Examining Antimicrobial Stewardship Program Implementation in Carceral Settings

Abstract

Antimicrobial resistance is a global threat that inequitably affects minoritized populations, including Black, Latinx, and Indigenous peopleespecially in carceral settings-and is largely driven by inappropriate antimicrobial prescribing practices. People whose identities are minoritized are more likely to be incarcerated, and people who are incarcerated experience higher disease risk than people who are not incarcerated. This article draws on a case of dental infection suffered by a woman who is incarcerated to consider key ethical and clinical complexities of antimicrobial prescribing in carceral settings. Antimicrobial Resistance in Carceral SettingsAntimicrobial-resistant (AMR) infections are an increasingly common cause of hospitalization and death, but programs preventing the development of antimicrobial resistance are incompletely implemented in low-resource health care settings. 1 Examples of such settings include carceral settings like jails and prisons, which have focused for several years on improving infection control for respiratory, viral, bloodborne, and foodborne pathogens through isolation, quarantine, and testing protocols, 2 but have devoted considerably less attention to preventing the emergence and decreasing the spread of AMR pathogens.Given the intersection of poverty, mental illness, trauma, and racism, infectious disease epidemics and pandemics disproportionately take root in carceral settings where residents are already at increased risk for negative health outcomes. In one study of probationers and people recently released from prison in Connecticut, Black individuals reported a greater number of impacts of incarceration on their well-being than White individuals. 3 The emergence of methicillin-resistant Staphylococcus aureus (MRSA) is a clear example of the impacts of incarceration on the dissemination of AMR pathogens in minoritized communities. The first outbreak of MRSA was reported in 1968 at Boston City Hospital 4 -a safety-net hospital renowned for providing care to financially disadvantaged persons in the greater Boston area-and outbreaks of MRSA infection and MRSA colonization were reported nationally in carceral settings in the early 2000s. 5 the Department of Medicine at Tufts Medicine in Boston, Massachusetts. She is also an associate professor of medicine