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Measuring antibiotic use – what is in the future?

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Antibiotic resistance has reached a crisis in human medicine. Finding ways to combat resistance is a goal of almost all national and international groups concerned with infectious diseases.

Practices of antibiotic use in all settings (human, animal and agricultural) are being put under the microscope. As the swine industry braces to confront the practical hurdles, and likely animal health challenges, resulting from Food and Drug Administration Guidance 213 and the new Veterinary Feed Directive requirements in the new year, there are calls for further limits on the availability and oversight of antibiotics for food animals.

As in so many other areas of farming, the balance between trust and transparency is shifting. These mounting pressures are not going away, regardless of the uncertainty about the impact that antibiotics used in food animals have on resistant infections in people. That question remains unresolved after five or so decades of debate. But there is little doubt the impact is not “zero”, and therefore all industries have a responsibility to review their practices and embrace the concept of “as little as possible, as much as necessary”.

The Pork Quality Assurance and PQA-Plus programs have done a great job in helping the industry progress in avoiding antibiotic residues in pork products (common in the 1980s but now rare), and in educating the work force about the legal requirements surrounding antibiotic use. But the bar continues to be raised.

On this issue, food animal veterinarians are shifting to center stage as they assume responsibility for the oversight of all medically important antibiotics given in feed and water, as well as all extralabel use of antibiotics. The “Guidelines of Judicious Therapeutic Use of Antimicrobials in Pork Production” of the American Association of Swine Veterinarians lays out many of the accepted principles in relation to the legal and practical aspects of therapeutic decision-making in swine. But the term “stewardship” is taking over from “judicious” or “prudent” in discussions about reducing inappropriate antibiotic use. The key difference is that while judicious-use deferred to professional judgment in decisions on antibiotic use, stewardship programs have a more data-driven approach including measurement of antibiotic use, and evaluation of specific prescribing practices. That is, they operate beyond the individual judgment of prescribers.

Some stewardship initiatives for food animals in other countries include the development of “formularies” that dictate specific uses for some conditions, measurement and benchmarking of antibiotic use, and arbitrary targets for reduction in use. It is to be hoped that no precipitous changes will occur in the short-term in the United States before the industry has had reasonable time to adapt to the significant changes coming on Jan. 1. It is important that the concept of optimization (including consideration of animal health and well-being) does not get consumed by the goal or reduction.

A cornerstone of antibiotic stewardship is measurement of antibiotic use, and understanding how the products are being used. You can’t manage what you don’t measure! In the United States, gross sales of veterinary antibiotics are reported and published by the FDA, but do not provide accurate data on use in individual species. The National Action Plan for Combatting Antibiotic Resistant Bacteria calls for better surveillance of antibiotic use in food animals, which is echoed by consumer groups and politicians seeking stricter regulation of antibiotic use in food animals, and increasingly by downstream customers seeking to meet consumer demands for more transparency in the food supply.

Several northern European countries have implemented very detailed and expensive measurement systems, even at the level of the individual farm or veterinarian, and in some cases with penalties for high users. However, the European Surveillance of Veterinary Antimicrobial Consumption group states that collection of detailed data on consumption by species at a national level is challenging and less comprehensive approaches will be required for most countries.

The issue of antibiotic use generally, and measurement in particular, has been widely discussed within and among the major food animal industries over the last 12 months, and some initial projects based on voluntary participation are emerging. Perhaps the biggest step in developing any voluntary programs is definition of purpose, which must include some potential benefits for participation. An emerging consensus among industry groups is that measurement of antibiotic use should primarily be oriented toward understanding patterns of use to inform stewardship initiatives with the goal of reducing inappropriate use. Establishing industry norms for benchmarking and tracking trends over time could be achieved relatively efficiently with sample based approaches, rather than efforts to measure use by all producers. Preferably this will include metrics that more closely reflect actual administration and are therefore more meaningful with respect to stewardship efforts.

The National Pork Board has recently formed a task force to guide the development and implementation of a voluntary pilot project to obtain baseline data on antibiotic use in the industry. This raises obvious concerns about control and confidentiality of data, how data would be analyzed and reported, among others, which will take time to address and resolve. But given the importance and visibility of this issue in the public eye, doing nothing is arguably not an option.

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