Pediatric ASP Toolkit

Advocacy Addressing Antibiotic Overuse in Animal Agriculture and the Environment
  • Antibiotic Resistant Organisms in Food-Animals and Meat

    Methicillin-resistant Staphylococcus aureus (MRSA)

    Extraintestinal E. coli Infection

    Non-typhoidal Salmonella Species

    5% are now resistant to 5 or more classes of antibiotics

    Campylobacter Species

    Ciprofloxacin resistance has overall increased from 13% in 1997 to almost 25% in 2011. FDA removed enrofloxacin from use in poultry in 2005.

  • Antibiotic Stewardship in Food Animals

    Historically, antibiotics have been used in food animals for growth enhancement, disease prevention, and to treat diagnosed disease in sick animals. U.S. Food and Drug Administration (FDA) Guidance for Industry #213, effective January 2017, no longer allows the use of antibiotics for growth promotion, and requires veterinarian oversight for use of antibiotics in food animals. As a result, the proportion of chickens in the United States raised with medically important antibiotics declined from more than half in 2014 to 8% in 2018. Nevertheless, an analysis by the Natural Resources Defense Council (NRDC) in late 2019 comparing agricultural antibiotic use between Europe and the United States found that the U.S. pig industry consumes antibiotics at a rate 6 times higher than the Danish pig industry, which is the world’s 4th largest pork exporter. Concern remains that allowance of antibiotics for disease prevention could perpetuate industrial methods of livestock production that emphasize confining a large number of animals in close quarters. Crowding and confining animals prompts a higher risk of disease outbreaks and of transmission of antibiotic resistant bacteria between animals and from animals to the environment. For many years, widespread antibiotic use in animal agriculture has contributed to the selection of antibiotic resistant bacteria within livestock hosts and their waste products. This puts the public at risk of being exposed to resistant bacteria through contact via soil or water, interaction with farm workers, and handling or consumption of contaminated meat products. Practices that promote meticulous antibiotic stewardship are vital in the effort to control antibiotic resistance. Veterinarians in the agriculture industry are working to address this use through more stewardship efforts.

    With the implementation of FDA Guidance for Industry #213, antibiotic sales for use in food producing animals initially decreased. The FDA’s 2017 Summary Report on Antimicrobials Sold or Distributed for Use in Food-Producing Animals showed a 33% decrease from 2016 through 2017 in the domestic sales and distribution of medically important antimicrobials approved for use in food-producing animals that are sold over the counter. However, FDA’s 2018 Report showed a 9% increase from 2017 through 2018 due to increases in use in beef and pork while reductions continue in poultry. Total sales of medically important antibiotics in 2018 amounted to 6,036,140 kg, compared to about 3.2 million kilograms sold for human medicine in 2015, the last year of available data. That means nearly two-thirds of all drugs of human importance (by weight) are being deployed on farms.

    Despite the widespread use of antibiotics in food animals suggested by these sales data, we know very little about which antibiotics are used in what animal species and for which indications. This knowledge gap contrasts sharply with the data available for human clinical use. For more information on incorporating food stewardship into an ASP, see the “Meat Procurement Strategies” section of the Antibiotic Stewardship Through Food Animal Agriculture Module produced by CCCAS.

    Antibiotic Stewardship Beyond Clinical Care

  • Food Procurement Resolutions

    Statement Development

    Including a statement with the support of hospital leadership in the ASP resolution on phasing out the purchase of meat raised with routine antibiotics will help expedite the adoption of a more comprehensive purchasing resolution. Review the resource Passing Food Purchasing Resolutions for guidance on the development, implementation of a resolution including sample policy language. Sample resolution templates are included. An effective policy statement should include:

    • Requirements for prescribers, education of patients/community and food service purchasing.
    • Details of the process that will be used to track and benchmark annual progress towards transitioning all meat and poultry products to sources raised without routine antibiotics.
    • The CCCAS Collaborative recommends including the following comprehensive policy statement: “Whereas our facility ASP will articulate a timeline for phasing out the purchase of meat raised with routine antibiotics and a reporting process to ensure benchmarks are met.”

    Implementing Resolutions

    It is important to plan out the implementation of your resolution with your multidisciplinary ASP team. This resource offers some guidance for consideration. Healthcare Procurement: Sustainable Meat and Poultry Guide. When aiming to change products purchased, it is important to work directly with the group purchasing organization and/or food service management company representatives to articulate the changes you aim to make. These entities will then work directly with supplier and distributors that are under contract to supply products to the organization. Should there be a limited number of available products through this avenue, you may then explore Identifying meat and poultry products available through institutional purchasing pathways outside of your GPO or management company’s purview – See Meat and poultry product list for some ideas. Ensure your Chief Financial Officer is amenable to this as there may be contractual or financial implications.”

    Food Service Staff Resources and Education

  • Actions Addressing Antibiotics in Food Animals for Clinical Settings

    Meat Purchasing

    1. Determine which label claims and standards the facility will use. Current food label certifications mean different things with regards to antibiotic use. This resource offers guidance on understanding meat and poultry certifications.
    2. Track purchases towards the goal of reducing or phasing out meat raised with routine non-therapeutic antibiotics. Tools for calculating meat reduction and tracking meat purchases can be found in the national Healthier Hospitals “Less Meat, Better Meat” challenge Less Meat, Better Meat Food Measures Overview. For more guidance see the “Tracking” section of the Antibiotic Stewardship Through Food Animal Agriculture Module produced by CCCAS.

    Ambulatory settings have a role to play in stewardship related to animal agriculture as well, and actions can be tailored depending on the attributes and services of the ambulatory setting. Whether they function as stand-alone centers, or within a network of facilities, discussion with foodservice leaders at these sites should not be overlooked.

    For outpatient centers with hot food service operation, opportunities are consistent with those mentioned for an acute care setting. For those without food service, if a full-service cafeteria with options for cooked meat is not present, educational and advocacy opportunities exist. This education may include:

    • Highlighting what the organization is doing to encourage less antibiotic use in meat production through purchasing, menu planning, or clinician’s personal choices.
    • Acknowledging that there are not antibiotics or antibiotic residues physically in the meat, rather antibiotic use in production contributes to broader exposure to antibiotic resistant bacteria.
    • Guide on purchasing meat raised without routine antibiotics if appropriate for the patient’s financial status, or consider sharing the names of restaurants and stores that champion the provision of meat raised without routine antibiotics. See the Chain Reaction II Report Card or this Fact Sheet for more information.
  • Environmental Exposure to Antibiotic Resistant Bacteria

    In addition to risks to human health associated with handling and consuming meat products, the surrounding community is at higher risk of exposure to antibiotic residues and resistant bacteria via soil, water, and interaction with farm workers who are carriers of drug-resistant bacteria. While the existence of antibiotic residues in meat products is tightly regulated and not a topic of high concern, antibiotics in the broader environment are poorly monitored and in many cases unregulated. The U. S. Geological Survey (USGS) reported in March 2002 that antibiotics were present in 48 percent of the streams tested nationwide; and half of those tested were downstream from agricultural operations. (Pharmaceuticals, Hormones, and Other Organic Wastewater Contaminants in U.S. Streams, 1999−2000:  A National Reconnaissance. Dana W. Kolpin*, Edward T. Furlong, Michael T. Meyer, E. Michael Thurman, Steven D. Zaugg, Larry B. Barber, and Herbert T. Buxton Environmental Science & Technology 2002 36 (6), 1202-1211.) However, antimicrobials, and other pharmaceuticals and their byproducts, are not considered contaminants with specified allowable limits under the Clean Water Act or Safe Drinking Water Act, Rather, they are considered Contaminants of Emerging Concern (CECs) and as such are not closely monitored or regulated. Similarly, while the United States Environmental Protection Agency monitors waterways for contamination by several species of microorganisms, monitoring is lacking to track the prevalence of antibiotic resistant genes in the environment.

    Multidrug-resistant pathogens have been associated with food-related illnesses. For example, a study dating back to April 1999 by the Government Accountability Office concluded that resistant strains of three microorganisms that cause foodborne illnesses in humans (Salmonella, Campylobacter, and E. coli) are linked to the use of antibiotics in animals.

    Soaps and household products (there are antibiotics in products like toys and trays marketed specifically to children).

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