Food Protection Trends - September/October 2016 - 392

writers and encouraging new groups to establish their own platforms to dialogue with lay audiences offer other avenues for spreading messages. The food industry Companies must manage animal production health in ways that minimize antibiotic use. However, although animal health (including immunization and good hygiene/ sanitation) is crucial, it isn't the total picture. Judicious use of antibiotics early in an animal's life can reduce the need for heavy antibiotic use later on. The food industry might consider a certification for products from companies that use antibiotics responsibly. Some large corporations are already setting the standards, and they may drive a certification process. The agricultural industry should continue to make educational videos. For example, in February 2011, Cargill aired a video on The Oprah Show detailing the processing of cattle in the beef industry, and viewer response was overwhelmingly positive (18). The food industry must consider all uses of antibiotics, including in grain crops and in the fermentation process of producing ethanol, where antibiotics are used to control overgrowth. Byproducts of fermentation are used in cattle feed. An estimated 30-50 percent of the diet of cattle may have low levels of antibiotics in it as a result of antibiotic use in fermentation processes (14). In addition, stakeholders must consider the liquid waste produced by these processes that wind up in streams. Medical professionals While hospitals generally recognize the need for antimicrobial stewardship programs, there are many pressures working against such programs. For example, health care providers are sometimes compelled to prescribe antibiotics to increase patient satisfaction (8). Other factors could include lack of clinician knowledge or time, or their attitudes and beliefs (8). As professionals in the field, the roundtable participants stressed the need to improve surveillance of prescribing habits in order to identify and remedy overuse and to track prescribing practices of all health care professionals and provide individual feedback. Researchers Studies should develop biomarkers to identify when to stop antibiotic treatment in patients, thereby using the minimum amount needed. Roundtable participants also suggested that new rapid diagnostic tests are needed to quickly identify the pathogen responsible for the disease we need to treat. These tests would lead to targeted (rather than broad-spectrum) antibiotic treatment. The CDC's National Antimicrobial Resistance Monitoring System, Enteric Bacteria (NARMS) is a public health surveillance system that tracks antimicrobial resistance in foodborne and other enteric bacteria (4). NARMS helps 392 Food Protection Trends September/October monitor changes in antibiotic resistance. It would also be useful for hospitals to have more NARMS-type tests. In addition, while resistance rates in local own medical centers are known, resistance typically cannot be monitored by region. CDC provides some state profiles, but data on resistance by smaller regions could impact prescriber behavior. Next, waste management remains a largely unexplored question. Both animals and humans may be contributing to antibiotic resistance by way of excreted metabolites of antibiotics. It is important for researchers to help us understand the extent of this underappreciated source of resistance. The National Institute of Health's (NIH) National Institute of Allergy and Infectious Diseases (NIAID) is an important stakeholder in the research endeavor. Many clinical trials are funded by industry, and there is a pervasive attitude that such research findings may be tainted (17). The roundtable recognizes that this attitude is counterproductive, while also recognizing that NIH and its various institutions such as NIAID need to play key roles. Policymakers Developing strategies that address the National Action Plan for Combatting Antibiotic Resistant Bacteria is paramount for policymakers, given the national and global (WHO) strategies that are in place or being developed. Developing safeguards is a key aspect of our strategy to protect antibiotics. The FDA has maintained a central role in the elimination of use of antibiotics for growth promotion in food animals. In a 2010 congressional testimony, FDA Director Dr. Janet Woodcock for the Center for Drug Evaluation and Research reported, "Preserving the effectiveness of current antimicrobials and encouraging the continued development of new ones is vital to protecting human and animal health against infectious microbes" (9). The report led to U.S. FDA Guidance #209, which established two voluntary principles (10): * Use of medically important antimicrobial drugs in foodproducing animals should be limited to uses considered necessary for animal health. * Use of medically important antimicrobial drugs in food-producing animals should include veterinary oversight/consultation. This guidance led to FDA Guidance #213, establishing procedures for voluntarily phasing out growth promotion indications for medically important antibiotics in alignment with Guidance #209, and proposing changes to the Veterinary Feed Directive (VFD) regulation (12). As a result, the use of antibiotics in animal feed for growth promotion has been eliminated. The FDA could play a role in helping consumers identify food companies using antibiotics responsibly. Worldwide, policy makers can work to demand regulatory oversight of food production.

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