Clinical Assessment,

Culturing, and Antibiotic

Prescribing for Animals

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Who’s who…• Rob Gibson, BS, MPH; NHVDL Managing

Director, microbiologist

• Sarah Proctor, MPH, DVM; Clinical Assistant Professor; shelter veterinarian

• Nate Harvey, VMD, DABVP; Assistant State Veterinarian, food animal & livestock practice

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Links

• https://nationaldairyfarm.com/dairy-farm-standards/antibiotic-stewardship/

• https://nationaldairyfarm.com/producer-resources/resource-library/

• https://www.youtube.com/watch?v=UCQKEe7P8EM&feature=youtu.be

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Will you see…• Companion animals?• Food animals?• Pet chickens?• Pot-bellied pigs?• Pet sheep, goats, cows?

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In case you don’t have any questions…

• Resources – Where do veterinarians go for prescribing insights – ISCAID, VIN, AVMA, AAHA,

AABP/AAEP/etc., FDA, others?– Where do veterinarians go for diagnostic insights – NHVDL, VIN, journals, IDEXX,

intuition/experience, others?• Testing options/challenges

– Where do veterinarians go for confirmation of suspected infectious disease – NHVDL, IDEXX, others?

– What are the limiting factors – cost, time lag to confirmation, client challenges, availability of drug for veterinary treatment, food withdrawals, others?

• Non-antimicrobial medications as alternatives/adjuncts – Are there things veterinarians can do that are similar to the use of NSAIDs and other OTC

medications in human medicine to ameliorate clinical signs and discomfort when antimicrobials aren’t necessary (or appropriate) treatment?

• Antibiogram project update/discussion – Challenges, timelines, etc.?– Will practitioners use this information? Should it be available on NHVDL website, elsewhere?– Will it be applicable to clinic-level treatment? How should it be applied at clinic-level?– Other project opportunities related to stewardship?

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More Questions • Other considerations when choosing an Abx?

– Owner compliance?– Familiarity with premises/animal/history/clinical

presentation?– Medical records? How/what to document?– Rx sources? On-line pharmacies?– Does size matter? Breeder? Farm? Barn?

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One more BIG question…

What has the greatest potential to create

beneficial change in veterinary

stewardship? 7

AVMA definitions• Prophylaxis – mitigate risk of anticipated

infection/illness

• Metaphylaxis – mitigate risk of subclinical infection becoming clinical/spreading

• Treatment – remedy in the face of evidence of disease

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Before we begin…

"If you think you understand antibiotic resistance, it clearly has not been explained properly to you.“

Mike Apley, DVM, PhDKSU CVM, Professor Clinical Pharmacology

President, American Association Bovine Practitioners

One more thing…

“Honest differences of opinion, honest differences in seeing and interpreting facts, are helps and not hindrances in getting at the truth.”

Teddy Roosevelt

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My elevator speech…• “I live in the same community, same state, same

environment that you do. I am a father, husband, son, brother, neighbor. My loved ones and I eat and drink just like you. We have access to the same food and water sources as you. My loved ones and I suffer the same effects as you when any of these causes harm. Protecting and safeguarding my loved ones comes before all else. I have the same concerns for my loved ones that you do for yours. I will not use or advocate anything that I believe poses an unacceptable risk to my loved ones. I go to the farmers market; Sam’s club; the grocery store; and my neighborhood market. I have a garden and occasionally I eat fast food. I believe everything in moderation is a pretty good way to live…” 11

My 2 cents• Any antibiotic use -- in food animals, humans, household pets,

horses, fish, fruit production, honey bees -- can contribute to antibiotic resistance.

• Zero risk of illness or death is an unachievable standard, so it is necessary, and very uncomfortable, to understand that there will always be some illness regardless of how discussions about antibiotic use and regulation progress.

• Numbers can lack perspective without something to which you can relate their scale. Add a denominator.

• No one has all the answers but hard questions are fair.

One Health…in words• From CDC…

The health of people is connected to the health of animals and the environment. This connection requires a multisectoral, One Health approach to improve health for all.

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Veterinary Oath• I solemnly swear to use my scientific

knowledge and skills for the benefit of society through the protection of animal health and welfare, the prevention and relief of animal suffering, the conservation of animal resources, the promotion of public health, and the advancement of medical knowledge.

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“Public opinion is everything.”

Abraham Lincoln

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What is the Goal of Abx regulation?

• One Health? Protecting human health? Removing any potential to harm human health? Something else?

• Is zero risk tolerance for human, animal, or environmental health reasonable? Achievable? Realistic? Beneficial?

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What is Improvement?• Is zero risk reasonable? Achievable? Realistic?

Beneficial?

• Protecting public health? Animal health? Environmental health? Removing any potential to harm any one of them?

• How do we measure changes – Reduced use? Sales? Changes in resistance?

• How do we know we are getting better?17

WHO strongly recommends an overall reduction in the use of all classes of

medically important antibiotics in food-producing animals, including

complete restriction of these antibiotics for growth promotion and

diseaseprevention without diagnosis.

WHO, Nov. 7, 201718

The US Approach • Shared goals can be challenging in One

Health

• Tradeoffs are a necessary part of the discussion – Greater Good

• Can we get to zero risk? Should we? For what?

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Abx Regulation in Animals• FDA CVM

– CVM approves Abx (safety, efficacy)– Veterinary Feed Directive (VFD)– White Paper – Supporting Antimicrobial Stewardship in

Veterinary Settings, 2019-2023

• USDA FSIS – labeling standards (supporting paperwork that claim is truthful)– NARMS – sample testing

• USDA VS – field studies of use• USDA ERS – trends and emerging issues, R&D• State roles – VCPRs, etc?

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Recent regulatory activities• VFD (January 2017)

– No feeding abx without Rx– No growth promotion use – Limits types of medications– Applies to food animals only

• FDA White Paper (September 2018)– Small animals– Biomass denominator– Not all classes abx approved for all species– “other species/unknown” category – includes

companion animals**21

Measuring outcomes thus far…

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Unintended consequences

• Dr. Per Henriksen, Danish Veterinary and Food Administration

• July 12, 2010 testimony to US Congress• “…Denmark’s ban on subtherapeutic

antibiotic use had changed the structure of livestock operations in the country, with large, intensively managed operations replacing small farms.”

Sales v. Use• Early data measurements• FDA & USDA surveys are ongoing• FDA 2016 Summary Report – veterinary

sales down 10%, veterinary sales of medically-important down 14%

• So what?

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Similar Levels of Antimicrobial Resistance in US Food Service Ground Beef Products with and without a

“Raised without Antibiotics” ClaimJournal of Food Protection, December 2018

• USDA ARS study• “little peer-reviewed research that supports claims that RWA meat

products harbor lower levels of antibiotic-resistant bacteria”• “can't support with the data the notion that there's more antibiotic

resistance in conventional ground beef…at least in the United States”

• “tetracycline-resistant enterococcus, which was found in 94.8% of conventional samples and 91.1% of RWA samples”

• “two of the most common tetracycline-resistance genes—tetA and tetB—were significantly more abundant in the RWA ground beef”

• "You don't need antibiotic use for antibiotic resistance to occur" • “possibility that the antibiotic-resistant bacteria and resistance genes

in the RWA samples were acquired during processing”• “should not be construed as a license to use antibiotics in food-

producing animals without regulation” 25

Pipestone researchMarch 4, 2019

• 4163 clinical submissions, 2002-2017

• “overall level of resistance has not changed”

• Antibiotic Resistance Tracker – 8M pigs; demonstrate “responsible…use practices…not about reducing antibiotics”

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Companion Animal Medicine

304,482 dogs332,845 cats

21,000+ horses

68% of US households own a

pet

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More from… One Health and the Politics of

Antimicrobial Resistance

In Europe, whole genome sequencing suggests that a bacteria known as vancomycin-resistant Enterococcus faecium (VRE) in human patients might have come from pet dogs rather than livestock, as initially suggested.

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Companion animals…• “Many antimicrobial classes designated…as medically important in

treating humans are also commonly used in companion animal medicine…”

• “Two antimicrobial classes commonly used in companion animal practice (i.e.e third-generation cephalosporins, such as cefpodoximeand cefovecin, and fluoroquinolones)…critically important to human medicine and of the highest priority for prudent use…”

• “If…prevented companion animal veterinarians from using these essential medications, the ability to treat routine and serious illnesses in companion animals would likely be compromised.”

• Erin Frey, DVM. The role of companion animal veterinarians in one-health efforts to combat antimicrobial resistance. JAVMA, Dec. 1, 2018.

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Does this mean anything?

“Regardless of the actual risk of zoonotic transmission, fear of transmission may have impacts on the human-animal bond and peoples’ interaction with their pets.”

Weese JS, van Duijkeren E. Methicillin-resistant Staphylococcus aureus and Staphylococcus pseudintermedius in veterinary medicine. Veterinary Microbiology, 2010. 30

Notes from 2018 Symposium

• Issues common to human and veterinary medicine...–Leadership buy in to implement

policies/tracking/etc. –Resources – people, $$–IT upgrades–Good data –Patient compliance 31

In Conclusion…

"Too often we enjoy the comfort of opinion without the discomfort of thought."

John F. Kennedy