Antibiotic resistance: a call to action to prevent the next epidemic of inequality

correspondence will welcome expressions of interest from experts who wish to contribute. ❐ The DECIDE-AI Steering Group Baptiste Vasey1 ✉, David A. Clifton2, Gary S. Collins3,4, Alastair K. Denniston5, Livia Faes6,7, Bart F. Geerts8, Xiaoxuan Liu5,7, Lauren Morgan9, Peter Watkinson10 and Peter McCulloch1 Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK. 2Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK. 3Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK. 4NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK. 5University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. 6Eye Clinic, Cantonal Hospital Lucerne, Lucerne, Switzerland. 7Moorfields Eye Hospital NHS Foundation Trust, London, UK. 8Healthplus. ai B.V., Amsterdam, The Netherlands. 9Morgan Human Systems, Shrewsbury, UK. 10Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK. ✉e-mail: 1 Published online: 1 February 2021 https://doi.org/10.1038/s41591-021-01229-5 References 1. Keane, P. A. & Topol, E. J. npj Digital Med. 1, 40 (2018). 2. Collins, G. S. & Moons, K. G. M. Lancet 393, 1577–1579 (2019). 3. Sounderajah, V. et al. Nat. Med. 26, 807–808 (2020). 4. Liu, X., Rivera, S. C., Moher, D., Calvert, M. J. & Denniston, A. K. Br. Med. J. 370, m3164 (2020). 5. McCulloch, P. et al. Lancet 374, 1105–1112 (2009). 6. Hirst, A. et al. Ann. Surg. 269, 211–220 (2019). 7. Bilbro, N. A. et al. Ann. Surg. 273, 82–85 (2021). 8. Price, W. N. II, Gerke, S. & Cohen, I. G. J. Am. Med. Assoc. 322, 1765–1766 (2019). 9. Dalkey, N. & Helmer, O. Manage. Sci. 9, 458–467 (1963). 10. Powell, C. J. Adv. Nurs. 41, 376–382 (2003). Competing interests X.L. is an industry fellow (observer) with Hardian Health. D.A.C. declares academic grants from GlaxoSmithKline and personal fees from Oxford University Innovation, Biobeats and Sensyne Health, outside the context of this work. B.F.G. is CEO and Founder of Healthplus.ai and declares consulting fees from NLC Ventures Netherlands. L.M. is director and owner of Morgan Human Systems. P.W. reports grants from National Institute for Health Research, grants from Wellcome, grants from Sensyne Health, and personal fees from Sensyne Health, outside the submitted work. Antibiotic resistance: a call to action to prevent the next epidemic of inequality To the Editor — The COVID-19 pandemic has revealed the deadly impacts of structural racism and systemic health inequalities on racial and ethnic minorities in the USA. Black and Hispanic/Latinx populations have been disproportionately impacted by COVID-19, accounting for nearly half of the cases and 37% of the deaths so far, despite making up less than a third of the US population1. This stark imbalance has highlighted the need to examine the role of racial and ethnic disparities in shaping health outcomes. Antibiotic resistance (AR) is widely considered to be the next global pandemic. When bacteria no longer respond to antibiotics, treatment is more costly and burdensome and is much less likely to succeed. As many as 162,000 US adults die from multidrug-resistant bacterial infections each year, which makes resistant infections the third leading cause of death2. Rising concerns about both the health impacts and economic impacts of AR have led to national efforts to increase surveillance, minimize inappropriate antibiotic use, jumpstart the development of diagnostics and antibiotics, and increase awareness of AR. However, the idea that AR could disproportionately impact racial and ethnic minorities has not yet entered the scientific discourse. The existing literature describing racial and ethnic disparities in antibiotic-resistant infections in the USA is scarce and conflicting. Racial and ethnic data are not routinely collected or checked for accuracy in many clinical settings. Of the few existing studies, some suggest that Black, Hispanic and lower-income people are at higher risk of infection with community-acquired antibiotic-resistant pathogens such as methicillin-resistant Staphylococcus aureus and drug-resistant Streptococcus pneumoniae3,4. However, such studies are exceptionally rare. While federal efforts in the past decade have made progress in standardizing the collection and reporting of race and ethnicity data in healthcare settings, many AR-related studies still lack these data. Nevertheless, there are a number of reasons to suspect that disparities in AR-related morbidity and mortality exist (Fig. 1). For example, while non-Hispanic Black people, Hispanic people and Asian people may receive fewer antibiotic prescriptions over their lifetimes than do non-Hispanic whites5, they may also be more likely to consume non-prescription antibiotics6. Living in crowded and/ or multigenerational housing, which is more common among racial and ethnic minorities7, increases risks of AR acquisition and transmission. Some minority groups may also frequently travel to their native countries, many of which have a high burden of resistant infections8. Nearly 60% of people working in US meat-processing plants are Black or Hispanic/Latinx9; occupational contact with ‘food animals’ may also increase minorities’ exposure to Nature Medicine | VOL 27 | February 2021 | 186–190 | www.nature.com/naturemedicine zoonotic, resistant pathogens. Finally, with more-frequent underlying comorbidities, racial and ethnic minorities are hospitalized for preventable conditions more often, which puts them at increased risk for drug-resistant hospital-acquired infections. Despite this, the US government’s new National Action Plan for Combating Antibiotic-Resistant Bacteria has not prioritized racial or ethnic disparities in AR-related outcomes for either investigation or intervention10. As scientists, researchers and citizens, we have an obligation to ensure that racial and ethnic minorities and economically disadvantaged people will not be disproportionately burdened by the AR crisis. First, we urgently need to understand the scale of underlying disparities in AR-related morbidity and mortality. Continued improvements in the collection of racial and ethnic data in healthcare settings will enable us to evaluate factors underlying disparities across different settings and levels of ‘urbanicity’. Second, we must improve AR literacy in low-income and minority communities by incorporating AR- and infection-prevention education into non-traditional settings. Tailoring future interventions to community settings such as bodegas, tiendas, daycares and classrooms, for example, could help curb unnecessary antibiotic use. Third, we must acknowledge that race or ethnicity is only one factor that might underlie disparities in AR. People who 187 correspondence ethnic inequality in AR has the power not only to inform and guid (...truncated)