Originally published by our sister publication Infectious Disease Special Edition

By Marie Rosenthal, MS

Disparities in care occur in every field, including infectious diseases, and are often due to implicit biases that can make them harder to overcome, according to Jacinda Abdul-Mutakabbir, PharmD, MPH, who spoke about correcting these disparities at the annual Making a Difference in Infectious Diseases (MAD-ID 2023) meeting, held in Orlando, Fla. 

How do you fix a mistake if you aren’t even aware you are making it? Many might think that such disparities would not be a problem if an infectious disease specialist is involved in a patient’s care. Everyone in infectious diseases knows that pathogens neither understand nor recognize boundaries, so any person with an infection would get the right drug for the right bug if an ID specialist was involved in their care. Unfortunately, that is not always the case. 

Several studies have shown that Black, Hispanic and other minoritized communities are less likely to receive an antibiotic or are more likely to receive the wrong antibiotic, or the wrong form of an antibiotic, than white people, so it is imperative that everyone in healthcare works to recognize and overcome disparities and social determinants of health, she said. Awareness and education are the keys.

“It’s my hope that you are able to describe the relationship between systemic racism and social determinants of health when providing treatment to patients with infections, and also identify the factors in antimicrobial resistance, or stewardship processes and policies that could result into disparities in care,” said Dr. Abdul-Mutakabbir, an assistant professor of clinical pharmacy in the Division of the Black Diaspora and African American Studies, Skaggs School of Pharmacy and Pharmaceutical Sciences, at the University of California, San Diego.

As a Black person growing up in Detroit, Dr. Abdul-Mutakabbir understood the systemic racism that not only Black people but many other groups have seen over the years. “I trained at the Detroit Medical Center, but I was also born in a hospital that is part of the Detroit Medical Center. So, am familiar with the disparities that plague the city.”

What really brought it home for her as an ID specialist was a 2020 study that looked at the optimal therapy for Enterobacteriaceae bloodstream infections based on diagnostic testing (Open Forum Infect Dis 2020;7[8]:ofaa278). Of the 450 Enterobacteriaceae infections studied, 73 (16%) were caused by ceftriaxone-resistant organisms. The Verigene diagnostic test accurately predicted the ceftriaxone susceptibility of 97% of the isolates compared with 70% to 80% with the traditional scoring tools—all good data from an antibiotic stewardship perspective. 

When resistance is viewed from an inequity lens, however, one starts to see serious differences, Dr. Abdul-Mutakabbir explained. “The study was conducted in Detroit, Mich., where 77.9% of the population identifies as Black/African American,” she said, and 75% of the patients included in the study were Black, 29.3% had chronic kidney disease and 40% had diabetes. 

“When I looked at this from the inequity lens, it was separated by Black and white. And then when I thought about the Black and white separation, 75% of the patients included in this study were Black,” she continued. “So that meant that the bulk of the individuals that had resistant organisms were Black individuals—a disparity in terms of antimicrobial resistance.”

That realization shifted her research focus, Dr. Abdul-Mutakabbir said.

And this wasn’t the case of just one study. Other studies show that minorities do not always get the right drug at the right dose, given in the right formulation, for the right duration. 

A retrospective cohort study that included 1,242 patients treated for skin and soft tissue infections included 224 (18%) Black patients, who tended to be younger and more likely to have kidney disease (24% vs. 18%), diabetes (18% vs. 36%) and documented penicillin allergies (18% vs. 23%). They were more likely to get clindamycin instead of cefazolin, which is the recommended first-line therapy (12% vs. 7%; P=0.04), even after controlling for methicillin-resistant Staphylococcus aureus colonization, infection and penicillin allergy (JAMA Netw Open 2021;4[12]:e2140798). 

“Kidney disease, diabetes and clindamycin are all associated with an increased risk for developing severe or fulminant Clostridium difficile infections, where racial differences have been reported,” Dr. Abdul-Mutakabbir said.
Another retrospective cohort study of seven pediatric emergency departments (EDs) that looked at 39,445 children (19.1% non-Hispanic white; 50.5% non-Hispanic Black; 30.3% Hispanic; and 7.8% other) treated for viral acute respiratory infections found that non-Hispanic white patients were twice as likely to receive antibiotics for viral infections after adjusting for age, insurance coverage, triage acuity level and provider type than minority children (Pediatrics 2017;140[4]:e20170203).

“The researchers said that the results are synonymous with potential implicit bias and non-Hispanic white children being considered ‘sicker’ and overtreated when compared with racially/ethnically minoritized children,” she explained. 

Although Dr. Abdul-Mutakabbir is personally familiar with racism and systemic racism against Blacks, Dr. Abdul-Mutakabbir acknowledged, there are many other areas where people are marginalized: homophobia, xenophobia, ableism, classism, ageism and sexism. All these beliefs contribute to a marginalization of people who identify within these groups. These explicit and implicit biases result in structural marginalization and inequitable outcomes, she said.

To overcome these biases, healthcare professionals must think about the patient that is in front of them, and not only look at the obvious race, age, etc., but ask about their living arrangements, ability to get to the clinic or office for follow-up visits, whether they have insurance coverage, and a host of other social determinants of health, because all of these things will have a direct effect on their care. 

“All these things are interrelated,” Dr. Abdul-Mutakabbir said. Lack of education and lower socioeconomic status have many implications, she added. “These individuals are less likely to have access to health services. So [they’re] less likely to have insurance, less likely to go to emergency rooms, less likely to have a primary care provider. So more likely to have inequitable outcomes.” 
How does an ID specialist overcome these biases? 

The first step is to use that time-honored “recipe” for success: right drug, right dose, right delivery and right duration—regardless of the patient’s race or ethnicity. And pharmacists and antimicrobial stewards are in a good place to make sure that the recipe is followed, she said.

Data not only to show the disparities, but also the value of methods to overcome them are imperative. Armed with data about these issues, the ID community can approach the C-suite and help institute change.

Dr. Abdul-Mutakabbir also recommended that people interested in repairing the disparities seen in healthcare today focus on one area at a time—better antimicrobial use among children in the ED, for instance—so that it is more likely to succeed. The inequities within the U.S. healthcare system took more than 200 years to build; they’re going to take a while to tear down. 

“Pick one thing. Pick something that you want to measure; pick an outcome [where] you want to look at the disaggregated data,” Dr. Abdul-Mutakabbir said, “because that’s what we’re missing from the literature. It’s hard to see the disparities that exist.” 

It’s important to “go back, reevaluate and advocate,” she concluded. “We want to ensure that … we continue to advocate for those patients that are marginalized because we know that that’s the important piece.” 

Dr. Abdul-Mutakabbir reported financial relationships with Shionogi and Entasis Therapeutics