Dr. Jeff Bender - One Health Antibiotic Stewardship Science and Practice - What are the Major Gaps in Knowledge or Translation? How Do We Find the Answers to What We Don't Know?
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One Health Antibiotic Stewardship Science and Practice - What are the Major Gaps in Knowledge or Translation? How Do We Find the Answers to What We Don't Know? - Dr. Kerry Keffaber, Chief Veterinarian, Scientific Affairs and Policy, Elanco Animal Health; Dr. Jeff Bender, Professor, Environmental Sciences, University of Minnesota; Dr. Nora Schrag, Clinical Assistant Professor/Agricultural Practices, Kansas State University; Mr. Joe Swedberg, Chairman of the Board, Farm Foundation, Hormel Foods Corporation (retired); Dr. David G. White, Associate Dean for Research, University of Tennessee Institute of Agriculture, from the 2017 NIAA Antibiotic Symposium - Antibiotic Stewardship: Collaborative Strategy for Animal Agriculture and Human Health, October 31 - November 2, 2017, Herndon, Virginia, USA. More presentations at http://www.swinecast.com/2017-niaa-antibiotic-symposium-antibiotic-stewardship
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Dr. Jeff Bender - One Health Antibiotic Stewardship Science and Practice - What are the Major Gaps in Knowledge or Translation? How Do We Find the Answers to What We Don't Know?
- 1. Science and Practice Gaps in Knowledge/Translation How Do We Find the Answers to What We Don't Know? Jeff Bender DVM, MS DACVPM University of Minnesota School of Public Health and College of Veterinary Medicine bende002@umn.edu
- 2. Overview • View from a hospital epidemiologist and a public health veterinarian – Infection control/prevention and biosecurity – Antimicrobial use – Stewardship programs – Education and outreach – Global policies
- 3. Clinically related Staphylococcus sp. identified through the Dermatology Service University of Minnesota VMC, 2008-2014 0 5 10 15 20 25 30 35 40 45 50 MRSP MRSS MRSA 2008 2009 2010 2011 2012 2013 2014 Number
- 4. Infection Prevention/Control • What are best practices to prevent infections? • Support for clinical decision making? – When to treat? – How long to treat? – What to treat with?
- 5. Antibiotic Use and Clinical Practice Guidelines • International Society for Companion Animal Diseases • Consensus • Global expertise
- 6. Antibiotic Usage in Alignment with Recommendations? • 67% of non-recurrent UTI and 44% of recurrent UTI received guideline recommended antibiotics • 80% of URI and 22% of bronchitis episodes were treated according to guidelines
- 7. Needed Supporting Materials for Clinicians • Development and evaluation of rapid diagnostic tests • Regional antibiograms • Best practices for improved biosecurity/infection control • Supporting clinical tests – Procalcitonin tests in humans
- 8. Antimicrobial Stewardship • Antimicrobial stewardship is the commitment to reducing the need for antimicrobial drugs by preventing infectious disease in cattle, and when antimicrobial drugs are needed, a commitment that antimicrobials are used appropriately to optimize health and minimize selection of antimicrobial resistance http://www.aabp.org/resources/AABP_Guidelines/AntimicrobialStewardship-7.27.17.pdf
- 9. Core Elements for a Companion Animal Stewardship Program • Clinic/practice commitment • Responsibility and authority • Implementing actions to improve antibiotic use • Surveillance: tracking, monitoring and measurable outcomes • Resources and education From AVMA Task Force on Companion Animal Stewardship
- 10. Antimicrobial Stewardship Programs • Which practices work? • What is the impact on patient health? • Economics – is it cost effective? • Need to monitor and evaluate interventions
- 11. Education and Outreach • Web-based training modules – Species specific/Case-based ( http://amrls.umn.edu/ – USDA – accreditation modules • AVMA client focused materials • Public education!
- 12. Global Policies • “Need to discover new antibiotics and alternative therapies…and commit resources on preserving effectiveness of existing antibiotics by reducing inappropriate use” (Prof Dame Sally Davies, Chief Medical Officer for England)
- 13. Annual Estimates of Death Attributable to AMR by 2050 amr-review.org/sites/default/files/World_Map.jpg
- 14. AMR National Action Plans (NAPs) • 85% of countries are developing or have developed NAPs • 52% of countries have developed a plan that addresses the One Health spectrum of animal, human, and environmental sectors • 52% of LMICs have national level measures in place on infection prevention and control in human healthcare, but just 7% have national surveillance systems for AMR in animals and food Wellcome.ac.uk/DRI
- 15. Global Research Needs • Harmonization of laboratory techniques • Evaluation of the impact of national programs • Document current antimicrobial use and resistance in countries with few resources and limited data • Monitor implementation of education and outreach to producers/farmers
- 16. Summary • Antimicrobial resistance continues to be a “Grand Challenge” • A Global challenge • Need to apply practical interventions • Evaluate programs • Identify best practices • Develop key communication messages to practitioners, clients, and the public
Notes de l'éditeur
- Good Morning. Thanks to the organizing committee for the invitation. I was asked to talk about “gaps in knowledge and translation”. I’ll focus on the translation piece reflecting my bias. The second part of the question was the “how do we find answers” and will let the panel wrestle with this topic after our presentations
- First my bias…I was the hospital epidemiologist for our teaching hospital and also am a public health veterinarian. I enjoyed pondering this question of knowledge and translation needs. Five items came to mind. Infection control/prevention, antibiotic use, stewardship programs, education and outreach and global policies.
- As a hospital epidemiologist, I would look at clinical isolates wondering why we were seeing a change in resistance and also wondering about environmental contamination and potential hospital acquired infections. This chart represents an increasing trend of MDR Staph and the potential environmental persistence of some of these organisms.
- Which leads to the next area…Infection Prevention and Control. This is an area where we clearly need more research and translation, both in production animals and companion animals. We need evidenced based best practices. What is the best way to clean endoscopes? How do we handle the new technologies that might be used to keep a patient warm in the surgery suite yet are blowing warm air over the patient? We also need support for clinical decision making. When do we treat? For how long? And with what? In veterinary medicine we have little information to provide guidance. In human medicine, shorter duration therapy has been documented to be as good vs. longer therapy. There are treatment guidelines for a number of clinical situations such as sepsis, ear infection, bronchitis…from with clinical trials. There are trials in human medicine documenting when (at what time) you should administer pre-operative antibiotics. In veterinary medicine this data is sparse or done on small samples of animals.
- This leads to the discussion about appropriate use. As mentioned in human medicine we have a number of clinical guidance documents. This is limited in veterinary medicine. Here are 3 developed by the ISCAID…one on superficial bacterial folliculitis (pyoderma) in dogs, UTI, and respiratory tract infections. These were done by consensus, with limited data and much debate. We need more of these and they should drive our research agenda to know when and which abx to administer for the optimum care of the patient.
- We also need research looking at the social science of why we do what we do. Recently Banfield asked their practitioners how they handle certain cases. They weighed the responses to the clinical guidance documents. What they discovered was that 67% of non-recurrent UTI and 44% of recurrent UTI received guideline recommended antibiotics. That’s pretty good unless you flip around the findings…to say that 33% of non-recurrent UTI and 56% of recurrent UTI did not receive the recommended antibiotics. Similarily, 80% of URI and 22% of bronchitis episodes were treated according to published guidelines. This is similar to what Dr. Lynfield pointed out yesterday from Minnesota. We need to be measuring these…and facilitating a discussion of why and how to improve compliance.
- We need tools that will help with clinical decision making. This includes the development and evaluation of rapid diagnostic tests., regional antibiograms, established best practices for improved biosecurity and infection control, and supporting clinical tests that may indicate that an infection is actually bacterial….such as the procalcitonin test used in human medicine.
- The next area for translation research is under the evolving topic of antimicrobial stewardship in veterinary medicine. I was pleased to see that the AABP came out with the Antimicrobial stewardship guidance document. Their proposed definition is ….
- There have been attempts to develop stewardship programs. These need to be tailored for individual practices in a variety of settings. These mirror the human stewardship programs but likely are not completely transferrable. The include… Part of what’s needed is to recognize that a “bundled” approach, using a number of different interventions is needed to limit disease spread.
- With stewardship programs we need to ask which practices work? Which do not? Do these practices have an impact on patient health or outcomes. What are the economics of these interventions? How do we monitor and evaluate stewardship interventions? These are difficult translation type studies but need to be done.
- From the standpoint of education and outreach. How do we measure acquisition of knowledge and change of practice. There are new educational tools…are these changing practices. How can create client focused materials to help communicate that antimicrobials may not be needed. How can we create public education campaigns and messages?
- The last topic relates to my most recent work on global workforce development. In a recent report from Wellcome Trust Prof Davies said that …
- In that same report that cited the annual estimates of Deaths attributed to AMR by 2050. We can debate the merits of the numbers but what I want to point out is where the impacts are cited to be the greatest. Note Africa and Asia as having the highest rates. Large vulnerable populations with limited resources. These are the same countries with limited surveillance and programs to detect, respond, and prevent infections.
- In fact when you look at which countries have responded to the call to develop NAPs. 85% of …. Note that the animal and environmental sectors in low and middle income countries do not have plans. Then we need to ask are these the correct and the best plans to reduce or control AMR infections?
- On this global scale, we need to harmonize lab techs, evaluate these developing NAP, document current AMU and AMR, and evaluate our educational efforts in these countries. We recently did a survey of awareness of veterinary students regarding AMR in chiang Mai Thailand…their responses were similar to our U MN students regarding their awareness/perception of the risk and role of companion animal abx use contributing to resistance.
- So in summary. AMR is a grand challenge….a global challenge We need to apply practical interventions We need to evaluate those interventions We need to identify best practices We need to develop key communication messages