The below resources are for educators, students/trainees, and others interested in materials that help explain and distill concepts pertaining to antimicrobial resistance, One Health, and more. Please feel free to use these resources in your courses or share them to your websites and social media. We only ask that you link back to us at www.LevyCIMAR.org when you do. You can email us with any questions at CIMAR@tufts.edu.
Antimicrobial Resistance and Inequality
Antimicrobial-resistant (AMR) infections can be deadly, and can impact anyone without discrimination including the young and otherwise healthy. “Superbugs”—or disease-causing bacteria that are resistant to treatment—are found in all regions of the world including right here at home in the United States. Resistant bacteria can be found in our food and all around us, including in our own bodies. This can be bad news for our health.
But AMR has even more far-reaching consequences that are often overlooked, and some of the most vulnerable groups in our society, including racial and ethnic minorities and the economically disadvantaged might be most at risk. Global changes in climate, urbanization, food production, and income inequality threaten to worsen these disparities.
The following infographics explain both how resistance emerges and spreads, as well as how it might impact marginalized communities more than the average person.
Food animal production in the United States is highly concentrated. From 1992 to 2012, the number of pig farms in the US decreased by 67% while annual pig production increased by more than 8 million. Many more animals are now raised on fewer farms; for example, the number of farms raising 5,000 or more animals increased 3.6 times during that same time frame.
Large-scale food animal farms rely on antibiotics to prevent and treat disease, and until recently, to promote growth. As a result, most antibiotics sold in the United States each year are sold for use in food animals, not in humans. Routine antibiotic use in animals can select for drug-resistant bacteria. Specifically, bacteria that have developed or acquired genetic mechanisms that allow them to survive in the presence of antibiotics are able to multiply and become dominant.
Drug-resistant bacteria selected for in food animals can spread to nearby communities through air, water, direct contact with animals and/or animal waste, and via pests like rats and flies. Heavy rainfall and flooding can lead to the run-off of bacteria-laden manure into the surrounding environment.
In some parts of the United States, concentrated animal farms are disproportionately located in communities that have the lowest income and the highest percentage of residents who identify as non-white. As heavy rainfall and flooding become more frequent due to climate change, these communities will be even more at risk of exposure to antibiotic resistance via the environment.
Persons experiencing homelessness in the United States face obstacles to self-care and personal hygiene. Clean bedding and facilities for laundering clothes, washing hands, and bathing can be difficult to access. Temporary housing solutions are often crowded and homeless persons are at higher risk of injection drug use.
Reduced hygiene and living in crowded conditions can increase homeless persons’ risks of acquiring drug-resistant skin infections like methicillin-resistant Staphylococcus aureus (MRSA). MRSA infections are more difficult to treat than ordinary Staph infections and can cause a range of complications, including pneumonia and sepsis. MRSA infections killed at least 11,000 people in the United States in 2019.
MRSA can contaminate hard-to-avoid surfaces in shared housing, including bedding and towels, doorknobs, furniture, food preparation areas, toilet handles, and remote controls. MRSA can survive for days or even weeks and may spread to people who touch contaminated surfaces. These bacteria can cause infections if they enter a cut, abrasion, or open wound.
After declining from 2010-2017, homelessness in the United States is on the rise again. The ongoing COVID-19 pandemic could further worsen recent trends. Ensuring all persons, regardless of housing status, have access to hygiene and sanitation facilities will be critical for preventing the spread of antibiotic resistance.
Urban informal settlements, sometimes referred to as “slums” or “shantytowns”, are common in many low- and middle-income settings across the globe. These settlements are typically crowded, may lack legal status, and are prone to flooding due to lack of adequate drainage. Often, residents cannot easily access clean water or toilets. As a result, infectious diseases like diarrheal illness are exceptionally common.
Slum residents regularly purchase antibiotics to treat and prevent illness from local drug sellers, who may lack medical training and typically don’t require prescriptions. Sometimes, the antibiotics they purchase are not effective. Because visiting a hospital can be prohibitively expensive, residents often try self-medicating with other types of antibiotics instead of seeking medical help. Frequent antibiotic use can destroy the populations of “good bacteria” living on and inside the human body that normally provide protection against pathogens. As a result, slum residents can be especially vulnerable to new infections with drug-resistant bacteria that circulate in the environment, including via drinking water, contaminated soil, food, and in animals.
More of the world’s population is expected to live in urban informal settlements in the next 30 years. Worryingly, almost 90% of urban population growth will occur in regions where most deaths attributable to drug-resistant bacteria are predicted to occur, namely Asia and Africa. As cities develop, ensuring equitable access to public health infrastructure will be critical for preventing the spread of antibiotic resistance.
The above information on AMR and Inequality was written by the Levy CIMAR’s Maya Nadimpalli, PhD, whose work involves using genomic and epidemiological approaches to understand how exposures to food, animals, and the environment can impact human colonization and infection with antibiotic-resistant bacteria, particularly in low-resource settings. The infographics were designed by Dr. Nadimpalli and Madeline Verbica, curriculum illustrator for Great Diseases.
Shorter is Smarter
Many people look to their doctor for everyday health needs, including treatments for common bacterial infections, such as a sinus or urinary tract infection (UTI). But while the antibiotics prescribed may help you in the short term, a longer course may cause resistance or other unwanted long term side effects.
Antibiotic overuse has become a key factor in antibiotic resistance, which has become a global crisis. Yet research shows that primary care physicians prescribe antibiotics in 10% of all outpatient visits. And the longer the duration of antibiotics for common bacterial infections like a UTI, the more likely that antibiotic resistance will develop. We asked the Levy CIMAR’s Shira Doron, MD, Infectious Disease Physician and Director of Antimicrobial Stewardship at Tufts Medical Center, how to know if you are being prescribed the appropriate antibiotic duration and how to avoid developing antibiotic resistance.
What is the appropriate duration of antibiotics to be prescribed?
The dosage of antibiotics may vary based on the infection and the antibiotic but a new guideline offers best practices on prescribing shorter-course antibiotics for some common infections.
Although there are exceptions for specific clinical factors, typically, a recommended 5-day antibiotics course applies for these four infections:
- Acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation
- Community acquired pneumonia (CAP)
- Urinary tract infections including uncomplicated kidney infection- could be as little as a single dose depending on the antibiotic
- Cellulitis (skin infection)
Is a shorter dose of antibiotics just as effective?
A shorter course of antibiotics for many common bacterial infections has been found to be just as effective – and in many ways, a smarter choice — than a longer course of antibiotics.
How do I talk to my doctor about whether the duration of antibiotics prescribed are appropriate for me?
Patients and doctors share the responsibility of antimicrobial stewardship. When your doctor prescribes an antibiotic, ask whether the recommended duration is as short as it can safely be. Also inquire as to whether you should “finish the prescription” even if you feel better, as prolonged antibiotics courses have just as much risk of creating resistance as too short a course. And remember: appropriate antibiotic use means prescribing the right antibiotic for the infection, in the right dose, for the right duration – every time.
The above information on “Shorter is Smarter” comes from Tufts Medical Center (TMC) and the Levy CIMAR‘s Shira Doron, M.D., TMC Director of Antimicrobial Stewardship, Attending Physician, and Hospital Epidemiologist. If you plan to use any of the materials from the “Shorter is Smarter” section, please credit and link back to us.
Funding Opportunities for Graduate Students and Post‐Doctorates
This document (.PDF) highlights several websites, databases, and other resources where graduate students and post-doctorates can find funding opportunities through Tufts University, as well as from the federal government, philanthropic foundations, and corporations.
The document also includes tips for finding the right opportunities and helping ensure one’s success when applying. Members of the Tufts community can find additional resources through the Tufts University Office for Corporate and Foundation Relations (CFR) website. CFR offers assistance through all stages of the proposal process.