ANTIBIOTIC STEWARDSHIP – GLOBAL TRENDS AND
INTERNATIONAL EXPECTATIONS
- FROM AWARENESS TO ACCOUNTABILITY
M van Vuuren SAVC Director: Food Safety and Food Security Portfolio
INTRODUCTORY REMARKS
Bacterial resistance against antibiotics received
meaningful global attention during the past two decades:
- to create awareness
- to promote antibiotic stewardship
Despite all the warnings, action to tackle AMR has not yet
matched the scale of the threat
ANTIBIOTIC STEWARDSHIP
Is a collective set of strategies to optimize the appropriate
use of all antibiotics to improve human and animal patient
outcome, and limit emergence of resistant bacteria whilst
ensuring patient safety when implementing interventions
Its most basic recommendation is that everyone should
use antibiotics responsibly and only when necessary, both
for the benefit of humans and the animals we care for
THE HAMMER BLOW WILL FALL ON LMICS
The review on antimicrobial resistance, chaired by Jim O’Neil, 2014
Klein et al. PNAS 2018 cgi/doi/10.1073/pnas.1717295115
• n=27 countries
• Between 2000 and 2015, antibiotic consumption, expressed in defineddaily doses (DDD), increased 65% (21.1–34.8 billion DDDs), and theantibiotic consumption rate increased 39% (11.3–15.7 DDDs per1,000 inhabitants per day).
• The increase was driven by low- and middle-income countries (LMICs), where rising consumption was correlated with meaningful growth in gross domestic product per capita (GDPPC)
7
WE ARE LOSING ANTIBIOTICS
FASTER THAN WE CAN PRODUCE
THEM
How did we land where we are?
Antibiotic ‘silver bullets’ have become victims of their own success
More attention was paid to other health issues
First world countries are divesting from AMR research and new
drug development
8
Experts say the grim financial outlook for the few companies still committed to antibiotic research is driving
away investors and threatening to strangle the development of new lifesaving drugs at a time when they are
urgently needed
Antibiotic start-ups like Achaogen and Aradigm have gone belly up in recent months, pharmaceutical
behemoths like Novartis and Allergan have abandoned the sector and many of the remaining American
antibiotic companies are teetering toward insolvency. One of the biggest developers of antibiotics, Melinta
Therapeutics, recently warned regulators it was running out of cash
9
OTHER FACTORS (APART FROM OVERUSE) THAT CONTRIBUTE
TO EMERGENCE OF RESISTANCE
Socio-economic disparity with concomitant sanitation issues in many parts of the world
Poor prescription and dispensing practices
Lack of national antibiotic resistance surveillance networks
Inadequate infection control facilities in many hospitals/animal facilities
The use of antibiotics in feed and water of production animals
Globally, 73% of all antimicrobials sold on earth are used
in animals raised for food.
11
Journal of the South African Veterinary Association, 2012: 83(1)
Results showed that 68% of antimicrobials surveyed
were administered in feed, and 12% in water
12
For Brazil, Russia, India, China and South Africa, antimicrobial consumption for animal production is expected to
grow by 99% by 2030 (13% for humans)
Intensification is a given, but the bad parts that lead to overuse/ need for antibiotics must be unravelled
INTENSIVE PRODUCTION FARMS
These are dynamic, sensitive production units that require immediate action to
safeguard the animals and prevent the spread of disease
Production animal veterinarians practice population medicine
14
ANTIBIOTICS, BACTERIA AND RESISTANCE GENES FOUND IN
DUST FROM FEEDLOTS
Environmental Health Perspectives, Feb 2015
Researchers found and documented aerial transmission of antibiotics,
feedlot-derived bacteria and DNA sequences encoding resistance
It explains how resistant bacteria could travel long distances into places
inhabited by humans
FREE AVAILABILITY OF ANTIBIOTICS
On many farms the increased production has not been accompanied by
improvements in biosecurity and management ……..
It results largely from the free availability of antibiotics in many countries
where administration does not require veterinary oversight and
antibiotics are administered to livestock freely and excessively
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GLOBAL CALL FOR VETERINARY OVERSIGHT OF
ANTIBIOTICS
Veterinary oversight of the use of antibiotics, and by implication the requirement
of prescriptions for and dispensing of all antibiotics by veterinarians or
authorised para-veterinarians is a short term objective (2017-2020) of the major
international agencies including the OIE, WHO, FAO and EC
The Tripartite will continue to monitor the progress of all Member States on an
annual basis
This is part of the FDA’s Five-Year Plan for Supporting Antimicrobial Stewardship in Veterinary
Settings and builds upon the momentum generated by the successful implementation of GFI
#213. Under GFI #213, animal drug sponsors worked in collaboration with FDA over a 3-year
period to voluntarily change OTC medically important antimicrobials used in the feed or drinking
water of food-producing animals to VFD/Rx marketing status and eliminated the use of these
products for production purposes (e.g., growth promotion).
18Represents the recommendations of the highest decision-making
body globally
Recommendation A1 states:
Member states must ensure responsible and prudent use by
competent, licensed professionals across human, animal and
plant health
Recommendation E2 states:
The IACG recommends the urgent establishment of a
One Health Global Leadership Group on Antimicrobial
Resistance, supported by a Joint Secretariat managed by the
Tripartite agencies (FAO, OIE and WHO), to inter alia monitor
and report on progress, gaps and accountability in the global
response to antimicrobial resistance
Accountability of Member States is mentioned no less
than 14 times in the document
19
JOINT EXTERNAL EVALUATION (JEE)
The international standards setting organisations such as the OIE, World Health Organisation
(WHO), and Food and Agricultural Organisation (FAO) are already working together in a
tripartite alliance to oversee the progress made by Member States. This objective is
achieved by means of the Joint External Evaluation (JEE) conducted by the WHO in
collaboration with the OIE and the FAO.
Country evaluations will continue on an annual basis to determine if countries are honouring
its commitments documented in their National Action Plans, ensuring accountability for
action
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WHAT ARE THE POSSIBLE IMPLICATIONS FOR FEED
MANUFACTURERS?
The OIE requires animal feed manufacturers in Member States to progress to a position where
medicated feed is limited to veterinary prescription
The objective is to diminish the overuse or inappropriate use of antibiotics that accelerate
bacterial resistance to antibiotics
It does not imply removal or banning of the currently registered animal feeds containing
antibiotics
What are the concerns related to veterinary oversight of antibiotics?
Why should antibiotics be placed under veterinary oversight?
What are the global trends with respect to antibiotic growth promoters?
Frequently asked questions
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OIE attitude is that Member States must
phase out growth promoters
The new PVS guideline includes prohibition
of growth promoters
SUBSTANDARD AND FALSIFIED ANTIBIOTICS
Substandard and falsified (SF) medical products are respectively:
medicines or vaccines that are authorised but fail to meet their quality standards or their
specifications, or
that are not authorised and deliberately misrepresent their identity, composition, or
source
One of the reasons for the interest in SF medical products by the international scientific
community is the potential contribution of these products to AMR
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HOW DO YOU REDUCE THE NEED FOR ANTIBIOTICS IN
ANIMAL HUSBANDRY?
Disease prevention
By improving animal health through sanitation, on-farm hygiene,
optimizing animal nutrition and access to clean water
Improved infection prevention and control (IPC) in animal facilities (biosecurity)
Optimized vaccination programmes
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Strategies for infection control
Visitor control on farms
Showering and changing of clothes
Disinfection of delivery vehicles
Good fences properly maintained
Quarantine and testing of newly introduced animals
All in, all out system of intensive farming
IN THE FINAL ANALYSIS
Veterinarians, animal producers and feed manufacturers must make
behaviour changes with respect to the prescription and use of antibiotics
- We all have to use antibiotics more responsibly
- We have to focus on measures to limit transmission of resistance
Proven countermeasures to diminish antibiotic resistance are available for
immediate action in animal husbandry
BEHAVIOUR CHANGE
People change if they think:
- it is important to change
- change is feasible
- they have the confidence to
implement change
Readiness to
change
Feasibility
Importance