Minnesota takes ‘One Health’ approach to antibiotic management

Minnesota has launched a comprehensive, multi-faceted plan to combat the rise in drug-resistant bacteria and promote antibiotic stewardship. State officials hope the effort can break down some of the tensions between human and animal health experts over antibiotic use and become a model for addressing the emerging public health crisis.

The five-year plan, released in early July, calls on the Minnesota Departments of Health and Agriculture, along with the Animal Health Council and the Minnesota Pollution Control Agency (MPCA), to work together to promote the judicious use of antibiotics in humans and animals and get a better idea of ​​how antibiotic use affects environmental health. The idea of ​​having the four agencies work on the issue is based on the One Health concept, which views the health of humans, animals and the environment as interdependent.

The plan has four main objectives:

  • Promote a better understanding of the responsible management of One Health antibiotics in all disciplines
  • Improving Human Antibiotic Stewardship Efforts
  • Strengthen the responsible management of antibiotics in animal health
  • Develop an antibiotic “fingerprint” tool to assess the persistence of antibiotics in the environment

The idea is that the plan will help guide all parties involved in promoting the wise use of antibiotics, from government agencies to health systems to animal health and agricultural associations.

According to Minnesota state epidemiologist Ruth Lynfield, MD, the plan is an acknowledgment that human and animal health experts, as well as agriculture officials, must work together to combat rising drug resistance, which is fueled in part by the misuse and overuse of antibiotics. The Centers for Disease Control and Prevention (CDC) estimate that antibiotic-resistant bacteria cause 2 million illnesses and 23,000 deaths annually.

Take a holistic approach

“I think we understand that we need to take a holistic approach to antibiotic management, and to be more effective, we really need to work together across disciplines,” Lynfield said. “We’ve been talking about this for quite a long time, and I don’t feel like we’ve made enough progress or traction, so we thought, ‘Well, let’s take a broader approach. “”

The problem of misuse and overuse of antibiotics in human health is well documented. According to a recent study published in JAMA According to the CDC, at least 30% of antibiotics prescribed in ambulatory care settings in the United States (approximately 47 million prescriptions) are unnecessary and driven largely by overdiagnosis.

“Prescribing an antibiotic” just in case “there is an infection is done every day in every hospital and outpatient clinic,” says Debbie Goff, PharmD, an infectious disease specialist at Ohio State University Medical Center, where she is part of the antibiotic management team. The risk that this type of over-prescription creates superbugs or leads to Clostridium difficile infections, says Goff, cannot be overstated.

Patient expectations, as well as confusion about how antibiotics work and antibiotic resistance, also play a role. A recent survey of nearly 10,000 people in 12 countries by the World Health Organization found that 64% think antibiotics can be used to treat colds or flu, even though antibiotics don’t work against them. viruses. More than three-quarters of respondents believed that antibiotic resistance occurs when a person’s or animal’s body becomes resistant to antibiotics.

“There’s a lot of work we need to do on the human side,” observes Lynfield.

Microbes do not discriminate

But many public health officials say there is just as much work to be done on the food production side, where the use of medically important growth-promoting drugs has been commonplace for decades. Data from the Food and Drug Administration indicates that of the antibiotics sold in the United States in 2009 for people and farm animals, nearly 80% were used for livestock and poultry.

This is exactly why a broader approach is needed, says Laura Kahn, MD, MPH, a researcher at Princeton University and author of the new book. One Health and the Politics of Antimicrobial Resistance. “We tend to focus only on humans,” Kahn says. “But microbes do not recognize a distinction [between humans and animals]so neither should we.”

The Netherlands is a country that is trying out the One Health approach. According to a recent article by BMJ, the Netherlands currently has one of the lowest levels of antimicrobial resistance in the world. Dutch health officials attribute this to a dual focus on antibiotic management in humans and agriculture. Under the Dutch One Health plan, doctors and farmers aim to halve the use of antibiotics.

“If we want to control a problem in the field of health, we must act wherever antibiotics are used,” said Dik Mevius, head of the National Reference Laboratory for Antimicrobial Resistance in Animals at the Central Veterinary Institute. from Wageningen University. BMJ.

In June, the 28 countries of the European Union agreed to launch national antimicrobial resistance plans based on a One Health model by the middle of next year.

Go beyond finger pointing

In the United States, however, bringing human health and animal agriculture officials together to address antibiotic stewardship has not been easy, as livestock producers feel they have been unfairly accused of having fueled drug resistance. That’s why what Minnesota is doing is so encouraging, says Nicole Neeser, DVM, who heads the Dairy and Meat Inspection Division of the Minnesota Department of Agriculture and represented the department in creating plan.

“Every time we have a collaborative effort like this, people in the animal agriculture industry get very nervous about whether this is going to be another one of those finger-pointing exercises, or can we to actually be productive and talk about things that we are doing and can do to address this issue in a productive way,” Neeser says. “I think this effort has been a lot more collaborative than what we’ve seen in the past.”

Goff thinks that kind of collaboration is essential. “If there is a willingness to listen and learn from each other and not point fingers, One Health teams can be key in the fight against antibiotic resistance,” she says.

Neeser says that under the plan, animal health experts and agriculture industry officials in Minnesota will continue to build on the tools and systems they have in place to help livestock producers use antibiotics more sensibly, such as inspection programs for antibiotic residues in meat and dairy products. She also believes the Veterinary Foods Directive (VFD), which will prevent the use of antibiotics approved for humans and animals for growth promotion purposes and require veterinary oversight for therapeutic purposes, will have an impact. significant. The new VFD rules will come into effect in January 2017.

On the human health side, one of the objectives is to create tools allowing healthcare establishments to follow the prescription of antibiotics. With these tools in place, the state hopes to develop antibiotic stewardship goals specific to different syndromes and different healthcare settings, as well as a tiered honor roll system to recognize healthcare systems that achieve these goals.

“Management is going to be different at different facilities,” says Lynfield, noting that not all health facilities will have the staff to devote to tracking antibiotic use and enforcing management guidelines.

But while Lynfield recognizes the need to create guidelines and benchmarks for the human healthcare system, she says they won’t make a difference unless healthcare institutions have senior leaders committed to management of antibiotics, as well as the resources needed to make management sustainable.

Gof agrees. “It’s not enough to ask antibiotic prescribers to do better,” she says.

Antibiotic resistance in the environment

The element of the plan that Lynfield is most excited about is the idea of ​​developing a way to measure the state’s antibiotic footprint. “It’s really based on the idea of ​​a carbon footprint,” she says. “We want to propose a mechanism that takes into account the persistence of an antibiotic in the environment.”

The tool would allow the state to measure the impact of antibiotics on the environment (soil, groundwater, and surface water) and determine which classes of antibiotics hang around longer than others. Research on this aspect of antibiotic use has been sparse, Lynfield says, but antibiotics have been detected in the environment. For example, a 2014 survey by the US Geological Survey and the MPCA found the antibiotic sulfamethoxazole to be the most commonly detected contaminant in groundwater in urban areas of the state.

And that’s a major problem, according to Kahn, because resistance genes, now persistent in manure and sewage due to overuse in humans and animals, are also starting to show up in the soil. “By throwing all these antibiotics into the environment, we’ve changed the environment in ways that we don’t understand.”

State officials say forming the plan is just the start of the process. At the moment, the plan lacks benchmarks for antibiotic reduction and focuses on collecting data and assessing the human and animal health landscape. Over the next two years, working groups will meet quarterly to set reasonable goals and review progress.

See also:

One Health Minnesota Antibiotic Stewardship Collaborative Five-Year Strategic Plan

May 4 CIDRAP report: “Study: 30% of outpatient antibiotic prescriptions unnecessary”

November 2015 WHO multi-country survey on antibiotic resistance

August 3 BMJ story about responsible antibiotic stewardship in the Netherlands

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