Action is needed to slow drug-resistant infections in vulnerable populations

Kalvin Yu, Vice President, BD Medical Affairs North America;
Diane Flayhart, Director, BD Global Public Health

As we recognize World AMR Awareness Week, we reflect on how the globe has recognized and reacted to public health crises and how these crises have impacted vulnerable populations.  With HIV, Hepatitis C, and more recently the COVID-19 pandemic, social determinants of health and related demographics such as gender, ethnicity, and socioeconomic status have been recognized in resulting in disproportionately deleterious clinical outcomes.^i,ii   

 Most recently, the 2024 United Nations Political Declaration on Antimicrobial resistance (AMR), acknowledged “the need to leave no one behind and reach the furthest behind first, and to ensure equitable and timely access to quality essential health-care services and safe, effective, quality, affordable essential medicines including antimicrobials, and vaccines, diagnostics, therapeutics and other health products”.^x,i

AMR has been referred to as the “silent” pandemic, however, recently The World Health Organization (WHO) listed AMR among top 10 threats for global health. Antimicrobial resistance threatens human and animal health and welfare, the environment, food and nutrition security and safety, economic development, and equity within societies.ⁱⁱⁱ  The US CDC is addressing AMR health equity as a part of CDC’s CORE Initiative, an agency-wide strategy to increase equity across public health.  Health disparities related to AMR may appear in a number of ways, including variance in risk of exposure or transmission, susceptibility to infection, and treatment received.^iv

Like the other public health crises, we are seeing signals yet again of AMR -related health disparities in vulnerable populations. A vulnerable patient can be identified by several factors, including patients who disproportionately suffer from disease, have difficulty in accessing medical care, have disproportionate morbidity and mortality outcomes, and have limited control or input into their healthcare.^v,vi

A recent study analyzed urinary tract infections caused by multi-drug resistance pathogens. It was found that young and elderly female patients alike (both of whom are vulnerable demographics for different reasons) were at risk for single and multiple first line antibiotic resistance. Increasingly, universal national guidelines may not reflect clinical need given that geography also mattered in this study. Higher rates of drug-resistance were seen in zip codes that coincided with a higher density of POC (persons of color) and lower socioeconomic income.^vii  This study represents real world evidence (RWE) which identify clinical gaps and the impact to vulnerable populations.  This type of data should used to help inform guidelines and be included in prospective clinical trials.

Patients undergoing chemotherapy are another vulnerable population who have higher rates of infection. As many as 1 in 5 cancer patients undergoing treatment are hospitalized due to infection, and antibiotics are the main line of defense.^viii Recently, a study showed that hospitalized cancer patients have a 2-fold increase in incidence of resistant pathogens causing life-threatening blood stream infections as compared to non-cancer patients.^ix  Looking more closely at  the impact of infection to cancer patients and other vulnerable patients , it was found that transplant and  myeloproliferative (MP) cancer  l patients had a higher burden of hospital onset bacteremia  compared to patients without either.^x,ii

High rates of drug-resistance limits choices for clinicians to treat their patients and can cause higher rates of mortality, increased length of hospitalization and costs. Antibiotics are a key and indispensable part of cancer treatment – many patients simply must take them – and for their benefit it is important to better manage the use of these medicines and address this crisis.

These findings aren’t just limited to the United States, they repeat themselves across the globe. Bacterial infections (excluding Mycobacterium tuberculosis) that are drug-resistance are estimated to be associated with approximately 5·0 million deaths annually, with 4.3 million occurring in low-income and middle-income countries (LMICs).^vi

We are at an inflection point with AMR. We have a clear call to action from the UN Declaration on AMR – countries committed to reducing the number of deaths globally associated with bacterial AMR by 10% by 2030. Let’s learn from historical public health crises and not repeat the same mistakes with AMR. Actions that we can take today to reduce the burden of drug-resistant infections and the impact to vulnerable patients, globally, include:

• Increase alliances between healthcare systems, public health policy and industry
• Delineate the clinical care gaps that need addressing via Real World Evidence
• Address clinical AMR gaps by developing metrics of success predicated on regionally supported existing infrastructure, such as leveraging required antimicrobial stewardship programs and linking them with required infection prevention insights^x

ⁱ Abrams EM, Szefler SJ. COVID-19 and the impact of social determinants of health. Lancet Respir Med. 2020 Jul;8(7):659-661. doi: 10.1016/S2213-2600(20)30234-4. Epub 2020 May 18. PMID: 32437646; PMCID: PMC7234789.
ⁱⁱ Edwards AE, Collins CB Jr. Exploring the influence of social determinants on HIV risk behaviors and the potential application of structural interventions to prevent HIV in women. J Health Dispar Res Pract. 2014 Winter;7(SI2):141-155. PMID: 27134801; PMCID: PMC4848455.
ⁱⁱⁱ https://www.unep.org/explore-topics/chemicals-waste/what-we-do/emerging-issues/antimicrobial-resistance-global-threat#:~:text=What%20is%20the%20impact%20of,development%2C%20and%20equity%20within%20societies; accessed 11/14/2023.
^iv https://www.cdc.gov/drugresistance/pdf/health-equity-antibiotic-resistance-fs-508.pdf; accessed 11/14/2023.
^v Centers for Disease Control estimate 2019 Threats Report: https://www.cdc.gov/drugresistance/biggest-threats.html
^vi Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis, The Lancet January 19, 2022DOI:https://doi.org/10.1016/S0140-6736(21)02724-0
^vii Antimicrobial Resistance Trends in Urine Escherichia coli Isolates From Adult and Adolescent Females in the United States From 2011–2019: Rising ESBL Strains and Impact on Patient Management, Clinical Infectious Diseases, Volume 73, Issue 11, 1 December 2021, Pages 1992–1999.
^viii https://kreftforeningen.no/en/antimicrobial-resistance-amr/what-are-the-consequences-of-antibiotic-resistance-for-cancer-patients/; accessed 11/14/2023.
^ix Gupta, V. Burden of Antimicrobial Resistance in Hospitalized Patients with Cancer: A Multicenter Analysis. Poster presented at: ASM-ESCMID 2023 Joint Conference on Drug Development to Meet the Challenge of Antimicrobial Resistance (ASM-ESCMID) 19-22September 2023; Boston, MA USA.
^x https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/infection-prevention-and-control-and-antibiotic-stewar.dship-program-interpretive-guidance-update; accessed 11/15/2023
^xi   https://www.un.org/pga/wp-content/uploads/sites/108/2024/09/FINAL-Text-AMR-to-PGA.pdf; accessed 11/08/2024
^xii Clinical characteristics associated with hospital-onset bacteremia and fungemia among cancer and transplant patients, October 2024, Infection Control and Hospital Epidemiology

DOI:10.1017/ice.2024.160