“As a doctor and researcher, I spend most of my time working in jails, and I was seeing a lot of skin and soft tissue infections (SSTIs),” Alysse Wurcel, MD, MS, explains. “Many were being treated with clindamycin, which is a second line treatment for SSTIs.”
Dr. Wurcel notes that, while racial differences in the treatment of other medical conditions have been established, less is known about SSTIs. “I became really interested in seeing whether there are racial differences in treatment for SSTIs,” she says. “We are learning that there are different levels of racism across medicine. It may be implicit bias; it may be something you learned in medical school that’s outdated. Many different factors may impact how patients are treated, but there is no physiologic reason why people should be treated differently for cellulitis.”
For a study published in JAMA Network Open, Dr. Wurcel and colleagues performed a sub-analysis of cross sectional data collected by Dr. Kimberly Blumenthal through Vizient, Inc. acute care hospital groups. Dr. Blumenthal is an allergist-immunologist and population health researcher at Massachusetts General Hospital and assistant professor at Harvard Medical School. Drs. Wurcel and Blumenthal collaborated with Dr. Utibe Essien, an internist and health disparities researcher at David Geffen School of Medicine at UCLA. The researchers used EHRs to determine patients’ race, which was classified as Asian, Black, American Indian/Alaska Native, White, or other, including those who did not specify. However, because the number of individuals who identified as Asian, American Indian/Alaska Native, and other was small, the study analyzed antibiotic use between Black (the referent group) and White individuals. Antibiotic use served as the study outcome.
Black Race Associated With Increased Use of Clindamycin
The analysis included 1,242 adults being treated for SSTIs at 91 US hospitals (45% women; mean age, 58), with more White patients (69%) than Black patients (18%). A history of penicillin allergy was more common among Black patients (23%) than White patients (18%).
“We controlled for penicillin allergy because that is one reason why people might get clindamycin. People who are labeled as penicillin-allergic can have worse outcomes as a result of receiving second-line antibiotics, including clindamycin,” Dr. Wurcel explains.
Piperacillin-tazobactam and vancomycin were the most frequently prescribed antibiotics, and use did not differ by race, according to the study results. White patients were more likely to receive cefazolin than Black patients (13% vs 5%), and clindamycin was more often prescribed for Black patients (12% vs 7%; Table). Following adjustment for multiple factors, White inpatients were more likely to receive cefazolin (adjusted OR [aOR], 2.82; 95% CI, 1.41-5.63) and less likely to receive clindamycin (aOR, 0.54; 95% CI, 0.30-0.96) compared with Black patients.
“First-line treatment with cefazolin for SSTI was more common among White patients,” Dr. Wurcel notes.
However, Black race was associated with greater utilization of clindamycin even in the absence of penicillin allergy—and after controlling for MRSA colonization and infection, according to the study results.
Striving for ‘Pharmaco-Equity’ in Medication Distribution
“My colleagues and I have hypotheses about the differences in antibiotic prescriptions by race, but further investigation is needed,” Dr. Wurcel explains.
She pointed to a similar example with documented evidence, in which a Black infant, a White infant, a Hispanic infant, and an Asian infant present to the ED with an ear infection. “We know, from previous research, that the White infant is more likely than any of those other infants to get antibiotics. We also know that a White child is more likely to be exposed to penicillin, and therefore more likely to have a documented penicillin allergy. That’s not
based in genetics. The difference is rooted in implicit bias and, ultimately, racism.”
The results show “that we need to investigate further and strive for pharmaco-equity, a term that was coined by Dr. Essien,” Dr. Wurcel says. “We need an equity framework to look at penicillin allergy and antibiotic use. What are the barriers that people face, and how does racism impact that? We should be striving to distribute all medicines equitably.”
