pneumonia diagnoses, it showed that patients from minoritized communities, predominantly black, and Latino communities, were less likely to be diagnosed with pneumonia; and being a condition that almost always for bacterial pneumonia, always requires antibiotics,” said Jasmine Marcelin, MD, FACP, FIDSA, associate professor, Department of Internal Medicine, associate medical director, Antimicrobial Stewardship Program, University of Nebraska Medical Center. “If you have fewer diagnoses of bacterial pneumonia, then that is not good stewardship.”

An Antimicrobial Stewardship (AS) Framework to Address the Problem
There are ongoing efforts to try and reduce unnecessary antimicrobial use, and this past week, a new framework titled Equity in Antimicrobial Stewardship Efforts (EASE) was launched and was detailed comprehensively in Antimicrobial Stewardship & Healthcare Epidemiology. It looks to address this major health care issue by looking to infectious diseases clinicians to help lead the way to minimize these health care inequities.

“Our framework proposed incorporates applicable aspects of the WHO, CDC, and CMS frameworks—in context with previously described functions of AS-to distinguish practical priorities to consider for integrating equity within AS-focused activities,” the authors wrote.

Abdul-Mutakabbir and Marcelin were both coauthors and codevelopers of this novel framework and paper. EASE is broken down into 5 priorities, and they include the following:

  • Priority 1: Identify Existing AS Inequities
  • Priority 2: Healthcare Team Education
  • Priority 3: Design AS Intervention to Address Inequities
  • Priority 4: Measure Intervention Outcomes
  • Priority 5: Disseminate Findings and Change Policies

Priority 1: Identify Inequities Using Data
Marcelin says EASE begins with the data and using the electronic medical records to capture the trends of care that medical institutions and stewardship programs can recognize and act upon.

“When we're seeing some trends in people who are coming from a certain zip code and folks who are coming from that zip code are predominantly from this racial or ethnic background, we may have noticed that group of individuals may have higher utilization of Medicaid services, etc., so how can we ensure that the care that we're providing to people who are coming to us from this zip code is optimal?”

Priority 2: Creating the Right Team
Abdul-Mutakabbir says it is about involving everyone from the C-suite of the organization to those in the clinical care trenches who are executing on stewardship programs and initiatives.

“A major part of it is having that buy-in from everyone that's going to be involved in that element of providing patient care,” Abdul-Mutakabbir said.

Upon getting everyone onboard, educating everyone is the next piece before the next priority of designing interventions to address these inequities.

This is the first in a two-part interview. In the first installment, Abdul-Mutakabbir and Marcelin discuss some of the challenges in antimicrobial prescribing practices and the priorities of the framework.


References
1. Parkinson J. How Disparities and Social Determinants of Health Can Affect Antimicrobial Stewardship. Contagion. February 27, 2024. Accessed May 8, 2024.
https://www.contagionlive.com/view/how-disparities-and-social-determinants-of-health-can-affect-antimicrobial-stewardship
2. Parkinson J. During the Pandemic, 75% of Hospitalized COVID-19 Patients Received Antibiotics, Despite Only a Minority Needing Them. Contagion. May 7, 2024. Accessed May 9, 2024.
https://www.contagionlive.com/view/during-the-pandemic-75-of-hospitalized-covid-19-patients-received-antibiotics-despite-only-a-minority-needing-them
3. Abdul-Mutakabbir JC, Tan KK, Johnson CL, McGrath CL, Zerr DM, Marcelin JR. Prioritizing Equity in Antimicrobial Stewardship Efforts (EASE): a framework for infectious diseases clinicians. Antimicrobial Stewardship & Healthcare Epidemiology. 2024;4(1):e74. doi:10.1017/ash.2024.69



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