Resumen de Wide-ranging guidelines on antimicrobials
RUNNING to 20 tightly printed pages, new European Commission guidelines on the prudent use of antimicrobials in veterinary medicine, which were published this month,1 are not necessarily something you would want to keep in a back pocket when visiting a farm, or even close to hand in the practice consulting room. Nevertheless, they are well worth reading, if only to confirm how keen legislators are to be seen to be doing something about antimicrobial resistance (AMR), or as a further illustration of how the momentum around tackling resistance continues to grow. The guidelines are not just aimed at veterinarians, but extend to the pharmaceutical industry, pharmacists, retailers and wholesalers, farmers and food business operators, national associations and authorities, and many others besides (see p 297 of this issue). Although not legally binding, they form only part of the European Commission's overall strategy on AMR, and the Commission points out that they will not prevent it from putting forward legally binding requirements if these are considered more appropriate.
The guidelines put welcome emphasis on the role of the veterinarian – and the veterinary prescription – in helping to ensure that antimicrobials are used appropriately, as well as on biosecurity, good farming practices and herd health planning in reducing the need for antimicrobial use. At the same time, they serve to emphasise the responsibilities associated with prescribing, noting, for example, that the prescription and dispensing of antimicrobials must be justified by a veterinary diagnosis in accordance with current scientific knowledge, and that prescriptions should be based on a diagnosis made following clinical examination of the animal by the prescribing veterinarian; where possible, antimicrobial sensitivity testing should be carried out, to determine the choice of antimicrobial. Routine prophylaxis must be avoided, the guidelines state, with prophylaxis being reserved for exceptional case-specific indications. Meanwhile, antimicrobial metaphylaxis should be prescribed ‘only when there is a real need for treatment’ and, in such cases, the veterinarian should justify and document the treatment on the basis of clinical findings on the development of a disease in a herd or flock.
The guidance rightly points out that ‘controlling AMR requires cooperation between public health, food, veterinary and environmental authorities, industry bodies, veterinarians, farmers and other parties, who all have responsibilities in this area’ and, in referring to antimicrobial use in companion as well as food-producing animals, is clearly intended to be comprehensive. However, while many of the recommendations make good theoretical sense, not all of them will necessarily be helpful. For example, the document suggests that ‘The pharmaceutical industry should prioritise and focus on developing and marketing alternatives to antimicrobials such as vaccines and rapid affordable diagnostic tests’ and that it should ‘prioritise tasks like dose optimisation (based on relevant pharmacokinetic and pharmacodynamic data), modern formulations of old classes of antibiotics such as penicillins (which are still effective against many animal diseases) and antimicrobials for minor use/minor species.’ While no doubt well intended, this is unlikely to encourage the pharmaceutical industry to invest in developing new classes of antimicrobials for use in animals and seems to reinforce the prospect, as outlined in a recent Editorial in Veterinary Record by J. W. Scannell and A. Bruce, of a future in which veterinarians may have to ‘expect to use less, more responsibly’ (VR, August 15, 2015, vol 177, pp 168-170).
The European Commission's guidelines are obviously aimed at Europe but, as highlighted by the Global Action Plan on Antimicrobial Resistance adopted by the World Health Organization in May (VR, May 30, 2015, vol 176, p 556), and as again highlighted during a summit on AMR during the World Veterinary Association's (WVA's) congress in Istanbul last week, AMR is a global problem, and tackling it demands a global, One Health approach. A One Health approach represents an important aspect of the UK's Five-Year Antimicrobial Resistance Strategy produced by Defra and the Department of Health in 2013 (VR, September 21, 2013, vol 173, p 254), and of the European Commission's action plan on resistance launched in 2011 (VR, November 26, 2011, vol 169, p 564). However, as the WHO has reported, relatively few countries around the world (only 34 of 133 participating in a WHO survey) have a comprehensive national plan in place to fight AMR, and in many countries, sales of antimicrobials (for use in people or animals) without a prescription are widespread.2 The extent of the problem was underlined at the WVA's summit in Istanbul last week, where it was reported that more than half of the countries belonging to the World Organisation for Animal Health (OIE) have no legislative controls over antimicrobial use, and where the critical role that veterinarians, working within a suitable legislative framework, can play in antimicrobial stewardship was emphasised. Steps continue to be taken in Europe and elsewhere to strengthen controls on antimicrobial use, but more effort needs to be devoted to developing controls and building veterinary capacity globally.
