British Society for Antimicrobial Chemotherapy Spring Meeting, Royal College of Physicians London March 2014 Antimicrobial Stewardship in Veterinary Medicine Peter Jones Immediate Past-President BVA
Is there a problem- who says? The problem is a /cking /me bomb and should be put on the Na/onal Risk Register which also includes catastrophic terrorist a<acks and other civil emergencies, Prof Dame Sally Davies said. UK Government included this topic on the agenda of the recent G8 mee/ng Mul4drug resistant (MDR) organisms Gram- e.g Salmonella and Gram+ e.g MRSA No new products in the R&D pipeline Infec4on with ESBLs not responding to treatment In human medicine the biggest problem is over prescribing in man Dame Professor Sally Davies UK Chief Medical Officer
.but the calls for ac4on keep on coming! Highly effec/ve control op/on to reduce selec/ve ESBL/AmpC producing bacteria at an EU level would be to stop all uses of cephalosporins/systemically ac/ve 3rd/4th genera/on cephalosporins or restrict their use Soil Associa/on report showed there is now overwhelming scien/fic evidence that an/bio/c use on farms contributes significantly to the spread of resistant E coli in humans Scien4fic Opinion on public health risks of bacterial strains producing extended- spectrum beta- lactamses and/or Amp/C beta- lactamases in food and food producing animals; European Food Safety Authority (EFSA) panel on Biological Hazards. EFSA Journal 2011;9(8):2322 E.coli Superbugs on farms and food: Soil Associa4on. - March 2012 Worldwide, the fact that greater quan//es of an/bio/cs are used in healthy animals than in unhealthy humans is a cause for great concern Dr. Margaret Chan Director General WHO March 2012 Bri/sh Veterinary Surgeons rely on the dispensing of medicines as a major part of their income stream and as such are to be considered as drug dealers An/microbial Resistance: Incen/vizing Change towards a Global Solu/on: Chatham House October 2013
Why is this such a problem..for vets? The European Parliament on December 6th 2012 adopted a resolu/on calling on vets to be prevented from the dispensing of an/microbials
What does the evidence really tell us?
Do restric4ons work? Experience in Denmark
Do restric4ons work? Experience in Denmark
And in the USA? : Incidence of resistance to fluoroquinolones in Campylobacter in man following the ban on enrofloxacin in poultry in the USA in 2005 Enrofloxacin banned in the US for poultry in 2005 NARMS 2011
mg/pcu
Further evidence that demands scru4ny The collec4ve data of the available studies reveal considerable differences in ESBL types between poultry and humans in Europe, leaving the ques4on open as to what extent livestock contributes to the spread of ESBL in humans While ecologically connected, animals and humans have dis4nguishable DT104 communi4es differing in prevalence, linkage and diversity, inferring that the sympatric animal popula4on is unlikely to be the major source of resistance diversity for humans Personal communica4on Chris Teale AHVLA UK Mather et al Proceedings of the Royal Society 22 April 2012 Vol279 No 1733. 1630 1639 Among animal isolates subjected to mul4locus sequence typing (MLST), only 1.2% were more than 70% similar to human isolates in gene profiles and shared the same MLST clonal complex with the corresponding human isolates. From a public health perspec4ve ESBL E.coli from animals may represent a reservoir of virulence and resistant genes rather than being the direct cause of infec4ons in humans Wu at el: PLOS ONE Sept 2013/Vol 8/Issue 9/ e 75392 Increasing scien4fic evidence suggests that clinical issues we face in human medicine are primarily the result of an4bio4c use in people, rather than the use of an4bio4c use in animals European Centre for Disease Control (ECDC) Fact Sheet 2011 Decoupling will not fundamentally alter the posi4on of veterinarians vis a vis the livestock farmer and could impact on the former s role as gatekeeper for administra4on of vet meds hrp://www.fve.org/uploads/publica4ons/docs/berenschot%20report_02_2010.pdf
What should the veterinary profession doing about it? Lobbying hard against bad law which does not solve the problem and may contribute to it Challenging misconcep4ons about the causes of resistance Arguing for management of resistance to be based on sound scien4fic risk assessment and not wholly on the precau4onary principle Promo4ng stricter condi4ons in best prac4ce for the use of certain categories of an4microbials, which have special importance in human medicine (e.g. fluoroquinolones and 3rd- 4th genera4on of cephalosporins) Striving for berer animal health management on farm to reduce the need for an4microbials Reinforcing the message and campaigning to raise awareness of the crucial importance of evidence based responsible use supported by appropriate guidelines, and possibly regula/on
Pig Veterinary Society
What more do we need to do? Need to further scru4nise our methods of using an4microbials and minimise our reliance on them Cura4ve Treatment (Therapy) Control treatment (Metaphylaxis ~ Prophylaxis in human terms) Preven4ve treatment (Prophylaxis and only excep4onally) Every vet must be made aware of the problem training, educa4on, guidelines: - NO EXCUSE FOR INACTION All vet must be held accountable for which an4microbial used RCVS New Code of Professional Conduct Clinical governance, health protocols Be ever vigilant and responsive as the profession con4nues to come under fire. Defend excep4onal use of Human Cri4cally Important An4bio4cs Reinforce the message that the major problem lies with over- use in the medical sector, but we must also play our part, and be seen to do so
This is where alliances marer Working together
How can the veterinary profession regulate the use of an4microbials? Through the RCVS Code of Professional Conduct 1. Veterinary surgeons and animals 1.5 Veterinary surgeons who prescribe, supply and administer medicines must do so responsibly.
Code of Professional Conduct - suppor4ng guidance Sec4on 4.22 The development and spread of an4microbial resistance is a global public health problem that is affected by use of these medicinal products in both humans and animals. Veterinary surgeons must be seen to ensure that when using an4microbials they do so responsibly, and be accountable for the choices made in such use.
Ensure compliance through the Prac4ce Standards Scheme PSS All prac4ces must comply with the core standards of the prac4ce standards scheme Inspectors will be assessing prac4ces compliance with responsible used guidelines and for prac4ces not in PSS, VMD inspectors will be checking for adherence to responsible use guidelines RCVS has amended the current PSS manual to to include the revision under sec4on 8, Medicines, which reads: A prac;ce must be able to demonstrate that when using an;microbials or anthelmin;cs, it does so responsibly and is accountable for the choices made in such use
Ques4ons in the guidelines for inspectors under review How do you work with clients to avoid the need for an/microbials? How do you avoid inappropriate use? How do you ensure that the appropriate an/microbial is used? What is the prac/ce policy on monitoring an/microbial sensi/vity? How do you minimise prophylac/c use? Does the prac/ce use an/microbials peri- opera/vely? If so, how is this jus/fied? Do you record devia/ons from an/microbial protocols? Is there a repor/ng system in place for suspected treatment failure?
Working together One Health UK 5 Year An4microbial Resistance Strategy 2013 to 2018, www.gov.uk/government/publica4ons/uk- 5- year- an4microbial- resistance- strategy- 2013- to- 2018
UK 5 Year An4microbial Resistance Strategy 7 Key Areas for future ac4on Improving infec4on preven4on and control prac4ces Op4mising prescribing prac4ce Improving professional educa4on Training and public engagement Developing new drugs, treatments and diagnos4cs Berer access to and use of surveillance data Berer iden4fica4on and priori4sa4on of AMR research needs Strengthened interna4onal collabora4on Work in these key areas will contribute to three overarching aims: 1. Improve the knowledge and understanding of AMR 2. Conserve and steward the effec4veness of exis4ng treatments 3. S4mulate the developments of new an4bio4cs, diagnos4cs and novel therapies
BVA and EAAD 2013 Resources for Veterinary Prac4ces Resources for Animal Keepers Responsible Use Poster Guidance on responsible use of an4microbials Webinar for Veterinary surgeons Recordings of clinical streams at 2012 BVA Congress CPD Suppor4ng efforts by specialist divisions e.g. BSAVA and BEVA Leaflet for pet owners: How to use an4bio4cs responsibly? for release on EAAD Leaflet for farmers: How can we safeguard an4bio4cs now and for the future? diro - Collabora4on with RUMA partners Myth Busters document for release on EAAD BVA Medicines Working Group charged with taking forward ac4ons from the UK Five Year An4microbial Resistance Strategy Editorials and ar4cles in veterinary press Reinforcing the message in every aspect of the BVA CPD programme www.bva.co.uk/eaad.
And finally? The message is clear if we don t change, then others will do it for us The use of an4bio4cs in veterinary medicine in Europe in the future will be different to how we use them now and with certain constraints on certain classes and on when we use them Thank you for your aren4on www.bva.co.uk