Association between health inequalities, antibiotic use and antibiotic-resistant infections in high-income countries: a scoping review
Authors: Casale E , Harvey E J , De Brún C , Finistrella V , Ashiru-Oredope D 
Published: November 2022

Abstract

Introduction
Health inequalities and antimicrobial resistance (AMR) present public health challenges. National guidance highlights the role of pharmacy professionals in reaching patients at risk of health inequalities.1 Pharmacy teams have the opportunity to involve their patients in shared decision-making and promote antimicrobial stewardship.2 An evidence gap exists regarding the association between factors that commonly contribute to health inequalities and antibiotic use amongst populations and risk of developing antibiotic-resistant infections.

Aim
To investigate the association between health inequalities, antibiotic use and risk of antibiotic-resistant infections in high-income countries, allowing pharmacy professionals to better understand the challenges and their role in tackling health inequalities and AMR.

Methods
Factors that commonly contribute to health inequalities and included in this review were: (i) Protected characteristics (age, ethnicity, disability, gender, sexual orientation); (ii) Socio-economic characteristics (employment status, deprivation, education, income, insurance); (iii) Vulnerable groups (migration status, sex workers, people who inject drugs (PWID), the homeless); (iv) Geography (region, urban or rural dwelling). The PRISMA-ScR was followed. Systematic literature searches were performed on OVID Embase and Medline and included published papers between January 2010 and April 2021. Exclusion criteria were research undertaken in low- or middle-income countries, viral (including COVID-19) and fungal infections and tuberculosis. Regular co-author meetings provided second checking of extracted data.

Results
Antibiotic use: Fifty-eight of 402 papers were included; most were from the USA (n=34) followed by the UK (n=12). Fifty papers focused on one or more protected characteristics, 37 on socio-economic characteristics, 21 on geography and 6 on migration status. Sample findings: In England, areas of high deprivation had increased antibiotic prescribing, with most deprived areas showing increased rates of broad-spectrum antibiotic use. In the USA, patients from rural areas were more likely to have nitrofurantoin for urinary tract infections inappropriately prescribed compared to urban dwellers. Antibiotic-resistant infections: Ten of 137 papers were included; the majority from the USA (n=6). Six papers focused on ethnicity, three on age and one each on deprivation, income, migration status, PWID and geography. Sample findings: In the USA, African American and Hispanic patients had higher rates of methicillin-resistant Staphylococcus aureus (MRSA) compared to patients of other ethnicities. Immigrants had lower rates of MRSA infections, but higher rates of methicillin-susceptible S. aureus wound infections, compared to USA-born citizens. Across Europe, E. coli infections resistant to aminoglycosides had strong association with income inequality.

Discussion/Conclusion
There is evidence for an association between health inequalities and antibiotic use, and health inequalities and risk of antibiotic-resistant infections. Further research is needed to understand how differences in antibiotic use affect AMR spread amongst populations. A study limitation includes addressing each health inequality individually without investigating how they may interact together to affect antibiotic use and infection resistance patterns. A strength is use of the PRISMA-ScR reporting guideline and systematic literature search. The pharmacy profession is trusted by the public3 and ideally placed in community and hospital settings to raise awareness of how health inequalities impact infection management and resistance rates, as well as advocate for equity of access in Core20PLUS populations.

References
1. National Institute for Health and Care Excellence, Community pharmacies: promoting health and wellbeing. 2018: https://www.nice.org.uk/guidance/ng102/chapter/Recommendations
2. O'Hare A, Harvey E, and Ashiru-Oredope D. Patient safety spotlight: how pharmacy teams can help minimise antimicrobial resistance. Regulate. 2022
3. Crossley, K. Public perceives pharmacists as some of the most trusted professionals. Pharmacy Times. 2019;18