How Sex and Gender Impact Antimicrobial Resistance Risk

By Lynn Lieberman Lawry, Senior Gender Advisor, MTaPS

Antimicrobial stewardship (AMS) helps to keep antimicrobials effective by decreasing their inappropriate use, a cause of growing antimicrobial resistance (AMR) to common first-line drugs used for treating life-threatening infections. More than 700,000 people die annually from drug-resistant infections, and this will increase to 10 million by 2050 if decisive actions are not taken, according to a UN report by a global panel of experts. As part of the Global Health Security Agenda, USAID MTaPS is assisting countries to increase their capacity to fight this growing global and national threat through AMS and related behavior change communication.

It is important to understand that both sex (identified by physical or physiological differences ) and gender (defined by socially constructed roles) impact vulnerability, exposure risk, and treatment and response that affect incidence, duration, severity, morbidity, mortality, and disability from infectious diseases, highlighted in a new paper. Sex and gender, therefore, also play important roles in AMR.

Sex Effects on AMR

Pharmacokinetics and Pharmacodynamics

Body weight, blood volume, and fat distribution differences between sexes have biological effects on how antibiotics are absorbed, distributed, metabolized, and eliminated (WHO). This is one of the reasons that females have more adverse drug events (ADE) and more frequently suffer from AMR than males.

Hormones influence AMR (they always seem to have a role!)

AMR is common among females during childbirth age and when females are pre-menopausal. But pubertal males also have marked increases in AMR. As per published research, with increasing age (decreasing hormonal levels), both males and females are at increased risk for AMR.

Pregnancy and AMR

Pregnancy, abortion, and childbirth, especially where these events take place in healthcare settings without safe or hygienic conditions, put these individuals at a higher risk of exposure to AMR.

Gender Effects on AMR

Roles and responsibilities increase AMR risk among women.

• Seventy percent of people employed in health sectors globally are women, which pre-disposes them to AMR risks (WHO):
  • Nurses, often women, play a pivotal role in IPC on a day-to-day basis.
  • Power inequities mean women may not have a voice to make changes for better infection control.
  • Women are both the formal and informal care givers at home and at work, increasing their exposure.
•  Reproductive age women are prescribed a higher number of antibiotics in primary care.
• If women contract an antibiotic-resistant infection, they may be less likely to receive or less able to afford the needed first- and second-line treatments.
• Where there is gender-based violence (like conflict settings), there are higher rates of sexually transmitted infections and more AMR.

Men are not exempt; they have other risk factors that put them at risk for AMR.

Men tend to self-prescribe antibiotics and may not finish the full course of antibiotics, leaving themselves at risk for AMR infections. Also, in some cultures, men consider having a disease (e.g., tuberculosis) a masculine trait and don’t present until they are very sick or have not been treated appropriately.

Did You Know?
A study showed that men are less likely to see hand sanitizer dispensers unless they are visually obvious such as in bright colors, centrally located, or visually appealing.

Make those sanitizer dispensers look like a circus to increase patient/provider hand hygiene!

 

Further, men have habits that put them at more risk for AMR infections, such as drug and alcohol use. Men who have sex with men are potentially at higher risk to drug-resistant gonorrhea.

One Health is an important consideration too.

Farming exposes people to resistant bacteria and animals that can serve as infectious vectors for emerging diseases like we have seen during the COVID-19 pandemic. Men and women have different exposures based on their cultural roles for taking care of animals, e.g., in some countries, women care for small farm animals, like chicken and goats, more than men.

What Does All This Mean for AMS?

• Understanding how sex (biological differences) and gender (constructed roles, behaviors, activities) influence AMR is a must.
• Strong AMS programs can help avert the need for second-line antibiotics, which are expensive and can ruin medicine budgets.
• AMR risk can be reduced by AMS and behavior change efforts that take sex and gender differences into account when designing interventions.

Practical Suggestions to Incorporate Sex and Gender in AMS and AMR Strategies:

• Examine National Action Plans on AMR to ensure they include sex and gender implications.
• Conduct a gender analysis to examine how factors, such as sex, occupation, income, age, hormonal status, risk factors, and geographic location, influence AMS and AMR to inform decision making.
• Design interventions for infection prevention and control (IPC) and social behavior change with gender differences in mind to ensure messaging appeals to your audiences.
• Develop AMR communications strategies that include messaging tailored to local gender roles and are designed to challenge harmful norms.
• Gender balance IPC committees to include a wider variety of views on how IPC can be better practiced.
• Ensure both men and women have equitable access to gender-appropriate personal protective equipment (PPE) as IPC measures.
• Train and motivate health workers to prescribe and promote judicious antibiotic use, keeping in mind gendered differences in care-seeking and antibiotic use among their patients.
• Emphasize hygiene in AMS programs at health care facilities – an aspect that poses the highest risk for reproductive age women.
• Use a One Health approach to include gender-targeted activities to address antibiotic overuse in agricultural and animal health settings.

Only by addressing sex, local gender differences, and the inequities thereof will we succeed in reducing the global threat of antimicrobial resistance.