A descriptive study of the association of Carbapenem-resistant Enterobacterales with environmental justice of a Southern urban county, USA

Background: Carbapenem-resistant Enterobacterales (CRE) present a threat to global public health systems, yet the environmental contribution to antibiotic resistance prevalence has been understudied. The risk of antibiotic-resistant bacterium proliferating may be greater in neighborhoods experiencing environmental injustice (e.g., contaminated water, housing density). We examine spatial correlations between CRE detection rates and the Environmental Justice Index (EJI) across census tracts in an urban county. Methods: We analyzed data from electronic health records of two major health systems from 2015–2020. Using global spatial autocorrelation tests (i.e., Global Moran’s Index) and bivariate spatial lag regression models we analyzed the association of EJI components and local CRE rates. Findings: The overall EJI exhibited significant clustering in the study area (Moran’s I = 0.51) and a strong positive association with local CRE positive culture rates (β = 0.44, SE = 0.10). The health vulnerability domain of the EJI (e.g., chronic disease burden) demonstrated the strongest association with CRE rates (β = 0.75, SE = 0.13). Measures of built environment (β = 0.42, SE = 0.16), water pollution (β = 0.41, SE = 0.11), housing type (β = 0.34, SE = 0.13) and housing characteristics (β = 0.41, SE = 0.10) displayed significantly strong associations with local CRE positive culture rates. Interpretation: These findings highlight the complex interplay between environmental conditions, social determinants, and health outcomes, indicating that areas with poor environmental quality and higher social vulnerability exhibited elevated CRE positive rates. This emphasizes the potential relevance of environmental and social disparities to antibiotic-resistant organism burden such as CRE.