77
Riduzione del farmaco e redditività aziendale: esperienze a confronto Annalisa Scollo DVM, PhD , ECPHM resident 13 Nov 19
Riduzione del farmaco e redditività aziendale: esperienze a confronto
Annalisa ScolloDVM, PhD, ECPHM resident
13 Nov 19
L’antibiotico-resistenza
Fonte: Pagina Facebook di AccuProbe Diagnostics
13 Nov 19
MESSAGGI GENERALI:
1. RIDURRE GLI ANTIBIOTICI NON VUOL DIRE LASCIARE GLI ANIMALI
AMMALATI
2. RIDURRE GLI ANTIBIOTICI NON VUOL DIRE RIDURRE TUTTI I
FARMACI
3. DALLA MASSA ALL’INDIVIDUO
13 Nov 19
Vie di somministrazione dell’antibiotico
VS
ORALE INIETTABILE
• Mangime medicato• Aggiunta nella vasca• Dosatron
Vie di somministrazione dell’antibiotico
ORALE Mangime medicato
PRO: L’allevatore non deve aggiungere nulla. Non si sbaglia dosaggio nella preparazione!
CONTRO: Se l’animale non ha appetito non ingerisce la dose necessaria
Vie di somministrazione dell’antibiotico
ORALE Aggiunta nella vasca
PRO: Si riesce a somministrare la giusta dose anche con scarso appetito.
CONTRO: Precisione operatore-dipendente
Vie di somministrazione dell’antibiotico
ORALE Dosatron
PRO: Un animale molto malato non è detto che vada a mangiare, ma è molto probabile che vada a bere.
CONTRO: Spreco di acqua, costi impianto.
Vie di somministrazione dell’antibiotico
INIETTABILEIniettabile
PRO: Vengono trattati solo i malati, anche se non mangiano. Risparmio anche economico.
CONTRO: Si fa più fatica
Linee guida
Per ridurre l’uso dell’antibiotico si
ridurranno i trattamenti di massa a favore di quelli
individuali
ContestoProva di campo Implicazioni
Protocollo d’azioneRegola 1:
Oltre il 20% del singolo box =
100% del box
Regola 2:
Oltre il 15% di tutti i box =
100% della stanza
Contesto ImplicazioniProva di campo
- 26% di antibiotico utilizzato- 32 cents/capo
Stessa mortalità+scarti 3,95%Stesso accrescimento 442 gr/giorno
Svezzamento
Ingrasso
- 93% di antibiotico utilizzato
Stessa mortalità+scarti 3,42%Stesso accrescimento
…in quante aziende l’uso dell’antibiotico è razionale?
• Indecisione sul fare o non fare un trattamento di massa
Come la CE quantificherà i nostri consumi?
Con la ricetta elettronica (OBBLIGATORIA PER LEGGE DAL 16 APRILE 2019) e la trasformazione delle quantità di antibiotico in DDD.
Cosa sono i CIAAntimicrobici di «importanza critica» in medicina umana
MACROLIDI
Come si è espresso il nostro Ministero della Salute
Come si è espresso il nostro Ministero della Salute
Esempio 1
Esempio 2
Esempio 3
Ho risolto il problema?
SI
Ottimo!
NO
Approfondimenti diagnostici
Segnalazione di Farmacovigilanza
0
2
4
6
8
10
12
14
16
2015 2016 2017 2018
no
si
Esempio DDDAit
Esempio DDDAit
Ci vogliono 1242 flaconi da 100ml di Enrofloxacina per arrivare alle stesse DDD di un trattamento di massa con Lincomicina in un magronaggio da
2500 suini (considerando che con 350 flaconi si punturano tutti gli animali
per 3 giorni).
Esempio DDDAitMagronaggio da 2500 posti
Farmaco Classevia di somministrazione DDDvet it CIA
Lincomicina 11% Lincosamidi Per os 3,4792no
Enrofloxacina 5% Chinoloni Iniettabile 0,0028si
Utilizzo di prodotti alternativi all’antibiotico
RIDURRE GLI ANTIBIOTICI NON VUOL DIRE ABOLIRE I FARMACI
Tutti i farmaci diversi dall’antibiotico vanno usati per aiutare l’animale a superare i primi sintomi di
malattia!
ANTINFIAMMATORI
ANTIPIRETICI
MUCOLITICI
Biosicurezza e strutture Salute
Management
VACCINI!
Prevenzione e vaccini
0
2
4
6
8
10
12
14
16
18
20
2016 2017 2018
Lawsonia
no
si
Il «peso» della mancata prevenzione
Prevenzione e vaccini
Grazie
Prevenzione e vaccini
ANTIMICROBIAL USE AND RESISTANCE IN
ANIMALS, PROBLEMS AND SOLUTIONS!
Prof. Jeroen Dewulf
VETERINARY EPIDEMIOLOGY UNIT
One world, One health
Linking antimicrobial use to antimicrobial resistance in 7 EU countries based
on monitoring data
y = -0,0002x2 + 0,0255x - 0,0707R² = 0,93
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0 10 20 30 40 50 60
Arc
sin
% A
M r
esis
tan
ce
Antimicrobial use (mg/PCU)
(a) Aminopenicillins (ampicillin)
y = 0,6887x2 - 0,1812x + 0,0135R² = 0,94
0
0,02
0,04
0,06
0,08
0,1
0,12
0,14
0 0,1 0,2 0,3 0,4 0,5 0,6
Arc
sin
% A
M r
esis
tance
Antimicrobial use (mg/PCU)
(b) Third generation Cephalosporins (cefotaxime)
y = 1,1278x2 - 0,2875x + 0,0221R² = 0,99
0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
0,4
0,45
0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8
Arc
sin
% A
M r
esis
tance
Antimicrobial use (mg/PCU)
(c) Fluoroquinolons (ciprofloxacin)
y = 0,1313x2 + 0,1234x - 0,0112R² = 0,99
0
0,05
0,1
0,15
0,2
0,25
0 0,2 0,4 0,6 0,8 1
Arc
sin
% A
M r
esis
tance
Antimicrobial use (mg/PCU)
(d) Amphenicols (chloramphenicol)
y = -0,0021x2 + 0,0241x - 0,0188R² = 0,80
0
0,01
0,02
0,03
0,04
0,05
0,06
0 1 2 3 4 5 6 7
Arc
sin
% A
M r
esis
tance
Antimicrobial use (mg/PCU)
(e) Aminoglycosids (gentamicin)
y = -0,0149x2 + 0,1752x + 0,0057R² = 0,81
0
0,1
0,2
0,3
0,4
0,5
0,6
0 1 2 3 4 5 6 7
Arc
sin
% A
M r
esis
tance
Antimicrobial use (mg/PCU)
(f) Aminoglycosids (streptomycin)
Chantziaras et al., J Antimicrob Chemother, 2014
Linking antimicrobial use to antimicrobial resistance in 7 EU countries based
on monitoring data
Chantziaras et al., J Antimicrob Chemother, 2014
Austria
Denmark
Netherlands
Belgium
Switzerland
SwedenNorway
1
2
3
4
5
6
7
1 2 3 4 5 6 7
Avera
ge a
nti
mic
rob
ial re
sis
tan
ce
ran
kin
g
Average antimicrobial use ranking
6
0
20
40
60
80
100
120
140
918 days on 200
Sarrazin et al., J Antimicrob Chemother, 2019
1 month a year
7
0
20
40
60
80
100
120
140
Sarrazin et al., J Antimicrob Chemother, 2019
8
TI sucklers 35%
TI weaners 56%
TI fatteners 9%
FACTORS RELATED TO ANTIMICROBIAL USE
1. Total amount of antimicrobial agents 2. Treatment dose and duration
3. Choice of antimicrobials 4. Administration route
The pipeline for new antibiotics in veterinary medicine is dry!
11
Veterinair gebruik van antibiotic in Europa: ESVAC
0
50
100
150
200
250
300
350
400
450
500
Antimicrobial use in mg/PCU (ESVAC)
2015 2016 2017
Mean 91,5 mg/kg PCU
Median 61,9 mg/kg PCU
Using less antimicrobials results
in less resistance
2011-2018: - 36%
Antimicrobial Resistance in commensal E.
coli
Trend analysis
What can we do about it?
Replacing antimicrobials by:
Improved feed
Improved housing
Feed additives
Improved Biosecurity
….
BIOSECURITY
=
The combination of all measures taken to reduce the risk of introduction and
spread of diseases on herd, region, country,… level
What is biosecurity
EXTERNAL BIOSECURITY
= Reduce introduction
- endemic diseases
- ”exotic” diseases
INTERNAL BIOSECURITY
= reduce spread
What is biosecurity
BIOSECURITY is (should be) the basis of any disease
control program
Why biosecurity
PRINCIPLES OF BIOSECURITY
Separation of infectious and susceptible animals
→ avoid both direct and indirect contact!
(all-in/all-out, working lines, hospital pen, …)
• Dependent upon herd situation (status, type,…)
• Perform well and consequent
CLEAN
(susceptible animals)
DIRTY
(direct and indirect
sources of infection)MEASURES
PRINCIPLES OF BIOSECURITY
PRINCIPLES OF BIOSECURITY
Feed
Pets and
rodents
Persons breath Air Transport vehicles,
Persons, clothing, hands
Live animals
LOW RISK HIGH RISK
material
Direct contact Indirect contact
People Semen Manure Domestic/feral
animals
Rodents Insects
(Vectors)
Aerosol Animal feed Water Fomites
Actinobacillus
pleuropneumoniaeX X X X X
Bordetella
bronchiseptica X X X X X X X
Brachyspira
hyodysenteriae X X X X X X X X X
Brucella suis X X X X X X X X
Classical swine fever
virus X X X X X X X X X
Clostridium
perfringens X X X X X X
Erysipelothrix
rhusiopathiae*X X X X X X X
Escherichia coli X X X X X X X X X X
Foot-and-mouth
disease virus X X X X X X X X X
Haemophilus
parasuis*X X
Lawsonia
intracellularis* X X X X X X
Leptospires X X X X X X
Mycoplasma
hyopneumoniae X X X X X X
Pasteurella multocida X X X X X X X
Porcine circovirus
type 2* X X X X X X X X
Direct contact Indirect contact
People Semen Manure Domestic/feral
animals
Rodents Insects
(Vectors)
Aerosol Animal feed Water Fomites
Porcine Epidemic
diarrhea virus*
X X X X X X X
Porcine parvovirus X X X X X X X
Porcine Reproductive
and Respiratory
Syndrome virus
X X X X X X X X X X X
Pseudorabies virus X X X X X X X X X
Salmonella spp. X X X X X X X X X X
Streptococcus suis X X X X X X X X
Swine influenza virus X X X X X
Swine vesicular
disease virus
X X X X X X X X
Transmissible
gastroenteritis virus
X X X X X X
Biosecurity in animal practice
and Veterinary Medicine., 2018
Reduction of the general infection pressure
→ breaking the infection cycle, reducing the burden on the
immune system↓
(cleaning, disinfection and empty period, vaccination, …)
PRINCIPLES OF BIOSECURITY
PRINCIPLES OF BIOSECURITY
• Size matters
PRINCIPLES OF BIOSECURITY
• ‘Thousand times a small chance becomes a large chance’
• Risk transmission route (p)
• Frequency transmission route (n)
• P = 1 – (1-p)n
• p= 0.1% (1 out of 1000)
• n= 52 (e.g. weekly)
• 5,06%= 1 – (1-0.001)52
28
Biosecurity = complex
• No protocol suitable for every herd
• Balance biosecurity – management
• Tool?
→ Scoring System
China
Germany
Finland
Belgium
Netherlands
Italy
Spain
Vietnam
Denmark
Ireland
France
South Africa
60
65
70
75
80
85
40 45 50 55 60 65 70
Exte
rnal bio
security
(%
)
Internal biosecurity (%)
Biocheck.UGent Worldwide
External biosecurity / Internal biosecurity
COUNTRY-LEVEL COMPARISON OF EXTERNAL AND INTERNAL BIOSECURITY
Check, Improve, Reduce
A SIMPLE AND EFFECTIVE APPROACH
34
Herd specific advice
Substantial reduction
antimicrobial usage without
jeopardizing production
by coaching?
35
61 Flemish herds
3 Herd visits
Intervention & follow up
36
37
Coaching
Hiatt, 2006 Livestock-adapted ADKAR®
CCCCCCCCCCCCCCCC
CCCCCCCC
CCCCCCCCCCCCCCCC
CCCCCCCC
CCCCCCCCCCCCCCCCCCCCC
CCCC
CCCCCCCCCCCCCCCC
CCCCCCCCCCC
CCCCCCCCCCCCCCCCCCCCC
CCC
ADKAR
buildin
g block
Description
building block
Score Explanation scores
A
(wa
ren
es
s)
Represents the
awareness that AMU
in livestock
production should be
reduced while this is
a risk for introduction
of antimicrobial
resistant bacteria in
animals and men.
1 Farmer missed all information regarding AMU and AMR. Is not aware there are reduction goals, nor is
aware AMU is a risk for AMR.
2 Farmer is aware of the recommendation to reduce AMR, but is completely denying the problems related
to AMR.
3 Farmer is aware that AMR should be reduced, but contests the role AMU in livestock. Mentions the role
of AMU in human medicine and/or the role of AMU in dogs and cats.
4 Farmer is aware that AMU should be reduced, and accepts the reduction goals.
5 Farmer is fully aware that AMU should be reduced, as he accepts the risks and opportunities for
livestock production. He takes responsibility for the AMU in the farm and embraces the reduction goals
for the farm.
D
(es
ire
)
Represents the
personification of the
awareness.
“Does the farmer
himself want to
reduce AMU in his
farm?”
1 Farmer states: ”This is not my problem. It does not concern me”.
2 Farmer will reduce, but is not the first adaptor. Farmer states: “my “neighbour” should also reduce”.
3 Farmer wants to reduce, but slowly. The goal is not to reach the lowest use possible, just enough is also
OK.
4 Farmers goal is to reach the lowest AMU possible, with equal costs.
5 Farmers goal is to reach the lowest AMU possible, even if there are considerable costs related to the
reduction.
K
(no
wle
dg
e)
Represents the
knowledge and skills
of the farmer to
implement measures
to improve health
and to reduce the
1 It is not clear what is causing the health problems in the farm. It is not possible to draw up an action
plan. The farmer and his network really do not know where to start.
2 Low or inaccurate knowledge, experience or skills which are needed for the execution of the action plan
are available for the farmer. Or, the underlying cause of the problem is not yet identified.
3 Information on health problem(s) is available for the farmer, action plan can be drawn up.
4 Information is available, but some discussion about the implementation. Support for the farm and farmer
Livestock-adapted ADKAR®
AWARENESS & AMU
MOTIVATION & AMU
42
% ADVISED
% FEASIBLE
% IMPLEMENTED
Registration symptoms & moment mortality for analysis
95 98 66
Hand hygiene, change coverall and clean boots 86 88 59
Change needles often 85 82 62
Hygiene lock per animal/age category 76 58 7
Use strict euthanasia policy 71 90 81
Wash sow before farrowing crate 68 45 20
Analysis drink water 1x/year well/pipes 68 98 80
Keep dog/cat out of the stable 49 34 21
AI / AO, do not return to younger age group 41 54 33
Use dirty road for transport of manure 20 100 75
Change wooden boards for plastic boards 10 67 83
Biosecurity & Management
43
%
ADVISED
%
FEASIBLE
%
IMPLEMENTED
Request slaughter findings for analysis 75 59 57
Additional vaccinations in general 51 94 81
Additional specific vaccinations: PCV2 16 100 62
Check serology titres in general 33 95 90
Adjustment of vaccination scheme: Atrofic
rhinitis8 100 80
Diagnostics & vaccination
44
%
ADVISED
%
FEASIBLE
%
IMPLEMENTED
Restrictive use of potent AM 92 72 45
Stop (routine) prophylactic treatment birth until
slaughter88 69 59
Stop prophylactic treatment in sows 24 90 83
Ask for resistance profile/sensitivity testing 7 79 0
Prudent antimicrobial
usage
314
38
119
42
135
4
5019
201
65
109
40
144
15
60
37
0
100
200
300
400
500
600
Tre
atm
en
t in
cid
en
ce
Piglets Finishers Birth-slaughter 205 days Sows
Average TI DDDA routine visit 1
Average TI DDDA curative visit 1
Average TI DDDA routine visit 3
Average TI DDDA curative visit 3
- 45.8%
- 81.6%
- 52.0%
- 31.7%
45
VISIT MEAN DIFFERENCE P-VALUE
Number of weaned piglets per sow per year
Initial 26.4
+1,1 <0.01Follow
up27.5
Daily weight gain (g/day) finishers
Initial 667.5
+7,7 0.01Follow
up675.2
Mortality in finisher period (%)
Initial 3.2
-0,6 0.04Follow
up2.6
46
Production parameters
Benefits - EconomicsBE: € 42,99 per sow/year
€ 2,67 per finisher/year
BE: € 4,46 per sow/year
FR: € 1,23 per sow/year
ADKAR
Coaching has a positive effect on :
Financial results
Biosecurity Antimicrobial use
49
“An ounce of prevention,
is worth a pound of cure”- Benjamin Franklin -
Jeroen Dewulf
VETERINARY EPIDEMIOLOGY
T +32 9 264 75 43
M +32 476 49 70 40
www.ugent.be
Ghent University
@jkdewulf
jkdewulf
