It has emerged that British Health Secretary Theresa Coffey thinks it might be a good idea if the access to antibiotics in the UK is loosened so that pharmacists will have the ability to dispense antibiotics to patients in certain situations. She has also unbelievably admitted that she has handed out antibiotics from her own supplies to friends and family. This unsurprisingly has prompted a fierce backlash from both medical practitioners and veterinarians in the UK and abroad, even causing ripples here in New Zealand.
I will admit that I haven’t looked into how she sees this new dispensing scheme working and I certainly don’t want to belittle the ability of the well trained hard working pharmacists so I am not really in a position to comment on this but… I am absolutely aghast that someone in her position would freely admit to doing something which is illegal here in New Zealand and I understand also in the UK and much of the rest of the world and that is dispensing antibiotics without the legal authority to do so. Anyway, that is a long winded way to introduce the topic of antimicrobial resistance and if you aren’t already amazed at the actions of the British Health Secretary, hopefully by the end of this podcast you will understand what all of the fuss is about. Ok, so firstly, what has the actions of the British Health Secretary got to do with veterinary medicine. The answer is simple, antimicrobials are not species specific. Human and veterinary medicine both use much the same antimicrobials, so it is in both professions interest to encourage rational use of the drugs. So a bit of background… firstly the shock statistic. There are reports of at least 700,000 human deaths worldwide each year due to microbial resistance with an estimate that if no action is taken, that figure could increase to 10 million globally per year by 2050! Without wanting to belittle the death rates of covid, in 2021 there were about 3.6 million deaths attributed to covid, potentially we have a world wide issue that if not addressed could cause almost 3 times the number of deaths per year as covid is at the moment by 2050. What are antimicrobials.. actually, lets stop here for a minute. I have been referring to antimicrobials so far so what is the difference between antimicrobials and antibiotics. Antimicrobials are compounds used against microbial organisms, which includes viruses, protozoa, fungi and bacteria whereas antibiotics are used against bacteria, so antibiotics are antimicrobials, but not all antimicrobials are antibiotics. Make sense? Sorry, I digressed. What are antimicrobials used for. There are three broad uses. The first is the obvious one, to treat known disease. The second is prophylaxis or prevention of disease and the third is as a growth promotant. Some examples of these. To treat a known disease is obvious. Perhaps for something like a skin cut that has become infected with bacteria. An example of prophylaxis would be perhaps a surgeon has undertaken abdominal surgery on a dog, which involves making an incision into the small intestine. This could potentially have resulted in a leak of intestinal contents into the abdominal cavity which obviously isn’t a good thing, with the risk of bacteria from the contents causing a peritonitis or infection in the abdominal cavity. At the time of surgery, or often just before even, the animal may be treated with appropriate antibiotics to minimise the risk of peritonitis occurring. Another example of this is a treatment called dry cow therapy where antibiotics are infused into the mammary glands of a dairy cow after she has finished her milking season, what is referred to as drying off, to stop her getting mastitis during the dry season. More on this later. The final use is as a growth promotion. This largely applies to intensive farming, particularly beef cattle, pigs, and chickens where antibiotics are mixed in the animals feed or water to minimise the effect any organisms may have on the growth rate. A real shotgun form of medication. There is an obvious red flag against this use. How commonly are antibiotics used in veterinary medicine? A study has shown that over a recent 2 year period 25% of dogs and 21% of cats in the UK received antibiotics. Another study puts the number of dairy cows receiving dry cow therapy in NZ at about 10% so still quite frequent. We have discussed current use of antimicrobials. Where does the problem lie. It was not until the late 1920s that the first true antibiotic was isolated. Alexander Flemming left a Petrie dish uncovered in his lab when he went on holiday. When he returned, he found the dish had been contaminated with a fungal colony. He also noted that all of the bacteria around the fungal colony had died. This was a repeatable finding. Hence penicillin was discovered. The relevance of this date is that it is very very recent in the bigger scale of things. I had the whole antimicrobial resistance thing put to me very eloquently a couple of years ago. Humans have stepped into a war between bacteria and fungi that has been going on for millions of years. Both groups of organisms often compete for the same space so fungi have evolved to produce toxins to kill off the competing bacteria. Bacteria, not wanting to be outdone have developed the ability to develop defences against the toxins. In a word, resistance. It must be remembered that almost all antibiotics in use today were originally developed from fungal toxins or based upon them. Is it not a bit naive for humans to step into this war thinking that millions of years of practice on behalf of the bacteria evading fungal toxins counts for nothing? So there is our problem. The micro-organisms, particularly bacteria are outsmarting us. It is now common practice to do what is called a culture and sensitivity. That is to identify the bacteria we are dealing with and then establish which antibiotics the bacteria is susceptible to. This is normally done by placing small disks infused with the common antibiotics onto the plate with the bacteria and if the bacteria are susceptible to the particular antibiotic, there will be no growth around the disk. Conversely, if the disk has no effect on the culture this denotes a resistance. When the bacteria is resistant to all of the antibiotics presented to it we refer to it as a superbug. Is this problem getting worse? Hell yes. To quote the World Health Organisation “Antibiotic resistance is rising to dangerously high levels in all parts of the world. New resistance mechanisms are emerging and spreading globally, threatening our ability to treat common infectious diseases” Surely we can just replace them with new ones, just like buying a new car or a toaster? Not really. At the moment there are only a small number of antibiotics being developed, mostly by small companies rather than large pharmaceutical companies. Being a bit cynical, I suspect this is because the larger companies have much more profitable drugs in their sights. To again quote the World Health Organisation “Without urgent action, we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill” Both the medical and veterinary professions are more than aware of these risks. It wasn’t that long ago that you went to your doctor with a cough or the flu and the first thing you were sent home with was a course of antibiotics “just in case there is an infection” or your cat had a limp, and it was sent home with antibiotics “just in case it is an infected bite wound”. I would like to think these days are gone. Antibiotic treatment is normally only indicated if:
• there is sufficient reason to suspect that a bacterial infection is present and • the infection is not likely to resolve without antibiotic therapy. So the core principles of responsible antimicrobial stewardship are as follows: Consider the impact of antibiotic use on the animal, its owner and other people, and the environment. 2. Animals should receive antibiotics only when there is a susceptible bacterial infection, antibiotics are required to maintain their health and welfare, and when no other treatment will work. 3. When antibiotics are used, dose rates and regimes should be designed for maximal efficacy and to limit re-treatment. 4. There are antibiotics considered so important in human medicine that they should not be used as first line treatment, and only used where no other treatment will work. 5. There will be a reduction in selection pressure for antimicrobial resistance if a smaller total amount of antibiotics are used in veterinary and human medicine. Here in New Zealand we are aiming at being antibiotic free by 2030 and the pathway to this antibiotic stewardship is neatly summed up by the 5 R’s plan: Reduction Reduction in antibiotic use is achieved by: 1. Preventative measures such as vaccination. 2. Avoiding use where there is no bacterial infection, for example, in uncomplicated viral infection. 3. Use of topical/local antimicrobials in preference to systemic delivery. 4. Avoidance of prophylactic antibiotic usage unless justified Refinement Continuously evaluate prescribing practices and therapeutic plans, based on: 1. Response to treatment 2. Previous similar cases 3. Published clinical studies 4. Local and published resistance data Replacement Selection pressure can be reduced by using non-antimicrobial alternatives where there is evidence of efficacy. Responsibility The success of a stewardship plan requires engagement, understanding, and personal responsibility of people at all levels involved in the prescription, treatment, and management of animals. Engagement will be achieved through: 1. Positioning of the program and a clear description of the justification to all involved. 2. Ensuring understanding of the core principles not just the operational procedures. 3. Encouragement of ‘upward leadership’ – empowerment of team members to contribute to success of the plan, to bring new ideas and innovation, and to refine the processes. Review A stewardship plan is a ‘living document’ and will be subject to periodic (at least annual) review to ensure objectives are met. 1. Animal health and welfare outcomes remain top priority and monitored to ensure they are achieved. 2. Audit of compliance should be undertaken internally and by independent bodies. 3. Reduction and replacement strategies should be monitored through measurement of animal daily doses used. 4. Susceptibility surveillance should be undertaken as appropriate to ensure appropriate selection of antimicrobials, maximise efficacy and monitor resistance in target pathogens. 5. Investigation of strategies that can be employed to improve stewardship of antimicrobials I will leave the last word again to The World Health Organization “Where antibiotics can be bought for human or animal use without a prescription, the emergence and spread of resistance is made worse. Similarly, in countries without standard treatment guidelines, antibiotics are often over-prescribed by health workers and veterinarians and over-used by the public”. And I must underline this statement again “Without urgent action, we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill” Were British Health Secretary Theresa Coffeys actions in any way acceptable? Antimicrobial Resistance. You gave what to who? The British Health Secretary, some left over antibiotics and a return to the dark ages. “Without urgent action, we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill” World Health Organisation This isn’t hyperbole, this is potentially our future (as if there aren’t enough other things to be concerned about). And then we have the British Health Secretary giving her left over antibiotics to family and friends. Really!!!
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