Maryn McKenna

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Update: Farm Animals Get 80 Percent of Antibiotics Sold in U.S.

December 24, 2010 By Maryn Leave a Comment

Two weeks ago, I broke the news of a new FDA report that estimated for the first time the amount of antibiotics sold in the United States every year for use in agriculture: 28.8 million pounds.

That long-awaited report didn’t answer a crucial question: What volume of antibiotics are sold in the United States each year for human use. It’s a crucial question because, in answer to concerns about antibiotic resistance arising on farms, the answer has always been that human medicine is equally culpable because it uses similar volumes of antibiotics.

The only research that has attempted to answer that question is contained in a decade-old report by the Union of Concerned Scientists that put the proportion of antibiotics going to animals at 70 percent of the U.S. total.

That UCS report and estimate are a decade old not because no one has cared about the topic, but because accurate updated figures have been so hard to get. So we owe a special holiday thank-you to the researchers at the Center for a Livable Future, who decided the release of the FDA report justified another attempt to get the numbers straight. They succeeded.

The proportion of antibiotics sold in the United States each year that go to animals turns out to be not 70 percent, but rather 80 percent. Here’s CLF’s Ralph Loglisci, who got the confirmatory numbers from the FDA:

In accordance with a 2008 amendment to the Animal Drug User Fee Act, for the first time the FDA released last week an annual amount of antimicrobial drugs sold and distributed for use in food animals. The grand total for 2009 is 13.1 million kilograms or 28.8 million pounds. I … contacted the FDA for an estimate of the volume of antibiotics sold for human use in 2009. This is what a spokesperson told me:

“Our Office of Surveillance and Epidemiology just finished an analysis based on IMS Health data. Sales data in kilograms sold for selected antibacterial drugs were obtained as a surrogate of human antibacterial drug use in the U.S. market. Approximately 3.3 million kilograms of antibacterial drugs were sold in year 2009. OSE states that all data in this analysis have been cleared for public use by IMS Health, IMS National Sales Perspectives™.”

3.3 million kilograms is a little over 7 million pounds. As far as I can determine, this is the first time the FDA has made data on estimates of human usage public.

At its blog, CLF lays out the math for each major drug class as sold for animal use and human use, with a long discussion of the significance of the different drug classes. Here’s the CLF table summing up the math, but please go over to CLF’s blog for its discussion.

Most important to note: Most of the drugs used in animal agriculture and in human medicine are functionally identical. That’s one reason why the overuse of antibiotics in animals is such a concern: When organisms become resistant on the farm to drugs used on livestock, they are becoming resistant to the exact same drugs used in humans. (One major drug category used in animals, ionophores, do not have a direct human analog. But use of them on farms is still a concern, because resistance factors can move freely between species of bacteria. That’s a discussion for another day.)

Loglisci’s conclusion is also worth underlining:

The next battle, which industry has already begun, is defining what non-therapeutic use will constitute. Producers are already claiming that the use of antibiotics for growth promotion has decreased, maintaining current low-dose usage is aimed at disease prevention. Regardless, all low-dose usage of antibiotics can lead to a significant increase in antibiotic resistance.

Image: Flickr/Epsos

Filed Under: Science, Science Blogs, Superbug Tagged With: agriculture, antibiotics, FDA, food, food policy, News, Resistance, Science Blogs

News break: FDA estimates US livestock get 29 million pounds of antibiotics per year

December 9, 2010 By Maryn Leave a Comment

This afternoon, the Food and Drug Administration posted without fanfare a report that many people have been waiting a long time for: Its first-ever estimate of the amount of antibiotics sold for use in food animals in the United States.

And the number is: almost 29 million pounds in 2009.

That’s a lot.

Is it more or less than was expected? It’s almost impossible to say. Estimates of the amount of antibiotics given to food animals in the United States are ferociously contested and plagued by squishy definitions and category creep. In 2000, the Animal Health Institute, which represents veterinary drug manufacturers, put total use at 17.8 million pounds. In 2001, the Union of Concerned Scientists, which campaigns (among other issues) to dial back use of agricultural antibiotics, estimated that 24.6 million pounds per year are used only for “non-therapeutic purposes” — that is, to make animals grow to market weight faster and to prevent them catching diseases in the close quarters of confinement agriculture.

The reason why antibiotic use on farms is a concern, of course, is because such use stimulates the emergence of drug-resistant organisms that move off the farm in animals, in groundwater, in dust, on the wind and in the systems and on the clothes of those who work there, and makes new resistance factors available to be swapped among bacteria. (For much more about that, see these three posts and this long archive at my former blog.)

The FDA’s estimate comes as the agency has been moving to curb agricultural antibiotic use after years of non-action. Today’s report, which is very short — basically a table and a bunch of footnotes — is the direct result of a 2008 amendment to the Animal Drug User Fee Act of 2003, which required manufacturers to report yearly on sales of agricultural antimicrobials. (Here’s an FDA Q&A on the report background.)

More important, though, today’s report dovetails with the FDA’s new effort to curb antibiotic use in agriculture, which Commissioner Dr. Margaret Hamburg said in October would involve “very serious scrutiny.” (Video here.) The main instrument of that effort is a “draft guidance” that the FDA opened for public comment over the summer, “The Judicious Use of Medically Important Antimicrobial Drugs in Food-Producing Animals” (pdf here). The point of that guidance is to ask agriculture to voluntarily withdraw from use the ag drugs that are functionally identical to drugs that are important in human medicine — because if bacteria become resistant to those drugs when they are used in animals, that newly derived resistance will also affect humans, making common diseases difficult or impossible to treat.

In addition to the volume figure, the real value of today’s brief report may be simply to make clear just what antibiotics are used in agriculture. Take a look at the report table at right, which lists the animal drugs used by amount sold within drug classes. (Note that the amounts are given in kilograms.) It lists:

Aminoglycosides: Human versions include streptomycin and amikacin.

Cephalosporins:  Human versions include Keflex and Rocephin.

Lincosamides: Human versions include clindamycin.

Macrolides: Human versions include erythromycin.

Sulfas: Human versions include half of the very common drug combos Bactrim and Septra.

Penicillins and tetracyclines: Yup, just what they sound like.

“NIR”: That’s FDA shorthand for “not independently reported” because they have few manufacturers or make up a small portion of the market. Among them are fluoroquinolones. Human versions: Cipro and Levaquin.

There’s much more to be said about the issue of antibiotic use in agriculture, especially because the lone piece of legislation addressing it, the Preservation of Antibiotics for Medical Treatment Act, is currently in lame-duck limbo. This report is an important piece of data for the ongoing debate.

Update: I asked some experts in the field to comment on the release of this data. Dr. David Wallinga, director of the Food and Health program at the Institute for Agriculture and Trade Policy in Minneapolis (also William T. Grant Foundation Distinguished Fellow in Food Systems and Public Health at the University of Minnesota School of Public Health) replied:

Clearly, antibiotic use in animal agriculture is huge, and as the FDA and CDC and WHO all agree, much of it is unnecessary. Data collection is important. But, because resistant bugs quickly adapt, we can’t afford to wait for data to take action to reduce antibiotic use wherever possible. That includes routine uses of antibiotics for cattle developing liver abscesses because they’re force-fed grain rather than grass, as well as antibiotics used to make animals get fatter faster.

Update 2: A day after the release of this report, Rep. Louise Slaughter (D-NY), author of PAMTA and a public-health microbiologist, commented on the data — and also said she’ll be reintroducing the legislation again in the next Congress in January.

This report illustrates the overuse of antibiotics in food animal production and makes a strong case for some common-sense limits on antibiotic use. We are putting millions of pounds of antibiotics into the food supply unnecessarily every year. This cannot continue and it’s my hope that these new data from the FDA will encourage even more members of Congress to join me next year when I reintroduce this legislation.  Moreover, the FDA must move fast to issue strong regulations on antibiotic usage in agriculture.

Update 3: Tom Philpott, senior food and agriculture writer at Grist — and a farmer, so he knows the territory — covered the FDA report and this post in a very kind and typically forthright post of his own.

Update 4: Helena Botttemiller, ace food-policy reporter for Food Safety News, covers this as well, noting how little mainstream media interest there has been. Any opinions why?

Cite: 2009 Summary Report on Antimicrobials Sold or Distributed for Use in Food-Producing Animals, FDA, Dec. 9, 2010

Image via Flickr user net_efekt under CC

Filed Under: Science, Science Blogs, Superbug Tagged With: agriculture, antibiotics, FDA, food, food policy, News, Resistance, Science Blogs

News break: Pre-exposure prevention of HIV works. But.

November 23, 2010 By Maryn Leave a Comment

There’s huge news today in the results of a major drug trial for HIV prevention, but the news comes balanced with significant cautions and caveats. For the first time, researchers have shown that if men who are not infected with HIV take routine doses of AIDS treatment drugs, they can markedly reduce their risk of becoming infected.

Writing in the New England Journal of Medicine, a multi-national team show that, when HIV-negative sexually active men take the once-daily pill Truvada (actually a combination of two AIDS drugs, FTC and DTF), they reduce their risk of becoming infected with HIV by an average of 44 percent. Among men who took the pill diligently — proven in the trial not only by counting their remaining pills but by analyzing their blood for drug residue — the protection rose to 73 percent.

The finding is powerful evidence that it is possible to protect people who are at high risk of infection — even in very resource-poor settings — from acquiring HIV. The 2,499 men in six countries who participated in the study were chosen because they were very high risk: they had sex with other men, as gay men or as self-identified transgender women; they had multiple sexual partners (on average, 18 in the 3 months before the study began); two-thirds regularly had anal sex without condoms; and two-fifths regularly traded sex for drugs, food, shelter or money. [Read more…]

Filed Under: Science, Science Blogs, Superbug Tagged With: AIDS, HIV, News, Science Blogs

News break: 1 in 7 Medicare patients seriously harmed by hospitals

November 16, 2010 By Maryn Leave a Comment

I’m giving a speech at a conference this morning, so this has to be quick, but I can’t let it pass by, and neither should anyone else: It’s huge, sad news.

The Office of the Inspector General of the US Department of Health and Human Services released a report this morning showing that 13.1 percent of Medicare patients experienced a medical error during hospital stays that caused serious patient harm: prolonged hospital stay, permanent harm, life-sustaining intervention, or death.

If you project the study population — 780 patients over one month in October 2008 — out to the US population, that’s the equivalent of 134,000 people suffering serious medical harm in a year.

One and half percent of the patients died as a result of those errors: the equivalent of 15,000 patients in a year.

And an additional 13.5 percent experienced a medical error that caused them temporary harm.

And those adverse events, permanent or temporary, caused — just in the study month — an additional $324 million in health care spending.

And — if your jaw hasn’t dropped to the floor by now, this will do it — FORTY-FOUR PERCENT of those harms and errors were preventable. (Sorry to shout.)

Just. Outrageous.

And the government agrees, saying in the report’s Executive Summary that these errors are occurring at an “alarming rate.” (p. iv)

Those of you who are on the hospital and infection control sides of the aisle will know how long — and sometimes seemingly fruitless — the struggle against medical error has been. (Medical error includes hospital infections, which include MRSA, the subject of my recent book and therefore my part-time obsession.) It seems sometimes that we have done nothing since the publication of To Err is Human, the seminal 2000 Institute of Medicine report that exposed the rate of medical error in the US to be at least 98,000 events a year, but rack up fresh estimates of horror.

The report came out of the new initiative by the HHS Center for Medicare and Medicaid Services to deny reimbursement for care following adverse events, as a carrot-and-stick approach to attempting to force errors down. It is dry and sober and precise in its methodology, and not long, less than 80 pages. It is worth reading in its entirety.

(H/t to my AHCJ colleague Charles Ornstein of ProPublica, who flagged the report’s release on Twitter.)

Image by Flickr user Romana Klee under CC

Filed Under: Science, Science Blogs, Superbug Tagged With: CMS, HAI, News, Science Blogs

News break: A new type of MRSA spreads in Ohio

October 22, 2010 By Maryn Leave a Comment

The annual meeting of the Infectious Diseases Society of America is taking place this week in Vancouver. This afternoon, one of the researchers presenting there released a startling bit of news: the spread in Ohio (and likely elsewhere in the United States) of a MRSA strain that is common in the rest of the world but so unusual in the US that it was last seen here in the 1990s and has never caused infections here.

The strain is ST239, sometimes called the Brazilian clone, and it’s serious stuff: It causes major epidemics and is responsible for something like 90 percent of all the MRSA infections in hospitals in Asia. Its hallmark is that it very multi-drug resistant — including to just about all the oral antibiotics that are used against MRSA.

Brief recap — disease geeks, go on ahead and we’ll catch up: MRSA stands for methicillin-resistant Staphylococcus aureus, the most common drug-resistant infection in the world (and, shameless self-promotion alert, the subject of my recent book). All MRSA strains, at a minimum, are indifferent to the beta-lactam antibiotics, a group of drugs that share a four-cornered arrangement of atoms at the center of their base molecule. That structure allows the beta-lactam drugs to disrupt staph’s cell membrane, killing the bacterium. When staph evolved a work-around for that attack, it became resistant not just to methicillin, which hasn’t been sold for years, but to all the other beta-lactams as well — of which there are dozens; they are the fundamental, basic antibiotics used in medicine every day. Over the years, MRSA has also gained the ability to defuse the attack of additional drugs and drug families, by exchanging with other bacteria bits of DNA containing additional resistance genes. At the same time, the pace of new-drug approvals has slowed dramatically.

OK, back to today’s news.

At IDSA this afternoon, Dr. Shu-Hua Wang, an assistant professor of medicine at Ohio State University, revealed the results of an analysis of MRSA strains that showed up in a surveillance network that links Ohio State and seven rural hospitals nearby. Between January 2007 and January 2010, 7 percent of the 1126 MRSA strains they found in sick patients turned out to be ST239 — the first ST239 infections ever recorded in the US.

The infections were serious: half of the patients had bloodstream infections and one-fourth had pneumonia. And they were unusually difficult to treat: The bacterial samples were indifferent not only to the beta-lactams, but to a wide array of additional drugs: clindamycin, tetracycline, trimethoprim/sulfamethoxazole (TMP/SMX, usually called Bactrim or Septra), moxifloxacin, and gentamicin. They were susceptible only to vancomycin, the MRSA drug of last resort for decades, and one newer drug, linezolid (Zyvox).

That is a dismaying list. Here’s why: In the search for drugs that still work against MRSA, medicine has increasingly turned to older drugs — ones that until recently were never been used against the bug, because there were newer, better drugs available. Tetracycline and TMP/SMX are two of the great remaining hopes for treating MRSA infections without rolling out the really big-gun drugs that should be reserved for life-threatening emergencies. If the resistance factors carried by ST239 knock out the older generics, MRSA infections will become yet harder to treat. As appears to have happened in Ohio:

“Twenty-two percent of the patients experienced relapse and failure of their drug regimens,” Wang said in a briefing for the media. “Another 22 percent died within 30 days.”

The 77 patients infected with ST239 tended to be male and older, and they were apparently already ill: 74 percent had been hospitalized before, 44 percent had had surgery, 29 percent had been in a nursing home, 17 percent had been on dialysis. Where the ST239 first came from and how it spread isn’t clear, Wang said, except that the surveillance network results show the earliest cases to have been treated at Ohio State. It may have spread to the rural hospitals from there.

The most worrisome implication of today’s news may not be the appearance of ST239 itself — it is so common in the rest of the world that its return to the US may just have been a matter of time — but rather the possibility that public health may not be able to keep track of it. In everyday medicine, isolates are tested enough to identify the organism and to determine its susceptibility to antibiotics; those results deliver enough information to determine a patient’s  best treatment. Multi-locus sequence typing, the test that identified ST239 in the Ohio patients, is expensive and complex and delivers more information than a clinician really needs; it’s most used in academic research labs. So it is entirely possible that patients could become infected with this strain without the strain being detected, unless the physician treating them happened to put together the puzzle pieces of the unusual resistance pattern.

This possibility seems to have been on Wang’s mind in Vancouver. To track the spread of ST239, “Increased molecular surveillance is needed,” she said. But she offered some workarounds — less expensive, more commonly used assays — whose results could be used to cast a net of detection for the spread of this new strain.

MRSA image from the Public Health Image Library, CDC; poster previously sold by Threadless, original design by Olly Moss

Filed Under: Science, Science Blogs, Superbug Tagged With: IDSA, MRSA, News, Science Blogs

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