Mississippi doctors write more outpatient prescriptions for antibiotics than doctors in any other state except Kentucky and West Virginia, according to data released Wednesday by the Centers for Disease Control. And health officials say many of these prescriptions are unnecessary.

A generation ago, these numbers would have raised little more than an eyebrow. Doctors traditionally viewed antibiotics as a harmless treatment, with few side effects. But across the last two decades, antibiotic-resistant infections have skyrocketed around the country. And health professionals who’ve tried to curb their overuse have met resistance of their own.

“This has been going on for many, many, many years. In the 25 years I’ve been practicing medicine, it has been a struggle the entire time. … It’s gaining prominence because it’s getting worse,” said Dr. Mark Horne, vice chair of the board of trustees for the Mississippi State Medical Association. 

Since their introduction in the 1920s, antibiotics have transformed medicine, turning once deadly infections into easily treatable illnesses. But their reputation as a cure-all has a downside: Approximately 30 percent of all antibiotics prescribed to patients in clinics and emergency rooms in the United States are unnecessary, according to the CDC.

“Changing behavior is difficult and it takes a shift in the culture of how we use antibiotics,” said Lauri Hicks, a medical epidemiologist for the CDC.

And the misuse of antibiotics has led to antibiotic resistance, which the CDC calls “one of the most serious and growing threats to public health.” The CDC estimates that more than 2 million people are infected with antibiotic resistant organisms annually, resulting in approximately 23,000 deaths.

“We cannot wait to act because we’re already in a place where we’re seeing infections where there are very few or no options for treatment,” Hicks said. “Going back a few decades (infections) were usually in hospital patients with lots of underlying medical conditions. But we’re now seeing lots of these antibiotic resistant infections in otherwise healthy people in the community, and that’s what’s really concerning. It’s having an impact on everyone.”

Since 2011, the national numbers for antibiotic prescriptions have declined about 5 percent, going from 877 prescriptions per 1,000 people in 2011 to 835 in 2014. West Virginia and Kentucky, the two states with higher numbers than Mississippi, have seen similar declines, dropping from 1,355 to 1,285 and from 1,321 to 1,262, respectively, between 2011 and 2014.

What makes Mississippi’s numbers more troubling, however, is that they’re on the rise, going up nearly 4 percent since 2011, from 1,186 prescriptions in 2011 to 1,222 in 2014.

“There’s great geographic variability in antibiotic prescribing, and the South, particularly the Appalachian regions through Louisiana and Mississippi, have greater rates, and compared to the Pacific Northwest, (Mississippi) has rates that are twice as high,” Hicks said.

In Washington State in 2014, doctors wrote 600 prescriptions for antibiotics for each 1,000 residents. In Oregon, that number was 570.

In the meantime, Hicks and Horne said it has been difficult to pinpoint why Mississippi has had such a hard time reining in the overuse of antibiotics.

One factor could be Mississippi’s lack of doctors, Horne said. The state has just 159 doctors per 100,000 people, the worst doctor shortage in the nation.

Dr. Mark Horne, vice chairman of the board of trustees of the Mississippi State Medical Association.
Dr. Mark Horne, vice chair of the board of trustees of the Mississippi State Medical Association. Credit: Mississippi State Medical Association

“It certainly is reasonable to believe that with the under supply of providers, that providers have to see more and more patients and have less time. And giving a prescription for an antibiotic is typically fast and easy and takes care of the immediate problem,” Horne said.

Hicks said that while the CDC has not shown a correlation between a lower density of doctors and a proliferation of prescriptions and antibiotics, they have been able to show that this is closely related to lower income areas, where these shortages often exist.

The CDC has also shown a link with chronic health conditions, which she said could suggest that Mississippians require more antibiotics on average.

“When we look at the map for other chronic conditions, say obesity, we see that the map looks quite similar, so there could also be health disparities that contribute to the health of the state,” Hicks said. “It’s probably a pretty complicated answer.”

Percentage of hospitals in each state in 2015 with antibiotic stewardship programs, which strive to curb the overuse of antibiotics. Twenty-four percent of Mississippi hospitals had these programs, the third lowest percentage in the country.
Percentage of hospitals in each state in 2015 with antibiotic stewardship programs, which strive to curb the overuse of antibiotics. Twenty-four percent of Mississippi hospitals had these programs, the third lowest percentage in the country. Credit: Centers for Disease Control and Prevention

Although Horne said several hospitals in the state have antibiotic stewardship programs, which advocate for what the CDC calls “responsible antibiotic use,” Mississippi has no legislation mandating these programs, nor does it have a comprehensive statewide program to address the issue, although Horne said reducing antibiotic overuse is a priority of the Mississippi State Medical Association.

Only 24 percent of Mississippi hospitals had an antibiotic stewardship program in 2015, which ties it with Minnesota for third-lowest percentage in the country. The national average that year was 48 percent.

In the last few years, both Kentucky and West Virginia have implemented state-based programs, funded by the CDC, to curb antibiotic overuse. Hicks said these “may be having an impact.”

Last year, the President’s Council of Advisors on Science and Technology recommended that a regulatory requirement for antibiotic stewardship be in place by the end of 2017. The report coincided with an executive order from President Obama calling for regulations requiring antibiotic stewardship programs and other actions to preserve drug efficacy as multidrug-resistant pathogens continue to rise.

“What we hope is that all hospitals would have stewardship programs in compliance with the core elements we have published,” Hicks said.

In the meantime, Hicks stressed that bringing down the number of antibiotics needs to be a priority in Mississippi and the rest of the country.

“These drugs are precious resources, and we must reserve them for the time we really need them,” Hicks said.

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Larrison Campbell is a Greenville native who reports on politics with an emphasis on public health. She received a bachelor’s from Wesleyan University and a master’s from Columbia University's Graduate School of Journalism.Larrison is a 2018 National Press Foundation fellow in public health, a 2019 Blue Cross Blue Shield Foundation of Massachusetts fellow in health care reporting and a 2019 Center for Health Journalism National Fellow.

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