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Race, Research, and Health Care Associated Infections

Learning Objectives
1. Describe disparities in Clostridium difficile infection
2. Describe disparities in Candida infection
3. Recognize ways that the medical research community can contribute to identifying disparities in hospital-acquired infections
0.5 Credit CME

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Audio Transcript

Welcome to Stories of Care, a podcast from the American Medical Association and CDC's Project Firstline. In this episode, we are joined by Dr Jacinda Abdul-Mutakabbir, Assistant Professor of Clinical Pharmacy at the University of California San Diego. Listen as Dr Abdul-Mutakabbir discusses her passion for examining racial disparities in health care associated infections and why it's important to encourage more researchers to look through this lens.

To earn CME for listening, visit amafirstlinestories.org and click on the title of this episode to complete the quiz.

Megan Srinivas, MD, MPH: Hi, Dr Abdul-Mutakabbir. Thank you so much for joining us today.

Jacinda Abdul-Mutakabbir, PharmD, MPH: Thank you so much for having me. I'm really excited to be here.

Srinivas: Well, I'm excited. You have such a wealth of knowledge and background on this topic that we're gonna delve into today. So, I'm really excited to, to first off, just hear how you've kind of gotten here. Where did your career start?

Abdul-Mutakabbir: I started undergrad at Howard University in Washington, DC. Following Howard, I went to pharmacy school in Connecticut, which was definitely an entirely different vibe but still on the East Coast. And then following pharmacy school actually went back for residency training at Howard.

And it was such an awe-inspiring experience for me. And for many different reasons, I think, when you go back to a hometown, or when you go back to a place that you're really familiar with, especially in a training capacity, you get to this place where you really see it through a different lens. So, for me, when I was at Howard as an undergrad student, I didn't really think of it as being like this metropolis or being this area that was comprised of so many minoritized people and just even the HIV population that we had there at Howard. And once I went back for training, I was just so overcome with one, just like, DC has a very familial context for me, like it's like going back is being there, is being with family. But then when I saw just the predominance of infectious diseases, especially the HIV population, I was overcome with just this need to change the way that healthcare looked for people that look like me.

Srinivas: Did you want to go into infectious disease when you were at Howard? Did you know that? Or was it kind of in pharmacy, you were like, “Hey, maybe let me go check this out.”

Abdul-Mutakabbir: It's so funny because no, I absolutely did not. I remember when I was at Howard as an undergrad, I actually wanted to be a pharmacologist. So I wanted to get a PhD.

I think for me, though, it really became it became a conversation of how could I have more patient interaction? So I actually worked as a pharmacy tech while I was in undergrad, and I loved it.

I love the community that I served. I loved having that connection with the patients. I think when the patients come see the pharmacist, it's a different type of connection that you have.

But when you come into the community, it's such a difference you can make in someone's life by, you know, addressing them by name, you know, asking them, “How are your kids doing. I see you got this medication. How's everything going? Can I talk to you about it?” And I loved it. I really love the connection that I had.

So that was when I decided to go into pharmacy. But as I was in pharmacy school, it was really my infectious diseases teacher and I'll give her a shout out. Dr Dora Wiskirchen. She was amazing. But she was so excited, she was so passionate, and she was so smart. And I was like, listen, I want to be just like her. She's such a superstar. And she saw that I really was, I was doing well in the class. And she pulled me to the side, and she really honed my interest. She was so excited that I was so interested. And honestly, she's actually still one of my mentors till this day, every time that I make a big career move, her and I talk about it. You know, she gives me her insight. When I decided to do a postdoc after, an infectious diseases-focused postdoc, she actually directed me right to the program that I went to. Luckily, it was back in my hometown in Detroit, but she was just such a source of support. And I think that's so important in education.

But when I went and did my postdoc in Detroit, where I am from, and I did my Masters in Public Health, that was really what flipped, I think, disparities on its head for me. Because while I was there in Detroit, and I don't know if it was the MPH or just being older and being back and, or being focused in infectious diseases and being back home, but it really forced me to kind of reckon with just the differences that we see in health care.

But it was actually when I started in academia. And I've trained on the benchtop. So, I went into my faculty job thinking, “Okay, I'm doing benchtop science, maybe a little bit of outcomes research, but that's what I'm doing.” Because that's what I trained in. And I knew I wanted to bring disparities in.

I didn't really know, I didn't really see the synergy. But it was really when my research partner, who Dr Karen Tan, who was at Loma Linda. Her and I had a research student look up an article because we wanted to look at rapid diagnostics. And when we were looking at rapid diagnostics, we were just trying to figure out, okay, what can we add to the current body of literature that discusses rapid diagnostics?

But our student, when he pulled up the study, and naturally it's from Detroit. It was when he was presenting his study and it was by Kim Claeys, Jason Pogue, so really good researchers that trained in Detroit and that worked in Detroit at the time.

And when we looked at that study, which was on multi-drug resistant ESBLs, so extended-spectrum beta-lactamases, and how rapid diagnostics could be influential there.

When we looked at the patient demographics, it was just, we had Black patients. And then we had non-Black patients, or white, majority white patients. And then when I thought about the actual number that we had there, the actual number of patients that we had, there was like 83% of the patient population, a part of the study, were Black individuals. So, now, when I thought about the study, or when I thought about the context of the rapid diagnostics, it went from being, you know, that we had this study about MDR ESBLs and how a rapid diagnostic tool could be influential to there are more Black patients than white patients who are more likely to be diagnosed these ESBL infections, and they were more likely to have chronic comorbidities. They were more likely to have all of these other things that would exacerbate that infection.

So then, when I thought about that, now it forced me to look into the context of just Detroit in general. So, what is the makeup of the city? Well, we know that it's like 70% Black. And I know that cause I was born at a DMC [Detroit Medical Center] hospital. You know, I was raised there. That's my city. So, when I looked at that study, I think it became personal to me.

So then, now, as I move forward in my disparities research, it's now personal. So now I think every time I'm doing this research, I think about it in the context of how can I decrease resistance for folks that look like me, because I saw it initially in that context of people that look like me or where I was from.

Even when I looked at the demographics of the age, makeup of the patients, my family members could be included, you know, a part of that retrospective study. So, I think, you know, that really is what pushed me and honed my interest. So, I have to thank my student, who is now Dr Kenneth Nguyen, for really forcing me into that position where I had to consider that.

Srinivas: So, you're talking about other things that influenced why the Black cohort was getting sicker and having worse outcomes, getting more infections. What are those other things?

Abdul-Mutakabbir: Right. So, when I really consider, and I think taking it from the context of just Detroit and just the overall demographic makeup and the things that are there.

What I really thought about were social determinants of health. And I will say that during my MPH program is when I was really faced with those inequities that exist, especially in the context of Detroit. So, when I thought about education. Well, Black individuals are less likely to graduate from college, to go into higher education.

When I think about my MPH program, I was the only African American student in my entire class. And I mean, it was in Detroit. Wayne State is located right in the middle of Detroit. So, it's so surprising that in this, in a place where there are 70%, you know, African American people, I would be the only person getting my Masters in Public Health that was African American.

And then when I thought about that, I think about, you know, the tools that we learn in the MPH program, but more so just what is it that education provides? Health literacy, vaccine literacy, antimicrobial resistance literacy. So now you have these patients that don't know anything about these things that can happen when you get an infection. So now they're not taking precautions. And when we think about chronic comorbidities, you're not going to take precaution, precaution on the chronic morbidity that can exacerbate or cause, you know, this element because at the end of the day, you don't know, you are not being provided the opportunity to have the educational capacity.

And then, when I think about just the access to health care, there is so, I mean, when I think about just the insurance, when I think about my own family and the insurance disparity that we have. I think, I mean, it really put it into context for me, because so many individuals are on Medicaid or Medicare or uninsured at all. So that can also affect how it is that individuals are being able to be seen for these chronic comorbidities that can be causative or that can offer that opportunity for infections to stem after.

When we think about just housing, how is it that infections go from person to person to person? I can say my own home in Detroit was multi-generational. My grandmother lived with us for 20 plus years. You know, it was her, it was my mom and dad, my brother and sisters. So many people in one location, so many opportunities for bacteria, for different resistant organisms, if you have folks that have been hospitalized for a long time, to go from person to person to person.

So, I think that I, when I really think about it, it's definitely social determinants of health and the inequities that exist amongst them. But I think that we have very clear indicators. If we really break down and think about what are the social determinants of health, very clear indicators that disparities exist, but we have to link those to the outcomes that we see.

Srinivas: No, you're so right. And then also just changing the way we educate the health care worker population. It's about changing the frame of how we think to approach each person's story so differently. And so, when you first started doing all this research, what was the first bug? I know you mentioned you had looked up these papers, all about ESBLs and everything. What was the first bug that you personally delved into and started to see these connections?

Abdul-Mutakabbir: So, for us, and I think, you know, my group anyway, when we think about infectious diseases and being an infectious disease person, the first place that you start, of course, is C. diff, right? It's like, alright, we know that we're doing a good job or we know that we're doing a bad job if we have high C. diff rates. So, we had a resident and she was really, she wanted to come on.

She was like, “Listen, you know, I want to do ID research.” And we said, you know what, we're going to hone this interest. We want for her to be invested into stat. And so, um, Dr Jina Lee is her name. And she's such a star. And when she started her project, it started off as a concordance project, right? You know, the regular, “I got to get this project done before I leave residency.” The concordance project, and she just wanted to see, you know, this is when fidaxomicin came out.

It's like, let's use that as our go to. So, then we wanted to say, she wanted to see. Okay. Are we seeing concordance? Are patients being treated, you know, with the guideline directed therapy? So very cursory research and my research partner and I, we had a meeting and she presented, you know, what she wanted to do to us and I, and we looked at my research partner who trained in a very similar program as I did.

And we say, you know what? Let's take this further. And of course, you know, to Jina's dismay, we say, collect insurance information. Let's add in race and ethnicity. You know, let's see what type of differences we see here. Because it really became, you know, we have to consider the community that we're in.

Loma Linda is a, is located in San Bernardino. San Bernardino is one of the most disparaged places in the United States, but also the, I believe, fifth most populous county in California.

Abdul-Mutakabbir: But our area is in an area of very high vulnerability.

So, we have a high population of Hispanic individuals that live there. And honestly, when we look at it from just more of a health care standpoint, we have an over-representation of Black and Hispanic patients, especially when we consider infectious diseases.

We really wanted for the C. diff study to be representative of our population, of our hospital. We wanted to know, you know, what is it that we see, how can we contribute to, you know, the current body of literature in a substantial and meaningful way.

Srinivas: Something that can actually be applied, because what we see is we often can't apply it to minority populations, we can't apply it to women or different types of often underrepresented groups because we don't have the research.

Abdul-Mutakabbir: Exactly. And I, and I was like, we have the forum, we have the place to do it. We have the data, we have the interested students. Let's do it. Wow. Yeah. So, um, Jina wanted to probably rip my hair out my head, but we got it done.

So, as she was doing this study, what we saw was that we had more Black patients, excuse me, more minoritized patients. So, racially and ethnically minoritized patients that, but majority Hispanic and Black that were a part of this study. So, they were more likely to have C. diff in general, and then they were more likely to have severe and fulminant C. diff. So, as we did this study, and one thing I will say is not only can you have mentorship just directly, but also from journal editors from peer review.

So, we sent the manuscript to be reviewed. And we sent it to ICHE [Infection Control and Hospital Epidemiology] where it's currently published, but the editor-in-chief there, who is absolutely amazing, he really worked to help us bring up the story, and we went ahead and when we first submitted the article, it was very descriptive. Like, we had this number of patients, you know, they had chronic comorbidities.

They were more likely to have CKD [chronic kidney disease] and diabetes. But we didn't really have that connection of how was that, or how are the chronic comorbidities relative to what it is that we were seeing in terms of the outcome, meaning the increased severe and fulminant CDI [C. diff infection] and the increased hospitalization of those patients that were minoritized.

So, what we did was we, we brought in another great friend of mine, Dr Sarah Jorgensen, and she did, who is a stats wizard, and she did some statistical analysis for us. But we did an additional, it's a counterfactual mediation analysis. So, we tried to figure out what was the contribution of CKD? Because that was a prominent chronic disease that we saw.

What was the contribution of that to the severe and fulminant CDI in the patients that were racially and ethnically minoritized? So, what we saw was that CKD actually mediated or pre-existing diagnoses contributed to about 10% of that causality or that potential risk in the patient developing the severe or fulminant CDI.

So I think for us though, what we're thinking about is when we see these patients that look this way, they are minoritized, they have these comorbidities, then we immediately have that trigger in our mind.

We want to watch them for C. diff.

Srinivas: And you're highlighting something that's so important. And I think it's something that gets a little bit jumbled in medicine. We have this, this movement of trying to open up equity in medicine, right? So, you know, for so many years, people have miscategorized and said Black populations are allowed to have a higher kidney creatinine than white populations. When in reality we know it's not actually based on race and that leads to Black people getting kidney disease that isn't treated as soon and higher transplant rates and later rates of transplant. But what you're saying is completely different, and I don't want people to mix that up. Race is important, but it's how we interpret it in medicine.

It's not about changing the way we interpret the numbers, it's about thinking about risk factors. That's what you're saying, and I think it's so important to highlight.

Abdul-Mutakabbir: Absolutely. And thank you so much for really pulling that out. When you think about science, it's very easy to use, you know, stats to explain away why it is that we see something.

But I think what's missing from the literature, my research partner and I always challenge each other to really think about what is the causality. And when we see these numbers. Not taking them just face value, really thinking through. And we challenge our researchers to do the same. Why does this happen?

And we don't, you know, do the cursory explanation of, “Well, you know, the minoritized patients were more likely or, you know, have the higher number.” But we don't think that, that the health care system is at all to blame or, you know, that social determinants of health are all to blame. But I think we have to take away that feeling of blame, that feeling of wrongdoing because no one's saying that anything is wrong. We're identifying the issue. Taking the numbers for what they are, thinking through the context of why it exists. And then just trying to be better and how we deliver the therapies.

Srinivas: Yep. No, that's, that is so important. Like the studies that show that when you take payer source into account that you sometimes neutralize the race difference.

That's because we're looking at the risk factors associated. And so, I think it's great what you're emphasizing. And unfortunately, we don't have many studies when we look at hospital acquired infections, looking at these differences, do we?

Abdul-Mutakabbir: No. And you know what? And that is what we are working, my group and I, to contribute to the literature. But also really encouraging other folks to do that. And there are journals that are really interested in this, ICHE, ASHE [Antimicrobial Stewardship and Healthcare Epidemiology], so the SHEA [Society for Healthcare Epidemiology] journals, are really dedicated to really amplifying the disparities in infectious diseases. I have worked with both with both editors of each journal. They have been so supportive and very encouraging.

We need for infectious disease organizations, all professional organizations, honestly, to deem this as important, you know, as we do as investigators. Because when there's a prioritization, then other people will prioritize researching it. But I even think that, as a reviewer, when I'm reviewing articles, and if I don't see disaggregated data, then I'll ask for it.

If I don't see, you know, that minoritized populations are not represented in the data, then I'll ask for it. My group, we started to, because we got this from a reviewer, we have started to add social vulnerability into our context. Because I think one thing that you brought up that's really important is, of course, you know, we have race and ethnicity, but it doesn't really give us all of the risk factors.

But when you can look up someone's social vulnerability, and we use the CDC social vulnerability calculator, which comprises a lot of different factors that can contribute to how it is that folks are able to access care and so on and so forth. It's right on the CDC website. We take the address from the patient.

We place it into that calculator. And then we can figure out what level of vulnerability they're at because then that also becomes the conversation. And then we can add more context. So, when we say that people of racially and ethnically minoritized backgrounds or people that identify as a part of that community are more likely to have these chronic comorbidities, then we can link that to social vulnerability.

And now we have an argument in saying, you know, “well, they're more likely to come from areas of low SES [socioeconomic status],” and we have the numbers to prove that. Really making that relationship clear.

Srinivas: Yep. And emphasizing that it's integral to every aspect of analysis when it comes to medicine.

I mean, that's a great tool. So, thank you for sharing that one out there for everybody to hear and know that they can use too. And then what you're saying about, even as a reviewer. The editors of these journals have so much power and really directing and shaping how research is formed. And these are integral questions.

The AMA, through the Center [for] Health Equity, has actually been working on trying to promote that as one of the focuses. Of saying every piece of research, even if you think it has nothing to do with racialized inequities, you have to ask the question. Or gender inequities, or gender orientation inequities.

You have to ask the question, are other populations that are not typically represented, was there an opportunity for them to be represented, and can we extrapolate this data to treat them based on what you have at hand? And that is so key. That is so key. And so, then you took that view, and, I mean, we're talking a lot about C. diff, and let's be honest.

Everybody in health care, we see C. diff nonstop.

Abdul-Mutakabbir: Unfortunately, right? Not, not the best thing to see.

Srinivas: We do, we do. It's not what we want to see, but hey, it's out there. But then you also took it to other diseases, other bugs. So, Candida, right? You started to look at fungal infections. Tell me about that.

Abdul-Mutakabbir: Yes. This was one of our postdoc projects and Dr Victoria Grant, we affectionately call her Tori. She was doing her research and she now is a fungal expert and she's, she took us along for the ride. But as we were doing her research, we had to once again, figure out what is the story we tell. Because we do have research on Candida. So, with our patient population, patients that we serve, what is the story that we have?

And for Tori, we were, this was really a pre-study to try to make the argument for T2 Candida for, so rapid diagnostics implementation that we wanted to do at the hospital. But as we looked back into the pre data collection that she did, what we saw was once again, we were seeing that a racially and ethnically minoritized individuals were more likely to be a part of this population, a part of the study population.

So, they were more likely to have these Candida infections. Which, once again, placed us into this position where we now have to think about what inequities exist that would make this true. So, we, we are seeing the same thing that we saw in CDI where they were more likely, you know, to have chronic comorbidities. More likely to have diabetes.

But once again, they were younger. So, I mean, you're seeing these things happen. But, I mean, even when we think about life expectancy, we see, like, a 10-year difference between minoritized groups and the majority. And we saw, we see this in our study. But it's because of those mediating factors, those inequities and social determinants of health that we see this.

So, when we were here and we were able to, when we did see some resistance, I was excited to be able to exploit what we saw. But it was the difference in the resistance that got me. So, it was for the majority patients or our non-racially and ethically minoritized, we saw Candida glabrata. When we looked at our minoritized patients, we saw Candida parapsilosis. So, we saw different Candida species there when we thought of when we, when we even looked at these patients. And then we thought about, well, why may this exist? Potentially the TPN placement, potentially because they were more sick or is it some type of environmental exposure.

Srinivas: Because I mean, yeah, it's one thing for people to get sicker based on social determinants of health. But where is the exposure and the different Candida coming from, especially when they're in the same geographic environment.

We think about this from coming from what soil, your environment, things that everybody's mutually exposed to, right?

Abdul-Mutakabbir: Yep.

Srinivas: I'm fascinated. I want to know if the TPN, if that's factored in, if that neutralizes the effect.

Abdul-Mutakabbir: Absolutely.

Srinivas: You left me on a cliffhanger, is what I'm telling you.

Abdul-Mutakabbir: I know, right? I know. And that was kind of what the reviewer said in the manuscript. They were like, “We have to know what happens here. We have to know what's going on.” And I told Tori that when she was doing the project and I was like, “Tori, this is big, you know, this is a big paper because we don't talk about, you know, resistance enough.” But to see the difference there, even the way that we explored it, it came from, and I wish I remembered the first author's name, but an ID Week abstract where they saw differences in Candida species, and it was different based on social vulnerability. But we didn't have social vulnerability in this study. We hadn't accounted for that. Because this was earlier in our publication journey. So now we are including it, but that also forces me to go back and reconsider, how do we determine vulnerability or that type of exposure that, those environmental factors. But I mean, so interesting.

I hope that people take this and run with it in their own institutions. You know and try to figure out where that lies.

Srinivas: Yeah, see if it's replicable and what the changes are.

Abdul-Mutakabbir: Right. 100%.

Srinivas: What is the most important thing that you want to leave the average person listening to our podcast episode right now, what is the most important thing that they need to take away and know how they can be involved in this?

Abdul-Mutakabbir: I think that the biggest thing, and one thing I always tell my group when we're talking, is think about the most marginalized patient that you have. And oftentimes, you know, they straddle so many different areas of marginalization.

You have a patient. Black, let's say they're Black. Let's say they're transgender. Let's say that they're, you know, older. Let's consider, you know, these different aspects that they may have. Or they're Hispanic and, you know, fit the things that I described. Think of your most marginalized patient and think about the care that they're currently receiving.

And then how is it that I, in my role, can have, can impact their outcomes or change the way that their outcomes look. That's how I always view my research. That's how I always view my placement. And as an investigator is, how can I serve the most marginalized patient that I know? How can I make sure that medicine serves them?

And I think that if you keep that at the forefront of your mind, you can't go wrong. Because you're going to serve the people at the top if you can serve the most marginalized. You can serve the most marginalized person, everybody else is fine.

Srinivas: Yeah, I love it. That is, that is the mantra to live by. I love it.

Thank you so much, Dr Abdul-Mutakabbir, for being here today. This has been such an enlightening conversation and the work that you're doing, I mean, I'm still on that cliffhanger, I'm waiting for the follow-ups. So, thanks so much for joining us. And I look forward to seeing what you and your group does in the future.

Abdul-Mutakabbir: Thank you so much. Thank you for having me.

Stories of Care is a publication of the AMA and CDC's Project Firstline. Project Firstline is a national infection control training collaborative, working to provide all health care professionals with the foundational infection control knowledge they need and deserve to protect themselves, their patients, their coworkers, and their communities. For more information, trainings and other infection control resources, visit CDC.gov/projectfirstline and AMAfirstline.org.

Audio Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 0.50  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 0.50 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 0.50 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 0.50 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 0.50 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 0.50 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


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