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Keeping antibiotic use alive in U.S.

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“We estimate that by 2050, 10 million lives a year and a cumulative $100 trillion of economic output are at risk due to the rise of drug-resistant infections if we do not find proactive solutions now to slow down the rise of drug resistance. Even today, 700,000 people die of resistant infections every year.”

That’s from the final report of the Independent Review of Antimicrobial Resistance (IRAR), chaired by macroeconomist Jim O’Neill, past commercial secretary to the United Kingdom Treasury-Minister of State and chairman of Goldman Sachs Asset Management. The report was commissioned in 2014 by then-U.K. Prime Minister David Cameron to explore antimicrobial resistance (AMR) from a global economic perspective and recommend solutions.

You can find similar bleak predictions from assorted national and international organizations.

For instance, last September, the World Bank published the report Drug-Resistant Infections: A Threat to Our Economic Future. The report suggests, “Drug-resistant infections have the potential to cause a level of economic damage similar to — and likely worse than — that caused by the 2008 financial crisis.”

“Fundamental change is required in the way that antibiotics are consumed and prescribed, to preserve the usefulness of existing products for longer and to reduce the urgency of discovering new ones,” according to the IRAR report. “Governments should be held accountable on this goal to reduce the demand for antimicrobials, and in particular, antibiotics, as should the main sectors that drive antibiotic consumption: health care systems, the pharmaceutical industry, and the farming and food production industry.” The point being that AMR is a growing problem affecting everyone.

Read more from this series:

Part 1: Where we stand on the antibiotic dilemma

Part 2: 6 antibiotic myths explained

Part 3: The economics of antibiotic use

Part 4: How antibiotic overuse in human medicine impacts beef producers

Although it’s impossible to predict the future, authors of the IRAR report explain, “What we can be certain of is that, in the absence of interventions to slow the emergence of resistance, and increase the supply of new antibiotics, the impacts will be felt not just in isolated areas but at a far more fundamental level, across our societies and healthcare systems.”

Thumb through the position statements and policies of some of beef’s biggest customers, and you’ll find AMR front and center because it matters to their customers.

“We advocate for programs that allow for the humane care of animals, meaning sick animals must be treated. Yet, antibiotics should only be used when an animal has, or is at risk of developing, a health condition that antibiotics are needed to treat, and only at the prescribed dosage that has been proven to be effective,” according to Wendy’s Antibiotic Use Policy and Guidelines.

“We support efforts to reduce — and when possible eliminate — the need for medically important antibiotics in animals raised for food. We know this won’t be easy, and it may take time, but we believe it is a logical approach to preserving the therapeutic benefits of antibiotics for human and veterinary medicine,” the Wendy’s statement concludes.

“McDonald’s recognizes the importance of decisions made by beef, pork, poultry, dairy and egg producers in managing the animals entrusted to their care …” according to McDonald’s Global Vision for Antimicrobial Stewardship in Food Animals. “We strongly support the implementation of all education, training and outreach programs, and seek the development of verification programs for judicious antimicrobial use in all species to achieve our vision for antimicrobial stewardship.”

“Having to use an antibiotic for disease prevention or control means we failed at everything else we can do to prevent that disease,” says Mike Apley, veterinarian and professor of production medicine and clinical pharmacology at Kansas State University’s College of Veterinary Medicine. “They can be valuable tools, and in some cases they are definitely needed, regardless of our best efforts. But, in some cases, our best efforts can greatly reduce the need for their use.”

That single statement highlights the difference between antibiotic stewardship and the judicious use of antibiotics. Often, the terms are used synonymously, but they mean quite different things, both of which are essential in preserving antibiotic use to treat disease in animals and humans.

Antibiotic stewardship includes both the prevention of the disease drivers for antibiotic use, and then the judicious use of these tools when needed, Apley explains. Although this article aims at antibiotics specifically, keep in mind that antimicrobials include antibiotics (substances produced by one organism which inhibit the growth or survival of another) and synthesized compounds, which do the same (e.g. the sulfas and fluoroquinolones such as ciprofloxacin).

“In its broadest sense, antimicrobial stewardship encompasses any activity that promotes the judicious use of antimicrobial agents in human medicine, veterinary medicine and animal agriculture around the globe to help combat antimicrobial resistance and preserve drug effectiveness,” according to the University of Minnesota Center for Infectious Disease Research and Policy (CIDRAP).

“But this definition still leaves out the very important aspect of prevention of the disease pressure, which turns an antibiotic-centric approach [judicious use] into stewardship” says Apley.

Closer to home, the veterinarian first has the responsibility of using diagnostics to accurately define the problem. In other words, whether it’s a respiratory disease, foot rot, or another bacterial or viral complication.

“As a veterinarian, once the disease pressure is identified, you enter into a cycle of asking if there is a non-antibiotic alternative which will prevent, control or treat the disease challenge,” Apley explained during a webinar, “Animal Care Resources” earlier this year. “Can I do it with vaccines? Can I do it with environment, with genetics, with altering production pressure, with biosecurity? We are expected to do that first.”

The primary goals of antimicrobial stewardship, according to CIDRAP, are to:

  • slow the spread of antimicrobial-resistant organisms
  • extend the lifespan of existing antimicrobial agents and protect the effectiveness of new ones
  • improve the quality of patient care and minimize adverse effects of antimicrobial therapy, such as toxicity, allergic reactions and increased risk of Clostridium difficile infection
  • enhance capabilities to identify resistant organisms and monitor the prevalence of resistant infections in people and animals
  • reduce the use of antimicrobial agents in veterinary medicine and animal agriculture, without compromising animal health and the food system’s ability to meet global demands
  • decrease environmental contamination and exposure to antimicrobial waste in the environment

Judicious use of antibiotics, on the other hand, has to do with how to use antibiotics most effectively when they are required.

“The principles of judicious use of antibiotics are encompassed in the following,” say the Washington State University authors of The Doctrine of Judicious Antibiotic Use: “Use an antibiotic only when indicated, choose a cost-effective agent which provides appropriate antimicrobial coverage for the diagnosis that is suspected, and prescribe the optimal dose and duration for the antimicrobial which maximizes clinical therapeutic effect while minimizing both drug-related toxicity and the development of antimicrobial resistance.”

“We must use an antibiotic that has been demonstrated to be safe and effective for the purpose, while assuring use of the antibiotic in the manner in which it has been shown to be safe and effective,” Apley explains. “That requires protocols and records. The days of chalk marking a feedlot steer to show that it has been treated, or just taking a nip out of the tag, are gone.”

Veterinarians need to have written protocols with their producers, Apley says. “It’s not an unreasonable expectation from our consumers and from the public, legislators and regulators that we have a defined plan for using antibiotics, and that we also monitor how it’s being done.”

Of course, implementing and monitoring protocols demands a working relationship between producers and their veterinarians.

“We are always still asking if the antibiotic intervention is necessary,” Apley explains. “If not, we stop. If yes, then we go right back to the stewardship cycle and keep asking if there is a non-antibiotic alternative. The biggest catastrophe in antibiotic use is when we expose the animal and the bacteria, with no beneficial result of the antibiotic.”

Antibiotics are the solution in some cases, but Apley encourages producers to work with their veterinarians to first try other preventative measures such as vaccines, biosecurity, animal flow through working facilities, environmental management, culling and diagnostic testing to first control disease, and therefore decrease the need to use antibiotics.

“For producers and veterinarians, antibiotic resistance isn’t just about whether we do or don’t affect human antibiotic resistance,” Apley says. “It’s about also preserving these valuable tools for use on our animals 10 to 20 years down the road. We have to be good stewards of [antibiotics], and that means doing everything we possibly can to minimize our need to use them. Then we can have them when we do need them for decades to come.”

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