Approaches for quantifying antimicrobial consumption per animal species based on national sales data: a Swiss example, 2006 to 2013

The vehicle of administration, feed or water, and prandial state influence the oral bioavailability of amoxicillin in piglets

Feed and water components may interact with drugs and affect their dissolution and bioavailability. The impact of the vehicle of administration (feed and water) and the prandial condition of weaner piglets on amoxicillin´s oral bioavailability was evaluated. First, amoxicillin's in vitro dissolution and stability in purified, soft, and hard water, as well as release kinetics from feed in simulated gastric and intestinal media were assessed. Then, pharmacokinetic parameters and bioavailability were determined in fasted and fed pigs using soft water, hard water, or feed as vehicles of administration following a balanced incomplete block design. Amoxicillin showed similar dissolution profiles in soft and hard water, distinct from the dissolution profile obtained with purified water. Complete dissolution was only achieved in purified water, and merely reached 50% in soft or hard water. Once dissolved, antibiotic concentrations decreased by around 20% after 24 h in all solutions. Korsmeyer-Peppas model best described amoxicillin release from feed in simulated gastric and intestinal media. Feed considerably reduced antibiotic dissolution in both simulated media. In vivo, amoxicillin exhibited significantly higher bioavailability when delivered via water to fasted than to fed animals, while in-feed administration yielded the lowest values. All treatments showed a similar rate of drug absorption. In conclusion, we demonstrated that water and feed components, as well as feed present in gastrointestinal tract of piglets decrease amoxicillin´s oral bioavailability. Therefore, the use of oral amoxicillin as a broad-spectrum antibiotic to treat systemic infections in pigs should be thoroughly revised.

Telehealth as a Component of One Health: a Position Paper

INTRODUCTION

One Health (OH) refers to the integration of human, animal, and ecosystem health within one framework in the context of zoonoses, antimicrobial resistance and stewardship, and food security. Telehealth refers to distance delivery of healthcare. A systems approach is central to both One Health and telehealth, and telehealth can be a core component of One Health. Here we explain how telehealth might be integrated into One Health.

METHODS

We have considered antimicrobial resistance (AMR) as a use case where both One Health and telehealth can be used for coordination among the farming sector, the veterinary services, and human health providers to mitigate the risk of AMR. We conducted a narrative review of the literature to develop a position on the inter-relationships between telehealth and One Health. We have summarised how telehealth can be incorporated within One Health.

RESULTS

Clinicians have used telehealth to address antimicrobial resistance, zoonoses, food borne infection, improvement of food security and antimicrobial stewardship. We identified little existing evidence in support of the usage of telehealth within a One Health paradigm, although in isolation, both are useful for the same purpose, i.e., mitigation of the significant public health risks posed by zoonoses, food borne infections, and antimicrobial resistance.

CONCLUSIONS

It is possible to integrate telehealth within a One Health framework to develop effective inter-sectoral communication essential for the mitigation and addressing of zoonoses, food security, food borne infection containment and antimicrobial stewardship. More research is needed to substantiate and investigate this model of healthcare.

Method to Assess Farm-Level Vaccine and Antibiotic Usage Utilizing Financial Documentation: A Pilot Study in a Commercial Pig Farm in South Africa From 2016 to 2018

The purpose of the study was to develop a blueprint using financial documentation to describe and quantify vaccine and antibiotic usage (ABU). This method was piloted in a commercial pig farm in South Africa, with the ultimate hope to serve as a tool in a future species-specific vaccine and ABU surveillance system. Data collection was based on templates from the European Surveillance of Veterinary Antimicrobial Consumption (ESVAC) network and the World Organisation for Animal Health (WOAH). Invoices from 2016 to 2018 were used as the main data source. In addition, monthly statement of accounts were used to check for missing invoices. An inventory check was done to ensure that the correct antibiotic concentrations were used in subsequent calculations. Livestock counts and slaughter statistics were also collected to be used as denominator data. Cost calculations for the procurement of antibiotics and vaccines were also done. The study showed that veterinary medicinal products were purchased only from a single veterinary practice. A total of 291 invoices were issued over 3 years, of which 2.75% (8/291) were missing and could therefore not be used in quantification. Tetracyclines (453.65 ± 25.49 kg and 135.16 ± 3.31 mg/kg), followed by quinoxalines (258.33 ± 8.04 kg and 77.07 ± 3.93 mg/kg) were used in the highest amounts, both in terms of weight (kg) and adjusted for animal biomass (mg/kg). Vaccines used on the farm targeted seven different diseases, namely enzootic pneumonia, erysipelas, ileitis, infectious infertility, leptospirosis, neonatal pig diarrhea and porcine circovirus disease. An average of 103 546 vaccine dosages was purchased for ZAR1 302,727 ($ 84,620¹) per year, whereas the average cost for the procurement of antibiotics was ZAR 907,372 ($ 69,561) per year. The study showed that invoices and monthly statement of accounts, in combination with an inventory check and on-farm production statistics, are useful data sources to quantify vaccine and ABU in the absence of veterinary prescriptions. In addition, vaccinating pigs were more expensive than administering antibiotics.

A Survey on the Rationale Usage of Antimicrobial Agents in Small Animal Clinics and Farms in Trinidad and Jamaica

The extensive and indiscriminate use of antibiotics is known to contribute to antimicrobial resistance. Unfortunately, there are no public records of antimicrobial use (frequency or dosage) administered to animals in two major CARICOM (Caribbean Community) countries: Trinidad and Tobago, and Jamaica. Surveillance would promote amendments and discussion on a Caribbean antimicrobial-use protocol. In this study, an online survey was conducted using cross-sectional qualitative interviews via email, targeting veterinary clinicians working in clinics and farms in Trinidad and Jamaica, to identify how antimicrobials are used in the two countries. Out of the thirty-two (32) clinicians interviewed in Trinidad, 22 (68.75%) were small animal practitioners, and 10 (45.45%) were mixed practitioners. While in Jamaica, a total of Twenty six (26) clinicians responded, of which 17 of them (65.38%) were small animal practitioners and nine (34.62%) were mixed practitioners. A total of 95.2% of clinics and farms in Jamaica and 87.1% in Trinidad did not use standard antimicrobial protocols, which could be due to the limited availability of resources. The broad-spectrum antibiotic, amoxicillin, and amoxicillin/clavulanic acid were the most commonly used drugs in small animal practices in both countries (71.9% and 53.8% in dogs), (78.1% and 65.9% in cats); amoxicillin is also used frequently in mixed animal practice in Jamaica (44.4% in goats, 33.3% in cattle and 22.2% in sheep and pigs), while procaine penicillin and streptomycin was the most frequently used in mixed practice in Trinidad (60% in cattle and goats, 50% in sheep), which could explain the potentially increased risk of antimicrobial resistance.

Analysis of antimicrobial sales data of the main distributor in Quebec from 2016 to 2019: An estimate of usage in dairy cattle, horses, and small animals

Because antimicrobial usage (AMU) data are crucial in understanding and dealing with the threat that antimicrobial resistance (AMR) poses to global health, data of the sale of antimicrobials from 2016 to 2019 of CDMV Inc. - a major distributor of veterinary products in Canada - were collected and analyzed for the province of Quebec. The primary objective was to describe the evolution of AMU sales data for dairy cattle, small animals, and horses; a secondary objective was to determine effects of a new provincial regulation on antimicrobials of very high importance (in Quebec) on sales for dairy cattle. Results are described in milligrams of antimicrobials per kilogram of animal biomass (mg/PCU) for dairy cattle, small animals, and horses; intramammary products were analyzed for number of treatments per 100 cow-years; and results for dairy cattle were compared in Canadian-defined course doses for cattle (DCDbovCA) per 100 cow-years to a recent study for this species in Quebec. Between 2016 and 2019, there were decreased sales of Category 1 antimicrobials for all species included in the study (Category 1-VI for small animals). This reduction was even more apparent for dairy cattle, for which a 76% decrease occurred from 2018 to 2019 (1.7 to 0.4 mg/PCU). This marked reduction was attributed to the new regulation implemented in February 2019. Since a farm- and clinic-level AMU monitoring system has not yet been implemented in Quebec, analysis of CDMV Inc. sales enabled observations of temporal trends in AMU for dairy cattle, horses, and small animals. These temporal trends based on CDMV Inc. sales will be useful for making comparisons and validating trends derived from farm- and clinic-level data generated by a monitoring system.

Antimicrobial usage in Swiss fattening pig farms: is there still potential for improvement?

OBJECTIVE

The aim of this study was to analyze antimicrobial usage (AMU) in fattening pig farms that took part in the SuisSano/Safety + Health Programme in Switzerland over the year 2020 and to discuss the potential for further improvement. Usage was examined according to the antimicrobial's class and indication for use, with emphasis on highest priority critically important antimicrobials (HPCIAs).

METHODS

Data on AMU from 1411 farms, reported in an electronic treatment journal, was used. AMU was quantified through treatment incidence (TI) based on Swiss Defined Daily Doses (DDDch). Indication of use for each antimicrobial class was analyzed with particular focus on HPCIAs.

RESULTS

The total TI of all antimicrobials used in the farms corresponds to 8.9 DDDch per 1000 pig-days at risk, of which HPCIAs represented 2.6 %. A total of 140 farms (9.9 %) partake in HPCIAs usage, with tylosin (73.8 % of total HPCIA TI) and colistin (22.8 % of total HPCIA TI) being the most frequently antimicrobials used. The most common indication for treatment with HPCIAs was gastrointestinal disorders (62.1 % of total HPCIA TI).

CONCLUSION AND CLINICAL RELEVANCE

This study shows that the efforts made in recent years to foster prudent use of antimicrobials and, especially HPCIAs in Swiss pig production, have been successful. Indeed, 90.1 % (1271 of 1411) of the farms did not use any HPCIAs over the year 2020. Of the recorded treatments, HPCIA's represented only 2.6 % of the total TIs used in fattening pigs. Since many farms do not use any HPCIAs, knowledge can be obtained from these farms to identify practices which can further reduce or even stop HPCIAs usage. Moreover, information concerning indications for HPCIAs usage provide input concerning where treatment options other than HPCIAs should be explored by both farmers and veterinarians.

Canadian Dairy Network for Antimicrobial Stewardship and Resistance (CaDNetASR): An On-Farm Surveillance System

Canada has implemented on-farm antimicrobial resistance (AMR) surveillance systems for food-producing animals under the Canadian Integrated Program for Antimicrobial Resistance (CIPARS); however, dairy cattle have not been included in that program yet. The objective of this manuscript was to describe the development and implementation of the Canadian Dairy Network for Antimicrobial Stewardship and Resistance (CaDNetASR). An Expert Panel (EP) of researchers was created to lead the development of the dairy surveillance system. The EP initiated a draft document outlining the essential elements of the surveillance framework. This document was then circulated to a Steering Committee (SC), which provided recommendations used by the EP to finalize the framework. CaDNetASR has the following components: (1) a herd-level antimicrobial use quantification system; (2) annually administered risk factor questionnaires; and (3) methods for herd-level detection of AMR in three sentinel enteric pathogens (generic Escherichia coli, Campylobacter spp., and Salmonella spp.) recovered from pooled fecal samples collected from calves, heifers, cows, and the manure pit. A total of 144 dairy farms were recruited in five Canadian provinces (British-Columbia, Alberta, Ontario, Québec, and Nova-Scotia), with the help of local herd veterinarians and regional field workers, and in September 2019, the surveillance system was launched. 97.1 and 94.4% of samples were positive for E. coli, 63.8, and 49.1% of samples were positive for Campylobacter spp., and 5.0 and 7.7% of samples were positive for Salmonella spp., in 2019 and 2020, respectively. E. coli was equally distributed among all sample types. However, it was more likely that Campylobacter spp. were recovered from heifer and cow samples. On the other hand, it was more common to isolate Salmonella spp. from the manure pit compared to samples from calves, heifers, or cows. CaDNetASR will continue sampling until 2022 after which time this system will be integrated into CIPARS. CaDNetASR will provide online access to farmers and veterinarians interested in visualizing benchmarking metrics regarding AMU practices and their relationship to AMR and animal health in dairy herds. This will provide an opportunity to enhance antimicrobial stewardship practices on dairy farms in Canada.

Survey on Antimicrobial Drug Use Practices in California Preweaned Dairy Calves

The California (CA) dairy industry was surveyed in July 2017 to evaluate producers' knowledge and perceptions and antimicrobial drug (AMD) use in preweaned dairy calves following the implementation of the nationwide veterinary feed directive final rule (VFD) in January 2017 and prior to statewide implementation of CA Senate Bill (SB) 27 in January 2018. Together, these regulations require veterinary oversight for all uses of medically important antimicrobial drugs (MIADs) administered to livestock in CA. Survey questionnaire was mailed to 1,361 CA Grade A milk producing dairies and calf ranches across CA resulting in a 12% (169) response. Most respondents (83%) were aware of the VFD and SB 27 changes. Use of antibiotics was perceived as important (77%) in raising preweaned dairy calves and judicious use of antibiotics was ranked as the most important antimicrobial stewardship practice, amongst record keeping, observing withdrawal periods, having a valid Veterinarian-Client-Patient-Relationship (VCPR), and use of alternatives to antibiotics. Treating sick calves was the major indication for AMD use (90.5%); however, few producers reported use of antibiotics to control (12.7%) or prevent disease (11%). Neomycin sulfate, chlortetracycline, oxytetracycline and sulfamethazine were the most used AMD. The respondents reported a decreased use of AMD in milk (10%) and in solid feed (5%), and discontinuation of one or more AMDs used in milk (18.6%) or in solid feed (5%) post-VFD rule implementation in 2017. Most respondents reported keeping treatment records and the information recorded included date (82%), dose (44%) and route (15%) of AMD used. A few respondents reported they had initiated use of alternatives to AMDs, such as vitamins (32.6%), minerals (25.6%), herbal remedies (11.6%) and pathogen specific antibodies (7%), post-VFD. The limited changes noted in AMD use could be attributed to the short period between the implementation of the VFD and the time of the survey. Our study outcomes identified opportunities to improve AMD use practices, including record keeping and use of AMD alternatives, and provides a baseline for future evaluation of the impact of these regulatory changes, as well as guidance for the future recommendations on best practices to promote judicious AMD use.

Understanding farmers' and veterinarians' behavior in relation to antimicrobial use and resistance in dairy cattle: A systematic review

To tackle antimicrobial resistance, it is vital that farmers' and veterinarians' antimicrobial use behaviors and attitudes toward resistance are understood so that we can identify how beliefs and motives influence practices. Current literature details qualitative and quantitative research that explores the knowledge, attitudes and perceptions of dairy farmers and veterinarians with respect to antimicrobial resistance and antimicrobial practices, and the reported findings are varied and conflicting. Our objective was to conduct a systematic review to assess the evidence and knowledge gaps in the published literature. We identified articles via database searches of Embase, Medline, PubMed, Scopus, and Web of Science; we limited findings to published articles available in English with no publication year restrictions. Article screening was conducted at 3 levels: title, abstract, and full text. Of the 349 articles identified, 35 were retained for systematic review. Transparency of reporting was assessed for each study using the Consolidated Criteria for Reporting Qualitative Research (COREQ) framework. Quality was assessed using the Critical Appraisal Skills Programme qualitative checklist. Findings relating to dairy farmers' and veterinarians' knowledge, attitudes, and perceptions on antimicrobial resistance and practices were thematically analyzed. The comprehensiveness of reporting was variable: studies reported 5 to 26 of the 32 COREQ checklist items. Five key themes emerged from the data: knowledge and awareness of antimicrobial resistance; factors influencing farmer and veterinarian decision-making; perceived barriers and facilitators to reduced antimicrobial use; perceived responsibility for antimicrobial resistance; and the role of the farmer and veterinarian relationship in reducing antimicrobial use. Awareness of prudent antimicrobial use was not uniform between studies. Many factors influence farmers' and veterinarians' decisions to use antimicrobials, including animal welfare and available resources. The farmer-veterinarian relationship is a potential barrier or facilitator of reduced antimicrobial use, depending on the perceived relationship dynamic. Encouraging collaboration between farmers and veterinarians could lead to shared responsibility for reducing antimicrobial use. This review provided a coherent picture of what is currently known and identified gaps in the current knowledge to inform future behavioral intervention research. Increased knowledge, skill development, resources, engagement, and further research to address the gaps we identified are the main recommendations to effectively overcome barriers, elicit appropriate behavior change, and achieve reduced antimicrobial use in dairy cattle.

Survey of production animal veterinarians' prescription practices, factors influencing antimicrobial drug use, and perceptions of and attitudes toward antimicrobial resistance

OBJECTIVE

To assess production animal medicine veterinarians' prescription practices and identify factors influencing their use of antimicrobial drugs (AMDs) and their perceptions of and attitudes toward antimicrobial resistance (AMR).

SAMPLE

157 production animal veterinarians in the United States.

PROCEDURES

An online cross-sectional survey and digital diary were used to gather information regarding perceptions on AMD use and AMR and on treatment recommendations for production setting-specific disease scenarios. Results were compared across respondents grouped by their selected production setting scenarios and reported years as veterinarians.

RESULTS

The most commonly selected production setting disease scenarios were dairy cattle (96/157 [61.1%]), backgrounding cattle (32/157 [20.4%]), and feedlot cattle (20/157 [12.7%]). Because few respondents selected swine (5/157 [3.2%]) or poultry (4/157 [2.5%]) scenarios, those responses were excluded from statistical analysis of AMD prescription practices. Most remaining respondents (147/148 [99.3%]) reported that they would recommend AMD treatment for an individual ill animal; however, responses differed for respondents grouped by their selected production setting scenarios and reported years as veterinarians when asked about AMD treatment of an exposed group or high-risk disease-free group. Most respondents reported that government regulations influenced their AMD prescribing, that owner and producer compliance was a veterinary-related factor that contributed to AMR, and that environmental modifications to prevent disease could be effective to mitigate AMR.

CONCLUSIONS AND CLINICAL RELEVANCE

Results of the present study helped fill important knowledge gaps pertaining to prescription practices and influencing factors for AMD use in production animal medicine and provided baseline information for future assessments. This information could be used to inform future interventions and training tools to mitigate the public health threat of AMR.

Small and Large Animal Veterinarian Perceptions of Antimicrobial Use Metrics for Hospital-Based Stewardship in the United States

Background: Robust measurement and tracking of antimicrobial use (AMU) is a fundamental component of stewardship interventions. Feeding back AMU metrics to individual clinicians is a common approach to changing prescribing behavior. Metrics must be meaningful and comprehensible to clinicians. Little is known about how veterinary clinicians working in the United States (US) hospital setting think about AMU metrics for antimicrobial stewardship. Objective: To identify hospital-based veterinary clinicians' attitudes toward audit and feedback of AMU metrics, their perceptions of different AMU metrics, and their response to receiving an individualized prescribing report. Methods: Semi-structured interviews were conducted with veterinarians working at two hospitals in the Eastern US. Interviews elicited perceptions of antimicrobial stewardship in veterinary medicine. Respondents were shown a personalized AMU Report characterizing their prescribing patterns relative to their peers and were asked to respond. Interviews were recorded, transcribed, and analyzed using the framework method with matrices. Results: Semi-structured interviews were conducted with 34 veterinary clinicians (22 small animal and 12 large animal). Respondents generally felt positive about the reports and were interested in seeing how their prescribing compared to that of their peers. Many respondents expressed doubt that the reports accurately captured the complexities of their prescribing decisions and found metrics associated with animal daily doses (ADDs) confusing. Only 13 (38.2%) respondents felt the reports would change how they used antimicrobials. When asked how the impact of the reports could be optimized, respondents recommended providing a more detailed explanation of how the AMU metrics were derived, education prior to report roll-out, guidance on how to interpret the metrics, and development of meaningful benchmarks for goal-setting. Conclusions: These findings provide important insight that can be used to design veterinary-specific AMU metrics as part of a stewardship intervention that are meaningful to clinicians and more likely to promote judicious prescribing.

Monitoring of Farm-Level Antimicrobial Use to Guide Stewardship: Overview of Existing Systems and Analysis of Key Components and Processes

The acknowledgment of antimicrobial resistance (AMR) as a major health challenge in humans, animals and plants, has led to increased efforts to reduce antimicrobial use (AMU). To better understand factors influencing AMR and implement and evaluate stewardship measures for reducing AMU, it is important to have sufficiently detailed information on the quantity of AMU, preferably at the level of the user (farmer, veterinarian) and/or prescriber or provider (veterinarian, feed mill). Recently, several countries have established or are developing systems for monitoring AMU in animals. The aim of this publication is to provide an overview of known systems for monitoring AMU at farm-level, with a descriptive analysis of their key components and processes. As of March 2020, 38 active farm-level AMU monitoring systems from 16 countries were identified. These systems differ in many ways, including which data are collected, the type of analyses conducted and their respective output. At the same time, they share key components (data collection, analysis, benchmarking, and reporting), resulting in similar challenges to be faced with similar decisions to be made. Suggestions are provided with respect to the different components and important aspects of various data types and methods are discussed. This overview should provide support for establishing or working with such a system and could lead to a better implementation of stewardship actions and a more uniform communication about and understanding of AMU data at farm-level. Harmonization of methods and processes could lead to an improved comparability of outcomes and less confusion when interpreting results across systems. However, it is important to note that the development of systems also depends on specific local needs, resources and aims.

Eight years of sales surveillance of antimicrobials for veterinary use in Germany-What are the perceptions?

A surveillance system for sales volumes of antimicrobial agents for veterinary use was established in Germany in 2011. Since then, pharmaceutical companies and wholesalers have been legally obliged to report annual volumes of veterinary antimicrobial products sold to veterinary practices or clinics located in Germany. The evaluation of sales volumes for eight consecutive years resulted in a considerable total decrease by 58% from 1706 tons to 722 tons. During the investigation period, two legally binding measures to control the risk of antimicrobial resistance resulting from the veterinary use of antimicrobials were introduced, a) the German treatment frequencies benchmarking in 2014 and b) the obligation to conduct susceptibility testing for the use of cephalosporins of the 3^rd and 4^th generation and of fluoroquinolones in 2018. Both had a marked impact on sales volumes. Nonetheless, the category of Critically Important Antimicrobials as defined by the World Health Organization kept accounting for the highest share on sales volumes in Germany in 2018 with 403 tons, despite an overall reduction by 53%. Sales surveillance is considered essential for data retrieval on a global scale and inter-country comparison. However, the usability of a surveillance system based on sales data for risk management of antimicrobial resistance has limitations. The German system does not include off-label use of antimicrobial products authorized for human medicine and does not allow for identification of areas of high risk according to animal species, farm and production types and indications for treatment. For further reduction and enhanced promotion of a prudent use of antimicrobials, targeted measures would be required that could only be deducted from use data collected at farm or veterinary practice level. A surveillance system based on use data is currently lacking in Germany but will be established according to Regulation (EU) 2019/6 on veterinary medicinal products.

Standardization of Therapeutic Measures in Antibiotic Consumption Monitoring to Compare Different Livestock Populations

Using sales data, information on antimicrobial consumption in animals is collected cumulatively across the European Union and member countries of the European Economic Area, which is documented and reported by every country and published within annual reports by the European Surveillance of Veterinary Antimicrobial Consumption (ESVAC). These serve to perform cross-border comparisons of antimicrobial consumption, despite their ambiguity due to the different units and key figures used. To improve comparability, the European Medicines Agency has introduced the population correction unit (PCU), which represents the biomass of a livestock population and is related to antibiotic consumption. However, the PCU does not consider the variability of how a livestock population is composed structurally regarding the proportions of production types contained therein. To achieve better comparability between the different geographical areas, we therefore applied a system of standardization in different examples and in real antimicrobial consumption data. This was done by quantifying the consumption of antibiotics by livestock in exemplary regions and countries (Denmark, Germany, France) by means of the active substance used (mg/kg) and subjecting it to a direct and indirect standardization procedure to identify and measure differences in consumption in relation to the composition of livestock demographics. The consideration of livestock demographics results in substantial effects when comparing antimicrobial usage in livestock. To achieve a more compelling comparability in the context of monitoring antibiotic consumption in livestock populations, we recommend using an indirect standardization method, to control potential confounding effects caused by different livestock demographics. This assumes that animal populations can be structured accordingly well. Correspondingly, detailed information on antimicrobial usage by species should be available for this type of stratification.

Challenges of antimicrobial consumption surveillance in food-producing animals in sub-Saharan African countries: Patterns of antimicrobials imported in Cameroon from 2014 to 2019

OBJECTIVE

Antimicrobial consumption surveillance is a useful tool for planning antimicrobial resistance control strategies and risk analysis. The present study was carried out to evaluate the consumption trends of antimicrobials for veterinary use in food-producing animals in Cameroon from 2014 to 2019.

METHODS

Data on quantities of classes of active substances were collected from the records of the technical authorization to import veterinary drugs of suppliers' invoices at the Ministry of Livestock (MINEPIA); animal population data were collected from the FAO-Stat database.

RESULTS

The study revealed that 217.67tonnes of antimicrobials (by weight of active substance) were imported during the 6-year period, with an average of 36.28±10.11tonnes per year. Tetracyclines (31.71%), sulfonamides (23.84%), quinolones (11.11%) and β-lactams (10.17%) were the most commonly imported classes of antimicrobials. With regard to the importance of veterinary antimicrobials to human medicine, critically important antimicrobial (34.3%), reserve (4.6%) and watch (25.5%) groups as classified by the WHO AWaRe categorization were recorded. Overall, a mean of 5.24±1.40mg/PCU (population correction unit) was used in all food-producing animals during the 6-year period. However, the mean quantity of antimicrobials adjusted by animal biomass was highest in poultry (213.32±50.26mg/kg), followed by pigs (63.04±18.87mg/kg), cattle (4.11±2.20mg/kg), sheep (0.83±0.43mg/kg) and goats (0.47±0.24mg/kg).

CONCLUSION

Strict surveillance systems of antimicrobial consumption in the country are vital to optimize control strategies. Monitoring importation data of veterinary antimicrobial products could be useful for sub-Saharan African countries to quantify consumption and estimate trends for antimicrobial usage effectively.

Sales data as a measure of antibiotics usage: Concepts, examples and discussion of influencing factors

Monitoring and surveillance of antimicrobial usage in animals is a public health concern and different methods are currently discussed widely in public, science and politics. The objective of the paper is to present the available methods of monitoring and to discuss possible differences in the assessment of the antibiotics treatment. Sales data are expressed as the average amount of substance per animal or kg live weight (e.g. population‐corrected unit, PCU). The number of Defined Daily Doses (nDDDvet) is calculated by extrapolating sales data with average animal weights and defined drug doses to a number of treatments theoretically applied to animals. In contrast, the number of Used Daily Doses (nUDDvet) displays the actual number of treatments which have been applied. As sales data are relatively easily obtained, they are frequently used. However, their results are influenced by the composition of the population and by the dose of the substances. As both may vary strongly between countries, direct comparison of sales data between countries may be misleading. The concept of analysing sales data is shown by exemplarily using the methods in the ESVAC report 2015. The presentation of usage data in terms of nDDDvet or of nUDDvet increases the comparability of the data from different countries or time periods. Furthermore, fluoroquinolones and third‐/fourth‐generation cephalosporins which, among other substances, bare a potential risk for human health, are used at low doses. Hence, their use contributes to a sales reduction while contrasting the guidelines of prudent use. nDDDvet or nUDDvet have the ability to better reflect the treatment frequency and thus to better link antibiotics use to public health concerns. Quantification of antibiotics should assist to focus on prudent use of antimicrobials to reduce the burden of resistant bacteria and, thus, enhance public health, animal health and animal welfare.

Data-driven approach to using individual cattle weights to estimate mean adult dairy cattle weight

BACKGROUND

Knowledge of accurate weights of cattle is crucial for effective dosing of individual animals and for reporting antimicrobial usage. For the first time, we provide an evidence-based estimate of the average weight of UK dairy cattle to better inform farmers, veterinarians and the scientific community.

METHODS

Data were collected for 2747 lactating dairy cattle from 20 farms in the UK. Data were used to calculate a mean weight for lactating dairy cattle by breed and a UK-specific mean weight. Trends in weight by lactation number and production level were also explored.

RESULTS

Mean weight for adult dairy cattle in this study was 617 kg (sd=85.6 kg). Mean weight varied across breeds, with a range of 466 kg (sd=56.0 kg, Jersey) to 636 kg (sd=84.1, Holsteins). When scaled to UK breed proportions, the estimated UK-specific mean weight was 620 kg.

CONCLUSION

This study is the first to calculate a mean weight of adult dairy cattle in the UK based on on-farm data. Overall mean weight was higher than that most often proposed in the literature (600 kg). Evidence-informed weights are crucial as the UK works to better monitor and report metrics to measure antimicrobial use and are useful to farmers and veterinarians to inform dosing decisions.

Extrapolating Antibiotic Sales to Number of Treated Animals: Treatments in Pigs and Calves in Switzerland, 2011-2015

To evaluate the contribution of antimicrobial use in human and veterinary medicine to the emergence and spread of resistant bacteria, the use of these substances has to be accurately monitored in each setting. Currently, various initiatives collect sales data of veterinary antimicrobials, thereby providing an overview of quantities on the market. However, sales data collected at the level of wholesalers or marketing authorization holders are of limited use to associate with the prevalence of bacterial resistances at species level. We converted sales data to the number of potential treatments of calves and pigs in Switzerland for the years 2011 to 2015 using animal course doses (ACD). For each authorized product, the number of potential therapies was derived from the sales at wholesaler's level and the ACD in mg per kg. For products registered for use in multiple species, a percentage of the sales was attributed to each authorized species according to their biomass distribution. We estimated a total of 5,914,349 therapies for pigs and 1,407,450 for calves in 2015. Using the number of slaughtered animals for that year as denominator, we calculated a treatment intensity of 2.15 therapies per pig and 5.96 per calf. Between 2011 and 2015, sales of veterinary antimicrobials decreased by 30%. The calculated number of potential therapies decreased by 30% for pigs and 15% for calves. An analysis of treatment intensity at antimicrobial class level showed a decrease of 64% for colistin used in pigs, and of 7% for macrolides used in both pigs and calves. Whereas the use of 3rd and 4th generation cephalosporins in calves decreased by 15.8%, usage of fluoroquinolones increased by 10.8% in the same period. Corresponding values for pigs were −16.4 and +0.7%. This is the first extrapolation of antimicrobial usage at product level for pigs and calves in Switzerland. It shows that calves were more frequently treated than pigs with a decreasing trend for both number of therapies and use of colistin, macrolides and cephalosporins 3rd and 4th generations. Nonetheless, we calculated an increase in the usage of fluoroquinolones. Altogether, this study's outcomes allow for trend analysis and can be used to assess the relationship between antimicrobial use and resistance at the national level.

Pilot prescription survey of antineoplastic agents: real-world data from veterinary teaching hospitals in Japan

The collection of real clinical records from veterinary practices and analysis of these records helps to establish evidence‐based veterinary medicine and further improves animal health and welfare. Prior to the collection of nationwide clinical records, we downloaded the data from the digital accounting systems of two veterinary teaching hospitals in Japan, and the prescriptions of antineoplastic agents were surveyed for a 5‐year period from 2009 to 2013. The ratio of the number of patients prescribed antineoplastic agents to the total number of prescriptions was <5% at both hospitals, and >80% of those patients were dogs. The overall number of prescriptions included more oral rather than injectable formations, whereas among antineoplastic agents, injectable formulations were prescribed more frequently at both hospitals. The most frequently prescribed agents were almost identical at both hospitals: platinum compounds, such as carboplatin and cisplatin (CDDP), vincristine and doxorubicin. The most frequently prescribed product combined with CDDP was doxorubicin at Hospital A. Antiemetic agents combined with CDDP included dexamethasone, ondansetron and metoclopramide, but these antiemetic agents were combined fewer than 10 times among 197 CDDP prescriptions. The prescription history, including the number of prescriptions, dosing intervals and combined medications, was provided by the survey. Although the present database consisted of data from two hospitals, our results indicate that a broad analysis can be conducted using integrated data from multiple hospitals and practices for further cohort studies.

Quantitative risk model to estimate the level of antimicrobial residues that can be transferred to soil via manure, due to oral treatments of pigs

Veterinary antimicrobials can spread via manure onto agricultural fields, representing an emission of these products or their active metabolites into the environment. This causes concerns regarding the role of antimicrobial residues in the development, selection and spread of resistance. Aiming to approach this issue quantitatively, first a literature review was performed on the bioavailability and extent of in vivo biotransformation of twelve antimicrobials commonly used in pigs orally, and on the level of their persistence in manure. This information was then used in a model estimating the level of each of these administered antimicrobials that is present in manure at the end of common storage durations in pits and, thus, readily applied onto soil. From the studied antimicrobials, the highest level of residues in stored manure was estimated for doxycycline (55% of the initial amount of doxycycline administered orally to pigs after six months of manure storage), as a combining result of its high use in pigs, low bioavailability and high stability in manure. Other antimicrobials (e.g. amoxicillin) are readily degraded and therefore pose less threat. The results of this study highlight the importance of rational antimicrobial use and of further research on pharmacokinetics of antimicrobials and their degraded products in different environmental compartments, to efficiently control the spread of residues and/or resistance genes from manure to these matrices.

Strategies to combat antimicrobial resistance: anti-plasmid and plasmid curing

Antimicrobial resistance (AMR) is a global problem hindering treatment of bacterial infections, rendering many aspects of modern medicine less effective. AMR genes (ARGs) are frequently located on plasmids, which are self-replicating elements of DNA. They are often transmissible between bacteria, and some have spread globally. Novel strategies to combat AMR are needed, and plasmid curing and anti-plasmid approaches could reduce ARG prevalence, and sensitise bacteria to antibiotics. We discuss the use of curing agents as laboratory tools including chemicals (e.g. detergents and intercalating agents), drugs used in medicine including ascorbic acid, psychotropic drugs (e.g. chlorpromazine), antibiotics (e.g. aminocoumarins, quinolones and rifampicin) and plant-derived compounds. Novel strategies are examined; these include conjugation inhibitors (e.g. TraE inhibitors, linoleic, oleic, 2-hexadecynoic and tanzawaic acids), systems designed around plasmid incompatibility, phages and CRISPR/Cas-based approaches. Currently, there is a general lack of in vivo curing options. This review highlights this important shortfall, which if filled could provide a promising mechanism to reduce ARG prevalence in humans and animals. Plasmid curing mechanisms which are not suitable for in vivo use could still prove important for reducing the global burden of AMR, as high levels of ARGs exist in the environment.

Antimicrobial Usage in Animal Production: A Review of the Literature with a Focus on Low- and Middle-Income Countries

Antimicrobial use (AMU) in animal production is a key contributor to antimicrobial resistance (AMR) worldwide. As consumption of animal protein and associated animal production is forecast to increase markedly over coming years in low- and middle-income countries (LMICs), accurate monitoring of AMU has become imperative. We summarized data from 89 scientific studies reporting AMU data in animal production published in English since 1998, identified through the 'ISI Web of Knowledge' search engine. The aims were as follows: (a) to describe methodologies and metrics used to quantify AMU; (b) to summarize qualitative (on-farm prevalence of use) and quantitative (amounts of antimicrobial active principle) data, in order to identify food animal species at the highest risk of AMU; and (c) to highlight data gaps from LMICs. Only 17/89 (19.1%) studies were conducted in LMICs. Sixty (67.3%) reported quantitative data use, with 'daily doses per animal-time' being the most common metric. AMU was greatest in chickens (138 doses/1000 animal-days [inter quartile range (IQR) 91.1⁻438.3]), followed by swine (40.2 [IQR 8.5⁻120.4]), and dairy cattle (10.0 [IQR 5.5⁻13.6]). However, per kg of meat produced, AMU was highest in swine, followed by chickens and cattle. Our review highlights a large deficit of data from LMICs, and provides a reference for comparison with further surveillance and research initiatives aiming to reduce AMU in animal production globally.

Risk Ranking of Antimicrobial-Resistant Hazards Found in Meat in Switzerland

Human exposure to bacteria resistant to antimicrobials and transfer of related genes is a complex issue and occurs, among other pathways, via meat consumption. In a context of limited resources, the prioritization of risk management activities is essential. Since the antimicrobial resistance (AMR) situation differs substantially between countries, prioritization should be country specific. The objective of this study was to develop a systematic and transparent framework to rank combinations of bacteria species resistant to selected antimicrobial classes found in meat, based on the risk they represent for public health in Switzerland. A risk assessment model from slaughter to consumption was developed following the Codex Alimentarius guidelines for risk analysis of foodborne AMR. Using data from the Swiss AMR monitoring program, 208 combinations of animal species/bacteria/antimicrobial classes were identified as relevant hazards. Exposure assessment and hazard characterization scores were developed and combined using multicriteria decision analysis. The effect of changing weights of scores was explored with sensitivity analysis. Attributing equal weights to each score, poultry-associated combinations represented the highest risk. In particular, contamination with extended-spectrum β-lactamase/plasmidic AmpC-producing Escherichia coli in poultry meat ranked high for both exposure and hazard characterization. Tetracycline- or macrolide-resistant Enterococcus spp., as well as fluoroquinolone- or macrolide-resistant Campylobacter jejuni, ranked among combinations with the highest risk. This study provides a basis for prioritizing future activities to mitigate the risk associated with foodborne AMR in Switzerland. A user-friendly version of the model was provided to risk managers; it can easily be adjusted to the constantly evolving knowledge on AMR.

Reliable estimation of antimicrobial use and its evolution between 2010 and 2013 in French swine farms

Background

There has been a strong implication of both the French swine industry and the national authorities on reducing the use of antimicrobials in swine production since 2010. The annual monitoring of antimicrobial sales by the French Veterinary Medicines Agency (Anses-ANMV) provides estimates but not detailed figures on actual on-farm usage of antimicrobials in swine production.

Results

In order to provide detailed information on the 2010 and 2013 antimicrobial use in the French swine industry, the methodology of cross-sectional retrospective study on a representative sample of at least 150 farms has been elected. The analysis of the collected data shows a strong and significant decrease in antimicrobial exposure of pigs between 2010 and 2013. Over three years, the average number of days of treatment significantly decreased by 29% in suckling piglets and by 19% in weaned piglets. In fattening pigs, the drop (− 29%) was not statistically significant. Only usage in sows did increase over that period (+ 17%, non-significant), which might be associated with the transition to group-housing of pregnant sows that took place at the time. Also, over that period, the use of third- and fourth generation cephalosporins in suckling piglets decreased by 89%, and by 82% in sows, which confirms that the voluntary moratorium on these classes of antimicrobials decided at the end of 2010 has been effectively implemented.

Conclusions

The methodology of random sampling of farms appears as a precise and robust tool to monitor antimicrobial use within a production animal species, able to fulfil industry and national authorities’ objectives and requirements to assess the outcome of concerted efforts on antimicrobial use reduction. It demonstrates that the use of antimicrobials decreased in the French swine industry between 2010 and 2013, including the classes considered as critical for human medicine.

Environmental Subconcussive Injury, Axonal Injury, and Chronic Traumatic Encephalopathy

Brain injury occurs in two phases: the initial injury itself and a secondary cascade of precise immune-based neurochemical events. The secondary phase is typically functional in nature and characterized by delayed axonal injury with more axonal disconnections occurring than in the initial phase. Axonal injury occurs across the spectrum of disease severity, with subconcussive injury, especially when repetitive, now considered capable of producing significant neurological damage consistent with axonal injury seen in clinically evident concussion, despite no observable symptoms. This review is the first to introduce the concept of environmental subconcussive injury (ESCI) and sets out how secondary brain damage from ESCI once past the juncture of microglial activation appears to follow the same neuron-damaging pathway as secondary brain damage from conventional brain injury. The immune response associated with ESCI is strikingly similar to that mounted after conventional concussion. Specifically, microglial activation is followed closely by glutamate and calcium flux, excitotoxicity, reactive oxygen species and reactive nitrogen species (RNS) generation, lipid peroxidation, and mitochondrial dysfunction and energy crisis. ESCI damage also occurs in two phases, with the primary damage coming from microbiome injury (due to microbiome-altering events) and secondary damage (axonal injury) from progressive secondary neurochemical events. The concept of ESCI and the underlying mechanisms have profound implications for the understanding of chronic traumatic encephalopathy (CTE) etiology because it has previously been suggested that repetitive axonal injury may be the primary CTE pathogenesis in susceptible individuals and it is best correlated with lifetime brain trauma load. Taken together, it appears that susceptibility to brain injury and downstream neurodegenerative diseases, such as CTE, can be conceptualized as a continuum of brain resilience. At one end is optimal resilience, capable of launching effective responses to injury with spontaneous recovery, and at the other end is diminished resilience with a compromised ability to respond and/or heal appropriately. Modulating factors such as one's total cumulative and synergistic brain trauma load, bioavailability of key nutrients needed for proper functioning of restorative metabolic pathways (specifically those involved in the deactivation and clearance of metabolic by-products of brain injury) are key to ultimately determining one's brain resilience.

Veterinary Expert Opinion on Potential Drivers and Opportunities for Changing Antimicrobial Usage Practices in Livestock in Denmark, Portugal, and Switzerland

Reducing antimicrobial use (AMU) in livestock is requested by Public Health authorities. Ideally, this should be achieved without jeopardizing production output or animal health and welfare. Thus, efficient measures must be identified and developed to target drivers of AMU. Veterinarians play a central role in the identification and implementation of such efficient interventions. Sixty-seven veterinarians with expertise in livestock production in Denmark, Portugal, and Switzerland participated in an expert opinion study aimed at investigating experiences and opinions of veterinarians about the driving forces and practices related to AMU in the main livestock sectors (broiler, dairy cattle, fattening/veal calf, and pig industry) of the aforementioned countries. Opinions on potential factors influencing the choice of antimicrobials and opportunities to reduce AMU were collected. Antibiograms are seldom used, mainly due to the time lag between testing and obtaining the results. The perceived percentage of treatment failures varied between countries and livestock sectors; however, little changes were reported over time (2005-2015). The animal health problems of each livestock sector most frequently leading to AMU did not vary substantially between countries. Mandatory official interventions (i.e., binding measures applied by national or international authorities) were highlighted as having the biggest impact on AMU. There was a variation in the experts' opinion regarding feasibility and impact of interventions both between countries and livestock sectors. Nevertheless, improved biosecurity and education of veterinarians frequently received high scores. Most veterinarians believed that AMU can be reduced. The median potential reduction estimates varied from 1% in Swiss broilers to 50% in Portuguese broilers and veal/fattening calves in all countries. We hypothesize that the differences in views could be related to disease epidemiology, animal husbandry, and socio-economic factors. A profound investigation of these disparities would provide the required knowledge for developing targeted strategies to tackle AMU and consequently resistance development. However, experts also agreed that mandatory official interventions could have the greatest impact on antimicrobial consumption. Furthermore, improvement of biosecurity and education of veterinarians, the use of zinc oxide (in pigs), improving vaccination strategies, and the creation of treatment plans were the measures considered to have the largest potential to reduce AMU. This paper can inform policymakers in Europe and countries with a similar animal production regarding their AMU policy.

Review of transmission routes of 24 infectious diseases preventable by biosecurity measures and comparison of the implementation of these measures in pig herds in six European countries

This study aimed to review the transmission routes of important infectious pig diseases and to translate these into biosecurity measures preventing or reducing the transmission between and within pig herds. Furthermore, it aimed to identify the level of implementation of these measures in different European countries and discuss the observed variations to identify potentials for improvement. First, a literature review was performed to show which direct and indirect transmission routes of 24 infectious pig diseases can be prevented through different biosecurity measures. Second, a quantitative analysis was performed using the Biocheck.UGent™, a risk-based scoring system to evaluate biosecurity in pig herds, to obtain an insight into the implementation of these biosecurity measures. The database contained farm-specific biosecurity data from 574 pig farms in Belgium, Denmark, France, Germany, the Netherlands and Sweden, entered between January 2014 and January 2016. Third, a qualitative analysis based on a review of literature and other relevant information resources was performed for every subcategory of internal and external biosecurity in the Biocheck.UGent™ questionnaire. The quantitative analysis indicated that at the level of internal, external and overall biosecurity, Denmark had a significantly distinct profile with higher external biosecurity scores and less variation than the rest of the countries. This is likely due to a widely used specific pathogen-free (SPF) system with extensive focus on biosecurity since 1971 in Denmark. However, the observed pattern may also be attributed to differences in data collection methods. The qualitative analysis identified differences in applied policies, legislation, disease status, pig farm density, farming culture and habits between countries that can be used for shaping country-specific biosecurity advice to attain improved prevention and control of important pig diseases in European pig farms.

ECDC, EFSA and EMA Joint Scientific Opinion on a list of outcome indicators as regards surveillance of antimicrobial resistance and antimicrobial consumption in humans and food-producing animals

ECDC, EFSA and EMA have jointly established a list of harmonised outcome indicators to assist EU Member States in assessing their progress in reducing the use of antimicrobials and antimicrobial resistance (AMR) in both humans and food-producing animals. The proposed indicators have been selected on the basis of data collected by Member States at the time of publication. For humans, the proposed indicators for antimicrobial consumption are: total consumption of antimicrobials (limited to antibacterials for systemic use), ratio of community consumption of certain classes of broad-spectrum to narrow-spectrum antimicrobials and consumption of selected broad-spectrum antimicrobials used in healthcare settings. The proposed indicators for AMR in humans are: meticillin-resistant Staphylococcus aureus and 3rd-generation cephalosporin-resistant Escherichia coli, Klebsiella pneumoniae resistant to aminoglycosides, fluoroquinolones and 3rd-generation cephalosporins, Streptococcus pneumoniae resistant to penicillin and S. pneumoniae resistant to macrolides, and K. pneumoniae resistant to carbapenems. For food-producing animals, indicators for antimicrobial consumption include: overall sales of veterinary antimicrobials, sales of 3rd- and 4th-generation cephalosporins, sales of quinolones and sales of polymyxins. Finally, proposed indicators for AMR in food-producing animals are: full susceptibility to a predefined panel of antimicrobials in E. coli, proportion of samples containing ESBL-/AmpC-producing E. coli, resistance to three or more antimicrobial classes in E. coli and resistance to ciprofloxacin in E. coli. For all sectors, the chosen indicators, which should be reconsidered at least every 5 years, are expected to be valid tools in monitoring antimicrobial consumption and AMR. With the exception of the proposed human AMR indicators, the indicators are in general not suitable to monitor the effects of targeted interventions in a specific sector, such as in a single animal species or animal production sector. Management decisions should never be based on these indicators alone but should take into account the underlying data and their analysis.

Real world data of a veterinary teaching hospital in Japan: a pilot survey of prescribed medicines

The prescription data from a digital accounting system of a veterinary teaching hospital collected between 2008 and 2011 in Japan were downloaded, stored in a database and analysed using a statistical analysis software, SAS. Seventy-six per cent of all prescriptions were drugs approved for human beings. The most frequently prescribed category was 'Agents against pathogenic organisms', such as antibiotics and chemotherapeutic agents, followed by 'Cardiovascular agents'. Seventy-five per cent of prescribed oral formulations in the category 'Agents against pathogenic organisms' were drugs approved for human beings, while 78 per cent of the injectable prescriptions were those for veterinary. A total of 36 oral antipathogenic products were prescribed, and among them amoxicillin was prescribed the most, followed by cephalexin for human beings and enrofloxacin for veterinary. The pattern of cyclosporin prescription, which is the most prescribed product other than 'Agents against pathogenic organisms', was surveyed. The capsule formulation was primarily used for dogs, while oral solutions were preferably used for cats. This pilot study is the first analytical data of real prescription in hospitals in Japan and one of the longest surveys in veterinary world.

Comparison of Antimicrobial Consumption Patterns in the Swiss and Danish Cattle and Swine Production (2007-2013)

Veterinary antimicrobial consumption patterns vary considerably across Europe. These differences are not only limited to the total amount consumed but are also observed with regards to the relative proportion of the various antimicrobial classes used. Currently, most of the data on veterinary antimicrobials are reported at sales level without any information on the consumption by different animal species. This hinders a proper comparison of antimicrobial consumption at the species level between countries. However, it is imperative to improve our understanding on antimicrobial usage patterns at the species level, as well as on the drivers contributing to those differences. This will allow for development of tailored interventions with the lowest possible risk for human health, while ensuring effective treatment of diseased livestock. An important step to attain such an objective is to perform detailed comparisons of the antimicrobial consumption in each species between countries. We compared antimicrobial consumption estimates for cattle and pigs in Switzerland and Denmark, in order to distinguish species-specific patterns and trends in consumption from 2007 to 2013. Swiss data were obtained from a previous study that assessed methodologies to stratify antimicrobial sales per species; Danish antimicrobial consumption estimates were assembled from Danish Integrated Antimicrobial Resistance Monitoring and Research Programme reports. A decrease in antimicrobial consumption in milligrams per kilogram of biomass was observed for both countries (4.5% in Denmark and 34.7% in Switzerland) when comparing 2013 to 2007. For pigs and cattle, the overall consumption per kilogram of biomass of most antimicrobial classes was higher in Switzerland than in Denmark. Large variations in the relative consumption of different antimicrobial classes were also evident. Sulfonamides/trimethoprim and tetracyclines were consumed in a higher proportion in Switzerland than in Denmark, whereas the relative consumption of penicillins was higher in Denmark. The differences observed in veterinary antimicrobial consumption are not solely related to animal demographic characteristics in these two countries. Other factors, such as the level of biosecurity and farming practices, veterinarians and farmers’ education, or governmental/industry programs put in place might also partly explain these variations. These differences should be taken into account when aiming to implement targeted interventions to reduce antimicrobial consumption.