Prepared and delivered by Dr. Maureen E.C. Anderson, Lead Veterinarian, Animal Health & Welfare, Animal Health & Welfare Branch, Ontario Ministry of Agriculture, Food and Rural Affairs.
Slide 1. Hello, my name is Dr. Maureen Anderson, I am a lead veterinarian animal health and welfare at OMAFRA, and I am very pleased to be able to present this webinar on the often-talked-about but sometime easier-said-than-done topic of veterinary antimicrobial stewardship, specifically within the agricultural sector.
Slide 2. Let’s start with why we even care about antimicrobial stewardship. I’m sure everyone watching this presentation is familiar with antimicrobial drugs and how important they are for protecting animal health and welfare and the safety of our food supply. But we always need to keep in mind that many of those same or related drugs are equally important to maintaining our own health and those of our loved ones.
Slide 3. Both of these things are of course threatened by the ongoing emergence of antimicrobial resistance, which makes these precious drugs ineffective against the bacterial infections we’ve become all to accustomed to treating with them. And that applies to infections in people, and in animals, as well as the bugs that move between people in animals. And this is a problem all over the world, including right here in Canada, Ontario and our own backyards.
Slide 4. There are lots of scary numbers out there, like 2 million AMR infections in the US alone every year, leading to 23 000 deaths, and estimates that if we don’t change something in a hurry by 2050 AMR infections could cause 10 million deaths worldwide annually, surpassing even cancer as a cause of death. And so there are some who quite rightly fear we may enter the post-antibiotic era. We take it for granted that if scrape a knee or cut a finger, and it doesn’t heal properly and gets seriously infected, that we can use an antibiotic to help get it under control. But in the post-antibiotic era, as in the pre-antibiotic era prior to the 1940s, it is not far-fetched for a person to go septic and potentially die from a cut on a finger. And that is part of the reason our grandparents and great-grandparents always wanted us to be so careful about getting injured.
Slide 5. And we need to remember that selection for more resistant bacteria happens every time we use in antimicrobial, whether it be in a human, animal or the environment. When you use an antimicrobial you are treating the world. So yes, one of the cornerstones of stewardship is reducing antimicrobial use so we’re not needlessly accelerating this process
Slide 6. When you look at where we currently use antimicrobials in Canada, no one can deny that on a gross kg basis we use more in animals, up to 80%. Even when we correct for the body mass of animals vs humans being treated, we still use about 1.5 times more antimicrobials in animals by mass. This has in the past lead to a lot of finger-pointing at agriculture and a seemingly obvious target for reductive interventions.
Slide 7. When you look at how Canada compares with other countries in terms of antimicrobial use in animals (corrected for population), we’re not the worst, but there is certainly room for improvement.
Slide 8. But it’s critical to remember how interconnected we all are – humans animals and even the environment – and that means we all have an important role, no matter what the size, to play in combating antimicrobial resistance.
Slide 9. In terms of arguing over who is to blame or who is more to blame for AMR, that ship has sailed.
AMR is here and now we need to deal with it – together.
Slide 10. So what to do? To be good antimicrobial stewards, we can’t just look at how much, we also need to look at what types of drugs we’re using. As you can see here, there are large differences in the classes of antimicrobials being used in animals and people, and all these drugs have different potencies and different levels of importance for treating serious infections in people.
Slide 11. Looking at it another way, these pie graphs show how different the breakdown of antimicrobials by class is in humans and livestock, and how similar it is in humans and companion animals.
Slide 12. There are many definitions of antimicrobial stewardship out there, and you’ll notice they tend to share some key words like improve, monitor or measure. And a lot of them talk specifically about use, but what I really want to drive home is that stewardship is not all about use, it’s more than just prescriptions. It’s also about, perhaps even more so, when NOT to use antimicrobials, and what else we can do instead to prevent and treat infections
Slide 13. So this is my preferred definition of antimicrobial stewardship: The multifaceted approaches required to sustain the efficacy of antimicrobials and minimize the emergence of antimicrobial resistance. So that’s a very broad definition, and a lot of things fall under it
Slide 14. For example, recent regulatory and policy changes made by the federal government can be considered part of their stewardship efforts. There is a lot more information on these changes on the FAAST website, but the ultimate effect is that all medically important antimicrobials for use in animals now require a prescription from a veterinarian. And to quote the late great Stan Lee, “with great power comes great responsibility”, so veterinarians need to up their game with regard to stewardship as well. While this is not a “new” role, we could call it a “renewed” role, and it has never been bigger or more important.
Slide 15. Veterinarians are now responsible to guiding the use of all medically important antimicrobials, which includes everything in Health Canada’s categories 1, 2 and 3. While most of the products used in livestock fall into categories 2 and 3, there are several drugs, notably ceftiofur, that fall into category 1, with which we need to be especially careful.
Slide 16. The College of Veterinarians of Ontario, the licensing body for veterinarians in the province, has been working diligently to provide veterinarians with guidance documents to help them in their renewed role. These include practice standards on prescribing dispensing compounding and extra label drug use…
Slide 17. As well as the veterinarian-client-patient relationship, telemedicine and remote dispensing. All of these materials are available directly on the the CVO website.
Slide 18. If concern about superbugs and the spectre of the post-antibiotic era and professional ethics and responsibility aren’t sufficient motivation to drive better antimicrobial stewardship in an agriculture context, then also consider the evolving attitudes of consumers here in Canada and in our export markets. We effectively operate under and are given a “social license” to use antimicrobials in livestock, and like it or not that licence is currently being put under the magnifying glass.
Slide 19. We want to do everything we can to maintain that licence, even if it requires some extra effort. As this slide form the US Center for Food Integrity shows, the alternative is social control, which is much more rigid and costly, but there are or course several examples of countries where this is now the model.
Slide 20. So what’s going to happen now? It is very important to realize at the end of the day, despite the very real impact that AMR has on livestock, agriculture and veterinary medicine, that human health concerns will always trump everything else, so it’s critical that as veterinarians and animal owners, we do our part as antimicrobial stewards in order to maintain our social license to use these drugs. That means also working together in sectors that haven’t traditionally had a lot of strong veterinarian-client-patient relationships, such as backyard livestock, bees and fish. It also means that, sooner or later, we’re going to have to show people the numbers to provide evidence that we are hitting out targets, and even to set those targets in the first place.
Slide 21. A lot of producers and veterinarians are leery of AMU surveillance for a number of reasons. There is certainly a time-slash-pain-in-the-butt factor that needs to be addressed, but that’s something we continue to work on with the wonders of modern technology. With regard to the fear factor, I like to say that veterinary practices, and the same can be said for farms, generally fall into one of two categories. If you are at a clinic that does a fantastic job of antimicrobial stewardship, that’s great! We need you to share your story – and your numbers – so others can do the same and we can prove it to everyone else. If you are at a clinic where you try hard, but perhaps fall a bit short in some areas of stewardship, know that you are not alone by a longshot! But sharing your data helps identify those common pain points so that collectively we can develop tools to help everyone do a better job. There is theoretically a third category, those who make no specific efforts with regard to antimicrobial stewardship, but in this day and age I hope that category has gone the way of the dodo, as this is no longer an issue that anyone in can afford to ignore.
Slide 22. It’s also important to acknowledge that there are a lot of factors that we need to work to overcome when it comes to antimicrobial stewardship. For one thing, change is hard, and not uncommonly expensive, and we need to play the long game because that’s what the bacteria are doing (and they’ve been around for millions of years, so they’re really good at it!). Other issues include cost of diagnostic tests that could help guide antimicrobial use, pressure from clients who are used to getting antibiotics for their animals and aren’t immediately concerned with the broader implications of treating their animal, herd or flock, and in veterinary medicine, especially compared to human medicine, a general lack of sound, evidence based antimicrobial use guidelines for when we do have animals that need treatment. All of these are challenges we need to work on, but none of them are reasons to not put our best effort in when it comes to stewardship.
Slide 23. Case in point, the Canadian Veterinary Medical Association has just launched its new online interface for antimicrobial use guidelines in beef, dairy, poultry, swine, small ruminants and companion animals, to help Canadian veterinarians with their decision-making when it comes to treatment of these species. The guidelines were specifically developed for this website by leading veterinary experts in Canada. Any licensed veterinarian in Canada can access these guidelines until April 1st, 2019
Slide 24. But as I keep saying, stewardship is not just about use, it’s also about refining, stopping and even preventing use. There are lots of other components that can be incorporated into a stewardship program at any practice. One of the keys is to tailor the program to what works at a particular clinic, or on a particular operation, depending on size, species, location and a host of other factors.
Slide 25. On-farm tools like this simple algorithm for treatment of diarrheic calves can have a dramatic impact on antimicrobial use. In one study, this particular algorithm was shown to reduce AMU in diarrheic calves by 80%, with no significant change in overall mortality.
Slide 26. Tools like this infographic from the Ontario Animal Health Network are useful for talking to clients about stewardship in ways they can understand, while showing how their animals can often be treated effectively without antimicrobials.
Slide 27. So to finish off, I will leave you with a quick-and-dirty “antimicrobial stewardship 101” guide, that should be at the core of every clinic and on-farm stewardship program. DO use antimicrobials in a targeted way, to treat susceptible infections, following label directions whenever possible, and always the guidance of a veterinarian. Do NOT use antimicrobials out of habit, or as a “hail Mary”, when they are not indicated (such as for viral infections), or when other measures can be used to prevent infection instead.
Slide 28. Thank you very much for your time and attention, and please visit the FAAST website at www.amstewardship.ca to make use of the plethora of available resources they have there.