Taking up a new challenge with a role in resistance
I qualified as a vet from Bristol university in 2000 and went into small animal clinical practice for eight years. I was lucky enough to work in a number of great practices, and developed an interest in feline medicine. However, I reached the point at which I was looking for a new challenge – I didn't feel ready to go into practice partnership or to specialise more deeply, so after a break working overseas for various animal rescue and neutering projects, I returned to the UK take up a position in the civil service fast stream to learn about policy development.
I initially worked in the Home Office, but after two years moved to the Veterinary Medicines Directorate (VMD) to become a veterinary assessor for medicines applications. I started my current position as head of the antimicrobial resistance (AMR) unit last January – it's a role that combines science and policy development and requires an understanding of the pharmaceutical and livestock industries, and of veterinary practice.
"My role combines science and policy development and requires an understanding of the pharmaceutical and livestock industries, and of veterinary practice"
AMR, particularly antibiotic resistance, is currently very high profile and is increasingly being recognised as a significant issue for human and animal health. This political and media focus makes the work of my team challenging – but it also means that we really have a chance to make a difference.
The AMR unit at the VMD is a small team but we cover a wide portfolio of work. We are responsible for three different strands of ‘evidence’ collection:
- We gather data in order to gain a greater understanding of antibiotic resistance and the factors that impact on its development
- We monitor sales of veterinary antibiotics in the UK
- We coordinate the surveillance of resistance levels in bacteria in animals – both zoonotic bacteria and veterinary pathogens; and oversee a number of AMR-focused research projects that are funded directly by the VMD
Collection and analysis of these data feed into the creation, and subsequent implementation, of government policy aimed at minimising the risks to animal and public health presented by antibiotic resistance. The Government's approach to managing this risk is set out in the UK ‘One Health’ AMR Strategy, on which we collaborated closely with colleagues in the Department of Health and Public Health England.
"Antibiotic resistance is increasingly being recognised as a significant issue for human and animal health"
In addition to data collection and policy development, the team has an outreach and education programme, aimed at raising awareness of the issue of antibiotic resistance, and on the importance of using antibiotics responsibly. This work encompasses many strands – from working closely with veterinary and livestock industry bodies, to promotion of responsible use messages in national and specialist media.
Resistance in the news
The importance of AMR has been recognised for many years, not just in the UK – the first World Health Assembly AMR resolution was agreed in 1998. However, the need to accelerate progress in this area has been highlighted recently; in particular by the 2011 EU ‘AMR Strategic Action Plan’, the 2012 EU Council Conclusions on AMR, and, in the UK, by the most recent annual report of the Chief Medical Officer, Dame Sally Davies, who has ranked antibiotic resistance alongside terrorism as a threat to the UK.
In the veterinary field, attention on AMR has been driven, in part, by the growing awareness that changes to the way in which vets can prescribe antibiotics may be implemented through the upcoming revision of the EU Directive for Veterinary Medicinal Products – the EU law from which our national Veterinary Medicines Regulations are taken. In addition, there is a growing body of research into resistance in veterinary bacteria – and into the ways in which resistant bacteria and resistance genes may potentially be transmitted between animals, people and the environment. Interpretation of this research, with respect to assessing risk factors, is complex but the high level of output of research findings has maintained a focus on resistance.
Whatever the reasons, we welcome the rising profile of AMR – it is key in mobilising action across all sectors involved and therefore essential to achieving our goals.
A problem for everyone
Cases of treatment failure as a result of resistance are currently more common in human medicine than in the veterinary field, but that doesn't mean that vets and animal keepers can take a back seat. Concerns have been raised about the possible role that animals – particularly those kept for food – play as a potential reservoir of resistant bacteria or of resistance genes. For example, genes that confer the ability to produce extended-spectrum beta-lactamases (ESBLs) have been found in commensal and pathogenic bacteria from food animals. Bacteraemias resulting from ESBL-producing enterobacteriaceae are a significant problem in human medicine. Evidence currently suggests that the types of ESBLs found generally differ between people and animals in the UK, but studies in other EU countries have found greater crossover.
"Concerns have been raised about the possible role that animals play as a potential reservoir of resistant bacteria or of resistance genes"
We are working towards a greater understanding of the significance of different potential routes of transmission of resistance between species. However, the key point is that any use of antibiotics drives the development of resistance in bacteria. Interaction between people, animals and their shared environment – whether through direct contact (between owners and pets), or indirectly through the food chain (via meat production, or spreading slurry on land used to grow crops), is unavoidable. So we need to focus on minimising resistance development in bacteria in animals, not only to protect their health and welfare, but also to minimise the overall burden of resistance present in bacteria in general.
A need for new antibiotics
A key disincentive to investment in the production of new classes of antibiotic is uncertainty about future markets. This is particularly pertinent to the veterinary field, since any new classes of antibiotics that are developed are likely to be reserved for human medicine, and be subject to strict controls; that is, kept as a last resort option for treatment. Pharmaceutical companies are understandably not keen to invest in the costly development of drugs for which there will be no market. Encouraging investment into the development of antibiotics whose use could then be severely restricted is a formidable challenge. One of the workstreams of the new UK AMR Strategy is examining ways to incentivise the production of new antibiotics. Whether, or when, such drugs would be available to a veterinary market remains an area of debate.
Regardless of whether new classes of antibiotic become available, we need to focus on effective stewardship of the antibiotics that we already have, to maintain their efficacy. That is why the VMD, and other organisations like the BVA, the Responsible Use of Medicines in Agriculture Alliance (RUMA) and the RCVS, are focused on promoting responsible use. In addition, we need to encourage research into whether the dose regimens authorised for those antibiotics already available, particularly those that have been in use for a long time, are optimal – not only to achieve the desired treatment effect, but to minimise the development of resistance. It may also be that combination therapy can aid in maintaining antibiotic efficacy – there are a range of avenues which have not yet been fully explored.
"We need to focus on effective stewardship of the antibiotics that we already have, to maintain their efficacy"
In the meantime, vets can ensure that they are using antibiotics responsibly by following the guidance that's out there – veterinary and industry bodies have worked hard to produce a range of excellent sector-specific and general reference material. There are also an increasing number of relevant continuous professional development courses for vets who want more detailed information. Key principles are simple:
Avoid using antibiotics whenever possible, by promotion of good husbandry and biosecurity
Choose the right drug for the right bug, using narrow spectrum antibiotics as a first line
Monitor antibiotic sensitivity whenever possible, and before using broad spectrum and, in particular, critically important antibiotics
Minimise perioperative and prophylactic use; and
Report any suspected treatment failures to the VMD
I appreciate, coming from a clinical background, that vets face many external pressures, including expectations and demands from clients, which may influence decision making when prescribing. That's why we also try to target responsible use messages at animal keepers and pet owners, too.
However, vets are essentially the gatekeepers for veterinary antibiotics, and need to take this responsibility seriously – if you look at some other EU countries, the freedom for vets to prescribe certain drugs, particularly the critically important ones, has been curtailed. The Government is clear that vets are best placed to decide what the most appropriate treatment for their patients should be, but with this privilege comes the need to be proactive in making the right prescribing decisions.