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Why does antimicrobial stewardship matter and who is responsible?

David Tisdall talks about the reasons why AMS matters, and who's responsibility this is.
And really, we want to wrestle together with the idea of why antimicrobial stewardship matters. And ultimately, who is responsible for antimicrobial stewardship? Now, I’ve tried to pull together some of the different reasons why antimicrobial stewardship really matters. And the first is really surrounding the whole one-health idea and antimicrobial resistance. It’s something that we all have a stake in solving. And it’s something that we’re all responsible for preventing. And the actions that we can take as veterinary practitioners can have a very real effect on human health. And so we need to take ownership of that challenge. Antimicrobial resistance is clearly a growing problem. And there’s a whole range of reasons why that emerges. Yes, inappropriate prescribing is a real key problem.
And that’s important because it’s ultimately the total antimicrobial use that drives antimicrobial resistance developments. The more we prescribe– in fact, every time we make a prescribing decision to administer antimicrobials– we’re contributing to a selection for antimicrobial resistance. And sometimes, that selection pressure isn’t just for the antimicrobial we’re using. But we might inadvertently be driving resistance to other classes through the phenomenon of co-selection of resistance. And antimicrobial resistance becomes even more important when we’re talking about critically important antimicrobials and those of highest priority. They’re really the drugs of last resort. They’re the medicines we use to treat resistant infections.
And prescribing in veterinary practice has the potential to drive development of resistance to critically important antimicrobials, which may have an impact on human health. It’s important to say that by far and away, the biggest driver of antimicrobial resistance in human health care is prescribing in human health care. And as part of this course, we’re offering a perspective of a human health care practitioner, who’ll be speaking to you about some of the ways that they’re tackling AMR. And I think that will be really useful and insightful. But although the veterinary contribution to antimicrobial resistance in human health is relatively small, that doesn’t mean it’s not important. And it’s definitely something that we need to take ownership for and address.
There’s the challenge that actually, antimicrobial development has stalled. There haven’t really been any new classes of antimicrobials from the 1980s. And that means we’ve got a gradually reducing armoury of medicines that we can use to fight some of these resistance infections. And so we need to be really careful to preserve the resources that we do have. For patients to die of an untreatable infection in human health care because of antimicrobial resistance is becoming an increasingly common problem. And we don’t see that as much in veterinary practice, but it is there. And if we don’t continue to be good stewards of antimicrobials, if we don’t improve our stewardship, then we’ll only continue to progress in that direction.
Antimicrobial stewardship matters from a perspective of food security.
If you’re a production animal vet, then you’re working with the food supply chain. And actually, there’s a responsibility there for thinking about residue limits, withdrawal periods, the efficiency of production, and how antimicrobial use can relate to that. And then there are economic and industry pressures that have a role to play, here.
The challenge of making sure we’re prescribing, rather than simply dispensing, antimicrobials. Particularly when antimicrobials might be used to prop up a management system that would otherwise be less efficient. Or perhaps it’s more cost effective to prescribe and treat than not to do so. And finally, there are global and local political and social issues that influence antimicrobial stewardship, that put it right at the top of the political agenda. So antimicrobial stewardship really matters for all these reasons, and many more that I haven’t been able to talk about. If we’re all agreed that it matters, then actually where does the responsibility land for that? Now, there is a very good correlation between antimicrobial use and antimicrobial resistance.
But this was a study looking at the correlation between veterinary antimicrobial use and antimicrobial resistance in food-producing animals. Most particularly, looking at antimicrobial resistance in E. coli isolates. And you can see that there is a very strong correlation between increasing antimicrobial use along the x-axis and increasing antimicrobial resistance ranking on the y-axis. So the message here is that using more antimicrobials is ultimately going to create more antimicrobial resistance. But who’s responsible for that? Well, in one sense, I suppose, it’s all of us, isn’t it? This is a global problem. And globally, we all need to take ownership of our part in that.
Whether that’s when we’re going as a patient to our GP, when we go and see a doctor and we’re not well– maybe we’ve got flu or something like that– we need to make sure that we’re not pushing general practitioners to prescribe antimicrobials to us.
Or perhaps it’s when we’re in our consulting room. When we’re on the other side of the table, as it were, and we’re making that prescribing decision. And there’s a concerned owner there with their pet, who is very poorly.
How do we take ownership of antimicrobial stewardship in that context? Is it the vet or is it the owner who is responsible?
Or perhaps it’s in the decisions that we make about where we buy our food from, or about whether we engage in preventative health care programmes for our pets, or about whether we choose to have our children vaccinated, or about the way we speak to our students.
So in some senses, actually, everyone is responsible for this.
But in fact, I think as vets, we have a unique and important responsibility, one that we really need to take ownership of. Because ultimately, as vets in the UK, we are the gatekeepers. The only reason an antimicrobial might end up on a farm or on an equine yard or going home with a small animal pet owner is because a vet has prescribed that antimicrobial. And we need to take ownership of that responsibility. Just because an animal owner might be administering that antimicrobial, and they might be doing it in our absence, doesn’t mean that we’re not responsible. This is a real opportunity for vets to seize the agenda, here.
To drive forward with a proactive approach to health care and an agenda for preventative medicine, a push towards client education. We have the potential to have a really transformational impact in the practice of our clients, who by and large trust us greatly and respect the advice and guidance that we give. We have a real potential to motivate change, here. But actually, we have a clear responsibility to do so. And as we do have that gatekeeping role, we must stand up and take ownership of that. Hopefully, as you go through this course, you will come up with some ideas of where you can stand, of where you can take ownership of your responsibility for antimicrobial stewardship within your local context.

Now you have thought about what AMS means to you in step 1.3, David Tisdall will discuss why it matters and who is responsible for it, in this video.

His main ideas on why AMS is important are summarised below:

  • Antimicrobial resistance (AMR) is a true One Health problem, which can have a very real effect on human and animal health, and the environment.
  • The main driver for AMR development is total antimicrobial use and good AMS will help reduce excessive and inappropriate prescribing.
  • Resistant bacteria and the mechanisms of resistance are able to transfer between human and animal populations.
  • Antimicrobial development has slowed, so there are no new classes available to treat resistant infections.
  • Morbidity and mortality due to antimicrobial resistant bacteria is already a very serious problem in human healthcare and a growing one in veterinary medicine.
  • Food security – how antimicrobial use can relate to efficacy of food production.
  • It is a local and global issue, affecting everyone.

Who is responsible?

In a sense, everyone is responsible. From our choice in food sources, to our expectations of our GPs to provide us with antibiotics, to our own prescribing decisions; because it is a global problem, we all have to take ownership for our part in it.

However, vets have a unique and important responsibility, in their role as gatekeepers of antimicrobials in animal health. The only reason an antibiotic could be found on a farm, in an equine practice or with a small animal owner, is through vets. It is important to ensure we are prescribing responsibly, not just dispensing. This is part of good AMS. Over the rest of the course, you will explore ways to play your part in improving AMS within your local context to help tackle this global problem.

For further reading, please see the links in the see also and downloads sections. Use the comments section to discuss your views on where the responsibility for AMS lies. Why do you think what you do?

Please find a downloadable copy of the PowerPoint slides used in the video in the downloads section below.

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Antimicrobial Stewardship in Veterinary Practice

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