Antibiotic prescribing in health and justice settings (HJS)-surveillance and opportunities for quality improvement
Authors: Fleming N , Farmer D , Oliver-Williams C , Ottaway P 
Published: November 2024

Abstract

Introduction
Improving surveillance of antibiotic prescribing and reducing health inequalities in antimicrobial resistance (AMR) are priorities in the new 5 year AMR national action plan (2024-2029)1. People in contact with the justice system are one of the inclusion groups in the CORE20plus5, a national NHE England approach to support reduction of health inequalities.2

Aim
This project aimed to collate and analyse all antibiotic prescribing data from English prisons in order to identify opportunities for quality improvement.

Method
This project analysed antibiotic prescribing data from September 2022 to current date for the first time in HJS from the IT system used in all prisons in England. No ethical approval is required as surveillance is of anonymised data only.
Data was broken down by age band (18 and under, 19-49, 50 and over), category of prison, region, ICB, individual prison and antibiotic type.
The dashboard allows benchmarking across sites and comparison with primary care, as prisoners in HJS are considered to have similar infections to primary care patients.

Results
The majority of prescribing is in male prisoners, reflecting the male/female population split. The most frequently prescribed antibiotics are those used for: skin and soft tissue (including acne), respiratory tract, dental and urinary tract infections. A number of focus areas for quality improvement have been identified, including:

Broad spectrum antibiotics
(Cephalosporins, Co-amoxiclav and Quinolones), target of &lt;10% total antibiotic prescribing in primary care, in HJS, currently 11%. Appropriate quinolone prescribing is a target in all settings due to recent MHRA alert3.
Acne prescribing represents a significant proportion of antibiotic prescribing in HJS. Lymecycline 12%, whereas in primary care &lt;3%.
Duration of Antibiotic Courses: In primary care there is a medicines optimisation opportunity ambition to achieve 75% prescribing amoxicillin 500mg as 5 day duration. In HJS only 27% is for 5 days. When prescribing 100mg doxycycline for respiratory infections, NICE guidance recommends a 5 day course, but in HJS only 3% is prescribed as a 5 day course. For UTI in female prisons, nitrofurantoin 100mg MR is most commonly prescribed, NICE guidance for UTI in women is for 3 days; 47% in HJS are for 3 days, but 35% are 7 day courses.

Discussion and Conclusion
This dashboard provides insight into antibiotic prescribing data allowing opportunities for quality improvement opportunities to be identified and antimicrobial stewardship interventions to be evaluated.
This work will progress to tackle the focus areas identified. Next steps are to work with antibiotic champions from HJS to co-produce intervention plans, share patient safety messages, trial available resources, rollout interventions and monitor impact via the dashboard.

Limitations
Indications are not available from the data but extrapolated from the antibiotic prescribed.
The dashboard is currently an excel spreadsheet in NHSE. It will be moved to a platform that enables access by individual prisons.

References
1. UK 5-year action plan for antimicrobial resistance 2024 to 2029 - GOV.UK (www.gov.uk) May 2024
2. NHS England » Core20PLUS5 – An approach to reducing health inequalities for children and young people
3. Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate - GOV.UK (www.gov.uk) Jan 2024