# Penicillin Allergy Labels and High-risk Antibiotic Prescribing Among Incarcerated Individuals Receiving Antibiotics Across Four US Carceral Systems

## TL;DR

This study found that 10% of incarcerated individuals had a penicillin allergy label, which increased their chances of receiving high-risk antibiotics for C. difficile infections.

## Contribution

The study is the first to examine penicillin allergy labels and high-risk antibiotic use in incarcerated populations across multiple US states.

## Key findings

- 10.2% of incarcerated individuals had a penicillin allergy label.
- Penicillin allergy labels were associated with more than twice the odds of receiving high-risk antibiotics for C. difficile infections.
- Demographic factors like race and ethnicity were linked to penicillin allergy label prevalence.

## Abstract

Optimization of antibiotic prescribing is critical to reducing antimicrobial resistance, yet antimicrobial stewardship programs remain relatively uncommon in carceral settings. Despite the disproportionate health burden faced by incarcerated populations, limited data exist on the prevalence of penicillin allergy labels (PALs) in these sites. This study examined the carceral systems in 4 states (Maine, New Hampshire, Washington, and Minnesota's Hennepin County Jail) and determined the prevalence of PALs, their demographic predictors, and the relationship between PALs and the prescription of high-risk antibiotics for Clostridioides difficile infection (CDI)—as defined by the National Healthcare Safety Network.

We conducted a retrospective cohort study using the de-identified data from 4 carceral systems, restricted to incarcerated people who received at least 1 antibiotic prescription between 2020 and 2023. We performed univariate and multivariate logistic regression analyses, adjusting for age, sex, race, and ethnicity. We reported adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

The final study cohort consisted of 10 603 individuals, with a PAL prevalence of 10.2%. Individuals with PALs were less likely to be male (aOR, 0.462; 95% CI, 0.355–0.601) or Hispanic (aOR, 0.500; 95% CI, 0.272–0.920) and more likely to be White non-Hispanic (aOR, 1.458; 95% CI, 1.075–1.978), or American Indian/Alaska Native (aOR, 2.466; 95% CI, 1.641–3.707). PALs were significantly associated with increased odds of receiving high-risk antibiotics for CDI (aOR, 2.412; 95% CI, 1.893–3.074).

Our findings highlight the need for targeted antimicrobial stewardship and penicillin allergy de-labeling efforts among incarcerated individuals needing antibiotics.

In a multi-state study of incarcerated individuals receiving antibiotics, 10% had a penicillin allergy label, which was associated with more than twice the odds of high-risk C. difficile-associated antibiotic use. Correctional health systems should be included in antimicrobial stewardship and penicillin allergy delabeling to improve care and equity.