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Committee:
Infectious Disease
Recommendations for Strengthening Antimicrobial Stewardship in Veterinary Medicine and
Animal Agriculture
Title:
I. Statement of the Problem:
Antimicrobials, along with improved sanitation and vaccines, are responsible for great advances in
health and life expectancy in the 20th century. 1 However, the benefits of these lifesaving drugs are at
risk due to the combination of bacterial resistance and inadequate new drug development.2
Antimicrobial resistance is recognized today as one of the most critical threats to health and security
of the world’s population.3 The CDC report, Antibiotic Resistance Threats 2013, identifies antibiotic
resistant bacterial infections as the cause of more than 2 million illnesses and 23,000 deaths
annually in the US.4 Use of antimicrobial agents, including those used in human medicine, veterinary
practice, animal agriculture, and aquaculture, contribute to the emergence and dissemination of
antimicrobial-resistant microorganisms. Resistance genes do not respect phylogenetic,
geographical or ecological borders. Transmission of resistant organisms can occur not only between
animals and humans, but also from food and other animal products, and through environmental
routes such as effluents and sewage. Antibiotic resistant infections are accompanied by more severe
illnesses, more deaths, higher healthcare costs, and increased harm to society.5
The One Health Initiative acknowledges that human, animal and environmental health are closely
linked, and that collaboration to achieve solutions to problems that span these realms, such as
antimicrobial resistance, is imperative.6 Injudicious use of antimicrobials in one person or animal can
harm other people and animals, making stewardship of antimicrobials not only scientifically
imperative but also ethically right. Previous CSTE position statements have addressed improving
surveillance for antimicrobial resistance, and promoting antimicrobial stewardship in human
medicine.7, 8 This position statement recommends a comprehensive and collaborative One Health
approach to address antimicrobial stewardship, and suggests actions that local, state and federal
public health agencies can take to improve understanding and application of stewardship strategies
across the spectrum of human and animal health.
Antimicrobial use in companion animals, animal agriculture and aquaculture benefits humans
through improvements in animal health. Antimicrobials are used therapeutically in companion and
food animals for treatment, control and prevention of disease. Historically, antimicrobials have also
been used in animal agriculture for non-therapeutic uses including growth promotion and feed
efficiency (also known as production purposes) however, these production practices will be phased
out as outlined in FDA’s guidances #209 and #213.9 These changes, including greater oversight by
veterinarians, are anticipated to improve stewardship. Selection pressure and development of
resistance secondary to antimicrobial use has important implications for animals and humans as
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many of the same antimicrobial classes are used in both. Resistant bacterial infections may spread
between animals and humans via diverse routes, including direct contact, eating contaminated food
or cross-contamination during food preparation, and environmental contamination of soil and water.
For example, poultry workers in the United States have been reported to be 32 times more likely to
be colonized by gentamicin-resistant E. coli and are at a higher risk of infection by multi-drug
resistant E. coli than residents of the community surrounding the poultry operation.10 The two most
important resistant bacterial infections transmitted to humans from food animals through food
transmission routes are Campylobacter and non-typhoidal Salmonella, which can colonize food
animals without causing signs of clinical illness in the animal.4, 5 MRSA from swine is another
emerging threat with zoonotic transmission documented.11 Strains of MRSA have also been isolated
from companion animals with known exposure to human owners infected with MRSA, suggesting
that resistant organisms are also transferred from humans to animals.12 In addition, some agricultural
crops are fertilized with animal manure that may contain antimicrobial resistant organisms. Multiple
outbreaks of E.coli associated with produce were traced to contact between fresh produce and
manure.13, 14 As these infections may spread in otherwise healthy human hosts without healthcare
exposure, the risk of transmission within the general community increases, resulting in previously
treatable infections such as urinary tract, gastrointestinal, or skin and soft tissue infections that may
be difficult or impossible to treat.
A challenge encountered in antimicrobial stewardship is accurate measurement of use. Better data
are needed regarding antimicrobial use in human medicine, veterinary medicine and animal
agriculture. Current US regulations allow over-the-counter (OTC) use of many medically important
antimicrobials in the veterinary/agricultural setting, making it difficult to quantify use or determine
how and for what purposes they are used—therapeutic or production. Current metrics available for
tracking antimicrobials in animal agriculture are based on aggregate sales data which do not
accurately reflect actual use for the animal agriculture industry. In order to target specific practices
that increase the development of resistance, specific data are needed and should include accurate
classifications of drugs, dosage, species and indication (treatment, prophylaxis, production) to
understand how and where antimicrobials are being used. By December 2016, medically important
antimicrobials delivered in feed or water will be available only under supervision of a licensed
veterinarian.9 This action will no doubt improve judicious usage of antimicrobials in food animals.
AVMA’s general judicious antimicrobial use principles for all species have been long established and
are regularly updated, as are species-specific judicious use guidelines; it is imperative to encourage
adoption of these guidelines into clinical practice. Stewardship programs are generally less well
developed in veterinary medicine than in human healthcare. State and local health departments
should develop a forum for sharing successful examples of stewardship programs between human
and animal health professionals, including examples from other countries. This type of sharing offers
an opportunity to promote stewardship, conserve resources and build valuable relationships.
Several recent activities in the public and political arena in the United States demonstrate a focus on
antimicrobial stewardship. Bills have been put forth in the US Congress to limit and measure use of
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antimicrobials in animal agriculture, including the Prevention of Antibiotic Resistance Act, introduced
in March of 2015, to address non-therapeutic uses of medically important drugs in animal
agriculture.9, 15-17 FDA has proposed rules which bring therapeutic use (treatment, control and
prevention) of antimicrobials under veterinary supervision and eliminate use of medically important
antimicrobials in animal agriculture for production purposes.9 These new rules will go into effect in
late 2016. In September, 2014 the Obama administration released several documents emphasizing
the need to combat antimicrobial resistance, including an Executive Order 18, the National Strategy
for Combating Antibiotic Resistance Bacteria 19, and the President’s Council of Advisors on Science
and Technology’s Report on Combating Antibiotic Resistance.2 In May 2015, the World Health
Assembly released a statement endorsing a global action plan to combat antimicrobial resistance. 20,
21
Many consumers’ advocates express concern about overuse of antibiotics in animal agriculture. In
response to consumer demand, McDonald’s Corporation has publically announced goals to
eliminate use of medically important antibiotics in their poultry supply chains.22 Some experts and
consumers support the development and implementation of alternatives to antimicrobial use, such as
using vaccines and probiotics, and through adoption of new technologies and changes in animal
agriculture husbandry practices.
Recognizing the importance of stewardship in all areas, the One Health Initiative highlights and
endorses the complex relationship between the human, animal and environmental health systems.
Action to combat antimicrobial resistance should be carefully evaluated by assessing risks and
benefits of various changes, openly debated, clearly communicated, and deliberately planned and
executed. However, the threat of antimicrobial resistance is real and growing, so lack of agreement
from all stakeholders cannot be an excuse for inaction. While acknowledging that we need more
information about what, how, how much, when, and where antimicrobials are used in animal health
and agriculture, enough is known to spur progress on judicious usage and antimicrobial stewardship.
When available, these additional data will be useful for assessing the impact and benefits of
stewardship activities as we attempt to protect and extend the usefulness of antimicrobials for
treating illness, and preventing suffering and death in both humans and animals.
One Health antimicrobial stewardship goals
1. Improved oversight and appropriate use of antimicrobials in human medicine, veterinary
medicine and animal agriculture.
2. Cooperative efforts to develop multidisciplinary sustainable antimicrobial stewardship
programs.
3. Educational campaigns and tools for practitioners, food animal producers, and the public
which reduce the demand for empirical therapy with antimicrobials when not clearly indicated.
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II. Statement of the desired action(s) to be taken:
1. CSTE recommends that CDC (e.g., One Health Office) engage state healthcare associated
infection (HAI) programs and public health veterinarians to collaborate with other agencies on
state and national initiatives that build relationships, and facilitate sharing stewardship
strategies between human and veterinary medicine, and animal agriculture. The degree to
which health departments can pursue collaborative efforts with CDC, or within their state, will
depend on resources available; collaboration between states may be an alternative option for
states without access to resources such as training or subject matter expertise.
2. CSTE recommends that FDA and other stakeholders such as US Department of Agriculture
(USDA), American Veterinary Medicine Association, and Centers for Disease Control and
Prevention (CDC), develop appropriate metrics for tracking antimicrobial use in animal
agriculture and companion animal practice.
3. CSTE recommends that CDC and other federal agencies increase funding for strengthening
monitoring of antimicrobial resistance. Funding should support state AR surveillance activities
as well as surveillance of resistant bacteria in food.
4. CSTE recommends that federal agencies, such as CDC, FDA, and USDA, coordinate a
publicly accessible electronic library where stewardship models, projects and educational
tools can be easily shared across jurisdictions.
See Appendix 1 for ideas and contact information.
III. Public health Impact:
●
●
●
Improve coordination and collaboration between animal health professionals, human
healthcare and public health experts to advance stewardship.
Improve measurement of antimicrobial use in animal agriculture and companion animal
practice.
Improve knowledge and understanding among prescribers across sectors regarding the
antimicrobial resistance crisis and strategies to reduce and prevent resistance.
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IV. References
1. Centers for Disease Control and Prevention. Achievements in Public Health, 1900-1999: Control of
Infectious Diseases. Morbidity and Mortality Weekly Report. 1999/48(29); 621-629.
2. Presidential Council of Advisors on Science and Technology. Report to the President on
Combating Antibiotic Resistance. September 2014.
http://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_carb_report_sept2014.
pdf
3. World Health Organization. ANTIMICROBIAL RESISTANCE Global Report on Surveillance 2014
Summary. Accessed Feb 13, 2015 at:
http://apps.who.int/iris/bitstream/10665/112647/1/WHO_HSE_PED_AIP_2014.2_eng.pdf?ua=1
4. Centers for Disease Control and Prevention. “Antibiotic Resistance Threats in the United States,”
2013. www.cdc.gov/drugresistance/threat‐report‐2013.
5. Mølbak K. Human health consequences of antimicrobial drug-resistant Salmonella and other
foodborne pathogens. Clin Infect Dis 2005; 41: 1613-20.
6. One Health Initiative One Health Initiative will unite human and veterinary medicine.
http://www.onehealthinitiative.com/index.php. Accessed 3/12/15.
7. Council of State and Territorial Epidemiologists—Centers for Disease Control and Prevention
(CSTE-CDC). CSTE Position Statement 13-SI-01. Recommendations for Strengthening Public
Health Surveillance of Antimicrobial Resistance in the United States.
http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/PS/ARIDSI2013CDC.pdf. Accessed
2/16/15.
8. Council of State and Territorial Epidemiologists—Centers for Disease Control and Prevention
(CSTE-CDC). CSTE Position Statement 14-ID-01. Recommendations for Strengthening
Antimicrobial Stewardship in the United States, including the Role of the State and Local Health
Departments. http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/2014PS/14_ID_01upd.pdf.
Accessed 2/6/15.
9. FDA-CVM. Guidance for Industry #209: The Judicious Use of Medically Important Antimicrobial
Drugs in Food-Producing Animals. U.S. Department of Health and Human Services. Food and
Drug Administration Center for Veterinary Medicine. April 13, 2012.
10. Price. "Elevated Risk of Carrying Gentamicin-Resistant Escherichia coli among U.S. Poultry
Workers" 2007. http://www.jhsph.edu/news/news-releases/2007/price-poultry-workers.html
11. Casey MA, Curriero FC, Cosgrove SE, Nachman KE, Schwartz BS. High-Density Livestock
Operations, Crop Field Application of Manure, and Risk of Community-Associated MethicillinResistant Staphylococcus aureus Infection in Pennsylvania. JAMA Intern Med.
2013;173(21):1980-1990.
12. Iverson, S.A., A.M. Brazil, J.M. Ferguson, K. Nelson, E. Lautenbach, S.C. Rankin, D.O. Morris,
and M.F. Davis. “Anatomical patterns of colonization of pets with staphylococcal species in homes
of people with methicillin-resistant Staphylococcus aureus (MRSA) skin or soft tissue infection
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(SSTI).” Veterinary Microbiology 176, no. 1-2 (March 2015): 202-8. Accessed March 9, 2015.
http://dx.doi.org/10.1016/j.vetmic.2015.01.003.
13. Besser RE, Lett SM, Weber JT, Doyle MP, Barrette TJ, Wells JG, et al. An outbreak of diarrhea
and hemolytic uremic syndrome from E. coli O157:H7 in fresh-pressed apple cider. JAMA
1993;269:2217-20
14. Levy SB. Emergence of antibiotic-resistant bacteria in the intestinal flora of farm inhabitants. J
Infect Dis 1978;137:688-90.
15. Prevention of Antibiotic Resistance Act, S 621, 114th Cong. (2015). Introduced March 2, 2015.
th
16. Strategies to Address Antimicrobial Resistance Act, HR 2285, 113 Cong. (2013), introduced June
6, 2013. Available at: https://www.govtrack.us/congress/bills/113/hr2285. Accessed on March 9,
2015.
th
17. Strategies to Address Antimicrobial Resistance Act, S 2236, 113 Cong. (2014), introduced April
10, 2014. Available at: https://www.govtrack.us/congress/bills/113/s2236. Accessed on March 9,
2015.
18. Presidential Executive Order to Combat Antibiotic Resistance. September 18, 2014. Available at:
http://www.whitehouse.gov/the-press-office/2014/09/18/fact-sheet-obama-administration-takesactions-combat-antibiotic-resistan. Accessed on March 9, 2015.
19. National Strategy for Combating Antibiotic Resistance Bacteria. Sept 2014. Available at:
http://www.whitehouse.gov/sites/default/files/docs/carb_national_strategy.pdf. Accessed on March
9, 2015.
20. World Health Organization. Draft Global Action Plan on Antimicrobial Resistance.
http://www.who.int/drugresistance/global_action_plan/en/
21. World Health Organization. World Health Assembly addresses antimicrobial resistance,
immunization gaps and malnutrition. http://www.who.int/mediacentre/news/releases/2015/wha-25may-2015/en/
22. McDonald’s Corporation. McDonald’s Global Vision for Antimicrobial Stewardship in Food Animals.
March 2015.
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V. Coordination
Agencies for Response:
(1)
Centers for Disease Control and Prevention
Thomas Frieden, MD, MPH
Director
1600 Clifton Road, NE
Atlanta, GA 30333
404-639-7000
[email protected]
(2)
Food and Drug Administration
Stephen Ostroff, MD
Commissioner of Food and Drugs (Acting)
10903 New Hampshire Ave.
Silver Springs, MD 20992-0002
1-888-463-6332
[email protected]
(3)
United States Department of Agriculture
Tom Vilsack, JD
Secretary of Agriculture
1400 Independence Ave., SW
Washington, DC 20250-3700
Agencies for Information:
(1)
American Veterinary Medical Association
Ashley Morgan, DVM
Assistant Director
1910 Sunderland Place, NW
Washington, DC 20036-1642
202-289-3210
[email protected]
(2)
Association of American Veterinary Medical Colleges
Andrew T. Maccabe, DVM
Executive Director
1101 Vermont Ave, NW
Suite 301
Washington, DC 20005
202-371-9195 ext 115
[email protected]
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(3)
United States Animal Health Association
Benjamin Richey
Executive Director
4221 Mitchell Ave.
Saint Joseph, MO 64507
816-671-1144
[email protected]
(4)
Nancy Sansalone
Interim Executive Director
American Society for Microbiology
1752 N Street, NW
Washington, DC 20036
202-942-9207 .
VI. Submitting Author:
(1)
Kelly Kauber, MPH
Washington State Department of Health
Antimicrobial Stewardship Coordinator
th
1610 NE 150 St
Shoreline, WA 98155
206-418-5589
[email protected]
Co-Author:
(1)
☒ Active Member
☐ Associate Member
John Dunn, DVM, PhD
Tennessee Department of Health
Deputy State Epidemiologist
State Public Health Veterinarian
th
4 Floor, Andrew Johnson Tower
710 James Robertson Pkwy
Nashville, TN 37243
615-741-5948
[email protected]
(2)
☒Active Member
☐Associate Member
Marisa D’Angeli, MD, MPH
Washington State Department of Health
Medical Epidemiologist
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th
1610 NE 150 St
Shoreline, WA 98155
206-418-5595
[email protected]
(3)
☒Active Member
☐Associate Member
Joni Scheftel, DVM, MPH
Minnesota Department of Health
State Public Health Veterinarian
Supervisor, Zoonotic Diseases Unit
625 North Robert Street
St. Paul MN 55155-2538
651-201-5107
[email protected]
(4)
☒Active Member
☐Associate Member
Marion Kainer, MD, MPH
Tennessee Department of Health
Director, Healthcare Associated Infections and Antimicrobial Resistance Program
710 James Robertson Parkway
rd
Andrew Johnson Tower CEDEP, 3 floor
Nashville, TN 37243
615 741 7247
[email protected]
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Appendix 1: Antimicrobial Stewardship Activities for consideration by CDC, and State or Local
Health Departments
CDC and state health departments may consider implementing any number of the strategies listed
below as resources allow:
1. Develop a One Health Stewardship Workgroup model that may be implemented at the state
level. Workgroups could include the state veterinarian and state public health veterinarian. A
multidisciplinary team can bring together varied expertise to raise awareness, build
community support and infrastructure, assess and address stakeholder insights and
concerns, educate stakeholders on the science of antimicrobial resistance and its
management, and establish priorities for the state program to leverage combined strengths
and avoid duplication. Representatives might include public health epidemiologists, human
healthcare providers, animal health professionals, practicing veterinarians, animal agriculture
industry stakeholders, environmental health professionals, feed mill operators, and
microbiologists. Each US state and territory has a CDC-funded HAI Coordinator, which can
be found here: http://www.cdc.gov/HAI/state-based/. A list of state public health veterinarians
is available at: http://www.nasphv.org/Documents/StatePublicHealthVeterinariansByState.pdf
2. Collaborate with veterinary and human medicine academic institutions to strategize on ways
to improve basic antimicrobial stewardship knowledge among food animal and companion
animal veterinarians-in-training, and human health care providers-in-training.
3. Collaborate with food animal veterinarians and state department of agriculture to improve
knowledge among food animal producers about antimicrobial resistance and the potential
benefits of improved stewardship.
4. Establish pilot projects in animal agriculture operations that bring together stewardship
experts from state health departments, food animal veterinarians, and industry for shared
learning opportunities.
5. Identify and spotlight food animal veterinarians and the animal agriculture operations they
work with that have successfully implemented stewardship practices to share successes,
challenges and lessons learned.
6. Develop and distribute educational tools for stakeholders that promote stewardship and
alternatives to antimicrobial therapy.
a. For companion animal veterinarians and their clients/patients
b. For food animal veterinarians and producers
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