Introduction
Antimicrobial resistance (AMR) will be the leading cause of death worldwide by 2050 without systems to decrease unnecessary antibiotic prescribing. Reference O’Neill1 Efforts to optimize antibiotic prescribing have been reported in most healthcare settings, with the notable exception of
carceral settings. The United States’ incarceration rates are higher than any other country’s with approximately 2 million people detained in jails (for short-term confinement typically less than 1 year) and prisons (for longer term confinement) each year. Reference Dholakia2 People who are incarcerated experience higher rates of chronic diseases (eg, human immunodeficiency virus, asthma, diabetes mellitus) and mental health conditions (eg, depression, schizophrenia). Reference Dholakia2 People with chronic diseases are more likely to be prescribed antibiotics compared to their healthy counterparts. Reference Queen, Zhang and Sears3 Our research team published a report of antibiotic prescribing in 11 Massachusetts county jails, which showed heterogeneity between facilities. Reference Szewczyk, Tenner and Grussing4 The current study aims to benchmark antimicrobial use with states’ prisons and comparing use in overall in New England.
Methods
In September 2022, key stakeholders from across New England carceral settings participated in the FABRICS (Fighting AntimicroBial Resistance in Carceral Settings) study. Maine, Massachusetts (MA), New Hampshire (NH), and Rhode Island (RI) Departments of Corrections agreed to share antibiotic prescription data. Of note, RI has a unified system of 6 jails and prisons, so the data reported represent all the state-run carceral facilities in that state (ie, jails and prisons). The data included all antibiotic orders started and completed between January 1, 2021, to December 31, 2021, by medical staff in the facility. Antibiotic generic name, route of administration, dose, frequency, and duration of prescription were included. Antibiotics were grouped into the following categories: (1) penicillins, (2) cephalosporins, (3) fluoroquinolones, (4) macrolides, (5) nitrofurantoin, and (6) medications with MRSA (methicillin-resistant Staphylococcus aureus) activity (ie, linezolid, vancomycin, clindamycin, doxycycline, minocycline, tetracycline, and sulfamethoxazole-trimethoprim) (see Appendix 1). Topical antibiotics and oral suspensions were excluded; intravenous, intramuscular, and oral antimicrobials were included. For each class of antimicrobials above, the defined daily dose (DDD) was calculated according to the equations for each facility and then combined to report on a state-level (please see Appendix 2). Average daily populations of facilities by year are published regularly. The DDD was developed by the World Health Organization 5 to compare antibiotic utilization across institutions and modified for application in prisons (see Appendix 3).
Results
The final cohort included 23 facilities. Anti-MRSA drugs were the most frequently prescribed class across all 4 states, followed by penicillins (see Figure 1). MA showed the highest overall antimicrobial use, with a combined DDD of 130 representing 12 facilities, nearly eleven-fold the DDD of the next state, NH (DDD = 19.6), representing 3 facilities. RI had the lowest DDD at 9.7, representing 1 conglomerate facility (see Figure 1). With the exception of 1 MA site, all facilities ordered more DDDs of anti-MRSA drugs than any other drug.
Figure 1. Defined daily doses of antibiotics by facility, 2021.
Discussion
Antimicrobial prescribing rates in prisons were highly variable across the 4 states when normalized for average daily population (see Figure 2). Heterogeneity between the states and between facilities within states suggests that there is room for standardization based on evidence-based pathways of infection evaluation and treatment. Antimicrobial stewardship programs (ASPs), first developed in inpatient settings, are tasked with tracking prescriptions, providing education to clinicians/patients on antibiotic appropriateness, and limiting the use of overly broad antibiotics, with the goal of preventing antibiotic-resistant bacterial infections. 6 ASPs are not routinely implemented in county jails and state prisons. A previous qualitative study by our team conducted in conversation with the facilities included in this study found that none of these facilities had ASPs. Reference Szewczyk, Tenner and Grussing4 However, the Federal Bureau of Prisons has implemented an ASP program, which led to decreased antibiotic prescriptions and feedback to prescribers on antimicrobial appropriateness. Reference Long, LaPlant and McCormick7
Figure 2. Defined daily doses of antibiotics by facility, 2021.
Anti-MRSA antibiotics were the most frequently prescribed. MRSA skin and soft tissue infections are a fear within carceral environments due to the nature of transmission and a history of outbreaks in jails and prisons from the early 2000s. 8 This knowledge potentially contributes to clinicians’ inclination to prescribe antibiotics with MRSA coverage for skin and soft tissue infections in carceral facilities despite guidelines recommending beta-lactam therapy for non-purulent cellulitis. The rates of MRSA in the community have been declining, reinforcing the recommendation to use penicillin or a first generation cephalosporin for skin and soft tissue infections. Reference Stevens, Bisno and Chambers9 ASPs could help decrease unnecessary or suboptimal prescriptions of anti-MRSA medications.
The major limitation in this study is that indications for antimicrobial prescription were not available, limiting the ability to evaluate the appropriateness of antibiotic prescriptions. Additionally, we did exclude facilities that offer psychiatric services in addition to incarceration. This is important because the highest rates of antimicrobial prescribing, consistent with literature suggesting the overdiagnosis of infections in mental health facilities compared to acute care hospitals. Reference Tieri, Alexander, Egge, Heintz and Livorsi10 Despite these limitations, our work furthers evidence the needs for increased attention to AMR in carceral settings.
Acknowledgments
None.
Financial support
This project was funded by the Tufts Springboard Grant. This project received support from the Tupper Foundation.
Competing interests
AGW works as an ID Liaison to Mass. Sheriffs Association.
Appendix 1
Antimicrobials by category. Anti-MRSA: Clindamycin, doxycycline, linezolid, minocycline, sulfamethoxazole/trimethoprim, tetracycline, vancomycin. Cephalosporins: Cefadroxil, cefixime, ceftriaxone, cefpodoxime, cefuroxime, cefadroxil, cefazolin, cephalexin. Fluoroquinolones: Ciprofloxacin, levofloxacin, moxifloxacin. Macrolides: Azithromycin, clarithromycin, erythromycin. Metronidazole, nitrofurantoin, penicillins: Amoxicillin, amoxicillin-potassium clavulanate, bicillin, dicloxacillin, penicillin VK, penicillin benzathine, piperacillin-tazobactam.
Appendix 2
The modified equation used for this analysis.
Appendix 3
Defined Daily Doses Equations. The equation from the World Health Organization.10
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