Dimensions of poverty as risk factors for antimicrobial resistant organisms in Canada: a structured narrative review

Abstract

Background Few studies have assessed the relationship between poverty and the risk of infection with antimicrobial resistant organisms (AROs). We sought to identify, appraise, and synthesize the available published Canadian literature that analyzes living in poverty and risk of AROs. Methods A structured narrative review methodology was used, including a systematic search of three databases: MedLINE, EMBASE and Web of Science for articles pertaining to poverty, and infection with AROs in Canada between 1990 and 2020. Poverty was broadly defined to include economic measures and associated social determinants of health. Based on inclusion and exclusion criteria, there were 889 initial articles, and 43 included in the final review. The final articles were extracted using a standard format and appraised using the Joanna Briggs Institute Levels of Evidence framework. Results Of 43 studies, 15 (35%) related to methicillin-resistant Staphylococcus aureus (MRSA). One study found a 73% risk reduction (RR 0.27, 95%CI 0.19–0.39, p = < 0.0001) in community-acquired MRSA (CA-MRSA) infection for each $100,000 income increase. Results pertaining to homelessness and MRSA suggested transmission was related to patterns of frequent drug use, skin-to-skin contact and sexual contact more than shelter contact. Indigenous persons have high rates of CA-MRSA, with more rooms in the house being a significant protective factor (OR 0.86, p = 0.023). One study found household income over $60,000 (OR 0.83, p = 0.039) in univariate analysis and higher maternal education (OR 0.76, 95%CI 0.63–0.92, p = 0.005) in multivariate analysis were protective for otitis media due to an ARO among children. Twenty of 43 (46.5%) articles pertained to tuberculosis (TB). Foreign-born persons were four times more likely to have resistant TB compared to Canadian-born persons. None of the 20 studies used income in their analyses. Conclusions There is an association between higher income and protection from CA-MRSA. Mixed results exist regarding the impact of homelessness and MRSA, demonstrating a nuanced relationship with behavioural risk factors. Higher income and maternal education were associated with reduced ARO-associated acute otitis media in children in one study. We do not have a robust understanding of the social measures of marginalization related to being foreign-born that contribute to higher rates of resistant TB infection.

Carriage of Antibiotic Resistant Bacteria and Associated Factors Among Food Handlers in Tamale Metropolis, Ghana: Implications for Food Safety

“…45 Furthermore, some food handlers may truncate the course of therapy because of their inability to pay for the full course of medication. 45,46 The use of antibiotics for less period of time than is required, can exert selective pressure on bacterial populations which contributes to their resistance. 44,45 Resistance to beta-lactams and fluoroquinolones must be of great concern as they are preferred to aminoglycosides for the treatment of serious infections because of their high efficacy and low toxicity.…”

Pathogen distribution and antimicrobial resistance in infections in migrants and nonmigrants in Denmark, a cross‐sectional study

“…However, it is often within the first year that the decline in AMR carriage happens [27, 28] and unfortunately, we did not have enough samples from the first year of stay in Denmark to explore this in more detail. Finally, different determinants for SES have been found to be linked with higher risk of AMR [30, 31] however as previously discussed we did not have access to a good proxy for SES such as education level. Our results are not generalizable to the whole migrant population in Denmark since we only included family‐reunited migrants and refugees.…”

“…A systematic review from 2018 studied the impact of poverty on colonisation and infection with drug-resistant organisms and found that in high income countries crowded living conditions, lack of education and low income were associated with carriage/ infection with AMR organisms [30]. Another review from 2022 on poverty and social determinants for health as risk factors for AMR organisms in Canada found an increased prevalence among indigenous groups and found higher income to be associated with a lower prevalence of MRSA [31]. Previous studies have also pointed to international travel as a risk factor for increased resistance [3,32,33].…”

Understanding Canadians' knowledge, attitudes and practices related to antimicrobial resistance and antibiotic use: Results from public opinion research

“…Multiple factors may contribute to this observation. This may be driven by a high burden of medical conditions in lower-income communities in Canada (( 9 )), including infections (( 10 )). Antibiotic use may be linked to lower vaccination rates with various vaccines in low-income communities (( 11 , 12 )).…”