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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

Stewardshipamanda.Beaudoin@state.mn.us

Ruth Lynfield, MDState Epidemiologist

ruth.Lynfield@state.mn.us