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COMBATING ANTIMICROBIAL
RESISTANCE
A One Health Approach to a Global Threat
PROCEEDINGS OF A WORKSHOP
Additional copies of this publication are available for sale from the National
Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800)
624-6242 or (202) 334-3313; http://www.nap.edu.
Consultant
ANNA NICHOLSON, Consulting Writer
__________________
1 The National Academies of Sciences, Engineering, and Medicine’s planning
committees are solely responsible for organizing the workshop, identifying topics,
and choosing speakers. The responsibility for the published Proceedings of a
Workshop rests with the workshop rapporteurs and the institution.
FORUM ON MICROBIAL THREATS1
__________________
1 The National Academies of Sciences, Engineering, and Medicine’s forums and
roundtables do not issue, review, or approve individual documents. The
responsibility for the published Proceedings of a Workshop rests with the
workshop rapporteurs and the institution.
Reviewers
1 INTRODUCTION
Workshop Objectives
Organization of the Proceedings of a Workshop
REFERENCES
APPENDIXES
A STATEMENT OF TASK
B WORKSHOP AGENDA
C BIOGRAPHICAL SKETCHES OF WORKSHOP SPEAKERS AND
MODERATORS
Boxes, Figures, and Table
BOXES
3-1 New U.S. Food and Drug Administration (FDA) Policy on Use
of Antimicrobial Drugs in Food Animal Production
3-2 A Critical Threat of Horizontal Gene Transfer
3-3 Promising Manure Management Strategies
FIGURES
3-1 Resistance to critically important antibiotics in nontyphoidal
Salmonella in the United States (1996–2014)
3-2 The Collective Antimicrobial Resistance Ecosystem (CARE)
model
3-3 Surveillance of antibiotic use in China
3-4 The spread of antibiotic resistance through various vehicles
3-5 Manufacturing as one of many potential sources of
antimicrobials in the environment
TABLE
4-1 Antimicrobial Stewardship Learning Outcomes
Acronyms and
Abbreviations
NAE no-antibiotics-ever
NARMS National Antimicrobial Resistance Monitoring System
NIFA National Institute of Food and Agriculture
RIF rifampin
TB tuberculosis
UN United Nations
USDA U.S. Department of Agriculture
Introduction
WORKSHOP OBJECTIVES
Major drivers of antimicrobial resistance in humans have been
accelerated by inappropriate antimicrobial prescribing in health care
practices; the inappropriate use of antimicrobials in livestock; and
the promulgation of antibiotic resistance genes in the environment.
The National Academies of Sciences, Engineering, and Medicine have
been engaged with the issue of antimicrobial resistance for nearly
two decades (IOM, 1998, 2010, 2011). To build on this work, to
explore developments since the last workshop was convened, and to
help parlay knowledge into immediate action, an ad hoc planning
committee,1 under the auspices of the Forum of Microbial Threats at
the National Academies, planned the 2-day public workshop
Combating Antimicrobial Resistance: A One Health Approach to a
Global Threat.
The workshop explored issues of antimicrobial resistance through
the lens of One Health, which is a collaborative approach of multiple
disciplines—working locally, nationally, and globally—for
strengthening systems to counter infectious diseases and related
issues that threaten human, animal, and environmental health, with
an end point of improving global health and achieving gains in
development. The approach can be used to examine how factors
across those three domains of human, animal, and environmental
health converge and contribute to the emergence and spread of
antimicrobial resistance. A concerted effort across these three
domains can help strengthen the fight against the threat of
antimicrobial resistance. Furthermore, the workshop was convened
to explore immediate and short-term actions and research needs
that will have the greatest effect on reducing antimicrobial
resistance, while taking into account the complexities of bridging
different sectors and disciplines to address this global threat. Topics
explored during the workshop include the following2:
__________________
1 The planning committee’s role was limited to planning the workshop, and this
Proceedings of a Workshop was prepared by the workshop rapporteurs as a
factual summary of what occurred at the workshop. Statements,
recommendations, and opinions expressed are those of individual presenters and
participants, and are not necessarily endorsed or verified by the National
Academies of Sciences, Engineering, and Medicine, and they should not be
construed as reflecting any group consensus.
2 The full Statement of Task is available in Appendix A.
2
Davies reported that the IACG’s initial work plan includes aligning
with the Sustainable Development Goals and WHO’s global action
plan; reviewing work ongoing by FAO, OIE, and WHO; and mapping
a framework for action. Making progress on metrics—surveillance,
monitoring, and evaluation—is also a priority for Davies. Progress is
being made, she noted, with the plans for the Institute of Health
Metrics and Evaluation to include antimicrobial resistance into the
Global Burden of Disease resource, which provides a tool to quantify
health loss from diseases, injuries, and risk factors so health systems
can be improved. Furthermore, 90 percent of the world’s population
is now covered by national action plans against resistance (WHO,
2017a). However, plans are meaningless without action, Davies
noted, and implementing plans will require more funding, which may
need more coordination on the national and global levels.
International push funding has increased dramatically since 2014,
she said, but more pull funding will be needed for diagnostics and
therapeutics.6 Davies concluded her presentation by encouraging the
audience to play a key role in the fight against antimicrobial
resistance by following infection prevention and control practices,
such as handwashing, which can reduce antibiotic consumption.
__________________
1 The European One Health Action Plan against Antimicrobial Resistance is
available at ec.europa.eu/health/amr/sites/amr/files/amr_action_plan_2017_en.pd
f (accessed July 31, 2017).
2 The Jaipur Declaration on Antimicrobial Resistance is available at www.searo.w
ho.int/entity/regional_committee/64/rc64_jd.pdf (accessed July 31, 2017).
3 The World Health Day “Antimicrobial resistance: no action today, no cure
tomorrow” policy package is available at www.who.int/world-health-day/2011/en
(accessed July 31, 2017).
4 World Health Assembly resolution WHA51.17 is available at archives.who.int/pr
ioritymeds/report/append/microb_wha5117.pdf (accessed July 31, 2017).
5 The other two conveners are Junshi Chen and Martha Lutterodt.
6 Push incentives, such as research grants, subsidized loans, and tax credits,
aim to reduce industry’s costs to help stimulate research and development through
the basic research, preclinical, and clinical trial phrases, whereas pull incentives,
such as add-on payments, market exclusivity, and intellectual property protections,
are provided during the approval process and the post-market period to create
viable market demand.
3
BOX 3-1
New U.S. Food and Drug Administration
(FDA) Policy on Use of Antimicrobial Drugs in
Food Animal Production
McDermott described a new FDA policy on the use of antibiotics
in food animal production as part of its efforts to combat
antimicrobial resistance. In January 2017, FDA completed the
implementation of Guidance for Industry #213, which eliminates
the use of antibiotics with importance in human medicine for
growth promotion purposes in food animal production. In addition,
the use of medically important antibiotics in feed and drinking
water of food animals has been transitioned to veterinary
oversight. Seven classes of antibiotics are affected:
aminoglycosides, lincosamides, macrolides, penicillins,
streptogramins, sulfonamides, and tetracyclines. Because the
affected classes are already being tracked as part of the National
Antimicrobial Resistance Monitoring System, he said, there is a
large body of phenotypic data currently being analyzed with new
metagenomic sequencing technology to establish prepolicy
baseline levels. McDermott was optimistic that those baseline
levels, which come from sample sources of different food animals
and resistances, will serve as reliable reference points for
evaluating the effect of this new policy.
SOURCE: McDermott presentation, June 20, 2017.