Antimicrobial Stewardship (2026) | National Commission on Correctional Health Care

Antimicrobial Stewardship (2026)

Home / Position Statements / Antimicrobial Stewardship (2026)
Back to Position Statements
Download as PDF

POSITION STATEMENT

Carceral systems have a critical opportunity to combat antimicrobial resistance—a growing global threat that undermines the effectiveness of lifesaving treatments—by implementing robust antimicrobial stewardship programs (ASPs) within their health care services. In addition to curbing the evolution of antimicrobial-resistant infections, ASPs can provide a mechanism to improve antibiotic usage, decrease adverse events associated with antibiotics, and ultimately improve patient outcomes. Because carceral facilities function within broader community health ecosystems, effective antibiotic stewardship also requires communication and collaboration with local and state health departments to monitor regional infection trends, coordinate outbreak response, and align antibiotic stewardship strategies with public health surveillance efforts.

discussion

It is well-established that antimicrobial-resistant (AMR) infections continue to be a global health threat. When the Centers for Disease Control and Prevention’s Antibiotic Resistance Threats in the United States 2019 report noted that more than 2.8 million AMR infections and 35,000 deaths occur annually, there was a silver lining: The number of deaths from AMR infections had decreased by 18% overall compared to the 2013 report.1 However, the July 2024 publication revealed a national trend in the wrong direction. Six bacterial hospital-onset AMR infections increased by a combined 20% during the COVID-19 pandemic and remained above prepandemic levels.2 This is important because carceral settings are recognized as high-risk environments for AMR infections, including methicillin-resistant Staphylococcus aureus.3,4,5 Despite limited efforts historically to address the spread of AMR in these settings,6,7 the CDC data underscore the critical need to develop and implement ASPs within carceral health care systems.

Implementing ASPs in carceral settings can be challenging because of competing demands on time and resources, including quarantine management, screening protocols, and viral/bloodborne pathogen infection control.8 Interviews with people incarcerated and correctional health care staff identified several common barriers to ASP implementation. These include the perception of correctional facilities as “dirty places” with inherently higher infection risk, clinician resistance to oversight of antibiotic prescribing, limited awareness and understanding of ASPs, and the prioritization of other urgent health concerns.9 Other key strategies of effective ASPs, such as penicillin allergy delabeling and the “watch-and-wait” approach, encounter logistical barriers and insufficient financial support.10

Numerous resources are available to help guide ASP development. Two of the most recognized resources are the CDC’s Core Elements of Antibiotic Stewardship11 and guidelines from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, Implementing an Antibiotic Stewardship Program.12

Key considerations for an ASP include the following:

  1. Secure leadership commitment. Within the carceral setting, commitment includes executive leadership, departmental administration, and health care services staff. Leadership should also support formal partnerships with public health authorities to ensure adequate infrastructure for surveillance reporting, outbreak coordination, and compliance with public health regulations related to communicable diseases and antimicrobial resistance. 
  2. Designate ASP leaders. Selecting a leader or co-leader responsible for ASP management and outcomes increases commitment and accountability. These leaders may focus their stewardship efforts locally or coordinate across the broader carceral system to support consistent and effective implementation. 
  3. Implement at least one targeted intervention. An ASP will implement at least one policy or intervention to promote appropriate antibiotic use. This action is tailored to the practice setting, available resources, and treatment capabilities of the facility. Common and effective actions include prospective audit and feedback, formulary authorization, and development of internal treatment guidelines. 
  4. Engage a multidisciplinary team. A comprehensive ASP engages a range of health care professionals—including physicians, advanced practice providers, nurses, pharmacists, dentists, and laboratory technicians—by leveraging their unique skills to strengthen stewardship interventions. Multiple discipline involvement in limited-resource settings maximizes the knowledge and skill sets available to the program. 
  5. Monitor and utilize data. Carceral systems will develop a reliable process to collect and analyze data related to antimicrobial usage and AMR infections. These data allow evaluation of the effectiveness of active interventions and identification of possible targets for future interventions. The collection of relevant data promotes knowledge sharing among many disciplines within the carceral system, both local and remote. Facilities should establish structured, bidirectional communication and collaboration with local and state health departments to share surveillance data, ensure timely reporting of reportable conditions, monitor regional AMR patterns, coordinate outbreak investigations, and align infection prevention strategies with broader public health initiatives. Such collaboration strengthens continuity between correctional and community health systems and supports timely identification of emerging AMR threats and alignment with community standards. Moreover, the availability of data creates valuable opportunities to publish findings on antimicrobial stewardship efforts in carceral settings—addressing a critical gap in the literature and contributing to broader public health knowledge. 
  6. Promote education and program awareness. A successful ASP includes strategies to educate staff on active stewardship efforts to reinforce appropriate, guideline-driven prescribing and improve effective communication strategies between clinicians and patients, resulting in improved antibiotic usage and patient care. 

Carceral settings are high-risk environments for AMR infections, and the implementation of ASPs is critically important to mitigate these risks. Leveraging nationally available resources and adopting a multidisciplinary approach can provide a strong foundation for effective stewardship efforts. It is recommended that each ASP be tailored to the specific needs of the facility, with clearly established methods for staff education and impact tracking. Furthermore, sustained support from organizational leadership is key for ongoing success, enabling sustainable and long-lasting improvement to patient outcomes and prevention of future complications.

Adopted by the National Commission on Correctional Health Care Governance Board Feb. 24, 2026

References

  1. Centers for Disease Control and Prevention. (2019). Antibiotic resistance threats in the United States, 2019. U.S. Department of Health and Human Services. https://www.cdc.gov/antimicrobial-resistance/media/pdfs/2019-ar-threats-report-508.pdf 
  2. Centers for Disease Control and Prevention. (2024). Antibiotic resistance threats in the United States, 2021–2022. U.S. Department of Health and Human Services. https://www.cdc.gov/antimicrobial-resistance/data-research/threats/update-2022.html 
  3. Centers for Disease Control and Prevention. (2003). Methicillin-resistant Staphylococcus aureus infections in correctional facilities—Georgia, California, and Texas, 2001–2003. Morbidity and Mortality Weekly Report, 52(41), 992–996. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5241a4.htm 
  4. Malcolm, B. (2011). The rise of methicillin-resistant Staphylococcus aureus in U.S. correctional populations. Journal of Correctional Health Care, 17(3), 254–265. https://doi.org/10.1177/1078345811401363 
  5. Pan, E. S., Diep, B. A., Carleton, H. A., Charlebois, E. D., Sensabaugh, G. F., Haller, B. L., & Perdreau-Remington, F. (2003). Increasing prevalence of methicillin-resistant Staphylococcus aureus infection in California jails. Clinical Infectious Diseases, 37(10), 1384–1388. http://www.jstor.org/stable/4483693 
  6. Wilk, S., Abdul-Mutakabbir, J. C., Doron, S., Yen, C., Berk, J., & Wurcel, A. (2024). Antimicrobial resistance in carceral settings. The Lancet, 404(10457), 1015–1016. https://doi.org/10.1016/S0140-6736(24)01693-3 
  7. Adebisi, Y. A., Jimoh, N. D., Faid, A. A., Olatunji, M. O., Opone, E. O., Olarewaju, O. A., Adetunji, A. P., Ezema, S. M., Niyibizi, J. C., & Lucero-Prisno, D. E., III. (2022). Neglecting antibiotic stewardship in prisons: A concern for antimicrobial resistance response. Annals of Medicine & Surgery, 81, 104423. https://doi.org/10.1016/j.amsu.2022.104423 
  8. Bick, J. A. (2007). Infection control in jails and prisons. Clinical Infectious Diseases, 45(8), 1047–1055. https://doi.org/10.1086/521910 
  9. Tenner, R. A., Grussing, E. D., Manning, D., Ngassa, Y., van den Berg, J. J., Andujar Vazquez, G., Doron, S., Campion, M., & Wurcel, A. G. (2024). “It’s easier to take a pill than fix a problem:” Qualitative analysis of barriers and facilitators to antimicrobial stewardship program implementation in carceral settings. BMC Global and Public Health, 2, 59. https://doi.org/10.1186/s44263-024-00090-1 
  10. Wurcel, A. G., Abdul-Mutakabbir, J. C., Doron, S., Yen, C., & Berk, J. (2024). Examining antimicrobial stewardship program implementation in carceral settings. AMA Journal of Ethics, 26(5), E399–E407. https://doi.org/10.1001/amajethics.2024.399 
  11. Centers for Disease Control and Prevention. (n.d.). Core elements of antibiotic stewardship. https://www.cdc.gov/antibiotic-use/hcp/core-elements 
  12. Barlam, T. F., Cosgrove, S. E., Abbo, L. M., MacDougall, C., Schuetz, A. N., Septimus, E. J., Srinivasan, A., Dellit, T. H., Falck-Ytter, Y. T., Fishman, N. O., Hamilton, C. W., Jenkins, T. C., Lipsett, P. A., Malani, P. N., May, L. S., Moran, G. J., Neuhauser, M. M., Newland, J. G., Ohl, C. A., Samore, M. H., Seo, S. K., & Trivedi, K. K. (2016). Implementing an antibiotic stewardship program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases, 62, 10, e51–e77. https://doi.org/10.1093/cid/ciw118