Contribution of socio-economic factors in the spread of antimicrobial resistant infections in Australian primary healthcare clinics

Mapping socioeconomic factors driving antimicrobial resistance in humans: An umbrella review

Introduction

Antimicrobial resistance (AMR) is one of the biggest public health challenges of our time. National Action Plans have failed so far to effectively address socioeconomic drivers of AMR, including the animal and environmental health dimensions of One Health.

Objective

To map what socioeconomic drivers of AMR exist in the literature with quantitative evidence.

Methods

An umbrella review was undertaken across Medline, Embase, Global Health, and Cochrane Database of Systematic Reviews, supplemented by a grey literature search on Google Scholar. Review articles demonstrating a methodological search strategy for socioeconomic drivers of AMR were included. Two authors extracted drivers from each review article which were supported by quantitative evidence. Drivers were grouped thematically and summarised narratively across the following three layers of society: People & Public, System & Environment, and Institutions & Policies.

Results

The search yielded 6300 articles after deduplication, with 23 review articles included. 27 individual thematic groups of drivers were identified. The People & Public dimensions contained the following themes: age, sex, ethnicity, migrant status, marginalisation, sexual behaviours, socioeconomic status, educational attainment, household composition, maternity, personal hygiene, lifestyle behaviours. System & Environment yielded the following themes: household transmission, healthcare occupation, urbanicity, day-care attendance, environmental hygiene, regional poverty, tourism, animal husbandry, food supply chain, water contamination, and climate. Institutions & Policies encompassed poor antibiotic quality, healthcare financing, healthcare governance, and national income. Many of these contained bidirectional quantitative evidence, hinting at conflicting pathways by which socioeconomic factors drive AMR.

Conclusion

This umbrella review maps socioeconomic drivers of AMR with quantitative evidence, providing a macroscopic view of the complex pathways driving AMR. This will help direct future research and action on socioeconomic drivers of AMR.

Geo-Temporal Variation in the Antimicrobial Resistance of Escherichia coli in the Community

Background: Antimicrobial resistance (AMR) is a global health challenge with significant global variation. Little is known about the prevalence on a smaller geographical scale. Objectives: This study aimed to explore the geo-temporal variation in antibiotic resistance in Escherichia coli (E. coli) urinary isolates in the Illawarra Shoalhaven region, a region south of Sydney. Methods: Data from urine E. coli isolates from people living in the community were geospatially analysed from 2008 to 2018. The proportion of resistant isolates was mapped by antibiotic type (amoxicillin with clavulanic acid, cefalexin, norfloxacin, and trimethoprim), postcode, and year. Results: Resistance varied by antibiotic, postcode, and over time, with some postcodes showing increased resistance one year and a decrease the following year. Areas with consistently higher resistance included metropolitan, port, and lake regions. We found low resistance in E. coli to amoxicillin with clavulanate, cefalexin, and norfloxacin (<5% to 10-19%) and the highest resistance for trimethoprim (10-19% to 30-39%). Overall, from 2008 to 2018, E. coli resistance to all four antibiotics increased in this region. Conclusions: This study shows temporal and geospatial changes in E. coli AMR over small geospatial areas, indicating the opportunity for geospatial analysis to assist in area-specific empirical treatment guidance.

A Biosocial Perspective to Understand Antimicrobial Prescription Practices: A Retrospective Cross-Sectional Study from a Public Community Health Center in North India

Background: It is well established by research that large-scale and indiscriminate prescribing, dispensing, and use of antimicrobials drive antimicrobial resistance (AMR) endangering the health and well-being of people, animals, and the environment. In the context of low- and middle-income countries (LMICs), the prescribing of antimicrobials is often not based on biomedical rationality but involves alternative logic driven by social, cultural, and institutional factors. This paper seeks to develop a "biosocial" perspective, reflecting a unified perspective that treats the biomedical and social conditions as two sides of the same coin. Methods: This analysis is based on an empirical investigation of prescription slips that patients carry to buy drugs from the pharmacy following an outpatient department encounter with the clinician. Data collection involves mixed methods, including the quantitative analysis of the antimicrobials prescribed and a qualitative analysis of the underlying reasons for these prescriptions, as described by doctors, pharmacists, and patients. Data analysis involved triangulating quantitative and qualitative data, to develop a "biosocial" perspective, which can provide implications for the development of antimicrobial stewardship policies, particularly relevant for health institutions in low- and middle-income countries. Results: Our analysis of 1175 prescription slips showed that 98% contained antimicrobials, with 74% being broad-spectrum antimicrobials. Only 9% of cases were advised antimicrobial sensitivity testing (AST) before initiating treatment. Qualitative findings indicated that patients had poor awareness of antimicrobials and pharmacists played a crucial role in counseling. Conclusions: This study highlights that antimicrobial prescriptions in public health settings are influenced by both biomedical and social factors, supporting a biosocial perspective. Although AMS interventions are predominantly biomedical, adhering to clinical standards and best practices, this study underscores the necessity of integrating a biosocial viewpoint by incorporating the experiences of pharmacists and patient groups. Strengthening diagnostic support, patient education, and interprofessional collaboration could improve rational antimicrobial uses in low-resource settings.

Longitudinal monitoring of sewershed resistomes in socioeconomically diverse urban neighborhoods

BACKGROUND

Understanding factors associated with antimicrobial resistance (AMR) distribution across populations is a necessary step in planning mitigation measures. While associations between AMR and socioeconomic-status (SES), including employment and education have been increasingly recognized in low- and middle-income settings, connections are less clear in high-income countries where SES remains an important influence on other health outcomes.

METHODS

We explored the relationship between SES and AMR in Calgary, Canada using spatially-resolved wastewater-based surveillance of resistomes detected by metagenomics across eight socio-economically diverse urban neighborhoods. Resistomes were established by shotgun-sequencing of wastewater pellets, and qPCR of targeted-AMR genes. SES status was established using 2021 Canadian census data. Conducting this comparison during the height of COVID-related international travel restrictions (Dec. 2020-Oct. 2021) allowed the hypotheses linking SES and AMR to be assessed with limited confounding. These were compared with sewage metagenomes from 244 cities around the world, linked with Human Development Index (HDI).

RESULTS

Wastewater metagenomes from Calgary's socioeconomically diverse neighborhoods exhibit highly similar resistomes, with no quantitative differences (p > 0.05), low Bray-Curtis dissimilarity, and no significant correlations with SES. By comparison, dissimilarity is observed between globally-sourced resistomes (p < 0.05), underscoring the homogeneity of resistomes in Calgary's sub-populations. The analysis of globally-sourced resistomes alongside Calgary's resistome further reveals lower AMR burden in Calgary relative to other cities around the world. This is particularly pronounced for the most clinically-relevant AMR genes (e.g., beta-lactamases, macrolide-lincosamide-streptogramin).

CONCLUSIONS

This work showcases the effectiveness of inclusive and comprehensive wastewater-based surveillance for exploring the interplay between SES and AMR.

Potential Causes of Spread of Antimicrobial Resistance and Preventive Measures in One Health Perspective-A Review

Antimicrobial resistance, referring to microorganisms' capability to subsist and proliferate even when there are antimicrobials is a foremost threat to public health globally. The appearance of antimicrobial resistance can be ascribed to anthropological, animal, and environmental factors. Human-related causes include antimicrobial overuse and misuse in medicine, antibiotic-containing cosmetics and biocides utilization, and inadequate sanitation and hygiene in public settings. Prophylactic and therapeutic antimicrobial misuse and overuse, using antimicrobials as feed additives, microbes resistant to antibiotics and resistance genes in animal excreta, and antimicrobial residue found in animal-origin food and excreta are animals related contributive factors for the antibiotic resistance emergence and spread. Environmental factors including naturally existing resistance genes, improper disposal of unused antimicrobials, contamination from waste in public settings, animal farms, and pharmaceutical industries, and the use of agricultural and sanitation chemicals facilitatet its emergence and spread. Wildlife has a plausible role in the antimicrobial resistance spread. Adopting a one-health approach involving using antimicrobials properly in animals and humans, improving sanitation in public spaces and farms, and implementing coordinated governmental regulations is crucial for combating antimicrobial resistance. Collaborative and cooperative involvement of stakeholders in public, veterinary and ecological health sectors is foremost to circumvent the problem effectively.

Epidemiological Characteristics and Antimicrobial Resistance Changes of Carbapenem-Resistant Klebsiella pneumoniae and Acinetobacter baumannii under the COVID-19 Outbreak: An Interrupted Time Series Analysis in a Large Teaching Hospital

Background: To investigate the epidemiological characteristics and resistance changes of carbapenem-resistant organisms (CROs) under the COVID-19 outbreak to provide evidence for precise prevention and control measures against hospital-acquired infections during the pandemic. Methods: The distribution characteristics of CROs (i.e., carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii) were analyzed by collecting the results of the antibiotic susceptibility tests of diagnostic isolates from all patients. Using interrupted time series analysis, we applied Poisson and linear segmented regression models to evaluate the effects of COVID-19 on the numbers and drug resistance of CROs. We also conducted a stratified analysis using the Cochran–Mantel–Haenszel test. Results: The resistance rate of carbapenem-resistant Acinetobacter baumannii (CRAB) was 38.73% higher after the COVID-19 outbreak compared with before (p < 0.05). In addition, the long-term effect indicated that the prevalence of CRAB had a decreasing trend (p < 0.05). However, the overall resistance rate of Klebsiella pneumoniae did not significantly change after the COVID-19 outbreak. Stratified analysis revealed that the carbapenem-resistant Klebsiella pneumoniae (CRKP) rate increased in females (OR = 1.98, p < 0.05), those over 65 years old (OR = 1.49, p < 0.05), those with sputum samples (OR = 1.40, p < 0.05), and those in the neurology group (OR = 2.14, p < 0.05). Conclusion: The COVID-19 pandemic has affected the change in nosocomial infections and resistance rates in CROs, highlighting the need for hospitals to closely monitor CROs, especially in high-risk populations and clinical departments. It is possible that lower adherence to infection control in crowded wards and staffing shortages may have contributed to this trend during the COVID-19 pandemic, which warrants further research.

Antimicrobial peptides: Defending the mucosal epithelial barrier

The recent epidemic caused by aerosolized SARS-CoV-2 virus illustrates the importance and vulnerability of the mucosal epithelial barrier against infection. Antimicrobial proteins and peptides (AMPs) are key to the epithelial barrier, providing immunity against microbes. In primitive life forms, AMPs protect the integument and the gut against pathogenic microbes. AMPs have also evolved in humans and other mammals to enhance newer, complex innate and adaptive immunity to favor the persistence of commensals over pathogenic microbes. The canonical AMPs are helictical peptides that form lethal pores in microbial membranes. In higher life forms, this type of AMP is exemplified by the defensin family of AMPs. In epithelial tissues, defensins, and calprotectin (complex of S100A8 and S100A9) have evolved to work cooperatively. The mechanisms of action differ. Unlike defensins, calprotectin sequesters essential trace metals from microbes, which inhibits growth. This review focuses on defensins and calprotectin as AMPs that appear to work cooperatively to fortify the epithelial barrier against infection. The antimicrobial spectrum is broad with overlap between the two AMPs. In mice, experimental models highlight the contribution of both AMPs to candidiasis as a fungal infection and periodontitis resulting from bacterial dysbiosis. These AMPs appear to contribute to innate immunity in humans, protecting the commensal microflora and restricting the emergence of pathobionts and pathogens. A striking example in human innate immunity is that elevated serum calprotectin protects against neonatal sepsis. Calprotectin is also remarkable because of functional differences when localized in epithelial and neutrophil cytoplasm or released into the extracellular environment. In the cytoplasm, calprotectin appears to protect against invasive pathogens. Extracellularly, calprotectin can engage pathogen-recognition receptors to activate innate immune and proinflammatory mechanisms. In inflamed epithelial and other tissue spaces, calprotectin, DNA, and histones are released from degranulated neutrophils to form insoluble antimicrobial barriers termed neutrophil extracellular traps. Hence, calprotectin and other AMPs use several strategies to provide microbial control and stimulate innate immunity.