The "criticall important antibiotic" debate

Last week, I mentioned the antibiotic use plenary session at the ASM-ESCMID conference on methicillin-resistant staphylococci in animals. The session was designed to discuss the use of "critically important antibiotics" in companion animals - drugs like carbapenems (imipenem, meropenem) and vancomycin, which are used for treating serious multidrug-resistant infections in people as well. After the (very lively) session, I was asked when I was going to write a follow-up post, so here it is.

The session went well and I’ll hit on some highlights.

I was on a panel with good colleagues Ulrika Gronlund-Andersson (Sweden) and Engeline van Duijkeren (Netherlands). Both are extremely well versed in the field and come from countries with different, but in general restrictive, policies pertaining to antibiotic use in animals. They also (not completely coincidentally) come from countries with less antibiotic resistance in companion animals, which means they don’t see the same degree of resistant bugs in patients that I do.

I was there as the guy from North America where we have absolutely no control over antibiotic use. It was strange being the one supporting more liberal use of antibiotics, since I’m often seen as being on the other extreme when I speak in North America. As I wrote earlier, I think (at least in my patient population) that we need to use some "big gun" drugs at times, but we also need to use them right.

It was a tough crowd. There were some nice differences in opinion, partly reflected in individuals’ backgrounds (clinical vs non-clinical, northern Europe vs other regions), but there were some great points too.

At one end, there was the opinion that banning the use of these drugs in animals altogether is acceptable. (A comment along the lines of "there are lots of dogs and cats available in animal shelters as a replacement if a pet gets a multidrug-resistant infection" was made, to varying degrees of agreement and outrage). I was at the other end of the spectrum, which really wasn’t at the other end of the whole spectrum, meaning I think we need to use these drugs at times, but we certainly don’t want unrestricted, imprudent use. We need to use them right, and very sparingly. I emphasized the point that every culture result is attached to a patient AND there’s a moral obligation to make sure that patient doesn’t suffer AND every patient is attached to an owner AND that attachment might be profound, with definite emotional and even health effects for the person associated with the animal's presence and condition.

An interesting set of comments came from a clinical colleague in southern Europe who said something along the lines of “I see vets in my country misusing these drugs so badly that I think we need to ban them. People won’t do it right so they shouldn’t do it." That’s hard to argue, and shows how we need to improve antibiotic use in veterinary practice. If it's clear they're being used poorly, we should lose access to them.

Another comment was along the lines of “I’m not concerned about OVC, where they have awareness, some restrictions and someone [me] as both a monitor and resource. But, that’s not the way most of the world works.” Again (taking the compliment and not trying to sound arrogant here), it’s hard to argue that point. However, it again comes back to figuring out how to improve antibiotic use and do things right. I think we’ve done at good job at our institution reining in use of important drugs, through education, peer pressure, surveillance and a bit of internal restriction.

There were a couple of comments like "If you only use them very sparingly, there can’t be any realistic risk, particularly compared to massive use in humans" and “Our hospital only uses them a couple of times a month,” supporting the general notion that internal restriction can be effective, and that makes sense, at least to me.

At the end, the moderator (another good colleague and expert in his own right, Luca Guardabassi from Denmark) polled the audience: Should these drugs be banned completely from animals or allowed with restrictions?

It was a pretty even split, but I think banning them came out ahead (with the disclaimer that the audience was biased towards people from countries with fewer resistance issues and more restrictions, and fewer clinical people). (A few people also came up to me after and said “I agree with you, but I was too chicken to say anything.”)

It was a great discussion, and I think it made both sides rethink their positions somewhat. I still think we need to have access to these drugs, since otherwise we’ll be saying "Sorry, your dog has a multidrug-resistant infection but I can’t use the antibiotic that would treat it, so we need to euthanize him now." At the same time, the status quo can’t continue. Misuse and overuse of critically important drugs is a problem in North America and beyond, and we have to figure out how to deal with it. Ultimately, restriction might be required, but it’s much better for the veterinary profession to deal with it internally, by improving practices on their own and internally restricting or regulating how they are used.

One question I posed to the audience was, rank these actions in terms of what you think their impact would be on antibiotic resistance in people and animals:

  • 1% reduction in fluoroquinolone use in humans
  • 5% reduction in amoxicillin/clavulanic acid use in humans
  • 5% reduction in ceftiofur use in food animals
  • 1% reduction in fluoroquinolone use in companion animals
  • 5% reduction in amoxicillin/clavulanic acid use in companion animals
  • 75% reduction in carbapenem use in animals
  • Ban on vancomycin use in animals

More food for thought (and maybe for a future post).

Yes, Ulrika, Engeline, Luca and I are still on speaking terms. A little wine and a (4 hour) Italian dinner heal all wounds.

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Comments (3) Read through and enter the discussion with the form at the end
Eileen - November 10, 2013 12:32 PM

I've read your entire blog now - thank you , it has been great fun (if that is the right term) seeing something from the other side (of medicine and the world!). Beat reading a novel any day!!

Funny you mention Italian food - because I live in northern (Germanic) Italy where the human medicine status is pretty good compared with Italian Italy.I was on Medrol last year when I had UTI problems. The local GP gave me a quinolone. For once I didn't go and check it out online - and for my sins ended up with an inflamed achilles tendon which took 9 months to improve far enough to throw away the crutches. There were other even worse effects but I'll miss them out here.

When I discussed it with several doctors here they told me they had been taught in medical school to use that family of drugs first line for UTIs. An indirect colleague of my husband is a doctor in the deep south - and I heard his wife browbeating him when their (medic) son had a cold (as far as she was concerned flu but he recovered overnight enough to celebrate New Year with us) to give the 26-year old an antibiotic.

As far as I can tell this is fairly common here - no wonder there is the attitude things would have to be banned altogether to get to the sensible use of antibiotics.

John Prescott - November 22, 2013 8:57 AM

Good blog, Scott. All of us are concerned about the "critically important" antibiotics and sometimes experience those "Holy ,,,," moments when you see the "Special Panel" antibiotic test plate with no areas of growth inhibition around any of the antibiotics. I find it infinitely strange that we have absolutely no annual reporting of susceptibility test data from companion animals by the various diagnostic labs. I have asked informally that we make multi-drug resistant, and especially carbapenemase and vancomycin-resistant bacteria reportable infections at both the national and provincial levels, but this doesn't seem to get any traction. If we can't measure these things, we can't manage them.

Gittan Gröndahl - November 29, 2013 8:35 AM

Great report there! Interesting to hear about the slight culture shock you seem to have perceived... :) I know the feeling...

The perceived polarization between non-clinical and clinicians in the question of (fighting against resistance using) restrictions you mention, is possible to counteract. I say that after seeing how Swedish clinicians have looked over their use of antibiotics and then acted, starting with the man in the mirror, pulling down the sales of antibiotics to dogs with 42% between 2006 and 2012. (See Swedish Veterinary Antimicrobial Resistance Monitoring 2012, page 40 http://www.sva.se/upload/Redesign2011/Pdf/Om_SVA/publikationer/Swedres-Svarm2013.pdf )

Most prominently, cephalosporins -70%, aminopenicillins with clavulanic acuid -52%, and fluorquinolones -51%. The emergence of multiresistant S pseudintermedius and MRSA triggered a number of local and national initiatives, leading to behaviour changes.

More on the question of restrictions:
I think that both vet clinicians and owners can understand and accept that some last-resort antibiotics are saved for our ill babies and grandmas and other severely ill people... End of the road, period. Because we all know one or more loved human one that would not have survived without them, and many of us know one or more that did not survive even with them, because of the multiresistant bug that caught them far too early.

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