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Communicable takes on hot topics in infectious diseases and clinical microbiology. Hosted by the editors of CMI Communications, the open-access journal of ESCMID, the European Society of Clinical Microbiology & Infectious Diseases.
[00:00:00]
Erin: Hello and welcome back to Communicable, the podcast brought to you by CMI Communications ESCMID's, open Access Journal, covering infectious diseases and clinical microbiology. My name is Erin McCreary, and I'm an ID pharmacist and the Senior Director of Infectious Diseases Strategy at UPMC in Pittsburgh, Pennsylvania.
In the us I am joined today by my co-host, Annie Joseph, clinical microbiologist at Nottingham University in the uk.
Hi Erin. Hi everyone. Happy to be here for this episode today.
Erin: Hey, Annie. We're so excited to have you. Today's episode is a special episode to Mark International Women's Day on March 8th in 2025, the editors of CMI comms and Communicable hosts got together to record two episodes on the topic of women and men in infectious diseases.
We shared our experiences of inequalities and challenges and discussed the direction of travel for both men and women in our field. For this year's episode, Annie and I have invited two women who are doing [00:01:00] amazing research in the field of sex and gender, and their on aspects of clinical infection and antimicrobial resistance.
Our first guest is Dr. Esmita Charani. Esmita is an associate professor at the University of Cape Town where she's undertaking a welcome trust career development fellowship on intersectional research in antimicrobial resistance. She's leading the Proteus study across South Africa and India, which stands for power relations and optimization of therapies and equity in access to antibiotics.
In the uk. She's an honorary reader in infectious diseases, AMR, and Global Health at the University of Liverpool. Her work in AMR has been recognized through the Academy of Medical Sciences uk. India, AMR, visiting Professor Award. She's also involved in mentoring and supporting clinical pharmacists and researchers across different healthcare settings and economies in implementing antimicrobial stewardship interventions.
Her work on equity and global health includes representation of people through imaging, which is really just. Really, truly fascinating work and I actually had the privilege of traveling through Australia with Esmita for about [00:02:00] three weeks, a few years ago. And I can attest she is as amazing in person as she sounds on paper.
Erin: So Esmita, welcome to Communicable.
Esmita: Thank you so much. It's great to be here.
Annie: Our second guest today is Dr. Annette Westgeest, an Infectious Diseases fellow at Leiden University Medical Center in the Netherlands.
She holds a PhD on Staphylococcus aureus colonization and Infection, including research conducted at Vance Fowler's lab at Duke University, USA. Her current research focuses on the influence of biological sex on severe staph aureus and other bacterial infections, as well as the clinical impact and management of staph aureus colonization, including MRSA.
Annie: She's actively engaged in promoting sex and gender sensitive research and clinical practice, and in recognition of her work, she was awarded a gender in research fellowship by the Netherlands Organization for Health Research and Development. Aimed at integrating sex and gender perspectives into health research and clinical care.
In 2025, she was an invited speaker at ESCMID [00:03:00] Global presenting on the impact of sex and gender on serious bacterial infections. And we're gonna hear more about this work. I had the pleasure of hearing this talk in person and it really left an impression on me. I've recommended it to many colleagues to go back and listen to it.
So welcome to Communicable Annette.
Thank you very much, Annie. Hi everyone, and thank you for having me.
Well, we are so excited to have you both, you both do such amazing work in this space. But before we dive into learning more about this work as a tradition here at Communicable, we start with a get to know you question for our guests.
Erin: So for this week we wanted to stick with the International Women's Day theme. So. What famous woman from history would you most like to meet and why? And I suppose they can be dead or alive. We didn't clarify that, Annie, but let's just say they can be dead or alive.
Annette, do you wanna go first?
Sure. I would choose Aletta Jacobs. She was the first woman, to officially attend a Dutch university, and actually the first female physician in the Netherlands around 1880. But she was also a, feminist and an activist who fought for things like [00:04:00] access to contraception for all women and also for women's suffrage.
Annette: So I just cannot imagine how much resistance she must have faced at that time. And I'd be very curious to hear what she would think about today's struggles and the position of women now, and of course how she would think we can best continue to progress.
Thank you for sharing that. That's a great choice, Esmita.
Esmita: That is such a good question. and I, think for me, you know, throughout history women have always been asked to or require to dim their light or lower their voice or hide their brilliance. And I can't choose any particular woman, but it's all the women who have been brilliant and have contributed so much to our history and society.
But I've had to not realize that in their own lifetime. And for example, for me, the Brontë sisters, in literature and how they had to write under the pseudonym of men, and struggled all their lives, . and their brilliance only came to light, after their lives were finished quite young, actually from TB for one of the sisters.
so I think it's that and recognition that. To [00:05:00] this day, and including in academia still in many spaces, women are asked to, just shine a little less, and I think that's something that still carries on.
Annie: Thanks, Esmita. , Okay. So now into our topic for the episode today, sex and Gender and their impacts on aspects of clinical infection and antimicrobial resistance.
So this is a pretty big and complex topic. So we're gonna try and break this episode into three sections, bringing in the expertise and opinions of our guests as we go. So firstly we're gonna talk about the context, why sex and gender is an important determinant in infection, and then sex and gender impacting patients with infection as the second section, what infections people get, the care they receive, and then finally, how sex and gender influence us as healthcare professionals working in the field of infection.
Erin: Yeah, this is a jam packed episode and we're so excited. So, Esmita, we're gonna start with you. Your work in this space has been absolutely transcendent, I would say, from the moment I met you, everything [00:06:00] you've taught me, and then following your work, even before I met you, and now it's really just incredible what you're doing.
So, from your discussions of imagery and global health, you serve as the co-principal investigator for the Centers for Antimicrobial Optimization Network, or CAMO net in the South African Hub and your publications on understanding gender. Inequities in antimicrobial resistance. I mean, you really just do it all.
And for our listeners, we will link, some of these publications in our show notes so you can access them after the episode or while you're listening, but Esmita. Can you give our listeners some background as to when sex and gender first started to be recognized as a determinant of infection related health?
And perhaps as you answer this question and, and break it down, maybe you can clarify both of those terms for our listeners so we're all on the same page as we'll be making some important distinctions during this episode.
Thank you so much, Erin. I think Annette might be better than me to explain the differences, but the way I understand it, and I, I come from a pharmacy background, so this, I, I have to learn to do this research and.
Esmita: It became an area of [00:07:00] importance for me in my research as I looked at more and more at how we, negotiate power within the healthcare setting to make decisions around antibiotics. and it all came down to the social and cultural norms, , that we adhere to, and that's intricately linked to our gender identities and many different identities that we have.
But sex usually refers to a person's biological characteristics, whereas gender is more about the socially constructed roles and norms. that we assume, or that we are given based on different societies that we live in based on religion, on culture, on practices within family, within society, and the communities in which we live.
and often, gender roles and norms are determined by sex individuals as well. So male, female, male versus female. and how those rules are set out in society. In the field of antimicrobial resistance. In the last 20 years we've been conducting a lot of research around antibiotic stewardship, around optimizing antibiotic use for human populations and [00:08:00] looking at the drivers of antimicrobial resistance.
And it's only in the last five, six years that we have started to talk about this from an intersectional lens. That includes looking at. Gender roles and norms within society, but also the biological differences that men and women have when it comes to disease. epidemiology, but also disease outcomes.
And there's still a lot of, information that we do not have. There's a lot of evidence that we need to gather around how gender norms and roles impact our experience and access to healthcare, but also how biological sex can impact Our infection rates and infection outcomes, and also how therapies are decided.
And therapeutics are determined around, this, and I as a pharmacist, as you would know, Erin, historically, most of the drug trials are carried out on a 70 kilo male. So that is the background of where we come from. There's so much bias in the evidence that we are using to determine therapeutic choices for our patient population, even at that level.[00:09:00]
Erin: Yeah, I mean, my health system just made the universal change to using C-K-D-F-E-E-G-F-R instead of Cockcroft gult for renal function, aligning with where the FDA is moving and publications coming out in the space to talk about, I mean, for what, 50, 60 years? We used an equation derived solely in men and then we just said, well, women are about 85% of a man.
Let's multiply by 0.85. That's wild. Considering how sh. Much weight it carries when you do a renal function calculation, but okay. On that note then, Esmita, can you give us a broad overview on the emerging, I know there needs to be a lot more data in this space, but the emerging evidence that there is for men and women and how they're impacted differently by AMR.
Esmita: So we are conducting intersectional research in this topic in South Africa and India, but the evidence that other colleagues are looking at as well, not just our work, looking at a. Sociocultural level, our access to healthcare, our access to education, access to resources that is [00:10:00] determined by gender roles and norms, and that can influence, health outcomes, including access to water hygiene and sanitation vaccination programs.
and also is something that's really important to realize is when we talk about gender inequality, we're not just talking about women here, we're talking about it's men, women, and, individuals who identify as. The spectrum of genders that exist for that. There is a lot less evidence than there is for men versus women, of course, because that work has been done for a longer period of time.
and so it is important to understand that there are negative and positive, influences regardless of whether you're a man for. Women or any other gender that you identify as. But we've not conducted a, very large piece of work looking at how power manifests in healthcare settings and how that has an impact on health outcomes and the health care experience.
And for example, there's a lot of evidence around, how women's experience of healthcare is so intricately different to that of men's experience of healthcare, particularly around childbirth and, pregnancy and breastfeeding, and that is [00:11:00] also related to the infection related, risks that each of these conditions, contain, but also looking broadly within society.
There is a lot of evidence around how, norms related to pregnancy, to women's physical mobility, to ownership and control of physical assets can also influence health outcomes. So even at that level, I know Annette has done a lot of much more. Detailed disease, specific research around gender, but we have to start from looking at society level.
what are the gender differences in terms of outcomes for health and access to healthcare resources? When it comes to antibiotic cues, there is evidence from, trials in Europe, but also in other parts of the world where there is a difference in, use of antibiotics and antibiotic consumption.
Esmita: With women being sometimes , overprescribed antibiotics in comparison to men even when we correct, for conditions such as uninary tract infections, which are more common in women than they are in men. so there is many different layers in which, you can look at this.
And then there is inappropriate diagnosis and management, by [00:12:00] healthcare providers. Biases related to how power is leveraged in healthcare settings. If you are a woman who is from less education, if you're a woman who's a migrant, if you are from a marginalized or vulnerable community, and how you are treated and your healthcare experience is very different to those who come from more privilege, and that is intricately linked to trust and the trust that is then developed in the healthcare system.
So the work that we've done on power has highlighted how. Trust in the healthcare system itself can be eroded based on the healthcare experience you have and that can have negative knock on impact, on, outcomes. Whether you are, you are man or a woman. I'm gonna stop there because it's a very complicated topic and it's very easy to go off piste and I don't want to go off piste.
Erin: No, that's amazing. I, we could listen to you answer this forever. You both are so brilliant in this space. In 2024, the WHO produced guidance on gender inequalities in AMR and made some short, medium, and long-term recommendations about how these inequalities should be addressed.
What [00:13:00] are the highlights from this guidance that you think make the most difference in terms of these national action plans?
Esmita: It is really important, and timely that the WHO is producing, guidelines such as this. and I and some of my colleagues, we contributed to this and we had a lot of round table discussions and really looked at the evidence that is coming out of trials, around infectious diseases, in different parts of the world.
but in a nutshell, it is about trying to understand where the evidence gap exists. And not to make assumptions and expectations in policy and guidelines without this understanding of, the gap in our knowledge and that we need to generate more evidence around the gendered impact of, antibiotic resistance in itself, but also Our response we have to have a much more gender focused response to how we develop interventions and therapies for, managing, antimicrobial resistance in different populations. What has been, significant about the work with A WHO is that it is very representative of its. Globally, we had a very [00:14:00] well-represented team of experts from economics, through to social sciences, through to medicine and infectious diseases who came to get to look at the evidence.
And it provides a template for, as we develop national action plans, as we renew the national action plans of different countries because most of them are now out of date. And COVID was a real, spanner in the works in terms of deflecting the attention from. National action plans for AMR. So it is really a lot of the countries are now updating their plans to consider having, gender focused recommendations and looking at vulnerabilities within the populations in the countries.
'cause these will differ based on, for example, in the US it might be a very different population that may be considered vulnerable to AMR comparison to India in comparison to South Africa. And I think it's contextualizing and understanding that. The other thing is to realize is the. These, they are only guidelines.
And really at country level, what needs to change is for us to bring this evidence into policy. And that's a much more complicated process, and it's very country specific in terms of [00:15:00] what actually makes it into policy. But what is encouraging is that the, un declaration also recognized, albeit briefly, the need to have a gender focus in the response to AMR.
And I think that's an important step in the right direction.
Erin: yeah, it sounds like we're slowly but surely getting there. So I think when we looked at this, in terms of national Action Plans on AMR, there's 145 countries that have some sort of national action plan, but 126 have no mention of gender or sex.
But that means we're slowly but surely getting there. And it's good to see this guidance outlined and, you're so right that it needs to make its way into law and policy. Well, Esmita, that was amazing. I think we're gonna transition now into impact of sex and gender on patient related outcomes.
So, Annie, do you wanna take it away?
Annie: Okay, thanks Erin. so in this second section, we're going to focus on how sex and gender impacts patient outcomes. Annette, can we start with clinical presentation? Do men and women have different or the same signs and symptoms of infection? I guess to me it's probably obvious that some infections, will be different between men and women.
[00:16:00] For example, urinary tract infections. But how about in more generalized infections syndromes, for example, in sepsis presentations?
Annette: Yes, there are certainly documented differences in clinical presentation of sepsis, between the sexes, for example, a lower frequency of fever in female patients with sepsis compared with males. Also in our study on sex differences in staph aureus bacteraemia, we were kind of surprised to find that female patients had higher acute illness scores at time of diagnosis.
So they were sicker at the start. and of course we know that men and women differ in their medical conditions and comorbidities, and that can also influence, clinical presentation, for example. Female staph aureus bacteraemia patients were more often on steroids, and more often dialysis dependent, compared to males.
but even after we accounted for these differences in medical conditions and source of bacteraemia, women continue to have higher, acute illness scores at [00:17:00] presentation. So at the same time, I think your question also highlights an area where I believe much remains unknown for many different diseases, but certainly in the field of id.
and one that I would certainly like to learn more about because we know from quite some different diseases that, for example, time to diagnosis is longer in women compared to men and. I tend to believe this is at least, partly driven by differences in clinical presentation, or by the way, we as physicians assess disease severity in women compared to men.
Of course, in addition to this, doctor's delay, patients delay may of course also play a role. And also, as Esmita already mentioned, sex-based difference exists in, for example, access to healthcare in certain settings. And this all contributes to differences in clinical presentation.
Annie: Thanks, Annette.
And can we pick up on, you just mentioned there about, doctor's delay or physician delay in, in recognition and, treatment of women presenting with [00:18:00] infection? I think there was a, study that was published way back in 2014, which was using, the dataset from one of the original surviving sepsis, campaign, centers.
called the Disparity two Study, and I think this was the first study that had really sort of come on, my radar about, there being differences in, adherence to care bundles in between men and women, and delays in antibiotics with female patients. it's not been the o only study, that seems to.
Have been, replicated across different geographical sites. I dunno if you want to touch on that. I'm thinking about the delays in, in antibiotics and care bundles specifically related to sepsis. Yeah. Annette, do you want to expand a little bit on the difference in presentation between men and women?
With the delays in antibiotics and adherence to care bundles that's been replicated a across different trials.
Annette: Yes. I think this difference is really fascinating, especially like the Disparity two study shows that it persists even after [00:19:00] adjustment for a presumed source of infection. so we know that in, Gram-negative bacteremia as Esmita already mentioned.
Urinary tract source is associated with lower mortality and women have much more often urinary tract source of bacteraemia. So that would've been a very plausible explanation for this difference, but apparently that's not what driving it. the delay in antibiotics and less adherence to sepsis bundles.
and what's also interesting is that has been reported consistently over time, also in studies after the one you mentioned and across different parts of the world, as you said. So I think for me it's really also a matter of awareness. So acknowledging that sex-based differences in care still exist also, still now, and.
Whenever I discuss these things with my colleagues, there's often a lot of disbelief. So, and I actually understand that because we all work in busy emergency departments, seeing lots of sepsis patients, and we really believe that we treat [00:20:00] everyone the same regardless of, for example, sex or race. So it feels quite uncomfortable to hear these findings.
but that's exactly why I think these studies are so valuable because they, they force us to do kind of a reality check and they're a call to action to, well, to really try to unravel the underlying reasons for these differences. So, because only then we can adjust the care and, do better for, well, eventually everyone.
Annie: Yeah, I think it's really interesting that you said it can feel uncomfortable. I remember having listened to your talk at, ESCMID Global in Vienna last year. I tweeted something about it being like, oh, these really interesting findings about staph aureus bacteremia and. Female patients. And, I just had a bit of a, it was a bit of a Twitter pile on with loads of men in the comments afterwards being like, no, no, no, this can't be true.
And I just thought it was like that initial reaction of lots of people was, no, the findings of this. You know, systematic review and meta-analysis [00:21:00] that Annette has done can't possibly be true because the data makes us feel uncomfortable. But I think that's exactly why it was so important to have that whole session at ESCMID global, talking about sex differences.
Because unless we're talking about it then, you know, I think we need to feel uncomfortable sometimes, don't we? To enable us to even begin to think about how we might change. So, as you've touched on Annette, some of your researchers focused on, sex differences and staph aureus bacteremia.
are there key biological differences that we should know about as well as all of the sort of social and cultural differences that we've, discussed already?
Annette: Yes, there are some important biological differences in infectious related immunity that are worth knowing, but it's actually very complex.
So, but just in general, adult women mount, stronger innate and adaptive immune responses than men. And that's, usually translate into lower susceptibility to infection and faster clearance of pathogens. but also, for example, in better vaccine responses in women. But of course the other side [00:22:00] of it is that, this also leads to more, women being more prone to inflammatory and autoimmune diseases, for example.
And a lot of these differences is thought to be hormone driven. So estrogen tends to enhance immune responses, whereas testosterone has more like immunosuppressive active, effects. But, well, as I said, it's complex and it's important not to oversimplify it, I think, because these difference are not universal and can be maybe also pathogen specific.
Because what we know from my studies in staph aureus bacteraemia doesn't really fit this picture because their female mice are more susceptible to little toxic shock than males. So overall, this is, I think, again, an area where there's still lots to learn. I.
And in terms of comparing it to other bloodstream infections, what about with gram-negative bacteremias? Is there still that kind of same, signal about higher mortality in, in one sex or another?
This is exactly the question we asked ourselves after we found that the mortality [00:23:00] was higher in females with staph aureus bacteraemia. So we wondered, is this, staph aureus specific or is this the same in other bloodstream infections as such as gram negatives? So we recently conducted a large cohort study and also again, a meta-analysis, on this focusing on sex difference in gram-negative bacteraemia.
Annette: And in those studies we found something very different. So, unadjusted mortality was here, actually lower in women, but once we adjusted for confounders and most importantly for source of infection, the association between sex and mortality disappeared. So that apparent survival advantage in women was really explained by.
Again, the fact that women much more often have urinary tract source of gram-negative bacteraemia, and that's associated, as I said before, with lower mortality. So we did not find the same, differences in gram-negative that we did in
Annie: I think one takeaway for me listening to you talk now and also from your presentation, last year in Vienna [00:24:00] was the real sort of pressing need here for standardized sex disaggregation of data in clinical trials. And I think, part of the issue is that for, you know, some, some of the systematic reviews that you've done.
Trials reporting by sex outcome and the outcome reporting was, just not there. So you weren't even able to include that for analysis, which really is, you know, it is almost just the finding in itself that if, the data isn't reported, then how can we even start to, you know, analyze and move forward.
this was something I think that came more to the public's attention during COVID. I remember some, sort of news reports about vaccination trials, that had reported sex disaggregated data, with higher adverse events being reported in female patients. And perhaps that had some impact about vaccine uptake and the public understanding about, you know, how vaccines may impact them differently.
but again, the majority of COVID vaccination trials didn't report their data by sex, which made the picture really unclear for people to be able to make [00:25:00] informed decisions. I think. I think I, do have to give a, plug to a, book here, which I've recommended to so many people over time called Invisible Women by Carolyn Creata Perez, who's a, a British campaigner, and she leads a campaign for, sex desegregation of data, not just in medicine, but across all aspects of life.
and it, it has really changed my opinion on how the world works, I think. So we'll put a link to that in our show notes as well. So perhaps change is coming. do you think we have something or anything to be hopeful about in terms of clinical trial data that serves both sexes and maybe all genders better?
Annette: I think so because, as you said, we were also really surprised that none of the randomized trials that we screened for both of the systematic reviews, reported sex desegregated data. And as you said, it's a critical gap. but I'm encouraged by the direction we're moving because we're now actively collaborating with investigators, running several of the major, staph aureus bacteraemia [00:26:00] trials, and to better understand how sex effects treatments and outcomes and gather all their data.
And these, collaborations have also helped to highlight that the, differences exist, of course, and that we need to do a better job of reporting them. And by the fact that they were almost all very receptive to this, subject and wanted to Collaborate. I'm very optimistic that future studies will more address and report sex differences.
We did a study last year where we looked at the top 10 infectious diseases journals and. Randomized controlled trials that have been published on bacterial infections, and actually we found that encouragingly to go afterwards.
Esmita: Annie and Annette were saying that. 97% of the 1200 trials were looked at do include either sex or gender in their data that they publish. So there is some level of data there is some improvement, but where there is a shortfall, is that less than half report on ethnicity and only a [00:27:00] minority report on education level and socioeconomic status.
So we still don't know because if you look at it from an intersectional lens, it's not gender alone. We need to look at whether the trial populations are representative of the wider populations in society that we actually want interventions to reach. And I think that's where the gap is, is overall the quality of demographic data that goes into trials needs to improve drastically.
And over the last 10 years, there has been no difference in the quality of the demographic data that we are producing. So I think that needs to improve over time for sure.
Erin: Yeah, it's a, great point from both of you and I know even doing observational data in my own institution, we're a pretty large health system with a massive amount of data.
And often with my own eyes by hand, going through patient's charts to collect data, often a lot of these variables are not reported, not collected. and so these are huge gaps. Start at the bedside too, right? I mean the entry nurse has to ask all these questions to enter it into the patient's chart.
So a long way to go there for sure. Which is a nice transition to wrap up this episode. So we've talked a lot [00:28:00] about the patient experience, clinical trial data, all y'all's work in this space, which is really just so fascinating. But we do wanna also ask about how sex and gender. Impact us, impact the professionals working in infectious diseases.
So we want to ask specifically about a few recent publications in the antimicrobial stewardship space. So getting into a little bit of our bread and butter, uh, as needed in pharmacy and antimicrobial stewardship. So there were two studies. One was. The CLASI study, C-L-A-S-I. It was out of the Mayo Clinic, pretty large study.
It was published in ICHE in 2023, and it found that females and male clinicians were equally effective at prospective audit with feedback, which for those who don't do antimicrobial stewardship, that's where you're looking at patients in an institution could be inpatient, outpatient, what have you, that are receiving any kind of antimicrobial and you're evaluating is that appropriate?
And how we define appropriateness varies quite tremendously. But you're essentially saying. Do I need to call and talk to the provider or the prescriber about this [00:29:00] antimicrobial, or is it mostly okay for this patient to receive? And they have a large, robust antimicrobial stewardship program at the Mayo Clinic, and they found that whether a female or a male was calling to make these interventions or recommendations, they were equally as effective.
But they did find that patients in the ICU were less likely to have their interventions accepted. So that whole premise of their sicker, we need more antibiotics. But sex and gender, didn't factor in here. But then there was a separate study that was also published in ICHE in 2023 by Valerie Vaughn and colleagues, and Valerie was recently on Communicable.
She's a friend of the pod, an excellent researcher out in Utah, and her group found that antibiotic stewardship recommendations made by female clinical pharmacists were less likely to be accepted by hospitalists, than those made by men. And this was follow-up work, published that work they published in 2022 by the same group that found that antibiotic timeouts conducted by women were less likely to result in an antibiotic change than those conducted by men.[00:30:00]
So two really strong groups in the stewardship space. Two somewhat conflicting results. guys, what are your, oh my gosh. I called you guys, guys. I'm the worst ladies. Thoughts on this? Esmita, do you wanna go first?
Esmita: Yes, I always refer to those two papers in my, presentations on work as well. I think it's really interesting from our own experiences as if I speak as myself, as someone who's worked as a clinical pharmacist for a decade and then who's been researching healthcare professionals and team dynamics for another 15 years.
It's really fascinating how much our. Social norms and culture impacts how we are able to practice evidence-based care, We, we think we give the evidence of the guidelines and policy to people and they will just follow them. Right? And it's so far from the reality because of these social rules that determine how we interact with each other, who has power in negotiating and decision making.
and so I'm very glad that data are being gathered around this from different, groups. And [00:31:00] they may be conflicting and that's okay because reality is complex. It's never going to be one way or another. But what is important to understand is how we leverage power in the healthcare space.
And I think there's a lot of work that needs to be done around this. I have a lot of faith in, the new generations of, Healthcare professionals are being, that are being trained, that are being trained in a much more aware culture than the previous generations. There's a lot of gendered hierarchies that exist in healthcare, and this is linked often also to geography, to country.
For example, we've done a lot of work in India where it's very, very hierarchical in the healthcare space with physicians making all of the decisions, you know, clinical pharmacists and nurses are emerging. In terms of being able to contribute, but they're not there yet. And what we have to understand in many parts of the world, it's actually very niche to have multidisciplinary team dynamics in operation, in stewardship.
It's not happening in many parts of the world. Maybe the us, uk, some parts of Australia, [00:32:00] few in South Africa. I think in private sector there is more resources possibly available to give to multidisciplinary stewardship. But again, in, government organizations and hospitals and institutions, resource limitations make it very difficult for pharmacists to be present in the wards to make decisions.
And then if your presence , does not become a constant, if you are not part of the culture within teams, it's very difficult to go in intermittently and, and make a difference. So it's, linked to resource allocation, it's linked to understanding the roles that different healthcare professionals have.
and then to bring it gender and culture unless, we actually have, institutional support. If we do not have that support from the hierarchy within institutions to support different healthcare professionals to be active in stewardship is going to make it very difficult. And then you bring the gender dynamic into this, in top of the medical hierarchies and the professionalism that exists in the healthcare space.
And that's the complexity we're dealing with. The reason I'm doing the work I'm doing now is because I wanted to collect a narrative lived experience of healthcare [00:33:00] professionals in different parts of the world, because throughout my career so many times I have come across this power play where female leaders in powerful positions telling me their story of how the challenges that they have faced that you wouldn't even believe.
You wouldn't think by looking at where they're on their career and what they're doing. But it exists. we are in a space where we don't talk about it often enough. And the one way to talk about it, not everything can be, written up or tested in a clinical trial. And I think when it comes to team dynamics and culture and how we operate, the social aspect of our work, which is so important, does need qualitative research.
We need to gather these narratives and these stories, and be able to share them as examples of the reality of what is happening in the healthcare space and how we negotiate power and how we can do better at negotiating power.
Erin: Yeah, absolutely. I mean, I do a lot of antimicrobial stewardship and I coach a whole system full of antimicrobial stewards, and I have to say, first of all, antimicrobial stewardship is the art of giving unsolicited advice.
You're not invited into the [00:34:00] conversation. To your point, it's almost like. You have to respect if they don't accept your recommendation right away. 'cause why would they blindly trust someone they don't really know or don't even know who's watching their patient. And a lot of the work is asynchronous.
you are sitting in an office looking at a patient on a computer calling up to the floor. So you're not even physically there. As much as we have a long way to go still in 2026 or 2023 when this work was published, it's hard for me to think that a physician would say no, solely because the recommender is a woman.
Erin: I really don't think that's it. I think it's more what about how women and females present. Themselves are willing to respond to pushback. How comfortable are they with developing discrepancy, with resistance development, with the emotions that range from prescribers, which are sometimes kind and sometimes I've had many an inappropriate prescriber, you know, yelling or being, being not so kind.
And how, how do you weather the storm, so to speak? And it's gotta be more about that power play and [00:35:00] interactions and the tendencies of men versus women than solely like. I will not stop this vancomycin because you're clearly a female pharmacist. A lot of times all they hear is a voice on the phone and they don't even know your name.
So I think that's, that's more the interplay, which I'm also really fascinated by what drives people and how they think. And even amongst women or amongst men, they behave so differently. They wanna be treated differently. They respond to different things in their environments.
So it's really tailoring science to What motivates people and every person is different. Esmita, you wrote one of my favorite you with Julie. Uh, your work prompted one of my favorite editorials ever of the bespoke stewardship and like using a hunting metaphor with surgeons and emergency medicine people, they'll look at a duck the same exact way and call it a different thing.
So I think that's really what this gets at for me.
I think, yeah, I think you've hit the nail. On the head actually, Erin, this is why intersectional research is so important is you have to contextualize the experience and the reaction in stewardship.
Esmita: You know, it is, like you say, it's diplomacy and we also have to learn [00:36:00] how to diplomatically practice our. Art or profession and how to negotiate and look at common outcomes of interest, which is what will drive the conversation forward. Yeah, and that's, that's important.
Erin: I think it's truly one of the hardest things to do in healthcare because it's really very little about data.
Infectious diseases is often the most gray space in the world, and it's really very much about how you communicate with people and not making them feel like they're wrong because you're calling to change something that They've set a path. They said, this is, you know how I wanna treat this patient.
And you're then interceding and saying, actually you should do something different. That's extremely challenging. , Everyone went into this to do the right thing for patients. So no one thinks they made a decision that could potentially not be the best for the patient, and it's just really challenging, challenging work.
This has been really remarkable rich discussion. I wanna thank you again, both for your time. Is there anything, Annette, that you would like to share with our listeners that we haven't explicitly asked you about, [00:37:00] either about your body of work or just general thoughts in this space, as we celebrate this International Women's Day?
No, I think we discussed lots of things and I agree with, what Esmita just said, that these studies are so important because all these studies that we mentioned, because it makes us and others talk and think about it and it sometimes makes it easier to discuss some things at your own, work or in the international field.
Annette: So thank you for hosting this episode, especially for International Women's Day, because I think this is one step further again, so thank you.
Erin: Yeah, absolutely. Thank you for being here and helping us further this conversation. Esmita, anything I haven't asked you about specifically that you'd like to share with our listeners?
Esmita: No, I think it's been a great conversation with like-minded, colleagues and I'm so grateful to have been given this opportunity and also how much I admire your work. Erin and Annie and Annette, I think it's, really nice to have this conversation with you all and see how we can take it forward and, share the platform with other colleagues as well in this space.
Erin: Annie's work is awesome. we haven't [00:38:00] actually hyped Annie enough up yet on this episode, but she is one of the most amazing microbiologists and, people ever running the whole country. I
Esmita: agree.
Erin: The United Kingdom over there, so just crushing it. we share the dreariest of living in the rainiest parts of the world in Pittsburgh and London.
So, alright, well thank you again, to our guest, professor Esmita Charani in South Africa. Dr. Annette Westgeest in the Netherlands for helping CMI Comms and Communicable Mark International Women's Day 2026.
And thank you to our listeners for listening to communicable the CMI Comms podcast. This episode was edited by.
Annie: Dr. Katie Hostetler Oy, and was peer reviewed by Dr. Casandra Bulescu at the "Dr. Victor Babes" Clinical Hospital of Infectious and Tropical Diseases in Bucharest, Romania. Theme music was composed and conducted by Joseph McDade. This episode will be citable with a written summary referenced by A DOI in the next eight weeks.
You can subscribe to Communicable on Spotify, apple, wherever you get your podcasts, or you can find it on ESCMID's website for the [00:39:00] CMI Comms Journal. Thank you for listening and helping CMI Comms and ESCMID move the conversation and ID and clinical microbiology further along.
we hope to see you all at ESCMID global in April. So very excited to head to Munich and hopefully we'll see you all there. So thank you so much.