I’m getting ready for next week’s ASM/ESCMID conference on methicillin-resistant staphylococci in animals, for which I’m involved in a plenary session about critically important antibiotics in companion animals. The whole area of antibiotics and animals in complex and controversial (and made worse by political agendas, lack of evidence and confusion about different issues).
Anyway, one thing that often gets overlooked is the difference between companion animals and food animals in how antibiotics are used, what regulations are in place, and what differences should be present between species. Just discussing antibiotics "in animals" isn’t adequate, because a pet dog is very different from a feedlot steer in many respects, and many of the issues around antimicrobial use are different as well.
One question that’s going to be up for debate is "should antibiotics that are used in serious resistant infections in people be used in animals?"
My answer to this important question has evolved a bit over the years. It’s "yes, but…"
The but is the important part.
- As a veterinary clinician, I see the need to treat my patients (or the patients I’m providing advice on).
- As someone who works in the field of antimicrobial resistance, I see the issues with drug use and resistance.
- As a parent, I don’t want my kids to develop a serious infection that I may have played a role in fostering.
- As a pet owner, I understand the desire to try to save the life of a pet.
That doesn’t even cover all the issues, but it shows the variety of standpoints that need to be considered.
Back to the question at hand. As I said, my answer is yes, but with disclaimers:
- We need to use antimicrobials only when required.
- We need to use antimicrobials properly.
- We need to take measures to reduce infections overall (so that less antimicrobial use is required).
At our veterinary teaching hospital, we have a restriction policy for vancomycin, an important human drug. For it to be used in an animal, the following criteria must be met:
- The offending bacterium must be susceptible to vancomycin (duh!).
- There must be no other reasonable antibiotic options that are likely to work.
- There must be a reasonable chance of survival with treatment.
- Systemic treatment of the infection is needed (i.e. it can’t just be treated with local therapy).
- The clinician must get approval from infection control (i.e. me).
That has happened twice in the past 12 years. Both cases were dogs with life-threatening abdominal infections; they were each treated with a short course of vancomycin and survived.
That’s probably 10-14 days of vancomycin use per ~200 000 patients. I don’t know what the comparable numbers would be for people in Guelph General Hospital down the road, but their use would be staggering compared to ours. Also, the risk of resistance with each use is presumably much higher for each human patient since they are in an environment where vancomycin resistant bugs are present (and therefore can be selected for with treatment). Vancomycin resistance is exceedingly rare in our hospital population, further decreasing the risk.
Is there some risk? Certainly. Use inevitably carries some risk.
Does our 2 / 200 000 use constitute a reasonable human health risk? I can’t see how it does.
So, is antibiotic use in animals something we can just ignore? Absolutely not. It’s a big problem, just like antibiotic use in people. However, just as all animal species issues aren’t the same, all types of antibiotic use aren’t the same.
Are there other things we can focus on to reduce resistance? Absolutely.
- A 1% improvement (i.e. decrease) in use of fluoroquinolones in animals would probably have a dramatically greater effect on resistance in human and animal pathogens than a complete ban on vancomycin. Fluoroquuinolones are a commonly used drug class in animals that is also important in people, and one in which resistance is certainly an issue.
- A 1% improvement (i.e. decrease) in use of of fluoroquinolones in humans would probably have an even greater effect.
- Better infection control, preventive medicine and other practices could potentially have an even greater impact by reducing infections and therefore the need for any drug therapy, and delaying the treat-resistance-more treatment-more resistance cascade.
Some people would say that any drug that’s of any relevance in humans should not be used in animals. Some veterinarians would say no one should control their prescribing practices. Like most things, I think there’s a happy (and more effective and practical) middle ground. It’s not the status quo, though. We need to have discussions about how to control antimicrobial use in all species, including humans, and not just pointing fingers at the other side. We also need to discuss how to improve infection control to reduce the need for antimicrobials, and how to improve the way we use antimicrobials when they are required. In order to have good discussions, we also need proper data (something that’s still lacking).
Different opinion? Feel free to comment (or show up in Copenhagen next week).