More Action Needed in National Action Plan for Combating Antibiotic Resistant Bacteria

On Friday, the White House will release its National Action Plan For Combating Antibiotic-Resistant Bacteria, but it leaked out this evening. The plan was initiated in last fall's Executive Order.

In the plan, even more than in the past, the White House highlights that the misuse of antibiotics in both human medicine and animal agriculture is creating a public health crisis. Therefore, many of us hoped that the White House's National Action Plan would do more to reduce the overuse of antibiotics in human healthcare and in the livestock industry, sectors where routine use of antibiotics is now breeding resistant bacteria that threaten humans.

While the action plan contains a number of important new initiatives for detecting, tracking and preventing superbugs, mostly in the context of human medicine, it fails to include real action to end the overuse of antibiotics in animal agriculture.

The problem is that the national plan perpetuates a massive loophole in FDA's existing approach to the use of antibiotics in animal agriculture. This plan, and FDA's plan, both focus on eliminating the use of antibiotics for growth promotion, but condone the routine use of antibiotics to help animals survive crowded, stressful and unsanitary confinement conditions (often called "disease prevention" uses).

Leaving this loophole in place means that antibiotic use on animals will not decline significantly.

All of the efforts made towards better education, data collection and stewardship are of secondary importance if the livestock industry is allowed to continue business as usual.

This shortcoming is particularly glaring given the clear threat described in the plan. For example, the plan states: "Misuse and over-use of antibiotics in healthcare and food production continue to hasten the development of bacterial drug resistance, leading to loss of efficacy of existing antibiotics. " It also says that "Antibiotic use in food animals can results [sic] in resistant Campylobacter than [sic] can spread to humans." It acknowledges that camplyobacter infections have been on the rise and that the bacterium causes about 310,000 antibiotic-resistant infections per year.

In several places, the plan describes aspects of the resistance threat posed by livestock use of antibiotics, but then fails to offer a sufficient remedy.

Consider this discrepancy:

On the one hand, the national plan says, "Antibiotic resistance is a global health problem that requires international attention and collaboration, because bacteria do not recognize borders."

Yet at the same time, the administration tries to draw a false distinction between growth promotion uses and disease prevention uses - a distinction not recognized by bacteria. Both uses often involve routine, low doses of antibiotics given to large groups of animals for long periods of time - ideal conditions for breeding drug-resistant bacteria.

Here's another discrepancy.

The plan says, "Because antibiotics in feed or water are typically administered to herds or flocks of food-producing animals, in-feed or in-water antibiotic use leads to an increased risk of selecting for resistance."

Yet, as I noted above, the plan allows disease prevention uses to continue - which often involve exactly the kind of herd-wide, feed- and water-based use of drugs the report criticizes.

Following FDA's existing plan, the National Action Plan relies on increased veterinary oversight to assure that these drugs will be used safely in feed and water. But consider this:

  • Large industrial farms already have vets on staff (so no big change there);
  • Large industrial farms hire vets to maximize herd productivity and profits, not to solve global health problems; the vets may even feel compelled to continue the routine use of antibiotics if the conditions on these facilities are bad;
  • Even in human medicine, this approach has had some issues. The Centers for Disease Control and Prevention (CDC) reports that half of all human use of antibiotics may be unnecessary even though a doctor's prescription is needed to get the drugs.

Overall, the report treats agricultural use of antibiotics with a much less rigorous approach than it applies to human use of the drugs, even though agriculture accounts for 70% of the sales of medically important antibiotics in the U.S. The action plan sets specific, numeric goals for the reduction of inappropriate antibiotic use in humans - 50% in outpatient settings and 20% in inpatient settings - but has no equivalent goals for animal agriculture. Maybe that's because the drug companies themselves have already acknowledged that the steps the plan recommends for livestock will not greatly affect antibiotic use.

A little silver lining

The national plan does call for some things that could be helpful.

It tries to strengthen the already strong science on animal agriculture's contribution to antibiotic resistance. Enhanced surveillance and collaboration between vet and public health labs are discussed. The CDC has been ordered to investigate the links between urinary tract infections in food. But we already have a strong body of science establishing the human health risks from the routine use of antibiotics in animal agriculture, and we need to start acting on it to phase out routine uses of antibiotics, even as we develop this additional data.

The action plan contains new initiatives to collect data about antibiotic use, management practices, and drug resistance in different points in the supply chain. However, it states that farm-level data collection will be voluntary, which means we will not be getting the full picture of what's happening.

Antibiotic resistant bacteria are a serious threat to public health and to national security. It is great to see that the Administration has put so much effort into the human medicine side of the equation. But without significant improvements to the animal agriculture uses of antibiotics, we still risk losing use of what are still miracle drugs.