Macro-level social determinants of antimicrobial resistance: Evidence from 94 countries

Abstract Background Prior evidence suggests that not only antibiotic use, but social factors such as infrastructure and governance drive the spread of antimicrobial resistance (AMR). We explore how macro-level social characteristics of 94 countries predict resistance rates among community- and hospital-acquired bacterial pathogens that substantially contribute to AMR-related deaths. Methods We used recent data from ResistanceMap, World Bank, and other open data sources to select 12 variables related to demographics, economy, healthcare, education, governance, infrastructure, and social inequalities that well predicted the proportion of 3rd generation Cephalosporin- or Carbapenem-resistant E. coli (n = 93) and K. Pneumoniae (n = 94), and Methicillin-resistant S. aureus (MRSA, n = 84). Given the variability in outcome measures across countries, all regression models were weighted with the prevalence of tests conducted in each country. Results In bivariate models, higher GDP per capita and longer life expectancy consistently predicted lower AMR rates. In multivariate models, lower spending on education and higher gender inequality in labor force participation were associated with higher AMR. The role of gender inequality was particularly large for the primarily community-acquired Cephalosporin-resistant E. coli, which was also predicted by a higher share of population living in rural areas. Mainly hospital-acquired MRSA and resistant K. Pneumoniae were more prevalent with rising corruption, whereas high poverty rate and out-of-pocket health expenditure seemed to matter only for K. Pneumoniae. The predictors explained 73-83% of variation in MRSA and cephalosporin resistance, and 46-50% in Carbapenem resistance. Conclusions Public health initiatives aimed at fostering gender equality could mitigate the spread of community-acquired AMR, whereas reducing corruption and income inequality are crucial for controlling hospital-acquired AMR. Key messages • Macro-level social factors explain more than 70% of between-country variation in MRSA and 3rd generation Cephalosporin-resistant E. coli and K. pneumoniae which are major causes of AMR-related deaths. • Gender equality may mitigate the spread of AMR in communities, whereas income equality and reduced corruption are essential for managing hospital-acquired AMR.