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FACULTY OF SCIENCE, ENGINEERING
AND COMPUTING
School of Life Sciences, Pharmacy and
Chemistry
MSc
IN
Microbiology
Jasmine Bagri
K
Perceptions of use and efficacy of antimicrobials
by the public, farmers, medical and Veterinary
professionals.
January 2018
Professor Mark Fielder, Professor Philip Terry, Dr Simon Gould
WARRANTY STATEMENT This is a student project. Therefore, neither the student nor Kingston University makes any warranty, express or implied, as to the accuracy of the data or conclusion of the work performed in the project and will not be held responsible for any consequences arising out of any inaccuracies or omissions therein.
Table of Contents
- Abstract
- Introduction
- Background of the topic
- Antibiotic use Human Medicine
- Antibiotic Use in Agriculture and Aquaculture
- Antibiotic use in Veterinary Medicine
- The public perceptions on the use and misuse of antibiotics.
- Policies in place to reduce AMR
- Aims
- Methods
- Questionnaire Results
- Participant Characteristics
- General questions relating to participants use of antibiotics
- Participants understanding of Antibiotic Resistance.................................................................
- Participants understanding of the different diseases that can be treated with antibiotics.
- Participants sources of information
- Discussion
- Participants characteristics
- An estimation of the Understanding of AMR/ antibiotics by participants in the current study
- Viral diseases
- Bacterial diseases
- Syndromic diseases
- Source of information
- Free text responses
- Future work
- Comparison between highest responding countries
- Free text responses
- Conclusion
- Acknowledgements
- References........................................................................................................................
- Appendix
- Consent form
- Statement by participant
Introduction
Background of the topic
Antibiotics have been in medical use since 1928 when Sir Alexander Fleming first discovered the revolutionary drug penicillin (Ventola, 2015), over the following years more were discovered and through modern day medicine have become more accessible (Ventola, 2015). However in turn there has been an increase in antimicrobial resistance (AMR) in the years following up until today (O’Neill, 2014). AMR occurs when a microorganism becomes resistant to the effect of the drug used to kill or inhibit the organism, this then leaves the microbe able to survive and spread, allowing the clonal expansion of the resistant gene (Anon, 2017). Despite there being a number of reports previously published on antimicrobial resistance and the potential effects for some time, AMR is still an ongoing global threat (Rather et al, 2017), with the chief medical officer Dame Sally Davies adding AMR to the UK’s risk register (Kissel et al, 2013).
Not only have antibiotics been used to save millions of patients’ lives but have also played an important role in facilitating major advances in medicine and surgery (Ventola, 2015). Antibiotics have prevented and/or treated infections that can occur in chemotherapy patients, patients with chronic diseases such as diabetes as well as surgeries such as organ transplants, joint replacements or cardiac surgery (Ventola, 2017). With an increase of other conditions such as diabetes and obesity, more people are becoming susceptible to infections which in turn means a potential increase in the number of antibiotics required (Anon (1), 2017). Other consequences might include the possibility of treatment failure, increased hospitalisation and prolonged illness (Anon (2), 2017). AMR already presents serious social and economic burdens. It is estimated to be responsible for 25,000 deaths annually in the EU, it is projected that AMR will cause 10 million deaths globally and cause more deaths than cancer by 2050 (O’Neill, 2014). Antibiotic resistance, as previously stated is a global health issue as well as a one health issue yet people are still not fully aware of the potential threat at both individual and community level (Rather, 2017). In 1943 it was noted by Sir Alexander Fleming that microbes were ‘educated’ to resist penicillin (Gould et al, 2013), when penicillin resistance first became an issue in the 1950s.
Although finding a new class of antibiotics will help with the treatment of bacterial infections, resistance will still occur in years to come, therefore it’s important to change the uses and perceptions of how antibiotics are used. Antibiotics are not only important in human medicine but also play an important role in agriculture and veterinary medicine, it is therefore important have to a good understanding as to how antibiotics are perceived and used in these different areas. This research will focus on the perceptions and uses of antibiotics in humans medicine alongside agriculture and veterinary medicine showing the importance of ‘One Health’.
Antibiotic use Human Medicine
The European Antimicrobial Resistance Surveillance Network (EARS-net) reports on levels of multidrug resistance of the following pathogens , Enterococcus spp. , Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanii, Psedudomonas b aeruginosa and Enterobacteriaceae resistant to cephalosporin’s, quinolones, and carbapenems (McKenna, 2013). In hospitals, some of the most commonly found resistant bacteria include Escherichia coli, K. pneumoniae, Ps. aeruginosa, S. aureus and Acinetobacter species (ECDC, 2016). Hospital acquired infections (HAI) are been recognised as a critical problem, affecting the quality of healthcare (Cornejo-Juarez et al, 2015). The emergence of multidrug resistance bacteria (MDRB) has developed into a public health concern particularly for those patients admitted to intensive care units (Cornejo-Juarez et al, 2015).
In 2016 it was estimated by the World Health Organisation (WHO) there were 490 000 new cases of Multi Drug Resistant-Tuberculosis (MDR- TB), with only 25% of these cases detected and reported. This form of Tuberculosis (TB) is resistant to the two commonly used anti-TB drugs, rifampicin and isoniazid the most effective first-line drug. Treatment of MDR- TB is now longer and not as effective as it once was as non- resistant TB, of all new cases reported MDR-TB has increased by 4.1% in 2016 (WHO, 2018). In the last 70 years, only 2 new TB drugs have come to market, research and development (R&D) investment into TB drugs is underfunded and at its lowest since 2008 (WHO, 2017) showing more funding is needed in research to help protect future lives against infections such as MDR-TB.
With increased political commitment to decrease antimicrobial resistance at a global, regional and nation level, the sixty-eighth World Health Assembly have endorsed the Global action plan to promote the development of new antibiotics. The aim of the Global action plan to ensure the continued availability of treatment options, one of the main objectives of the plan is to increase the R&D for new antibacterial treatments, this however cannot solely be resolved by the development of a single antibiotic but an ongoing program of drug discovery going forward (WHO, 2017).
Antibiotic Use in Agriculture and Aquaculture
Up to 70% of all antibiotics globally are consumed by animals, compared to the 30% consumed by humans (O’Neill, 2015) with such a high proportion it is fundamental to understand why this is to aid in the reduction of AMR. However due to poor surveillance and data collection in many countries it is difficult to know the total annual global consumption of antibiotics in agriculture, estimates range from 63,000 tonnes (Van Boeckel,
- to over 240,000 tones (Delia, 2015).
There are three main reasons as to why antibiotics are used in agriculture, firstly the treatment of disease in sick animals, secondly antibiotics are also used as a prophylaxis, this is when antibiotics are given to healthy animals to prevent diseases during illness in the herd and finally antibiotics are used as a growth promoter given to healthy animals to increase feed-to gain efficiency, by preventing infection so growth of the animals is not impended (O’Neill, 2015). Use of antibiotics as growth promoters was banned in the EU in 2006 (Scarafile, 2016).
There appears to be major knowledge gaps about the extent of antimicrobial that are used in livestock globally, relatively few countries have surveillance systems monitoring the quantity of antimicrobials used in food producing animals. A survey conducted by the World Health for Animal Health the Oficina International de Epizootias (OIE) in 2012, found only 27% of OIE member counties utilized an official system for collecting data on antimicrobial use in livestock (Teillant, 2015). Better surveillance would help pinpoint areas where the use
of antibiotics could be reduced. What is known is the antibiotics that are used in animals, whilst some of the antibiotics used are not current treatments in human medicine, others such as tetracycline, penicillin and sulfonamides are used in the treatment of human diseases (Landers, 2012). Of the 41 antibiotics approved for use by the FDA in food producing animals in the USA, 31 of those are categorised as being medically important for human use (O’Neill, 2015). This shows the importance of ‘One Health’, a principle that recognises human, animal health and the environment as being interconnected and that diseases transmitted from humans to animals and vice versa are tackled together rather than being treated as two separate issues (WHO, 2017). Its estimated that the global consumption of antibiotics will increase by 67% from 2010, 2030, with consumption amongst BRIC (Brazil, Russia, India and China) countries increasing by 99% in that same time (O’Neill, 2015). Highlighting why it is so important to understand how antibiotics are being used to help prevent such a high increase.
The use of antibiotics in aquaculture and its impact on the environment is an ongoing and growing concern (Watts et al, 2017). Being able to identify the amount of antibiotic being passed into the environment is very difficult, just like the use of antibiotics in food production, there is a need for better data (O’Neill, 2015). The use of antibiotics within aquaculture can be reduced as has been shown in Norway (Anon, 2016), a reduction of 99% between; 1987-2013 was achieved by improving farm hygiene. This was achieved with better selection of farm sites where there was good water exchange (Anon, 2016), and with stricter regulations, from 1989 it was mandatory to show copies of prescriptions issued to fish farmers to the Norwegian Government Fish Inspection and the Quality control service (O’Neill, 2015). This shows that reduction in the use of antibiotics can be achieved with better regulation enforced by government.
Antibiotic use in Veterinary Medicine
Antibiotics in veterinary medicine are widely used for therapeutic, metaphylactic or prophylactic treatment of bacterial infections (Hughes, 2012). Whilst there is data presented on the sales of antimicrobials in veterinary medicine by the European Surveillance of Veterinary Antimicrobial Consumption (ESVAC) and the Veterinary Medicines
health are prescribed by General Practitioners (GPs) (Llor, 2014). A recent study based in the UK, showed that 55% of GPs felt under pressure to prescribe antibiotics by patients, a further 44% of GPs also admitted that they prescribed antibiotic to make patients leave the surgery (Cole, 2014). The question might be asked that if patients were more aware of how antibiotics work and why they are prescribed, then patients may be less inclined to asked GPs to prescribe them. To help reduce AMR it is important that stakeholders and users have some understanding of what AMR is, and the implications this has on the treatment prospect going forward as antibiotics are believed to be quick and effective treatment by the public (Michael, 2014). However, members of the public are not aware that antibiotics are only effective against bacteria and not viruses such as the common cold (Al-Haddad et al, 106). A study found that 10.5% of respondents expected to be prescribed a course of antibiotics for a common cold (Gualano et al, 2015). Another contributing factor is when patients don’t complete their course of antibiotics. One study showed that 11.3% of respondents did not compete their prescribed course of antibiotics, when asked why, 65% responded stating they stopped when they either felt better or forgot to take the medication (McNulty et al, 2007). This shows more education is required for the public to understand the effectiveness and correct uses of antibiotics.
Self-medication with antibiotics with and without prescription. Self-medication with antibiotics is clearly an important issue, it is one of the most common reasons for the development of human pathogen resistance to antibiotic drugs (Michael et al, 2014). Therefore, it is important to spread more awareness among the public population about the adverse effects of antibiotic overuse (Rather et al, 2017). However, in some areas of the world self- medication is not by choice, recent studies have suggested that self- medication is more prevalent in economically deprived communities (Bennadi, 2014), these also are potentially areas where antibiotics can be sold legally without a prescription (Morgan et al, 2011). These are areas where better regulations are needed with the help of the government to prevent the incorrect use of antibiotics. For antibiotics to work, the correct class of drug needs to be prescribed along with correct dose and duration against a known and identified organism. This is a specific point of requirement detailed in Lord O’Neill’s AMR Review publication, if these factors are not considered the antibiotics may have, at best, limited affect and could lead to the development of resistance. Common
sources of self-medication are from previous prescriptions, friends and information from news articles (Bennadi, 2014).
Policies in place to reduce AMR In 2013, the UK Government released its 5-year strategy to reduce the number of antibiotics used, this included, in people, agriculture, animals and wider environment. However, it failed to provide specific guidelines for reducing farm antibiotic use, the strategy only contained general advice for farmers and vets, leaving it to the farmers themselves to decide on what is the correct form of treatment. (DoH, 2015). ‘A European One Health Action Plan against Antimicrobial Resistance’ also known as ‘One Health’ has the main goal to preserve the effective treatment of infections in both humans, animals and the environment. Key objectives include making the EU a best practice region, this includes better surveillance and implementing monitoring programs. Boosting research, and finally to ensure this is on a global level not just among the EU (Anon (3), 2017). It is important that human and animal health are recognised as one, they are interconnected so should therefore be tackled as one (Anon (3), 2017). In 2016 antibiotic use in food producing animals dropped by 27% in the UK, a target was set by the government to reduce antibiotic use from 62mg/Kg to 50mg/kg, this target was exceeded and reduced to 45mg/kg following the recommendations from the 2016 report on Antimicrobial resistance by Lord Jim O’Neill (Anon (3), 2017). In the UK sales of Colistin in human health, considered as one of the critically important treatments have dropped by 83% now accounting for less than 1% of all antibiotics sold for use in humans in 2016 (anon, 2017).
Aims The current study will look at the uses and perceptions of antibiotics in agriculture, by veterinary and medical professionals, farmers and the public. The data was collected through an online questionnaire filled out anonymously by the. The questions are intended to probe how each of these sector group uses and perceives the value of antimicrobials, the results will allow an indication of what areas needs addressing in terms of training/ guidance/ education both in terms of what stakeholders already know but also how the
Questions 21, 22, 23, were answered by ticking a box based upon the response that relates to them the most. Questions 7, 9 and 24 were answered by a numbers scale (e.g. On a scale of 0-4, “0” being no risk of harm to health, and to “4” being a high risk of harm to health). Participant were asked to tick a number depending on their answer. Questions 7b, 14 and 20 were answered with participants being able to write their own response to the question. Question 13 which involved a table of different diseases, participants responded by checking the boxes that reflected their response. Questions 17, 18, 19 were answered by checking the box that depending on their response.
Participants were asked to complete the question in accordance to their own opinion. Participation was voluntary; before starting the questionnaire, participants were given a brief of the background (in the appendix 1.1) of why the survey was being carried out as well as a consent form, this stated that the questionnaire was anonymous, participants were asked at the end of the questionnaire to give a random phrase/number, so facilitating the participant’s removal from the questionnaire if required. A debrief was also given at the end of the questionnaire, this contained further contact details and external links if the participant wanted further information about antibiotic resistance. Ethical approval was obtained from Kingston University Ethics committee before the questionnaire could be distributed. This questionnaire was passed by the Ethical board at Kingston University (ethics approval number: 161716). Checks were undertaken that the questions were not misleading or biased and abided by ethics guidelines.
Data Analysis
Analysis of data was undertaken with the data being downloaded into Microsoft excel and then into SPSS (publishers name please). The main test used to analyse the data was a chi- square test as well as descriptive statistics – such as detail here please.
Questionnaire Results
Demographic Data A total of 875 participants completed the questionnaire; 1 participant was removed as the answerers provided did not match their professional background. Results are split into 7 sections;
- Participant characteristics
- General questions relating to antibiotic use
- Understanding of antibiotic resistance
- Understanding of diseases
- Source of information
- Comparisons between Countries
- Free text responses
Participant Characteristics
A total number of 874 participants are included, 57.5% (503) were female, 41.6% (364) were male, 0.5% (4) other and 0.3% (3) stated they would rather not say. The average age of participants was 42 years (Std.Deviation ±12.8 years), the lowest age stated was 16 and the highest stated was 77, 10 of the respondents didn’t state their age. Participants were also asked their religion; Table 2 shows the results of the religions of the participants. The Highest response to religion was ‘No religion’ followed by ‘Christian’.
General questions relating to participants use of antibiotics
Respondents were asked a series of questions regarding their knowledge and usage of antibiotics, this section included the following questions;
- On a scale of 0-5 (5 being the highest) rank your medical science knowledge
- Have you previously taken antibiotics?
- Did you finish the course of antibiotics?
- Have you heard of antibiotics?
- Do you feel antibiotics cause harm? Participants were asked on a scale of 0 (being low) to 5 (being high) what they ranked their medical science knowledge as Figure 1 shows the means of participant’s knowledge from the four different groups.
Figure 1: Responses of the four groups on their medical science knowledge showing the means of participants medical science knowledge
Responses from the four groups were significantly different (F= (3,870) = 99.46, p=0.000). Those with a veterinary background showed the greatest level of medical knowledge with a mean score of 3.2, (SD ±0.7) with the lowest being the public at 1.8. (SD ±0.8). Post hoc analysis showed a significant difference between: Veterinary background and agriculture: p=0.000; Veterinary background and public: p= 0.000; and Medical background and agriculture: p= 0.0000.
Participants were asked if they had previously taken antibiotics, different responses included, ‘Yes’, ‘No’ and ‘Don’t know’. Table 4 shows the responses from the four groups.
Table 4: Responses of the four professional groups on whether they had previously taken antibiotics
Veterinary Medical Agricultural Public Yes 98.2% (55) 98.8% (173) 100.0% (55) 96.4% (567) No 1.8% (1) 0.6% (1) 0.0% (0) 3.1% (18) Don’t know 0.0% (0) 0.6% (1) 0.0% (0) 0.5% (3) (Number of participants shown in brackets)
Majority of participates that responded to this had previously taken antibiotics. A chi-square test was used to identify if there was a significant difference in responses across professional groups, in this case there was not a significant difference in how the groups responded to the question (Χ^2 (6) =5.84, p<0.442).
Following on, participants were then asked if they had finished their course of antibiotics, those respondents answered ‘No’ to having taken antibiotics were then asked to skipped to question 3. Responses to this question included, ‘Yes’, ’No’ and ‘Don’t know’. Table 5 shows the results from this question.
groups. Majority of all participants from all four groups answered ‘1’ on the scale indicating low levels of harm. Table 7 shows the responses from the four groups to the question ‘Are antibiotics an important part of medical treatment today?’, responses included ‘Yes’, ‘No’ and ‘Don’t know.
Table 7: Responses of the four professional groups on whether the respondents think antibiotics are an important part of medical treatment. Veterinary Medical Agricultural Public Yes 100.0% (56) 93.7% (164) 100.0% (55) 93.9% (522) No 0.0% (0) 4.0% (7) 0.0% (0) 1.9% (11) Not Sure 0.0% (0) 2.3% (4) 0.0% (0) 4.2% (25)
Results showed no significant difference (Χ^2 (6) =11.77, p<0.067) between the different groups responses as a high percentage of all participants answered ‘Yes’, out of the 874, only 47 participants stated either ‘No’ or ‘Not sure’. The medical respondents showed the highest ‘No’ response, whereas the public responded higher to ‘Not Sure’. Veterinary and agricultural participants only answered ‘Yes’ to antibiotics being an important part of medical treatment.
Participants understanding of Antibiotic Resistance
Section 3 examined the participants understating of antibiotic resistance, again, using a scale of 0 (being not aware) to 4 (being very aware) participants were asked ‘Do you have an understanding of how antibiotic resistance emerges?’ Figure 2 shows the marginal means of antibiotic resistance emergence from the 4 different groups.
Figure 2 : Responses of the four groups on their understanding of antibiotic resistance knowledge. Data represents Means of participant’s understanding of antibiotic resistance emergence from the 4 different professional backgrounds.
There was a significant difference between professional groups (F= (3,870) = 34.30, p<0.000) in how participants responded to the question. Veterinary, medical and agricultural showed similar results with means >3 with the public showing a lower mean score of 2.6 (SD ±1.2). Post tests showed significant differences specifically between veterinary background and public: p<0.000; Medical background; and public: p<0.000 Agriculture and public: p<0.002.
Participants were then asked their understanding of the term antibiotic resistance, from the following four statements, ‘My body is resistant to the bacteria’, ‘The bacteria in my body are not killed by the antibiotic’, ‘The bacteria are resistant to the antibiotic’ and ‘Stops me getting an infection in the future’. Table 8 shows the responses from the four different participant groups.
