Discussion

To our knowledge, this is the first SRMA on race and ethnicity and risk of community-acquired 3GC-R uropathogens. Overall, Hispanic/Latinx individuals were found to be at significantly higher risk of harboring 3GC-R uropathogens compared to White/Caucasian individuals. There was no difference in risk between Black/African American versus White/Caucasians, and while Asian persons were often found to be at higher risk than White individuals among studies included in our systematic review, this difference was not statistically significant in the meta-analysis.

Previous literature points to disparities in antibiotic resistant uropathogen risk between non-White and White persons, including higher likelihood of resistance against 3GCs among Hispanic persons compared to Non-Hispanic White persons. ^{Reference Sardá, Trick, Zhang and Schwartz22,Reference Stultz, Francis and Ketron23} A 2015 Morbidity and Mortality weekly report published by the Centers for Disease Control and Prevention found that Hispanic individuals were more likely to obtain their antibiotics from sources besides their healthcare provider or clinic and were generally more likely to be unaware of antibiotic resistance. ^{Reference Francois Watkins, Sanchez, Albert, Roberts and Hicks30} Another study analyzing motivations for non-prescription antibiotic use among Hispanic individuals in Houston, Texas found that many believed that going to the doctor to receive prescribed antibiotics was unnecessary, and many found it difficult to make time to travel to hospitals, wait in long lines, and pay high costs for antibiotics. ^{Reference Laytner, Chen and Nash31} As noted by articles included in our systematic review, international travel may also exacerbate exposures to 3GC-R bacteria among this population. Some members of Hispanic/Latinx communities may frequently travel to Latin American countries, and several studies have identified travel to these regions as risk factors for the acquisition of 3GC-R Enterobacterales. ^{Reference Worby, Earl and Turbett32,Reference Ponce-de-Leon, Rodríguez-Noriega and Morfín-Otero33}

No elevated risk of 3GC-R uropathogens was found among Black/African American individuals compared to White individuals in our study. This finding is notable due to historically higher rates of other community-acquired AMR infections, specifically methicillin-resistant Staphylococcus aureus (MRSA) infections among Black individuals compared to White persons. ^{Reference See, Wesson and Gualandi34,Reference Gualandi, Mu and Bamberg35} This finding suggests that the underlying factors driving the spread of MRSA versus 3GC-R uropathogens are likely very different and require future investigation.

Almost no studies included in our systematic review considered socioeconomic factors, in addition to race and ethnicity, as potential risk factors for 3GC-R uropathogen burden. Race and ethnicity have no biological basis but are instead social constructs that greatly affect individuals’ lived experiences and access to goods, services, and opportunities. ^{Reference Flanagin, Frey and Christiansen36} Race and ethnicity have traditionally been used in clinical research as proxy measures for socioeconomic risk factors, although this approach has begun to be questioned. ^{Reference Shaikh, Lee and Stokes37} One recent SRMA assessed the role of race in calculating risk for UTI by replacing race with other risk factors, including history of UTI, duration of UTI, and duration of fever, in a common prediction tool. The authors found that the accuracy of the prediction tool in assessing UTI prevalence among Black versus non-Black pediatric patients was maintained when race was substituted with these additional risk factors, indicating that other factors may be more specific and useful for understanding differences in risk. ^{Reference Mauro, Allen, Dauda, Molina, Neale and Lewis38} In our SRMA, two studies continued to find race and ethnicity to be significant risk factors for 3GC-R uropathogens even after adjusting for recent antibiotic use, patients’ preferred language, or prior UTI. ^{Reference Raphael, Glymour and Chambers25,Reference Megged27} Unknown or unmeasured social determinants of health likely contribute to disparate risks for community acquisition of 3GC-R uropathogens among these minority groups.

This study had several strengths. Firstly, we conducted an extensive literature search that did not restrict studies based on study location or included race/ethnicity groups. We included a hand-search to capture up-to-date literature on race/ethnicity and 3GC-R uropathogens. Furthermore, we had a large, pooled sample size, comprising over 13,000 individuals, allowing our meta-analysis to provide more robust insights into the association between race/ethnicity and 3GC-R uropathogens compared to the results of individual studies. ^{Reference Sriganesh, Shanthanna and Busse39}

Our study also had limitations. Firstly, we identified relatively few studies examining race, ethnicity, and risk of community-acquired 3GC-R uropathogens despite 3GC-R Enterobacterales being globally recognized as a serious health threat. ^8,9 Additionally, the inclusion of non-US studies in our meta-analysis would have provided a deeper understanding of potential racial and ethnic disparities in these infections in an international context; our main conclusions are limited to the US. Additionally, only one study provided adjusted effect measures analyzing 3GC-R risk between racial and ethnic groups that could be included in the meta-analysis. ^{Reference Raphael, Glymour and Chambers25} We thus calculated unadjusted risk ratios from raw case counts provided by the studies. Adjusting for similar covariates across all studies included in each meta-analysis would have allowed for more comparable effect measures. Articles included in our study mentioned how additional risk factors of harboring AMR pathogens include contaminated meat consumption, diabetes mellitus, invasive urological procedures, and previous urine catheters, though these risk factors were not further analyzed in our referenced articles and were therefore not explored in our study.

Another limitation is that the definitions of racial and ethnic groups likely differed across studies, and it was unclear whether race or ethnicity were self-reported by patients, thereby risking misclassification bias. Three studies ^{Reference Raphael, Glymour and Chambers25,Reference Mark, Hung, Salim, Tarlton, Torres and Frazee28,Reference Collingwood, Yarbrough, Boppana and Dangle29} defined Black and White as racial categories, while another ^{Reference Zhu, Rodado, Asmar, Salimnia, Thomas and Abdel-Haq26} used the terms African American and Caucasian, as opposed to Black and White. The terms Black and African American are commonly used interchangeably, though they may not include all the same individuals. Furthermore, three studies ^{Reference Zhu, Rodado, Asmar, Salimnia, Thomas and Abdel-Haq26,Reference Mark, Hung, Salim, Tarlton, Torres and Frazee28,Reference Collingwood, Yarbrough, Boppana and Dangle29} used the term Hispanic, while one ^{Reference Raphael, Glymour and Chambers25} used the term Latinx. Similarly, the terms, Hispanic and Latinx, are often used interchangeably, though the term “Hispanic” comprises individuals with ancestry from a primarily Spanish-speaking country, while Latinx refers to those with ancestry in Latin America. ^{Reference Alexander40} In the meta-analysis, we combined Black individuals along with African American individuals, and Hispanic along with Latinx individuals, though certain individuals may not identify with both Black and African American or Hispanic and Latinx. Finally, we considered “Asian” as a monolithic group, since the included studies did not differentiate between Asian communities who vary in their cultures and spoken languages, potentially masking differences in 3CG-R uropathogen risk among Asian communities.