Priority actions to fight antibiotic resistance: results of an international meeting

Drivers, alternatives, knowledge, and perceptions towards antimicrobial use among Tennessee beef cattle producers: a qualitative study

BACKGROUND

In recent years, there has been an increased awareness of antimicrobial resistance in both animals and humans, which has triggered concerns over non-judicious antimicrobial use. In the United States, antimicrobial use in food-producing animals for growth promotion or improved feed efficiency is perceived as non-judicious. To facilitate judicious antimicrobial use, the United States Food and Drug Administration implemented the Veterinary Feed Directive, effective from January 1, 2017. Interventions, such as the VFD, designed to ensure the judicious use of antimicrobials among cattle producers may be more effective if the factors that inform and influence producer AMU practices are addressed. The specific objectives of this study were to determine the following among Tennessee beef cattle producers: (1) the most common drivers for using antimicrobials, (2) the perceived alternatives to antimicrobials, (3) the knowledge and perceptions regarding antimicrobial resistance, and (4) the preferred avenues for receiving information on prudent antimicrobial use. A total of 5 focus group meetings with beef producers were conducted in East, Middle, and West Tennessee. Each focus group was video recorded and thematic analysis was performed using NVivo.

RESULTS

The factors that producers considered to drive antimicrobial use were the type of cattle operation, disease and animal welfare, economic factors, veterinarian consultation, producer's experience and peer support, Veterinary Feed Directive, and perceived drug efficacy. Vaccination, proper nutrition, and other good management practices were considered alternatives to antimicrobial use. To encourage vaccine use among small producers, participants suggested packaging vaccines into smaller quantities. Antimicrobial resistance was perceived to be a problem affecting animal and public health. Participants suggested additional education for cattle producers on the prudent use of antimicrobials as a measure for improving antimicrobial use. The veterinarian, producer associations and meetings, and county extension agents emerged as trusted avenues for channeling information on prudent antimicrobial use to cattle producers.

CONCLUSIONS

Several factors drive antimicrobial use among cattle producers in Tennessee. Participants generally perceived their antimicrobial use to be discreet and only when necessary. More awareness of drivers for the development of antimicrobial resistance and continuing education on prudent antimicrobial use is needed for Tennessee beef producers.

Experimental Epidemiology of Antibiotic Resistance: Looking for an Appropriate Animal Model System

Antibiotic resistance is recognized as one of the major challenges in public health. The global spread of antibiotic resistance is the consequence of a constant flow of information across multi-hierarchical interactions, involving cellular (clones), subcellular (resistance genes located in plasmids, transposons, and integrons), and supracellular (clonal complexes, genetic exchange communities, and microbiotic ensembles) levels. In order to study such multilevel complexity, we propose to establish an experimental epidemiology model for the transmission of antibiotic resistance with the cockroach Blatella germanica. This paper reports the results of five types of preliminary experiments with B. germanica populations that allow us to conclude that this animal is an appropriate model for experimental epidemiology: (i) the composition, transmission, and acquisition of gut microbiota and endosymbionts; (ii) the effect of different diets on gut microbiota; (iii) the effect of antibiotics on host fitness; (iv) the evaluation of the presence of antibiotic resistance genes in natural- and lab-reared populations; and (v) the preparation of plasmids harboring specific antibiotic resistance genes. The basic idea is to have populations with higher and lower antibiotic exposure, simulating the hospital and the community, respectively, and with a certain migration rate of insects between populations. In parallel, we present a computational model based on P-membrane computing that will mimic the experimental system of antibiotic resistance transmission. The proposal serves as a proof of concept for the development of more-complex population dynamics of antibiotic resistance transmission that are of interest in public health, which can help us evaluate procedures and design appropriate interventions in epidemiology.

Human Cystic Fibrosis Macrophages Have Defective Calcium-Dependent Protein Kinase C Activation of the NADPH Oxidase, an Effect Augmented by Burkholderia cenocepacia

Macrophage intracellular pathogen killing is defective in cystic fibrosis (CF), despite abundant production of reactive oxygen species (ROS) in lung tissue. Burkholderia species can cause serious infection in CF and themselves affect key oxidase components in murine non-CF cells. However, it is unknown whether human CF macrophages have an independent defect in the oxidative burst and whether Burkholderia contributes to this defect in terms of assembly of the NADPH oxidase complex and subsequent ROS production. In this article, we analyze CF and non-CF human monocyte-derived macrophages (MDMs) for ROS production, NADPH assembly capacity, protein kinase C expression, and calcium release in response to PMA and CF pathogens. CF MDMs demonstrate a nearly 60% reduction in superoxide production after PMA stimulation compared with non-CF MDMs. Although CF MDMs generally have increased total NADPH component protein expression, they demonstrate decreased expression of the calcium-dependent protein kinase C conventional subclass α/β leading to reduced phosphorylation of NADPH oxidase components p47 ^phox and p40 ^phox in comparison with non-CF MDMs. Ingestion of B. cenocepacia independently contributes to and worsens the overall oxidative burst deficits in CF MDMs compared with non-CF MDMs. Together, these results provide evidence for inherent deficits in the CF macrophage oxidative burst caused by decreased phosphorylation of NADPH oxidase cytosolic components that are augmented by Burkholderia These findings implicate a critical role for defective macrophage oxidative responses in persistent bacterial infections in CF and create new opportunities for boosting the macrophage immune response to limit infection.

Addressing Antimicrobial Resistance: An Overview of Priority Actions to Prevent Suboptimal Antimicrobial Use in Food-Animal Production

The growing concern regarding emergence of bacteria resistant to antimicrobials and their potential for transmission to humans via animal production has led various authorities worldwide to implement measures to decrease antimicrobial use (AMU) in livestock production. These measures are influenced by those implemented in human medicine, and emphasize the importance of antimicrobial stewardship, surveillance, infection prevention and control and research. In food producing animals, unlike human medicine, antimicrobials are used to control diseases which cause economic losses. This major difference may explain the failure of the public policies implemented to control antimicrobial usage. Here we first review the specific factors influencing AMU across the farm animal sector and highlighting the farmers' decision-making process of AMU. We then discuss the efficiency of existing regulations implemented by policy makers, and assess the need for alternative strategies, such as substitution between antimicrobials and other measures for infectious disease control. We also discuss the interests of regulating antimicrobial prices. Finally, we emphasize the value of optimizing antimicrobial regimens, and developing veterinary precision medicine to achieve clinical efficacy in animals while limiting negative impacts on public health. The fight against antimicrobial resistance requires both a reduction and an optimization of antimicrobial consumption. The set of actions currently implemented by policy makers does not adequately address the economic interests of farmers' use of antimicrobials.

Antimicrobial resistance: one world, one fight!

The lack of new antibiotic classes calls for a cautious use of existing agents. Yet, every 10 min, almost two tons of antibiotics are used around the world, all too often without any prescription or control. The use, overuse and misuse of antibiotics select for resistance in numerous species of bacteria which then renders antimicrobial treatment ineffective. Almost all countries face increased antimicrobial resistance (AMR), not only in humans but also in livestock and along the food chain. The spread of AMR is fueled by growing human and animal populations, uncontrolled contamination of fresh water supplies, and increases in international travel, migration and trade. In this context of global concern, 68 international experts attending the fifth edition of the World HAI Resistance Forum in June 2015 shared their successes and failures in the global fight against AMR. They underlined the need for a “One Health” approach requiring research, surveillance, and interventions across human, veterinary, agricultural and environmental sectors. This strategy involves concerted actions on several fronts. Improved education and increased public awareness are a well-understood priority. Surveillance systems monitoring infections need to be expanded to include antimicrobial use, as well as the emergence and spread of AMR within clinical and environmental samples. Adherence to practices to prevent and control the spread of infections is mandatory to reduce the requirement of antimicrobials in general care and agriculture. Antibiotics need to be banned as growth promoters for farm animals in countries where it has not yet been done. Antimicrobial stewardship programmes in animal husbandry have proved to be efficient for minimising AMR, without compromising productivity. Regarding the use of antibiotics in humans, new tools to provide highly specific diagnoses of pathogens can decrease diagnostic uncertainty and improve clinical management. Finally, infection prevention and control measures – some of them as simple as hand hygiene – are essential and should be extended beyond healthcare settings. Aside from regulatory actions, all people can assist in AMR reduction by limiting antibiotic use for minor illnesses. Together, we can all work to reduce the burden of AMR.

Agriculture and food animals as a source of antimicrobial-resistant bacteria

One of the major breakthroughs in the history of medicine is undoubtedly the discovery of antibiotics. Their use in animal husbandry and veterinary medicine has resulted in healthier and more productive farm animals, ensuring the welfare and health of both animals and humans. Unfortunately, from the first use of penicillin, the resistance countdown started to tick. Nowadays, the infections caused by antibiotic-resistant bacteria are increasing, and resistance to antibiotics is probably the major public health problem. Antibiotic use in farm animals has been criticized for contributing to the emergence of resistance. The use and misuse of antibiotics in farm animal settings as growth promoters or as nonspecific means of infection prevention and treatment has boosted antibiotic consumption and resistance among bacteria in the animal habitat. This reservoir of resistance can be transmitted directly or indirectly to humans through food consumption and direct or indirect contact. Resistant bacteria can cause serious health effects directly or via the transmission of the antibiotic resistance traits to pathogens, causing illnesses that are difficult to treat and that therefore have higher morbidity and mortality rates. In addition, the selection and proliferation of antibiotic-resistant strains can be disseminated to the environment via animal waste, enhancing the resistance reservoir that exists in the environmental microbiome. In this review, an effort is made to highlight the various factors that contribute to the emergence of antibiotic resistance in farm animals and to provide some insights into possible solutions to this major health issue.

Improved treatment of multidrug-resistant bacterial infections: utility of clinical studies

In a time of increasing antibacterial resistance and limited availability of new antibiotics, clinical studies are much needed to assess treatment options against multidrug-resistant organisms (MDROs). In this review, we describe the clinical challenge caused by MDROs and present recent evidence on how clinical studies may generate quality data to improve antibiotic treatment of MDRO infections. To this aim, we critically assess the current status, gaps and challenges associated with observational and interventional studies performed to assess MDRO treatment options. We address why observational studies are useful, which treatment options for MDRO have been explored by observational studies and how to improve quality and usefulness of observational studies. Furthermore, the utility of clinical pharmacokinetic/pharmacodynamic studies for improving MDRO treatment is described. Finally, we discuss interventional study designs, end points and margins, as well as ethical, logistic and statistical challenges, and current regulatory changes proposed to foster the development of new antibiotics.

Antimicrobial resistance: a global view from the 2013 World Healthcare-Associated Infections Forum

Antimicrobial resistance (AMR) is now a global threat. Its emergence rests on antimicrobial overuse in humans and food-producing animals; globalization and suboptimal infection control facilitate its spread. While aggressive measures in some countries have led to the containment of some resistant gram-positive organisms, extensively resistant gram-negative organisms such as carbapenem-resistant enterobacteriaceae and pan-resistant Acinetobacter spp. continue their rapid spread. Antimicrobial conservation/stewardship programs have seen some measure of success in reducing antimicrobial overuse in humans, but their reach is limited to acute-care settings in high-income countries. Outside the European Union, there is scant or no oversight of antimicrobial administration to food-producing animals, while evidence mounts that this administration leads directly to resistant human infections. Both horizontal and vertical infection control measures can interrupt transmission among humans, but many of these are costly and essentially limited to high-income countries as well. Novel antimicrobials are urgently needed; in recent decades pharmaceutical companies have largely abandoned antimicrobial discovery and development given their high costs and low yield. Against this backdrop, international and cross-disciplinary collaboration appears to be taking root in earnest, although specific strategies still need defining. Educational programs targeting both antimicrobial prescribers and consumers must be further developed and supported. The general public must continue to be made aware of the current scale of AMR's threat, and must perceive antimicrobials as they are: a non-renewable and endangered resource.

"The Chennai declaration" - Indian doctors' fight against antimicrobial resistance

“The Chennai Declaration” is the result of the first ever joint meeting of medical societies in India addressing antibiotic resistance. The declaration is not a policy by itself, but a call for a national policy. The Declaration has looked into all major aspects of the problem of antimicrobial resistance, has suggested practical solutions, explained in detail the responsibility of each and every stakeholder.

Ready for a world without antibiotics? The Pensières Antibiotic Resistance Call to Action

Resistance to antibiotics has increased dramatically over the past few years and has now reached a level that places future patients in real danger. Microorganisms such as Escherichia coli and Klebsiella pneumoniae, which are commensals and pathogens for humans and animals, have become increasingly resistant to third-generation cephalosporins. Moreover, in certain countries, they are also resistant to carbapenems and therefore susceptible only to tigecycline and colistin. Resistance is primarily attributed to the production of beta-lactamase genes located on mobile genetic elements, which facilitate their transfer between different species. In some rare cases, Gram-negative rods are resistant to virtually all known antibiotics. The causes are numerous, but the role of the overuse of antibiotics in both humans and animals is essential, as well as the transmission of these bacteria in both the hospital and the community, notably via the food chain, contaminated hands, and between animals and humans. In addition, there are very few new antibiotics in the pipeline, particularly for Gram-negative bacilli. The situation is slightly better for Gram-positive cocci as some potent and novel antibiotics have been made available in recent years. A strong and coordinated international programme is urgently needed. To meet this challenge, 70 internationally recognized experts met for a two-day meeting in June 2011 in Annecy (France) and endorsed a global call to action ("The Pensières Antibiotic Resistance Call to Action"). Bundles of measures that must be implemented simultaneously and worldwide are presented in this document. In particular, antibiotics, which represent a treasure for humanity, must be protected and considered as a special class of drugs.