mvma mn one health antibiotic stewardship v5...antibiotic stewardship concepts and minnesota’s one...
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Antibiotic Stewardship Concepts and
Minnesota’s One Health ApproachJune 21, 2017
Minnesota Veterinary Medical AssociationLunch and Learn
Dr. Gary D. NeubauerSenior Manager Dairy Technical Services – Zoetis
Past President MVMA & NMC
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ANTIBIOTIC STEWARDSHIP
Animals get sick, just like people.
• Without the proper use of antibiotics, animal welfare can be negatively impacted.
• Antibiotics work with the animal’s own natural defense systems to rid the animal of the bacteria causing the infection and regain good health.
• Antibiotics also may be appropriately used early in the disease process when animals have recently been exposed to disease-creating bacteria.
ANTIBIOTICS ARE USED TO TREAT SICK ANIMALS.
RESPONSIBLE USE OF ANTIBIOTICS IS:
• Administering medication under the guidance of a veterinarian
• Following the directions on the approved product label
• Using only the amount needed to treat the problem
ANTIBIOTIC STEWARDSHIP
ANTIBIOTICS MUST BE USED RESPONSIBLY
ANTIBIOTIC STEWARDSHIP IS:
• Working together to use antibiotics responsibly, under the guidance and supervision of a veterinary professional
• A commitment to educational efforts to promote the responsible use of animal health products
• Developing innovative and safe treatment options, including alternatives to antibiotics
ANTIBIOTIC STEWARDSHIP
USING ANTIBIOTICS RESPONSIBLY TODAY,
In Livestock
• Balanced nutrition• Clean environment• Shelter from elements • Husbandry• Vaccines• Coccidiostats (ionophores)• Antibiotics• Parasiticides• Probiotics
In Companion Animals
• Balanced nutrition• Clean environment • Shelter from elements• Husbandry• Vaccines• Preventive wellness care• Antibiotics• Parasiticides• Probiotics
ANTIBIOTIC STEWARDSHIP
ANTIBIOTICS ARE ONE OF MANY TOOLS
CURRENT LANDSCAPE FOR ANTIBIOTIC USE IN ANIMALS
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• Increasing regulations requiring veterinary oversight for antibiotics used in livestock animal feed and water
ANTIBIOTIC STEWARDSHIP
INCREASING FEDERAL REGULATIONS IS ONE TREND
April 2013:Guidance 209
defines judicious use of antibiotics in
animals
October 2015:Revised Veterinary
Feed Directive (VFD)
December 2013:Guidance 213 outlines
removal of growth promotion claims from
medically important antibiotics used in feed
October 2015:California SB-27
Jan. 1, 2017:VFD required: Growth-promotion label claims for medically important
antibiotics no longer legal
2014 2015 2016 20172013
2013
Discussions involving antibiotics brought to a government level, increasing public concerns
MORE GOVERNMENT AND NEWS REPORTS
September 2013:CDC publishes report on
antibiotic resistance threats to human health
in the United States
March 2015:White House announces National Action Plan for Combating Antibiotic-
resistant Bacteria
September 2014:President’s Council of Advisors
on Science and Technology (PCAST) release report on
combating antibiotic resistance
September 2015:Chain Reaction report published,
scoring fast-food restaurants with letter grades based on sourcing policies for
antibiotic use in food animals
2014 2015 2016
October 2015:California Gov. Jerry
Brown signs SB-27, a law that largely mirrors the
Veterinary Feed Directive
2013
Impacting antibiotic use in animals.
Chain Reaction Report
Recent decisions by some of the top food companies directly impact the animal health industry
FOOD COMPANY MARKETING STRATEGIES IMPACTING FUTURE USE OF ANTIBIOTICS
March 2015:McDonald’s announces plans
to source “chicken raised without antibiotics important to
human medicine”
July 2014:Cargill Turkey
announces plan to phase out growth-
promoting antibiotics
February 2016:Perdue plans to expand its NO ANTIBIOTICS EVER protein into mainstream
grocery
2014 2015 2016
March 2015:Pilgrim’s Pride, Tyson
Foods, Wal-Mart make prominent antibiotic policy announcements
October 2015:Subway plans to
source only chicken (2016), turkey (2018), pork and beef (2025)
raised without antibiotics
RESPONSIBLE USE OF ANTIBIOTICS IS A HOT TOPIC
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THE FOCUS: FARM TO FORKTranslating Food Technology: Some harsh reality about Europe's 'successful' limitation of antibiotic use
Legislation by Denmark in the early 1990s to ban its farmers from using antibiotics to make animals grow faster and more efficiently is generally held up as the beginning of a movement Europe-wide to control their use. Today, Danish farmers, unlike U.S. farmers, may only use antibiotics to treat and prevent specific disease in specific animals, and it must be done under supervision of a veterinarian. Those restrictions, according to advocates of similar legislation in this country, has been a success in cutting Danish animal antibiotic use in half between 1994 and 2000.
Some harsh reality about Europe's 'successful' limitation of antibiotic use
When Denmark banned antibiotics for "growth promotion," it was precisely that last category, those antibiotics relatively least important to human medicine, that it removed from the market. If that weren't illogical enough, that removal of those least important antibiotics actually spurred an increase in the use the more important antibiotics--those very antibiotics that advocates argue are most important to not use. That higher use of those more important drugs has continued to this day. In other words, Denmark might have cut its overall antibiotic use on farms, but it did so only by banning farmers from using the antibiotics doctors could most afford to lose and encouraging farmers to use more of the antibiotics doctors most want to protect.
Physicians and human health professionals• Hospitals, clinics, nursing homes
Livestock animal health industry • Veterinarians, producers
Companion animal health industry • Veterinarians, veterinary clinics, pet owners
Food and Drug Administration (FDA)• Regulates the rigorous antibiotic approval
process• Enforcement of violations
U.S. Department of Agriculture (USDA)• Routine surveillance of meat and milk to ensure
safe food
ANTIBIOTIC STEWARDSHIP
EVERYONE PLAYS A ROLE IN RESPONSIBLE USE AND THE ONE HEALTH INITIATIVE.
The Problem of Antibiotic Resistance
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• >2 million people are sickened each year with antibiotic-resistant infections– 23,000 die as direct result
• $20 billion in excess direct health costs estimated• Urgent and serious resistant bacterial threats
include:– Clostridium difficile (C. difficile)– Carbapenem-resistant Enterobacteriaceae (CRE)– Drug resistant Campylobacter, Neisseria gonorrhoeae,
non-typhoidal Salmonella, Salmonella Typhi, Shigella, S. pneumoniae, tuberculosis
– Extended spectrum β-lactamase producing Enterobacteriaceae
– Methicillin-resistant S. aureus (MRSA)– Multidrug-resistant Acinetobacter, Pseudomonas
aeruginosa– Vancomycin-resistant Enterococcus (VRE)
http://www.cdc.gov/drugresistance/threat-report-2013/
CDC Resistance Threat Report
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Global Commitment
ANTIBIOTIC STEWARDSHIP
• 7 meetings for veterinarians and human health professionals. • 8 continuing education sessions in the regions for veterinarians. • 3 national congresses for pet veterinarians. • 2 national congresses for livestock veterinarians. • 3 continuing education publications for pet and equine veterinarians. • 5 publications of continuing education for livestock veterinarians. • 3 software for veterinarians for livestock. • 4 national symposiums for veterinarians, human health professionals and
the media. • 6 national measures forming part of the Ministry of Agriculture's national
EcoantibioPlan 2017 for veterinarians, pharmacists, doctors, breeders and the general public.
FRANCE -CONSEIL NATIONAL DE L’ORDRE DES VÉTÉRINAIRES
Fighting Resistance
According to Centers for Disease Control and Prevention, four core actions can help fight resistance.
1. Prevent infections
2. Track infections
3. Improve prescribing (stewardship)
4. Develop new drugs and diagnostics
http://www.cdc.gov/drugresistance/about.html 24
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Drivers of Resistance
• Antibiotic use leads to resistance by selecting and enabling proliferation of resistant strains
– All antibiotic use has potential to drive resistance, whether or not appropriate
• Horizontal transmission of resistance genes among bacteria
• Acquisition of resistant bacteria
– Direct transfer of resistant bacteriaor genes among people, animals
– Contamination of food and water
– Contamination of environment
Who Uses Antibiotics?
• Human health care
– Acute care and critical access hospitals
– Long-term care (skilled nursing facilities)
– Outpatient facilities
– Ambulatory surgical facilities
– Dental clinics
• Animal health• Companion animal medicine
• Animal agriculture
• Aquaculture
• Plant agriculture• Fruit production
• Industry• Ethanol production
Antibiotic Stewardship
• Process of improving antibiotic use
• Recognizes importance of antibiotics– Essential to all aspects of health
– Shared resource
• Focused on optimizing use, not withholding antibiotics
• Goal is to optimize:
– Selection. Choosing the right antibiotic for the infection and patient
– Dose. Giving the right amount of antibiotic
– Duration. Giving the antibiotic for the right amount of time
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The Stewardship Balancing Act
Unintended consequences
• Toxicity, adverse drug effects• Risk of developing severe
infection, e.g., C. difficile• Emergence of resistance• Cost
Unintended consequences
• Untreated, more severe infection
• Disease spread in population
• Diagnostic uncertainty• Negative patient/client
relationships• Potential litigation
Prescribe Don’t Prescribe
History of Stewardship in Minnesota
• Health care– Minnesota Antibiotic Resistance Collaborative (early 2000s)– Antibiotic stewardship conferences held (2012-14)– Minnesota guidance and toolkits
• Animal health– Quality assurance programs– Producer and veterinary education programs
• Residue prevention and legal obligations• Veterinary accreditation modules
– Antibiotic use guidelines developed by veterinary groups – Participation in AVMA stewardship committee
• Challenges– Connecting facilities with tools, implementation support– Poor understanding across human, animal, environmental health
What About the Environment?
• Antibiotic residues found in groundwater, lakes, and streams– Macrolides: erythromicin, clarithromycin, virginiamycin, tylosin
– Fluoroquinolones: ciprofloxacin, moxifloxacin
– Sulfa drugs: sulfamethoxazole, sulfachloropyridazine
– Others: carbadox, trimethoprim
• Complex mixtures of antibiotics and metabolites
• Urban, agricultural pathways to contamination
• Consideration of disposal is essential
• Outstanding questions– How do antibiotics in environment influence overall resistance?
– How does antibiotic exposure impact ecology and human health?
– How can we mitigate impact on environment?
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Minnesota’s One Health Approach to Antibiotic Resistance
• Recognition that human, animal, and environmental health are interconnected
• Goal is to work collaboratively, across sectors, to improve the health of all
Minnesota One Health Antibiotic Stewardship Activities
Minnesota Dept. of Health
Communicating the Problem
• Human, animal, and environmental health are inseparable• All antibiotic use leads to resistance
– There is some contribution from every sector using antibiotics
• Lack of “proof” of harm is not an argument for irresponsible use
• Greater abuse in other disciplines is not an argument for injudicious use in yours
• There are unreasonable critics!– Exaggerate harms– Fail to acknowledge real benefits
• Behavior change is key
Antibiotics are a shared resource, and optimizing use benefits everyone.
Minnesota officials create program to combat inappropriate antibiotic use
Minnesota Health Commissioner Dr. Ed Ehlinger announces Friday, July 1, 2016, that four state agencies are working
together on the problem of overuse of antibiotics.
• Multi-partner initiative to address antibiotic use• Inter-agency approach by government
– MDH– Department of Agriculture– Pollution Control Agency – Board of Animal Health
• Stakeholders from academia, clinical practice, health and agriculture advocacy groups
• Mission– Provide a collaborative environment to promote judicious
antibiotic use and reduce the impact of antibiotic resistant pathogens
• Vision– Minnesota leaders in human, animal, and environment
health will work together to raise awareness and change behaviors to preserve antibiotics and treat infections effectively
One Health Antibiotic Stewardship Collaborative
Abbott Northwestern HospitalAllina HealthAssociation for Professionals in Infection Control and Epidemiology – MinnesotaBlue Cross Blue ShieldChildren’s Hospitals and Clinics of MinnesotaEmergency Physicians Professional Association- MinnesotaHealthEastHealthPartnersHennepin County Medical CenterLand O’LakesLeading Age MinnesotaM HealthMayo ClinicMerck Research LabsMetropolitan CouncilMinnesota Association of Physician AssistantsMinnesota Beef CouncilMinnesota Board of Animal HealthMinnesota Board of Medical PracticeMinnesota Board of Veterinary MedicineMinnesota Department of AgricultureMinnesota Department of HealthMinnesota Farm Bureau
Minnesota Farmers UnionMinnesota Hospital Association Minnesota Medical AssociationMinnesota Milk Producers AssociationMinnesota Nurse Practitioners Minnesota Pollution Control AgencyMinnesota Pork BoardMinnesota State Cattlemen’s AssociationMinnesota Turkey Growers AssociationNorth Dakota State UniversityPark NicolletRegions HospitalSanford HealthSt. Paul Infectious Disease Associates, Ltd.Stratis HealthUniversity of MinnesotaUniversity of St. ThomasUS Geological SurveyVeterans Affairs Healthcare SystemZoetis Animal Health
One Health Workgroup Affiliations
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Summit Discussions
WANTS FEARS
Collaboration, common goals,
recognize alignment & differences
Ineffective antibiotics,
untreatable infections, death, adverse
effects
Decisions made on unbiased data,
not politics or public perceptions
Reactionary decisions without
sound science, incorrect assumptions
Minimize environmental
contamination for
safe food and water supply
Overregulation replaces careful
medical assessment
No concerns about resistance,
infections, adverse effects
Negative impact on environment and
ecosystem
Community understanding
and informed participation
Strategic Plan Goals
• Promote understanding of one health antibiotic stewardship– Share resources through online platform– Support public engagement on antibiotic use– Hold exchanges among practitioners in different fields
• Improve human antibiotic stewardship– Make tools available to track antibiotic use across continuum of care– Set state human health antibiotic goals – Develop honor roll recognition system for health care facilities
• Improve animal antibiotic stewardship– Communicate national antibiotic goals for animal stewardship– Promote animal agriculture best practices– Increase access to stewardship resources for companion animal
medicine– Facilitate public engagement on animal stewardship
• Develop “antibiotic footprint” tools– Understand impact of antibiotics in the environment– Help prescribers make choices to decrease their own antibiotic footprint
MDH and Antibiotic Resistance
• Minnesota Antibiotic Resistance Collaborative (MARC) (early 2000s)
– Guidance and activities for outpatient and long-term care
• Antibiotic stewardship conferences (2012-14)
• Minnesota guidance and tools
– Acute care stewardship toolkit (2012)
– Long-term care stewardship toolkit (2014)
• Challenges:
– Connecting facilities with tools, implementation support
– Poor understanding across human, animal, environmental health
Use strategic plan process to re-empower coalition and build relationships
CDC Core Elements of Hospital Stewardship
• Leadership Commitment: Dedicating resources
• Accountability: Single leader
• Drug Expertise: Single pharmacist leader
• Action: Implementing at least one recommended action– Systematic evaluation of ongoing treatment need after 48hr
(“antibiotic time out”)
– Pharmacy-driven interventions (e.g., authorization, automatic dose adjustment)
– Infection-specific interventions (e.g., community-acquired pneumonia, UTI)
• Tracking: Monitoring antibiotic prescribing and resistance patterns
• Reporting: Regular reporting on antibiotic use and resistance – For doctors, nurses, relevant staff
• Education: Informing clinicians about resistance, optimal prescribing
Antibiotic Stewardship Team Members
• Prescribers
– Leader
– Representation from multiple departments
• Pharmacists
– Leader and staff pharmacists involved in prescription review, approval
• Nurses/Technicians
– Prevent infections (e.g., device removal, use protocols for antibiotic time-outs)
• Infection prevention and control staff
– Track colonization and infection with resistant organisms, interventions to prevent transmission
– Audit and feedback to improve stewardship and infection prevention compliance
• Laboratory
– Identifies multi-drug resistant pathogens and communicate with infection prevention staff
– Provide MICs and consultation with prescribers to guide antibiotic choice, dose
• Information technology staff
– Facilitate electronic medical/pharmacy/lab record use for stewardship tracking and feedback
Examples of Antibiotic Stewardship Actions
• Pharmacy interventions– Use of antibiotic formulary– Require pharmacist consultation,
approval for last-resort drugs– Audit process for restricted
antibiotics
• Processes to optimize prescribing– Antibiogram, identify bug-drug
mismatches– Communicate opportunities for
parenteral to enteral conversion– Drug de-escalation
• Focus on clinical syndromes – Order sets– Algorithms, e.g., criteria for
initiation of antibiotics– Audit use of evidence-based
practice guidelines
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Antibiotic Stewardship and Resistance Metrics
• Hospital/health system data– Audit and feedback to improve performance
• State data– Disease surveillance
• Multi-drug resistant organisms
• Clostridium difficile
– Health care quality nonprofits (e.g., MN Community Measurement)
• Small number of quality measures (e.g., upper respiratory tract infections, pharyngitis, otitis media)
• National data– Stewardship research (CDC and academic institutions)
– National disease surveillance (CDC)
– National Healthcare Safety Network
– Regional laboratory networks
– NARMS (USDA, CDC, FDA)
One Health Antibiotic Stewardship Website http://www.health.state.mn.us/onehealthabx
• Competing priorities– How to consider the good of the whole rather than individual
patients, animals?
• Definition of “optimal”, “judicious”, “appropriate”– How do we define this in an evidence-based way?
– What are the “low-hanging fruit” for stewardship in each field?
• Lack of data– How can we set goals and identify progress without data?
– How can we share data comfortably?
• Association does not equal causation– How can we design meaningful research?
• Communication– Across fields
– With public
Challenges to Stewardship in all Fields
One Health Antibiotic Stewardship Website http://www.health.state.mn.us/onehealthabx
Minnesota Contacts for One Health Stewardship
Amanda Beaudoin, DVM, PhDDirector of One Health Antibiotic
Ruth Lynfield, MDState Epidemiologist