What Does Disability Justice Require of Antimicrobial Stewardship?

Abstract

This commentary on a case argues that antimicrobial stewardship requires an intersectional disability justice approach if it is to be equitable, particularly for multiply marginalized patients with disabilities residing in nursing homes, who are more susceptible to antibiotic underand overtreatment. Disability justice concepts emphasize resistance to structural and capitalist roots of ableism and prioritize leadership by disabled persons. A disability justice perspective on antimicrobial stewardship means prioritizing clarification of presumptive diagnoses of infection in vulnerable patients, clinician education led by disabled persons, and data collection. CaseDr S is a resident physician responsible for admitting patients overnight. A patient, M, is being transferred from a nursing home (NH) for tachycardia and hypotension. The NH's physician, Dr P, started M on a broad-spectrum antibiotic prior to M's transfer. Dr S notices in M's record that M has had multiple episodes of being treated with antibiotics in-hospital or in the NH, but with no specific infection diagnosis. Dr S worries about exacerbating this pattern of possible excessive antibiotic use that might expose M to unnecessary toxicity and threat of antibiotic resistance. Dr S plans to be judicious with antibiotics when treating M. M arrives on the unit and is now under Dr S's care. M is 57 years old with a history of cardiac arrest resulting in anoxic brain injury. M has a tracheostomy and normally breathes on her own without a ventilator; however, for transport from the NH to the hospital, she has been connected to a ventilator. M turns her head to look at Dr S when Dr S speaks to M, but M cannot speak while connected to the ventilator, appears to Dr S to be uncomfortable, and does not reliably signal "yes" or "no" in response to Dr S's questions. Now that Dr S has met M, Dr S questions her initial instinct to limit antibiotics for M. CommentaryUp to 70% of NH residents are prescribed antibiotics over the course of a year, and 40% to 75% of such prescriptions may be inappropriate or unnecessary. 1 Many residents live