Antibiotic Stewardship in Veterinary Medicine and Production … · 1959 –Virginiamycin -...
Transcript of Antibiotic Stewardship in Veterinary Medicine and Production … · 1959 –Virginiamycin -...
Antibiotic Stewardship in Veterinary Medicine and
Production Animal Agriculture
Mike ApleyKansas State University
Defining Resistance
• Susceptibility or resistance testing?
• Clinical resistance?
• Epidemiological cutoffs?
– “Wildtype vs. Non-wildtype”
Antimicrobial Timeline
1910 – Arsphenamine (Salvarsan) – 1912 Neosalvarsan
1949 - Chloramphenicol
1949 – Neomycin - aminoglycosides1948 - Chlortetracycline
1955– Vancomycin - glycopeptides
1959 – Virginiamycin - streptogramins
Commercial availability for first member of major antimicrobial groups
1952 – Erythromycin - macrolides
1960 – Metronidazole
1968 - Clindamycin -lincosamides
1970 – Cefalexin - cephalosporins
1978 - Norfloxacin - fluoroquinolones
2000 - Linezolid - oxazolidinones
2003 - Daptomycin – cyclic lipopeptides
1935 – Prontosil(sulfanilamide)
1942 - Benzylpenicillin
The Basics of Clinical Pharmacology (in one slide)
• Can I do some good?
• Can I do any harm?
• Can I get it in the animal(s)?
• What is the cost?
Rice LB. Mechanisms of resistance and clinical relevance of resistance to beta-lactams, glycopeptides, and fluoroquinolones. Mayo Clinic Proceedings, 97:198-208, 2012.
Yearly sales data are available…
• These are the most recent data for veterinary sales with a food animal indication.
Resistance Challenges in Human and Veterinary Medicine
Resistance Challenges in Vet Medicine
• Weese has published an excellent review of antimicrobial resistance issues in companion animals (2008). The primary organisms addressed in this review are as follows.
– Staphylococcus aureus and Staphylococcus pseudintermedius: both methicillin susceptible and resistant.
– Enterococci: Enterocococcus faecium and Entercoccus faecalis.– Streptococci: Strep. zooepidemicus and Strep. Equi in horses,
Strep. canis– Escherichia coli– Salmonella– Pseudomonas
Animal Health Research Reviews. 9(2):169-176, 2008.
Mannheimia haemolytica
Mannheimia haemolytica
2008
2010
2012
2014
2016
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
≤0.25 0.5 1 2 4 8 >8
Ceftiofur
Mannheimia haemolytica
20082009
20102011
20122013
20142015
2016
0%
10%
20%
30%
40%
50%
60%
70%
80%
≤0.12 0.25 0.5 1 2 >2
Enrofloxacin
Mannheimia haemolytica
2008
2010
2012
2014
2016
0%
10%
20%
30%
40%
50%
60%
70%
≤0.25 0.5 1 2 4 8 >8
Florfenicol
Mannheimia haemolytica
20082009
20102011
20122013
20142015
2016
0%
10%
20%
30%
40%
50%
60%
70%
80%
≤0.5 1 2 4 8 >8
Oxytetracycline
2008
2010
2012
2014
2016
0%
10%
20%
30%
40%
50%
60%
≤0.12 0.25 0.5 1 2 4 8 >8
Penicillin
Mannheimia haemolytica
Mannheimia haemolytica
20082009
20102011
20122013
20142015
2016
0%
10%
20%
30%
40%
50%
60%
70%
≤8 16 32 64 >64
Spectinomycin
Mannheimia haemolytica
20082009
20102011
20122013
20142015
2016
0%
10%
20%
30%
40%
50%
60%
70%
≤4 8 16 32 64 >64
Tilmicosin
Mannheimia haemolytica
2008
2010
2012
2014
2016
0%
10%
20%
30%
40%
50%
60%
70%
≤1 2 4 8 16 32 64 >64
Tulathromycin
tilm
ico
sin
>64 1 27 94 15 693
64 5 8 3 6 99
32 8 4 1 3 4 53
16 46 44 5 1 1 16
8 2 62 34 1 1 2
≤4 8 71 204 26 2
≤1 2 4 8 16 32 64 >64
tulathromycin
Mannheimia haemolytica (n=1550 isolates)
83% - S/S or I/I or R/R3.6% - S/R mismatch
Macrolide agreement
• Reasons for discrepancies:
– Macrolide resistance in veterinary medicine
• erm(42) – tilmicosin, tildipirosin
• msr(E)-mph(E) – gamithromycin, tulathromycin
– Michael GB et al. 2012. Increased MICs of gamithromycin and tildipirosin in the
presence of the genes erm(42) and msr(E)-mph(E) for bovine Pasteurella
multocida and Mannheimia haemolytica. J Antimicrob Chemother.
• Both genes present on Mh1 and Pmu1 ICE
Mannheimia haemolytica MDR
2008
2010
2012
2014
2016
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
0 1 2 3 4 5 6 7
Why MDR Mannheimia haemolytica?
Tetracycline resistance
Tetracycline resistance
Aminoglycoside / spectinomycin
resistance
Tilmicosin / gamithromycin /
tulathromycinresistance
Ampicillin resistance
Aminoglycoside resistance
Streptomycin resistance
Sulfonamide resistance
Phenicolresistance
Tilmicosin / tildipirosin resistance
From: Michael, 2012 & Michael, 2012b
Individual Susceptibility Data
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2009 2010 2011 2012 2013
Pe
rce
nt
of
Iso
late
s -
Susc
ep
tib
le
Oxytetracycline
Tilmicosin
Enrofloxacin
Spectinomycin
Ceftiofur
Florfenicol
0%
10%
20%
30%
40%
50%
60%
0 1 2 3 4 5 6
Pe
rce
nt
of
Iso
late
s fo
r G
ive
n Y
ear
Number of Resistant Interpretations per Individual Isolate
2009 (55)
2010 (155)
2011 (179)
2012 (160)
2013 (240)
Pan-Susceptible
Multidrug Resistant
Threat level of URGENT
Clostridum difficile
Carbapenem-resistant Enterobacteriaceae
Drug-resistant Neisseria gonorrhoeae
Threat level of Serious Multidrug-resistant Acinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida
Extended spectrum -lactamase Enterobacteriaceae (ESBLs)
Vancomycin-resistant Enterococcus (VRE)
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant non-typhoidal Salmonella
Drug-resistant Salmonella typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
Drug-resistant Streptococcus pneumoniae
Drug-resistant tuberculosis
Threat level of Concerning
Vancomycin-resistant Staphylococcus aureus (VRSA)
Erythromycin-resistant Group A Streptococcus
Clindamycin-resistant Group B Streptococcus
Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.
Antimicrobial stewards seek to achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the costs of health care for infections, and limit the selection for antimicrobial resistant strains.
Infectious Disease Society of America
What is “Stewardship”?
2. Is there a non-antibiotic alternative which will appropriately prevent, control, or treat this disease challenge?
3. Selection of an antibiotic which has been demonstrated to be safe and effective for this purpose
4. Assuring use of the antibiotic as shown to be safe and effective
Yes…
1. Responsibility for appropriate diagnostics and establishment of an accurate and functional case definition
5. Is this antibiotic intervention still necessary?
While…
Current Guideline Examples
•AVMA Committee on Antimicrobials• Antimicrobial Stewardship for Veterinarians Defined
(policy adopted by the AVMA, 2018)• Includes core principles of antimicrobial stewardship in veterinary
medicine
• https://www.avma.org/KB/Policies/Pages/Antimicrobial-Stewardship-for-Veterinarians-Defined.aspx
• This is the start of the committee’s work.
AVMA Antimicrobial Stewardship Definition
Antimicrobial stewardship refers to the actions veterinarians take individually and as a profession to preserve the effectiveness and availability of antimicrobial drugs through conscientious oversight and responsible medical decision-making while safeguarding animal, public, and environmental health.
AVMA Antimicrobial Stewardship Definition
• Antimicrobial stewardship involves maintaining animal health and welfare by…
• implementing a variety of preventive and management strategies to prevent common diseases;
• using an evidence-based approach in making decisions to use antimicrobial drugs;
• and then using antimicrobials judiciously, sparingly, and with continual evaluation of the outcomes of therapy, respecting the client’s available resources.
Current Guideline Examples
• AVMA Task Force on Antimicrobial Use in Companion Animal Practice • https://www.avma.org/KB/Resources/Reference/Pages/Guidance-
for-Antimicrobial-Use-in-Companion-Animal-Practice.aspx
• American Association of Equine Practitioners guidelines
• American Association of Feline Practitioners/American Animal Hospital Association guidelines
• AVMA Judicious Therapeutic Use of Antimicrobials• With links to species-specific documents
• https://www.avma.org/KB/Policies/Pages/Judicious-Therapeutic-Use-of-Antimicrobials.aspx
Current Guideline Examples
• American Association of Bovine Practitioners
• Implementing Antibiotic Stewardship Plans
• Drug Use Guidelines for Bovine Practice
• Prudent Antimicrobial Use Guidelines
• http://www.aabp.org/about/AABP_Guidelines.asp
• American Association of Swine Veterinarians
• AASV Judicious Use Guidelines• https://www.aasv.org/aasv%20website/Resources/Antimicrobial%20Use/Antimicrobi
alUse.php
• Take Care - Use Antibiotics Responsibly brochure for producers (from Pork Checkoff Services Center.• http://porkcdn.s3.amazonaws.com/sites/all/files/documents/Anitbiotics/TAKECAREa
ntibioticFAQ.pdf
• American Association of Avian Pathologists
• AAAP-AVMA Guidelines for Judicious Therapeutic Use of Antimicrobials in Poultry
• https://aaap.memberclicks.net/assets/Positions/aaap.pdf
Food Animal Producer Organizations
•Policies, educational programs
•National Cattlemen’s Beef Association• Antibiotics Resource Center• http://www.beefusa.org/antibioticsresourcecenter.aspx
•National Dairy FARM Program• http://www.nationaldairyfarm.com/
•Pork Quality Assurance Plus• https://www.pork.org/certifications/pork-quality-
assurance-plus/
Challenges
•Moving from guidelines to implementation•Education•Research•Incentives•Resource availability and conservation•Monitoring with feedback loops
Total Use = Effective Use + Ineffective Use
The Ultimate Antibiotic Failure
= Bacterial Population Exposure Without Achieving the Desired Effect
Antibiotic
Resistance
Selection
= Antibiotic
Exposure +Exposed
Bacterial
Population
Equations
Water
Land
Fuel
Labor
$$$$
Technology
Feed
Base Livestock Production
Efficiency
Welfare
Food
Environment
Human Health?
Antibiotics
AnimalDisease
Outcome
DiseasePathogen
Location
Antimicrobials
Anti-inflammatory?
diffusionpHions
proteinsbiofilms
susceptibility
virulence
inoculum
age
other
disease
genetics
Therapy
total vs.
free?
pharmacokineticsregimen
pharmacodynamics
Physiological state
Husbandry
Immunity
diagnostics
case definition
Progression
nutrition
environment
stress
biosecurity
body
temperature
hydration
acid/base
production
level
Water
Land
Fuel
Labor
$$$$
Technology
Feed
Base Livestock Production
Efficiency
Welfare
Food
Environment
Human Health?
Antibiotics
Capturing Use Data
Granular
Coupled to cause
Accurate
Current Significant lag
Not coupled to cause
Approximate
Aggregate
What we would like… We would really rather not…
Easy Resource intensive
Enables benchmarking Unable to benchmark
Capturing Use Data
Granular
Coupled to cause
Accurate
Current Historical
Not coupled to cause
Approximate
Aggregate
Reality…
Easy Resource intensive
Enables benchmarking Unable to benchmark
Utility for individual production unit benchmarking
Ease of collection
Use by cause
Production unit
Tradeoffs
Sales Data
Population Estimates
DDD
DCD
Numerators
Drug Amount Exposures Duration
Denominators
Population Production
Disease Incidence?
No Records
Sophisticated Electronic Systems
Grams of drug Individual animal treatment records
Sales to production unit being measured Entire unit
Specific animal groups moving through the unit
Group level Feed consumption and inclusion rate
Target inclusion rate
Supplement used and inclusion rate of supplement
Micromachine records
Water consumption and inclusion rate or amount administered through water
Animals exposed (regimens)• Individual animal or group records
• Grams of drug used extrapolated by using Defined
Course Dose (DCD)
Protocol defined regimens for extrapolating average
course administration (grams)
If all animals receive a drug, then simple, it is the number
of animals in the system during the observed time period.
DCD accuracy declines as spread over more varying
administrations in different systems. (e.g., multiple
regimens and varying weights of animals at times of
administration)
Duration of exposure• Relatively straight forward for In-feed or in-water drugs where duration of exposure
equals regimen duration
Drugs administered daily (e.g., injection, intramammary tubes, oral medications
Individual animal records or group records may be used, or
Extrapolation from grams of drug based on DDD
• Breaks down for… Single administration antibiotics
2. Is there a non-antibiotic
alternative which will appropriately
prevent, control, or treat this
disease challenge?
3. Selection of an antibiotic
which has been demonstrated
to be safe and effective for
this purpose
4. Assuring use of the
antibiotic as shown to
be safe and effective
Yes…
1. Responsibility for appropriate
diagnostics and establishment of an
accurate and functional case definition
5. Is this antibiotic
intervention still
necessary?
While…
Antibiotic Stewardship