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Momentum on resistance

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INTEREST in antimicrobial resistance may have waxed and waned over the years but the subject has rarely been out of the news of late and the momentum continues to grow. This was demonstrated again last week, which saw: in the UK, the broadcast of a BBC Panorama programme warning of an ‘antibiotic apocalypse’; at EU level, the European Parliament giving its backing to a report on safer healthcare which focuses particularly on the use of antimicrobials; and, at global level, news that the World Health Assembly has agreed a new global action plan urging all countries to have national strategies to combat antimicrobial resistance in place by 2017. In these, as in other developments, the emphasis continues to be on trying to ensure that antimicrobials remain effective for use in human patients, and the need to do that is inarguable. However, the impetus being generated by all the political debate does raise concerns about the extent to which effective antimicrobials will continue also to be available for use in animals.

The problem, as far as veterinary use of antimicrobials is concerned, is perhaps best exemplified by the European Parliament's support for the report on safer healthcare. Discussing the content of the report in an article in The Parliament Magazine last week, Piernicola Pedicini, the European Parliament's rapporteur on safer healthcare, highlights the threat antimicrobial resistance poses to human healthcare and remarks that, as well as promoting responsible use of antibiotics in people, ‘We must also limit the use of antibiotics in veterinary medicine, including by decoupling veterinarians’ right both to prescribe and sell antibiotics, eliminating prophylactic use, as well as strongly restricting the metaphylactic use of antibiotics in animals.'1

It is important to ensure that antimicrobials remain effective for use in animals as well as people and that, in veterinary as well as human medicine, products are used responsibly. At the same time, it will be important to make sure that the controls applied are proportionate, relevant and evidence-based, and that, in practical terms, they have the desired effect. It is highly debatable whether decoupling the privilege to dispense from the right to prescribe veterinary medicines would lead to any reduction in the use of antimicrobials in animals and, indeed, this could prevent products being available for appropriate use when they are needed. Meanwhile, appropriate preventive use has an important role to play in preventing rapid spread of infection in groups of animals and undue restrictions could have implications for public health as well as for animal health and welfare.

The World Health Assembly's resolution on a global action plan2 provides welcome recognition that antimicrobial resistance is a global problem that needs to be tackled on a global basis. It represents a logical development following a World Health Organization (WHO) report last month which highlighted the extent to which use of antimicrobials varies around the world, as well as differences in the response to antimicrobial resistance in different regions. Among the findings of the report were that relatively few countries (34 of 133 participating in a WHO survey) have a comprehensive national plan in place to fight antimicrobial resistance; that, in many countries, sales of antimicrobials without prescription remain widespread; and that public awareness of the issue is low in all regions.3 Given the many practical issues involved, the resolution adopted by the World Health Assembly will not correct those deficiencies overnight, but it does represent a step in the right direction.

Although primarily concerned with the use of antimicrobials in human health, the World Health Assembly's resolution notes that national plans also need to cover the use of antimicrobials in animals and agriculture. In animals, as in humans, the ways and extent to which antimicrobials are used in different parts of the world vary greatly. For example, the use of antibiotics as growth promoters in animal feed has been banned in the EU for almost a decade, although it continues in other regions. The EU has had an action plan against antimicrobial resistance in place since 2011 but, even within the EU, the extent to which antibiotics are used to treat infections in people and in animals differs from country to country. Debate about the extent to which antibiotic use in animals contributes to the problems of resistance being encountered in human medicine continues to be hampered by a lack of data. However, as the UK Five Year Antimicrobial Resistance Strategy, produced jointly by the Department of Health and Defra in 2013, points out, ‘increasing scientific evidence suggests that the clinical issues with antimicrobial resistance that we face in human medicine are primarily the result of antibiotic use in people rather than the use of antibiotics in animals’.4 This does not in any sense absolve veterinarians from doing everything they can to ensure that antimicrobials are used responsibly but, in the context of the discussions taking place in the European Parliament, it should help put the issues into perspective.

As attention rightly focuses on resistance, there must be concern that the broad-brush messages being used to raise awareness of the problem globally will eclipse the efforts being made in some parts of the world to ensure that veterinary antimicrobials are being used responsibly and result in inappropriate restrictions being applied. Efforts are being made to obtain more data on veterinary use of antimicrobials through improved surveillance but the risk remains that, as the political head of steam continues to grow, decisions will be made before those data are available. Given the different challenges in the human and veterinary fields, and variations in the use of antimicrobials around the world, there must be concern that a blunderbuss will be applied when a more nuanced approach is needed.

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