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)

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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

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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

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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.

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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

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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

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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

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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