I’ve written (ranted?) about this before – namely the misuse of antimicrobials intended for treatment of aquarium fish in other species. Usually such posts are followed by a deluge of nasty emails along with a bunch of curious requests for links to fish antibiotic sellers (8% kickback available!).

Another sponsorship request came in this morning, prompting this rant. I guess it was a poorly programmed bot, or someone who didn’t carefully read even the title, let alone the content of my previous posts.

Picture of a bottle of 'fish ciprofloxacin'

In some ways, this issues is small potatoes in the grand scheme of the “silent pandemic” of antimicrobial resistance (AMR), something that impacts millions of people and costs billions of dollars every year, but it flies largely under the radar. However, even small potatoes need to be addressed when we’re dealing with a problem like AMR. Everyone has a role to play.

Why is diversion of fish antibiotics an issue?

Anytime an antibiotic is used, in any species (including humans) there are risks: adverse effects, treatment failure, emergence of resistance, etc. So, when antibiotics are used, we need to make sure we maximize the benefits and minimize the risks/costs. The more antibiotics are used without medical (human/veterinary) advice and control, the more risks and the fewer benefits there are.

What are “fish antibiotics?”

They’re the same antibiotics we use in people and other animals, but with “fish” slapped on the label. They’re marketed that way to try to keep them under the regulatory radar (even though it’s still illegal in some countries where they are sold this way). If you look at websites that sell fish antibiotics, you’ll often find the same drugs and same formations (even the same tablet sizes and shapes) as are used in other species. Websites are smart enough now not to explicitly say you can use them on yourself or in other species, but that’s pretty well known so they don’t have to, and product reviews show other people what’s being done.

Do many people actually use fish antibiotics on themselves?

It’s hard to say. One study of internet reviews reported that 2.4% of reviews suggested they were purchased for use in people (see screenshot below). That’s presumably an underestimate, since most people who buy fish antibiotics to use on themselves or their kids likely don’t write that in a review. A larger percentage probably bought them for use in their dogs or cats.

Is the ability to buy and divert fish antibiotics actually causing harm?

Who knows? However, there are a number of potential issues.

Adverse effects: Antibiotics are not innocuous. There’s always some risk of adverse effects. Some situations and some drugs pose higher risk, which is just part of the reason to always get medical advice before taking antibiotics.

Product safety: Who knows what’s actually in these products? A 500 mg ciprofloxacin tablet for fish might contain 500 mg of ciprofloxacin. However, I suspect it often doesn’t. It could contain more or less (both potentially being an issue) or contain contaminants. I’m not going to have much confidence in quality control for a product that’s being produced for dodgy or illegal sale.

Inadequate/ineffective treatment: Some reviews I’ve seen talk about use for things where there’s not much hope of the antibiotic working. People using it themselves have to know the right drug, the right dose and the right duration. I doubt that’s common.

Resistance: Anytime an antibiotic is used, there’s pressure to select for antibiotic resistant bacteria. At the individual level, it’s a small risk, but the more it’s done, the more that risk becomes relevant at a population level.

It’s easy to say “just stop it,” but we need to consider why this happens in the first place.

A general principle of antibiotic stewardship and good medicine is that antibiotics should be available only by prescription (human or animal). That helps makes sure they are used when needed, not used when not needed and used properly (right drug, dose, duration and any other necessary treatments).

Some people are looking for a cheaper option, even though they can afford to see a doctor or take their pet to a veterinarian, and purchase the proper product. However, what’s the true cost savings if the antibiotic they buy online isn’t necessary, is the wrong drug, is harmful or isn’t used properly?

Some people truly can’t afford the proper product. Access to treatment needs to be a right, not a privilege.

Lack of access to healthcare is a big issue. At the core of antibiotic stewardship is a need to improve human and animal health systems in general. Whether it’s because they can’t afford healthcare, don’t have access to a doctor or veterinarian in their area, have tenuous employment where they can’t get time to go see a doctor or veterinarian, some people truly have significant barriers to getting antibiotics through the proper pathways. We need to improve those pathways so people can get antibiotics when needed (for themselves and their pets) and get proper preventative healthcare to avoid needing antibiotics in the first place.

Education is another issue. If someone can buy something that is labelled the same and looks the same as a product licensed for people or other pets, it’s easy to see why they’d think it’s fine. We need more general education about antibiotics, antibiotic use and antibiotic resistance so people are more aware of the risks associated with misuse of these products.

So, what can be done about diversion of fish antibiotics?

When there are companies based in countries where it’s illegal to market products like this, it’s simply an enforcement issue. Selling over the counter fish antibiotics is illegal in the US (and in Canada) and many of the companies selling these products list US addresses. So, it’s a matter of someone deciding to crack down on these kinds of sales. That doesn’t address the broader issue of black market drugs being imported into North America, but it’s at least a start.

Even some “main stream” companies are involved in these scenarios, probably inadvertently, but it’s something they need to scrutenize. For example, I looked at Walmart’s PetRx website and there are reviews that indicate diversion of pet medications. I’m not sure how rigourous some of the US online veterinary pharmacies are with their verification of prescriptions and “vetting” of purchases, but some effort to minimize diversion would be good. At a minimum, removing reviews that show others are misusing these products (which might encourage others to do the same) is a no-brainer.

Undoubtedly, small improvements in antibiotic use in human healthcare, veterinary medicine and food production would have much more of an impact than completely eliminating diversion of fish antibiotics. However, the scourge of AMR is a complex, multifactorial problem. There will never be a simple, single solution. We need a toolbox of many different interventions that on their own only contribute a little, but put together and over time will have a larger impact. Low hanging fruit like this needs to be part of that.