Antibiotic Guardian Leeds Workshop

Welcome to Antibiotic Guardian Leeds
#antibioticguardian

Introduction to AMR
Event Chair
Dr Diane Ashiru-Oredope, Pharmacist Lead, Public
Health England

Developed by Public Health England
Why attend?
• Gain guidance on effective prescribing methods
• Hear the latest information on antimicrobial stewardship from leading experts
• Collaborate with fellow health professionals
• Receive resources to promote Antibiotic Stewardship in your workplace
Educational Roadshow Series
October 29th- Leeds
November 18th- Birmingham
February 24th-London
3 AMR: #AntibioticGuardian Roadshow Dr Diane Ashiru-Oredope

The importance of
antimicrobial stewardship
Jonathan Cooke
Imperial College London and
University of Manchester
j.cooke@imperial.ac.uk
jonathan.cooke@manchester.ac.uk
29/10/2015

Burden of AMR – O’Neill 2014
NOW
• At least 50,000 Deaths a year In EU and US
• € 1.5 billion cost in EU
2050
• 10 million deaths
• US$100 trillion effect on World GDP29/10/2015

Lancet ID October 15th 2015
Antibiotic Resistant bacteria found in up to
• 50·9% of pathogens causing surgical site
infections
• 26·8% of pathogens causing infections after
chemotherapy
• A 30% reduction in the efficacy of antibiotic
prophylaxis for these procedures would result in
up to 280,000 additional surgical site infections
and infections after chemotherapy
• Up to additional 15,000 deaths a year
29/10/2015

• There is a direct relationship
between antibiotic use and
development of resistance.
• If antibiotics use is reduced then
resistance will fall
Antibiotic Resistance and Antibiotic Use
29/10/2015

“We should consider adopting
any practice that reduces the
unnecessary use of
antimicrobials”
29/10/2015

• Megraj room, 1st floor, Commonwealth
Building, Hammersmith Campus, W12 0NN
29/10/2015

What is antimicrobial stewardship?
MACRO
• Policy
• Strategy
• Formularies, Guidelines, Policies
• Education
• Audits
• Research
MICRO
• Diagnostics - Sensitivity testing, CRP, WCC, CURB etc
• Prescribing
• Administration
• Monitoring – TDM, pK etc
• Communication
29/10/2015

UK Five-Year Antimicrobial
Resistance Strategy 2013 to 2018
3 strategic aims:
• Improve the knowledge and understanding of
AMR
• Conserve and steward the effectiveness of
existing treatments
• Stimulate the development of new antibiotics,
diagnostics and novel therapies
29/10/2015

Hospital Initiatives
29/10/2015

Antimicrobial Stewardship PEAS Criteria
• Patients and Personnel
• Education –
Competencies, Knowledge,
Communication
• Audits – Feedback, Change
management, DDDs, PPS
Surveillance, Clinical Outcomes
• Standards – evidence-based
Guidelines, Policies, Formularies, Safety
29/10/2015

Dryden M. Goddard C. Madadi A. Heard M. Saeed K. Cooke J. Bioengineered Surgihoney as an antimicrobial wound
dressing to prevent Caesarean wound infection: a clinical and cost-effectiveness study.
British Journal of Midwifery 2014;22:23–7
29/10/2015

• 60% Reduction in SSI
• Reduction in antibiotic use
• Reduction in duration of stay
• Reduction in costs
Dryden et al BJM 2014, 22:23-27
29/10/2015

General Practice
prescribes 80%
of all antibiotics
29/10/2015

New Antibiotics
New Diagnostics
29/10/2015

POC CRP testing in GP practices
• Significant reduction in antibiotic
prescribing at consultation
• Reduction in total antibiotic use
- up to 42% reduction
• Increase in patient satisfaction
29/10/2015

• Megraj room, 1st floor, Commonwealth
Building, Hammersmith Campus, W12 0NN
CRP POCT wide extent
CRP POCT some extent
29/10/2015

Thank You
Any Questions?
29/10/2015

Antibiotics Stewardship – Sharing
knowledge in community
Umesh Patel
Board Member
National Pharmacy Association

Introduction
Antibiotic resistance
 Driven by over-use and
inappropriate use
 Inadequate compliance
 80-90 per cent antibiotics
prescribed in primary care
 Control antibiotic use in
secondary care to prevent
healthcare associated
infections
A major global public
health issue
Human and animal
sectors in UK

History – pathway of resistance
Antibiotic Year introduced Year resistance
observed
Sulfonamides 1935 1940
Penicillin G 1942 1945
Streptomycin 1944 1958
Tetracycline 1948 1954
Erythromycin 1952 1983
Vancomycin 1955 1982
Cephalosporins 1964 1969
Quinolones 1967 1969
Carbapenems 1985 1998
Ciprofloxacin 1987 1990
Linezolid 2000 2003
Telithromycin 2003 2004

What is antibiotic stewardship?
 Ensure patients receive
optimal therapy
 Prevent overuse, misuse and
abuse of antimicrobials
 Minimise risk of antimicrobial
resistance (patient and community)

The UK strategy 2013 - 2018
Annual
report of the
Chief Medical
Officer
March 2013
 Five year plan 2013-
2018
 Developed by experts
 Optimal use of
antibiotics
 Risk of cross
infection minimised
 Imported bacteria
tackled
 Development of new
antibacterials

Antibiotic Guardian
Launched in September 2014
Anyone can become a guardian
including members of the public
Supported by the NPA
The Goal is to reach 100,000 – register
online

‘TARGET’ and ‘Start Smart then Focus’
• Evidence of infection
• Local guidelines
• Document clearly
• Culture prior to
treatment
• Single doses for
prophylaxis prior to
surgery
Guidance for
prescribing
antimicrobial
TARGET

Factors influencing antimicrobial
resistance
Over-use of antibiotics
Taking antibiotics inappropriate
Inappropriate use of antibiotics
Broad-spectrum antibiotics
used instead of narrow
spectrum
Allergies not investigated

Global impact of Antibiotic resistance
• Human impact – If not tackled 10 million extra deaths per
year globally from drug-resistant infections by 2050
 Greater than the deaths projected by cancer
 EU figure – 25,000 deaths in Europe each year
• Financial impact – Economic cost projected to $100
TRILLION (£65 trillion) in lost output
 More than the size of currently world economy
 Approx equivalent to 30 years of UK economy output
EU cost – €1.5 billion / yr - cost of healthcare expense and
lost productivity

Antibiotic Guardian; pledges from
pharmacists
•I will check that antibiotic prescriptions comply with local
guidance and query those that do not
•Every time a customer presents with a self-limiting
respiratory infection I will use the patient information leaflet
to explain the potential duration of illness and how to treat
their symptoms available at:
http://bit.ly/TARGET_patient_leaflets

How can the community pharmacist contribute in
the fight against antimicrobial resistance?
Advising on self-limiting conditions:
 Respiratory tract infections
 Urinary tract symptoms
 Eye conditions

 Respiratory tract infections
•Self limiting (up to two
weeks)
•Viral - antibiotics ineffective
•Rest, OTC analgesics, fluids
•Decongestants and cough
medicines
•Refer if worsening
symptoms or persists for
more than two weeks
•Refer if serious symptoms

 Urinary tract symptoms
•Not always a bacterial infection
•Mild infections in women self limiting;
dipstick test helps prescribing decision
•Moderate to severe infections in women
offer antibiotics, without dipstick test
•Culture if persistent, recurrent
infections or complications
•Refer men and children
•OTC analgesics, fluid, rest, cranberry
products for recurrent infections

 Eye conditions
•Infective (bacterial or viral)
or irritant
•Infective conditions usually
self limiting (1-2 weeks)
•Treat if more than 2 weeks
•Lubricant eye drops for
discomfort
•Good eye hygiene

Advising on self-limiting
conditions: how would you
respond?
• Coloured sputum
Cough
• Purchasing urine test strips
Urinary tract infections
• Advance sales
Eye infections

qds
 Patient counselling:
 When/how to take medicines
 Adverse effects
 Interactions
tds
pc
ac
om
prn
hs
Medicines optimisation

 Patient counselling (cont):
Antibiotics should not be:
Purchased whilst
on holiday abroad
Purchased over the
internet
Shared with
family/friends

Help
with
health
costs
HC1
1
NHS
Antibiotics
not
prescribed
 Managing patient expectations:
Pharmacist advice:
 Infections usually
viral
 Symptomatic relief
with over-the-counter
medicines
 Seasonal influenza
vaccine uptake
 Lifestyle advice

 The NHS Community Pharmacy Contract
NHS
Community
Pharmacy
Contract
Promotion
of healthy
lifestyles
Campaigns
Signposting
Premises
standards

 Relationships with local prescribers
Local
prescribing
guidelines
Help
with
health
costs
HC1
1
NHS
 Avoiding broad-spectrum
antibiotics
 Using narrow-spectrum
antibiotics
 Lowest effective dose
Shortest duration of time
From LAT

 Repeat prescriptions for antibiotics
Help
with
health
costs
HC1
1
NHS
•Increase risk of AAD/CDAD
•MUR eligibility
•Counselling on minor/major
side-effects
•Guidance on when to start
the course
•Reminder to complete the
full course

What the NPA is doing
• Developed resources for pharmacists on antimicrobial
resistance
• NPA Chief Pharmacist presented on the topic of
antibiotic stewardship at the Pharmacy Show in 2013
• Continues to promote the role that pharmacists can play
in antibiotic stewardship via:
 NPA advice lines
 Educational material on antimicrobial resistance for pharmacists
 Attending stakeholder events on antibacterial resistance

Healthy Eating
“The Route to Health
and Wellbeing”
75

Who is Tim Finnigan???
• Married, two children (grown up)

Who is Tim Finnigan???
• Married, two children (grown up)
• Likes running up hills and likes a pint
• 30 years R&D in Food and Drink
• PhD Canola protein, Government food research, APV,
General Foods and...

I’M HERE IN PART TO TELL
“THE QUORN STORY” BUT
ONLY IN THE CONTEXT OF…..
 AS AN ILLUSTRATION OF WHY WE NEED HEALTHY NEW PROTEINS WITH A
LOW ENVIRONMENTAL IMPACT
 AND THE GOOD NEWS THAT ‘IT CAN BE DONE’

The 1960s was a time of
huge achievements...
The context

....And growing concerns
The Green Revolution

A man with a big idea
Inter-generational equity

82
From 1964 to 1985 – time flies……….

+ a large number of ducks, rabbits, horses, turkeys…
..3 camels and one unfortunate mule
Chickens 110,000
Pigs 2,630
Sheep 922
Goats 781
Cows 557
The scale of livestock production is driven by our desire
for cheaper and more plentiful meat, but there are damaging
consequences, which at the moment are forecast only to intensify
The current context…

http://www.fao.org/fileadmin/templates/wsfs/docs/expert_paper/How_to_Feed_the_World_in_2050.pdf
http://www.tristramstuart.co.uk/FoodWasteFacts.html
http://ecowatch.com/2014/04/11/agricultures-greenhouse-gas-emissions-2050/
Challenge Consequence
To feed 9bn in 2050 FAO say we need a 60% increase in food production
some of the true costs of cheap and plentiful animal protein
Our demand for ever cheaper and more plentiful meat has
a number of potentially devastating consequences…
84

86

http://www.fao.org/fileadmin/templates/wsfs/docs/expert_paper/How_to_Feed_the_World_in_2050.pdf
http://www.tristramstuart.co.uk/FoodWasteFacts.html
http://ecowatch.com/2014/04/11/agricultures-greenhouse-gas-emissions-2050/
87

89
 THERAPEUTIC (disease
treatment)
 PROPHYLACTIC (disease
prevention)
 GROWTH PROMOTION
http://www.soilassociation.org/LinkClick.aspx?fileticket=H7srxwglZ-s%3d&tabid=313

For most of us it’s a real surprise to learn that
antibiotics are used so freely in animal production
80% ANTIBIOTICS PRODUCED IN THE USA FED TO ANIMALS
AS OUR DEMAND FOR CHEAPER AND PLENTIFUL MEAT RISES SO WILL THE USE OF
ANTIBIOTICS IN INDUSTRIAL ANIMAL PRODUCTION

Six ways we have undermined a wonder drug
http://s.telegraph.co.uk/graphics/projects/antibiotic-resistance/
Agriculture
Globally more than 70 per cent
of antibiotics are used in animal
agriculture including some of the
most potent antibiotics
available. In more than 100
countries antibiotics are
routinely added to animal feed
to promote growth. So-called
mega farms, intensive meat and
poultry farms where diseases
can sweep through herds, are
blamed in particular for overuse
Aquaculture
Intensive aquaculture (shrimp
and fish farming) has led to
growing problems with
antibiotics routinely used to
treat diseases. The industry
supplies the world with 110
million metric tonnes of food
fish per year. 75 per cent of the
antibiotics fed to fish are
excreted back into the water
Veterinary
In Britain the veterinary sector
has been criticised for
irresponsible prescription of
antibiotics, as vets can profit by
selling the same drugs they
prescribe. The government does
not track the use of veterinary
antibiotics in detail, with the
main data available the total
annual tonnage of antibiotics
sold. In 2012, 409 tonnes of
antibiotics were prescribed by
vets in Britain
Soil
Many antibiotics are non bio-
degradable and can persist in
high concentrations in soil for a
long time. An estimated 70
million tonnes of animal manure
waste is spread on to agricultural
land each year in Britain. Crops
can take up substantial amount
of antibiotics by the roots.
Antibiotics are also sprayed on
to crops, such as high value fruit
trees, to prevent bacterial
diseases.
Profit
Only four major pharmaceutical
companies are left in the
development of antibiotics.
Antibiotics are not as profitable
as other drugs taken for chronic
conditions. A successful course
of antibiotics takes only a few
days, unlike diseases such as
diabetes and blood pressure
where drugs can be taken for
years.

Italy, 2013
EFSA: “Overcrowding is a risk factor for disease
expression and other causes of poor welfare
and should be avoided”
Regular antimicrobial use facilitates high animal densities:
The Lancet Infectious Diseases Commission, 2013

• “Urgent action is needed to ... reduce antibiotic usage in animal
husbandry”, WHO, 2014
• “Use of antibiotics as growth promoters should be banned worldwide as
has happened in the EU”: The Lancet Infectious Diseases Commission, 2013
• “Routine preventative use of antibiotics is unacceptable” UK AMR Strategy:
Annual progress report and implementation plan, December 2014
“failure to address antibiotic
overuse in agriculture and
its role in drug resistance is
like trying to stop lung
cancer without factoring in
smoking…..”

96

Challenges for a scalable meat based
sustainable food future
Our biggest lever globally is to eat less meat

New FAO report quantifies the cost of industrial livestock
production to the environment

THE No 1 CONTRIBUTER
 1/3rd water use
 18% -30% of global GHG emissions
 45% of all land
 91% of rainforest destruction to date (1 acre per second)
 Species loss
 Ocean deadzones
 Habitat destruction
 The rise of the superbug
 Micronutrient depletion
 Unaccounted costs of poor health and environmental impact
 Animal welfare and cruelty on an unprecedented scale
All the evidence is there to see

“The need for new
business models that help
address the 9bn challenge
- including a healthy new
protein with a lower
environmental impact….”
Prof. Alan Knight Single Planet Living
Big steps toward small footprints

Transition away from meat made more difficult by
decline in cooking skills

102
Quorn fits easily into everyday life and
makes meat reduction simple…
102

At the heart of all Quorn foods is
mycoprotein…
So, what is it?
Natural appeal
Our 50 year ‘overnight success……….
So it can be done

10
4
At the heart of range of meat alternatives
available in 16 countries worldwide

“Quorn ….began by
taking the original
fungi found in soil and
domesticating it in the
same way that our
ancestors did with
many plants.”
Spector, T (2015) The Diet Myth. Weidenfield
and Nicholson pp 137
Quorn has many influential advocates
105

106
Additional Interest
SCFA production
Fibre (chitin and ẞ-glucans)
Mycoprotein as a food ingredient
Physical
Properties (shape)
Denny, A, Aisbitt, B and Lunn, J (2008) Mycoprotein and health. BNF Nutrition Bulletin 33: 298 – 310.
Bottin, J. (2014) Nutrition and Surgical Influences on appetite regulation in obese adults. PhD Thesis Imperial College London
BENEFITS
Texture creation
• Authentic meat-like texture
• Creation of fibrosity through fibre assembly
General Nutrition
• High quality protein
• Low fat content (membrane
phospho-lipids)
• High fibre (cell wall)
• Low energy density
Clinical Research
Programmes
• Lowering serum cholesterol
• Satiety
• Insulinemia and
glycemia in diabetics
Composition

107
Micrographs reveal how fibrosity is created
Quorn has a unique meat like texture

From humble beginnings the potential to
produce 45,000 tonnes of mycoprotein

By using the age old process of fermentation, we actually
increase the overall protein when we make Quorn…
Mycoprotein Beef Chicken
ToonesofProtein
Protein Yield per tonne of Wheat
used in the production of mycoprotein, beef & chicken
109

Environmentally benign when compared
with meat…..
 By working closely with Carbon Trust we have established that Quorn Foods offer significant environmental
benefits relative to meat.
 Quorn is the first and only meat free brand to have carried out such a systematic third party analysis of its
environmental footprint.
1 Geraldes, E & Freire F (2013) Greenhouse gas assessment of soyabean production: implications of land use change J Cleaner Production 54, 49 -60
2. Matsuka, T& Goldsmith, P (2009) World soyabean production: Area yeild and projections. In: J Food Agric Management review 12 (4) 143-161
3. Ercin, AE Aldaya, M &Hoekstra, AYl (2011) The water footprint of soymilk, soyburger and equivalent animal products. UNESCO IHE Inst Water Education. Report 49
4. Carbon Trust. Report to Marlow Foods (2014) Available on request
ENVIRONMENTAL COMPARISON PROTEINS AND MYCOPROTEIN
GHG
(kg/kg)
LAND
(ha/te)
WATER
(m3/te)
MYCOPROTEIN 1.6 0.17 860
source#4: carbon trust lifecycle analysis of mycoprotein. Report 2014
QUORN MINCE 2.4 0.4 1900
SOYABEAN 0.1 - 17.8 0.43 2500
source#1 source#2 source#3
BEEF (GRAZED) 121
(114 - 130) 5 21500
BEEF (MIXED) 30
(16 - 69) 3.5 19500
source#4: carbon trust lifecycle analysis of mycoprotein.
Report 2014
POULTRY 9 0.7 3970
Compared with Quorn mince ex factory
GHG LAND WATER
Beef
(mixed)
X12 X9 X10
Beef
(grazed)
X50 X12 X11
Poultry X4 X2 X2
110

What if every NHS member of staff ate the
same lunch as you will be eating today??
SAVED Fat: 56 tonnes = approx. 2 lorries full
SAVED Carbon:
7.4 million kg = 7,400 tonnes
[35x Angels of the North]
SAVED Water:
4 million tonnes (m3) = the
amount of water flowing in the
river Aire over 32 hours.
SAVED Land:
1400 hectares = 7x the
size of Roundhay Park
SAVED Calories kcal :
To feed 760 people for a
year (365 x 2,500 kcal)
INCREASED Fibre: 21 tonnes = approx. 1 lorry full

“For all Mankind’s supposed
accomplishments, his continued
existence is completely dependent
on six inches of topsoil and the
fact that it rains…..”

Welcome back
Dr Diane Ashiru-Oredope, MPharm DipClinPharm
MRPharmS, Pharmacist Lead, Public Health
England & Department of Health Expert Advisory
Committee on AMR & HCAI (ARHAI)

Gonorrhoea poses
significant disease
burden globally
Antimicrobial
resistance a
constant issue
Antibiotic
stewardship can
help within an
expert service
Internet offers
opportunities,
threats to control
Super-gonorrhoea-
fact or fiction?
Future interventions
and concerns

STIs (not HIV) 400
million cases/yr
Second biggest health
burden in young women
106 million cases
gonorrhoea/yr
35,000/yr cases in UK
600/yr in Leeds
Rising incidence in UK–
especially in MSM

Gram- negative diplococcus
Sexually acquired, direct eye inoculation
Rapid onset of symptoms in male urethra
10%men, 50-70% women no symptoms
Complications
◦ Female reproductive health – pelvic infection, infertility
◦ Male reproductive health – epididymitis, testicular infarct
◦ Blindness – neonates
◦ Major illness – endocarditis, meningitis, septic arthritis
◦ Death- ectopic pregnancy
Enhances susceptibility and transmission in HIV

Index patient
Source
Contact(s)
Highly infectious
Asymptomatic
Rapid treatment
Single, oral, DOT
High efficacy
Also treat contacts

Basic Reproductive
rate
Ro = B xc x D
Transmission
efficiency
Rate of
sex partner
change
Duration
of
infectiousness
Anderson RM. Transmission dynamics of sexually transmitted infections. In:
Holmes KK, Sparling PF, Mardh M-A et al. (eds) Sexually Transmitted Diseases,
3rd edn. New York: McGraw-Hill, 1999; 25–37

NAATS
Self sample
Urine, vulvovaginal,
throat, rectum
Confirmation needed
Microscopy
•Cervix, urethra,
•rectum, pus
•Needs confirmation
Culture
• Needs viable
organisms
• Media, warmth
Resistance
testing –
needs viable
organisms

Self refer or walk-in
Confidential, free
On-site diagnosis
Free treatment,
condoms
Partner management
Rapid results (text)
Over 2 million
visits/yr
HIV care also

NAAT+
• Contact (text/phonecall)
• Recall to a clinical service (GPreferral)
Treat
• Confirm, culture, screen for otherSTIs
•Ceftriaxone IM PLUS oral azithromycin
Trace
• Interview –partners to trace,treat
• Test of cure at 2weeks

Sentinel clinics
Labs send isolates
Clinics send details
◦ Risk factors
◦ Treatment
◦ Outcome
Routine Quarterly
returns- all
GU/Integrated SH
clinics

Unemo, M Shafer WM
Clin Micro Reviews 2014;27(3):587-613
“Both alarming and predictable”

Effective national change of prescribing
slowed developing resistance

UK Clinical Practice Research Database
Ciprofloxacin accounted for 42% scripts in 2007,
20% in 2011
Discontinued as therapy in 2005 (20-30% strains
resistant)
GPs diagnosed between 6% and 9% all
gonorrhoea in England
Wetten S,Mohammed H, Yung M, et al.
BMJ Open 2015;5:e007776.

GTOG- 8 UK clinics
◦ gentamicin
New agents
◦ Solithromycin
◦ Delafloxacin
Push for vaccine

Pharyngeal
infections silent,
transient but
transmissible
Rich environment for
genetic
transformation,
plasmid transfer
Less easy to cure
Lewis DA Sex transm Infect 2015
91:234-7

March 2015
◦ Series of cases-azithromycin resistant
N=16, mostly heterosexual under 25
Only 3 linked
Molecular analysis continuing
Concern re untraceable partners
◦ Enhanced surveillance
◦ Recalled, retreated
September 2015
◦ Continuing isolations, Macclesfield, Scunthorpe, Oldham
◦ PHE approached BASHH to alert clinicians
◦ Press interest …went viral

• Antibiotic-resistant STIs are a way to remind
ourselves of the dignity of the NHS project, its
elegant combination of generosity, ambition and
meaningful thrift, investing in a population because
they’re worth it, whatever they’ve been up to.”
http://gu.com/p/4chee/sbl

Surveillance
Rapid testing in clinics
Access to culture
Guideline driven treatment
Partner management
Tests of cure
Audit, trials
Web based services
NAATS only
Limited access to lab
Loss of provider skills in
microscopy, PN
Oral therapy only
Push to GP delivery
Loss of audit, research and innovation funding

Better STI prevention and control
◦ Easy access to testing, treatment, partner management
Effective surveillance
Stewardship of antibiotic access and use
Individual tailoring of treatment needs:
◦ Rapid tests/POCT for identification of gonorrhoea
◦ Rapid/POCT for AMR resistance in clinicalsettings
Novel agents
◦ Effective use of older agents
Vaccine development

President@bashh.net
Jan.clarke4@nhs.net

The Veterinarian’s Role
and options regarding disease detection, diagnosis,
treatment and prevention
John M Blackwell BVSc MRCVS
Senior Vice President BVA
AG Regional Conference
29th October 2015

BVA
• Membership Association (15000 members )
• Species Divisions
• Role
• Policy / Ethics Welfare / Overseas/
Member Services
• The “voice of the profession”

AMR: “One Health”
• Increase in resistant pathogens
including MR
• Evidence Base for Human/Animal cross
over
• Not just a human problem- (silos)
• UK Government Antimicrobial Strategy

Media statements!
• “if you eat a farmed salmon in America
it has probably eaten its own weight in
Antibiotics”
• “ ….a cut in the use of Antibiotics in
farm animals, one of the biggest causes
of resistance to the drugs”
• “slaughter sick animals rather than give
them antibiotics to help them recover”

Control
• Prescription remains the critical control
point: “ right to prescribe- privilege to
dispense”.
• Animals Under Care
• Diagnosis
• “ as little as possible as often as
necessary”

Neonatal enteritis
• Clinical examination
• Basic TPR
• Age
• Demeanour
• Hydration status
• Individual or group
• Concurrent infection

Diagnostic Samples
• Faecal individual or
pooled group
• Blood
• PME

Licenced VMP’s
Authorised medicines: VMD all
Antibiotics POMV.
Safety
Efficacy
Envioromental/toxicity
MRL’s withdrawal data/safety
Pharmacovigilance SARs

Diagnostics
• Time: Results historic but build
knowledge. Herd Health Planning
• In House Tests: Screen
• In House Culture/Sensitivity
• Pen-side Rapid Diagnostics: The future!

Treatment Protocols
• Within Herd Plan- written down
• 1st Line Dietary Modification oral
electrolytes
• 2nd Line to include Targeted
Antimicrobial based on previous
isolation and sensitivity testing
• 3rd Line veterinary intervention re
evaluation +/- systemic re hydration

Prevention
• Disease Host Pathogen Environment.
• Host Immunity Colostrum AntiB
Transfer – Boost by Vaccination or
supplementation
• Environment clean warm well ventilated
dry- biosecurity protocols ( sourcing
policy) and on farm

Stewardship: What should the veterinary profession
doing about it?
• Lobbying hard against bad law; it does not solve the problem and may worsen
it
• Challenging misconceptions about the causes of resistance
• Any changes must be evidence based on sound scientific risk analysis, not
wholly on the precautionary principle not on mis -representation of the
evidence or falsification of that evidence
• Promoting stricter conditions in best practice for the use of certain categories
of antimicrobials, which have high priority critical importance in human
medicine
• Better animal health management on farm to reduce the need for
antimicrobials
• Reinforcing the message and campaigning to raise awareness of the crucial
importance of evidence based responsible use supported by appropriate
guidelines, and possibly “regulation”

Key BVA actions – UK AMR 5 year strategy
Improve the knowledge and understanding of AMR
• Encourage education on minimising resistance and principles of responsible use,
including through engagement with veterinary students in their clinical years and
with full support of the Heads of Veterinary Schools.
•
• Responsible use principles and messages are being incorporated into all of the BVA
CPD courses. Consider options for responsible use training for farmers. RUMA
• We continue to work hard to raise awareness about AMR with the profession in
branch and regional meetings as well as Congress, and with the general public.
• BVA Responsible use guidance for the veterinary profession is being updated and
our species divisions are involved in producing advice tailored to their particular
sector e.g. small animals, horses, pigs. We will continue to encourage divisions to
take this approach.

Conserve and steward the effectiveness of existing treatments
• We have and will continue to call for quicker, cheaper and more accessible accurate
sensitivity and pen-side testing for vets.
• Recognise the need for improved data recording of use down to species/sector
level .Consider how such recording and reporting may be encouraged, how usage
may be measured and audited and how prescribing habits can be assessed.
Encourage development of Apps and enhanced practice management software to
promote data capture.

SAFEGUARDING ANTIBIOTICS
FOR THE FUTURE
Cóilín Nunan, Alliance to Save Our Antibiotics
The need to reduce farm
antibiotic use

“There is the danger that the
ignorant man may easily under-
dose himself and by exposing his
microbes to
non-lethal quantities of the drug
make them resistant.”
Alexander Fleming 1945

Fleming’s warning ignored
 “Prevention of Misuse Act” 1953 permits use of
penicillin and tetracycline as growth promoters (sub-
therapeutic doses).
 Outbreak of multi-resistant Salmonella in humans
acquired from calves in 1960s. Swann Committee
established.
 Swann committee recommends banning penicillin
and tetracycline as growth promoters but permits
mass medication to continue so long as prescription
obtained.

“The Swann report has changed nothing
essential….The farmers can get hold of
exactly the same antibiotics as before,
only it is more expensive now as you
need a vet’s prescription. Of course, in
all probability more antibiotics will be
used.”
Ernst Chain, Royal Society for Medicine, 1970

Chain was right!
Veterinary use 1966
(Swann report)
Veterinary use 2013
(VMD report)
Total antibiotic use 151 420
Beta-lactams 16.8 89
Tetracyclines 19.6 184
All statistics in tonnes active ingredient

Routine use continues
 EU growth-promoter ban in 2006, but in the UK nearly
90% of farm antibiotic use is still for group treatments,
in feed or drinking water.
 Some antibiotics can be prescribed to treat thousands
of pigs or poultry, even when no disease has been
diagnosed on the farm.
 Survey in Belgium showed that 93% of group
treatments on pig farms were purely prophylactic
(Callens et al. 2012).
 Science and Technology Committee (2014):
“we suspect that antibiotics may be routinely used on
healthy animals”.

No reducing trend of use in the UK
35
40
45
50
55
60
65
2008 2009 2010 2011 2012 2013
Antibiotic sales for food animals only per PCU
(mg/PCU)

Increasing veterinary use of critically
important antibiotics
0
500
1000
1500
2000
2500
3000
3500
4000
4500
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Modern cephs (kg)
Fluoroquinolones (kg)
Total (kg)

Antibiotic use is overwhelmingly in
intensively farmed pigs and poultry
Antibiotic sales
2013
(tonnes)
Population
correction unit
Pigs and poultry 306 1,775
Cattle 14 1,692
Fish 1 172
Sheep <1 2,765
Multi-species Up to 63 -
Sheep and cattle receive far fewer antibiotics because farmed
more extensively than pigs and poultry.

The UK compared with Europe
 Antibiotic use in pigs and poultry in Denmark, Finland,
Iceland, Norway, Netherlands and Sweden is at least 3-
5 times lower than in the UK.
 Use in UK cattle is much lower than in some EU countries
like the Netherlands.
 Sweden reduced group treatments by 98% in last 30
years.
 Netherlands banned routine preventative use and cut
total farm antibiotic use by 63% since 2007.
 Most EU countries permit routine use and a 2015 EMA
report has revealed that antibiotic use in European
food animals is about twice human use.

Little action in UK or at EU level
 Government ‘s 5-year strategy contains no reduction
targets for farm antibiotic use.
 VMD opposes banning group treatment of animals
where no disease has been diagnosed in any of the
animals.
 European Commission has proposed banning
preventative use of antibiotic feed additives, but
routine preventative use in drinking water would remain
legal.
 Commission proposal likely to be no more effective than
growth-promoter ban. UK pig industry already
preparing for switch to water.

Resistance can transfer to humans
 Resistant farm-animal bacteria can transfer to
humans via food, through the environment or by
direct contact.
 Farm-animal resistant bacteria sometimes infect
humans directly. They can also colonise human gut
temporarily, and then transfer a copy of their
resistance gene or plasmid to human pathogen in
gut.

Human and animal use contribute to
resistance crisis
 For many human infections resistance is due to
human antibiotic use.
 For salmonella and campylobacter, farm use is main
cause of resistance in humans (EFSA).
 For E. coli and enterococci, farm-animal use
contributes significantly, but some disagreement
over extent.

Rise of E. coli bacteraemia
0
5
10
15
20
25
0
5000
10000
15000
20000
25000
30000
35000
1990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014
Voluntary reports of E. coli bacteraemia in England, Northern Ireland and Wales
Fluoroquinolone resistance
3rd generation cephalosporin resistance
Gentamicin resistance

Resistance in farm-animal E. coli can
spread to humans
 Use of apramycin in veterinary medicine led to emergence
of an apramycin/gentamicin resistance gene AAC(3)IV in
human E. coli. Gene was on a plasmid which also carried
resistance to veterinary anthelmintic hygromycin B, indicating
veterinary origin (Johnson et al. 1994).
 Human and animal ESBL E. coli bacteria are generally not
the same (Wu et al. 2013). But similar ESBL gene-plasmid
combinations are found in animal and human E. coli
suggesting horizontal gene transfer
(Smith et al. 2015, de Been et al. 2014).
 Feeding antibiotics to pigs can increase number of E. coli in
faeces 20 to 100 fold (Looft et al. 2012).

Food as a source of resistant E. coli
When volunteers switched from normal diet to sterile diet,
antibiotic-resistant E. coli in their faeces fell up to 500-fold
Corpet 1993, Corpet 1988

Emerging problems: MRSA
 Livestock-associated MRSA (ST398) emerged in farm
animals in Europe a decade ago. Has now been found in
British pigs, poultry and cattle.
 Associated with use of modern cephalosporins, but also
tetracyclines and zinc feed additives.
 MRSA present on meat, but most humans cases are from
direct contact with animals.
 Increasing numbers of cases in humans with no livestock
contact being reported in Europe. German research says
that in areas of high livestock density it is now “a major
cause for human infection”
(Kock et al 2013).

Emerging problems: Clostridium difficile
 C. difficile has emerged in pigs and other farm animals.
Ribotype 078 most common strain, but others present.
Could be linked to increasing use of modern
cephalosporins in farming.
 Ribotype 078 increasing in humans, despite overall fall
in C. difficile, and is now one of leading strains in UK.
Appears to be “hypervirulent”.
 WGS shows 078 isolates in humans and animals can be
identical, suggesting possible transmission.
 Ribotype 078 is often more tetracycline-resistant than
other ribotypes found in humans, which is consistent with
veterinary origin of at least some human cases.

Sub-MIC selection of resistance has
implications for farm antibiotic use
 Selection for antibiotic resistance can occur at
antibiotic concentrations which are just a fraction of
the minimum inhibitory concentration (MIC) - up to
200 times lower.
(Gullberg et al. 2011, Andersson and Hughes
2014, Chow et al. 2015).
 This has implications for environmental antibiotic
pollution, residues in food and
carry-over of antibiotics in animal feed.

Environmental spread of resistance
 Most antibiotic-resistance genes
originate in the environment. ESBL
genes were present in soil before
they occurred in human infections.
 Antibiotic concentrations in liquid
manure, farmed soils, river
sediments can be sufficient to
select for resistance.
 Archived soils show large
increase in numbers of resistance
genes during antibiotic era
(Knapp et al. 2010).

Cutting antibiotic use can reduce
resistance in farm animals

0
20
40
60
80
100
120
VRE poultry
meat Germany
1995
VRE poultry
meat Germany
1998
VRE humans
Germany 1994
VRE humans
Germany 1997
Streptogramin
poultry
Netherlands
1997
Streptogramin
poultry
Netherlands
1999
Streptogram
pigs
Netherlands
1997
Streptgramin
pigs
Netherlands
1999
Streptogramin
humans
Netherlands
1997
Streptogramin
humans
Netherlands
1999
Falls in resistance in enterococci in animals and
humans after growth promoters banned

Withdrawal of ceftiofur from hatcheries
in Quebec

Human cases of livestock-associated MRSA
now falling in the Netherlands
0
500
1000
1500
2000
2500
3000
3500
4000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
AxisTitle
Large cuts in Dutch farm antibiotic use have reversed the trend of
rapidly increasing numbers of human cases of livestock-associated
MRSA
LA-MRSA
Total MRSA

Our key recommendations
 Ban mass medication of groups of animals where no
disease has been diagnosed in any of the animals.
 Greater restrictions on use of the critically important
antibiotics.
 Set ambitious targets for reducing total farm
antibiotic use.

Chairs concluding comments
Dr Diane Ashiru-Oredope, MPharm DipClinPharm
MRPharmS, Pharmacist Lead, Public Health
England & Department of Health Expert Advisory
Committee on AMR & HCAI (ARHAI)

Key learning points:
AMR: #AntibioticGuardian Roadshow Dr Diane Ashiru-Oredope

R E S O U R C E S T O O L K I T F O R
H E A LT H C A R E P R O F E S S I O N A L S
I N E N G L A N D
All resources and materials are available via
http://bit.ly/eaad-resources
Gateway Publication Number: 2014483

AMR: #AntibioticGuardian Roadshow Dr Diane Ashiru-OredopeEAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope200 AMR: #AntibioticGuardian Roadshow Dr Diane Ashiru-Oredope

EAAD & AG TOOLKIT: Digital for local adaptation
Leaflets, quizzes, crosswords, video & more
201
201
Antimicrobial Stewardship Dr Diane Ashiru-Oredope
EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope201 EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope

SOCIAL MEDIA GRAPHICS
To obtain the images and other messages for use on social media please request for a
social media pack by emailing: socialmedia@phe.gov.uk .
They can also be shared from PHE Social media platforms
Twitter: https://twitter.com/PHE_uk Facebook: www.facebook.com/PublicHealthEngland

Video created with TV doctor
Educates on antibiotic resistance; suggests three steps that public can
take to help and a call to become an antibiotic guardian. Available for
download

Posters: Public

Resources: PROFESSIONALs
PRESCRIBERS CHECKLIST
• The pack contains a prescribers checklist for health professionals working in
secondary care. The checklist provides practical advice on how to treat infections
in a responsible way with regards to antibiotic resistance. Also available on the
website are links to the TARGET and Start Smart then Focus toolkits and When
Should I Worry booklets to hand to patients.

Resources: PROFESSIONALs
TREATING YOUR INFECTION LEAFLET: GPs; Out of Hours practice; Community
Pharmacy
• A leaflet for health professionals working in primary care to use when provide
advice to patients. The leaflet provides practical advice on how to treat symptoms
of common self limiting infections and warning signs for serious illness.

Public Engagement –
Devon County Council, Parents & Children’s
centre
AMR: #AntibioticGuardian Roadshow
Dr Diane Ashiru-Oredope
The Listen to Your Gut campaign has been developed for parents by parents in
conjunction with Devon County Council’s Public Health Team and My Start
Children’s Centre in Ilfracombe, which is run by Action for Children
207 EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope

Educating children
Europe wide resource, led by Public Health England
EAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope

EAAD & AG is One Health:
VMD, BVA, Bella Moss

EAAD &Antibiotic Guardian: children
centres; hospitals; community pharmacies
University College London Hospitals
Awareness and engagement in Hospitals, community pharmacies,
universities, organisations in all UK Countries

Engagement via social media – e.g pictures
tweeted with #AntibioticGuardian

213
EAAD & Antibiotic Guardian
Significant activity on social media

2015: Practical examples:
• Engagement and support from leaders essential
• Lead local campaigns/patient engagement/health promotional activities using key
messages
• Contact your Comms Lead – press releases, social media
• Individuals can share pledge from AntibioticGuardian.com and encourage others to
do so
• Organisations to register planned activities online
• Highlight the day and the pledge on organisation’s website and premises
• Monitor the local implementation of relevant antimicrobial stewardship guidance and
toolkits
• Use social media (Facebook, Twitter) to engage with both local and national online
activity on the week building to and including 18 November
• Provide examples of good practice within organisations that can be shared as good
• Schools can use the materials for schoolchildren on the e-Bug website http://www.e-
bug.eu/
AMR: #AntibioticGuardian Roadshow Dr Diane Ashiru-OredopeEAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope

Plans for 2015
Further implementation of materials developed in 2015
100, 000 Antibiotic Guardians
Encouraging all to start plans early & collaborate
How can we reach the general public NOT connected to healthcare?
Innovative ideas
Antibiotic Guardian Roadshows – awards
AMR: #AntibioticGuardian Roadshow Dr Diane Ashiru-OredopeEAAD and Antibiotic Guardian Dr Diane Ashiru-OredopeEAAD and Antibiotic Guardian Dr Diane Ashiru-Oredope

National Awards
May 2016, Date and Venue tbc
Categories include:
Staff engagement: How have staff promoted Antibiotic Guardian and stewardship within their
organisation?
Community: How has your organisation worked within the community to highlight Antibiotic Guardian?
Prescribing: How has your organisation tackled prescription and prescribing antibiotics effectively?
Innovation: Tell us how you have demonstrated innovation to address Antimicrobial Resistance?
Antibiotic Stewardship: How have you improved or measured antibiotic usage in your area or
community?
AMS Research: How have you demonstrated development of research to support
Antimicrobial Stewardship?
For details of how to apply please visit
www.antibioticguardian.com

You are invited to become an Antibiotic Guardian
today and to ask others to join you
(You can do so now via your mobile device )

Why attend?
• Gain guidance on effective prescribing methods
• Hear the latest information on antimicrobial stewardship from leading experts
• Collaborate with fellow health professionals
• Receive resources to promote Antibiotic Stewardship in your workplace
Educational Roadshow Series
October 29th- Leeds
November 18th- Birmingham
February 24th-London

Antibiotic Guardian Leeds Workshop

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