IntroductionOver the last century, Westernmedicine has made tremendousadvances in fighting infectious disease.One of the keys to success has beenthe development of antibiotics—compounds that kill disease-causingbacteria or inhibit their reproduction.Unfortunately, effective antibiotics arethreatened by a global crisis inantibiotic resistance. As bacteriabecome increasingly resistant to one ormultiple antibiotics, treatments forcommon bacterial infections willbecome “increasingly limited andexpensive—and, in some cases,nonexistent.”1 Not only will it becomeharder to treat community-acquiredinfections, but key medicalprocedures—including chemotherapy,transplantation, and surgery—will alsoface far greater challenges. Already,more than 60,000 Americans die fromresistant infections each year.2

Because antibiotic resistance is causedin part by overuse of antibiotics inagriculture, health care food systemscan help by establishing a procurementpolicy under which they seek topurchase meat, poultry, dairy, andseafood products produced with fewerantibiotics, as further discussed below.

What is AntibioticResistance?As noted by the Centers for DiseaseControl and Prevention (CDC),“Antibiotic use promotes developmentof antibiotic-resistant bacteria.Antibiotic resistance occurs whenbacteria change in some way thatreduces or eliminates the effectivenessof drugs designed to cure or preventinfections. The bacteria survive andcontinue to multiply causing moreharm. Widespread use of antibioticspromotes the spread of antibioticresistance.”3

Unlike higher organisms, bacteria canreadily transfer genetic material notonly to their own offspring, but also tocompletely unrelated types of bacteria.Along with the rapid reproduction ofbacteria, this means resistance genescan be widely distributed in shortorder. Some bacteria, which the mediahave termed “superbugs,” end upresistant to multiple antibiotics - eventhe most powerful ones.

Is ResistanceTruly a Concern?CDC says that antibiotic resistance isamong its “top concerns.”4 As theInfectious Disease Society of Americanotes, “a perfect storm is brewing inthe field of infectious diseases,” bothbecause bacteria are increasinglyresistant and because the pipeline ofnew antibiotics is drying up aspharmaceutical companies find it farmore profitable to develop drugs totreat chronic conditions rather thanbacterial infections.5

Thus, preserving the effectiveness ofexisting antibiotics—by minimizingtheir overuse—is vital. Such overuseoccurs in human medicine as well as inagriculture. Just as steps are beingtaken to reduce overuse in humanmedicine, so too is it important to takeall feasible steps to reduce agriculturaloveruse as well.

Food Production andAntibiotic ResistanceMassive quantities of antibiotics areused in agriculture—in fact, anestimated 70% of the total quantity ofantibiotics consumed in the US areused as feed additives for poultry,swine, and beef cattle.6 Theseantibiotic feed additives are nottreatments for illness; rather, they areused for “nontherapeutic” purposes,i.e., to promote slightly faster growthand to compensate for poor animal-husbandry conditions that would

AntibioticResistanceandAgriculturalOveruse ofAntibioticsWhat Health CareFood Systems Can Do

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otherwise cause disease. Half of thoseantibiotics belong to classes of drugsused in human medicine. Becausedevelopment of resistance to oneantibiotic within in a particular classcan promote resistance to otherantibiotics in the same class, it’simportant to minimize use not only ofthe antibiotics that are directly used inhuman medicine, but also others inthe same class.

In addition, some antibiotics used intreating sick animals are of particularconcern—notably fluoroquinolones, aclass that includes the human-useantibiotic Cipro. In October 2000,the Food and Drug Administrationproposed to ban use offluoroquinolones in treating poultry,because of data linking such use toincreases in Cipro resistance bybacteria that cause severe foodpoisoning (specifically Campylobacter).While FDA’s regulatory process is socumbersome that the ban has not yetbeen finalized, several leading poultryproducers have already stated thatthey have ended use offluoroquinolones in poultry producedfor human consumption.

Medical Impacts ofAgricultural Antibiotics There is a strong consensus amongindependent experts that antibioticuse in agriculture contributes toresistance affecting humans:■ U.S. Institute of Medicine/National

Academy of Science: “Clearly, adecrease in antimicrobial use inhuman medicine alone will havelittle effect on the current[antibiotic-resistant] situation.Substantial efforts must be made todecrease inappropriate overuse inanimals and agriculture as well.”7

■ World Health Organization:“There is clear evidence of thehuman health consequences due toresistant organisms resulting fromnon-human usage ofantimicrobials.8 Theseconsequences include infectionsthat would not have otherwiseoccurred, increased frequency oftreatment failures (in some casesdeath) and increased severity ofinfections.”9

■ Alliance for Prudent Use ofAntibiotics: “[E]limination of non-therapeutic use of antimicrobials infood animals and agriculture willlower the burden of antimicrobialresistance…with consequentbenefits to human and animalhealth.”10

■ More than 300 organizations,including the American MedicalAssociation, American Public

Health Association, and HealthCare Without Harm, haveadvocated ending thenontherapeutic use of medicallyimportant antibiotics as feedadditives.11

What Can Be Done?Nontherapeutic use of medicallyimportant antibiotics as feed additivesis unnecessary. The practice has beenbanned in Denmark, the world’slargest exporter of pork. A recentstudy by the World HealthOrganization documented Denmark’ssuccess in phasing out such usewithout adverse effects on food safety,consumer meat prices, or animalwelfare.12 The European Union hasalso sharply restricted use of antibioticsas feed additives.

Are Alternatives Availableand What Is Their Cost?Chicken produced withoutnontherapeutic use of medicallyimportant antibiotics is widelyavailable at no cost premium in theU.S. In fact, McDonald’s purchasesonly chicken produced without use ofmedically important antibiotics asgrowth promoters,13 while the majorfood-service company Bon Appétitpurchases only chicken producedwithout any nontherapeutic use ofmedically important antibiotics.14

Other meats raised under suchconditions are also available, albeit ona more limited basis.15 Establishment ofa purchase preference for such meatswill stimulate producers to provideeven more of these alternatives atlower cost.

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U.S. Antibiotics Consumption

Nontheraputic use -Livestock

71%

Other (soaps, pets, etc.)10%

Therapy - humans15%

Therapy - livestock8%

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What Actions Can HealthCare Facilities Take?■ Educate your staff - Many health

care professionals are unaware ofthe relationship between foodproduction and antibioticresistance. Without knowledgethere will be no action. Use yourinternal email system, newsletter,grand rounds and other means toeducate your colleagues.

■ Enlist medical staff and infectioncontrol support - Medical staffand especially infection controlprofessionals appreciate the threatof drug resistant disease. Enlisttheir expertise to help providesupport for protective foodprocurement policies.

■ Adopt attached procurementguidelines - By adopting theattached food procurementguidelines, your facility can signalyour commitment to antibioticsafety to your food purveyor, yourlocal community and the broadhealth care community. Once youhave adopted the guidelines, letyour Group PurchasingOrganization (GPO), local media,professional organizations andothers know. Spread the word andhelp build national support.

■ Ask your GPO to comply -Frequently, health care purchasingdecisions are dictated by what isavailable from your GPO. If yourGPO does not supply meat raisedwithout non-therapeutic use ofantibiotics, let them know that youwant it. Communicate with otherfacilities in your GPO and let themknow of your interest.

For more information, see HealthCare Without Harm’s full “SampleProcurement Policy: Purchasing Meat,Poultry, Dairy and Seafood ProducedWithout Inappropriate AntibioticUse,” available online athttp://www.noharm.org/details.cfm?ID=893&type=document. Also visit www.noharm.org andwww.keepantibioticsworking.com.

Notes1. Interagency Task Force on

Antimicrobial Resistance. A PublicHealth Action Plan to CombatAntimicrobial Resistance. p. 9. Availableat www.cdc.gov/drugresistance/actionplan/aractionplan.pdf. Accessedon July 7, 2004.

2. Centers for Disease Control (CDC)“Campaign to Prevent AntimicrobialResistance in Healthcare Settings,”Atlanta, GA. Available athttp://www.cdc.gov/drugresistance/healthcare/problem.htm. Accessed July 7,2004. CDC notes that 90,000 patientsdie as a result of hospital-acquiredinfections, and that more than 70% ofthe bacteria that cause hospital-acquired infections are resistant to atleast one of the drugs most commonlyused to treat them.

3. Centers for Disease Control (CDC).Background on Antibiotic Resistance.Atlanta, GA. Available atwww.cdc.gov/drugresistance/community/#background. Accessed on July 7,2004.

4. Centers for Disease Control (CDC).Background on Antibiotic Resistance.Atlanta, GA. Available atwww.cdc.gov/drugresistance/community/#background. Accessed on July 7,2004.

5. Infectious Diseases Society of America(2003). Backgrounder: “Bad Bugs, NoDrugs—Defining the AntimicrobialAvailability Problem.” Available athttp://www.idsociety.org/Template.cfm?Section=Home&Template=/ContentManagement/ContentDisplay.cfm&ContentID=7591. Accessed July 7,2004.

6. Mellon et al. Hogging It: Estimates ofAntimicrobial Abuse in Livestock. Unionof Concerned Scientists: CambridgeMA. 2000.

7. Institute of Medicine, Board on GlobalHealth (2003). Microbial Threats toHealth: Emergence, Detection, andResponse. National Academy ofSciences Press, Washington, DC.Available at: http://books.nap.edu/books/030908864X/html/R1.html#pagetop. Accessed July 7,2004.

8. The term “antimicrobial” includesantibiotics and other compounds thatkill microbes or keep them fromreproducing.

9. Joint WHO/FAO/OIE ExpertWorkshop on Non-humanAntimicrobial Usage andAntimicrobial Resistance, Geneva, 1 -5 December 2003, ExecutiveSummary. Available at:http://www.who.int/foodsafety/micro/meetings/nov2003/en/. Accessed July 7,2004.

10. Alliance for Prudent Use ofAntibiotics (2002). The Need toImprove Antimicrobial Use inAgriculture: Ecological and HumanHealth Consequences. ClinicalInfectious Diseases, Volume 34Supplement 3. Available at:http://www.tufts.edu/med/apua/Ecology/faairExecSum_6-02.html. Accessed July7, 2004.

11. These organizations have endorsedlegislation (S.1460/H.R. 2932) thatwould phase out nontherapeutic use ofmedically important antibiotics. Seehttp://www.keepantibioticsworking.com/library/uploadedfiles/Endorsements_for_The_Preservation_of_Antibioti.doc.Accessed July 7, 2004.

12. World Health Organization (2003).Impact of antimicrobial growth promotertermination in Denmark.WHO/CDS/CPE/ZFK/2003.1.Available at: http://www.who.int/salmsurv/en/Expertsreportgrowthpromoterdenmark.pdf. Accessed July 7,2004.

13. McDonald’s Corporate Press Release,June 19, 2003. “McDonald’s Calls forPhase-out of Growth PromotingAntibiotics in Meat Supply, EstablishesGlobal Policy on Antibiotic Use.”Available athttp://www.mcdonalds.com/usa/news/current/conpr06192003.html. AccessedJuly 7, 2004.

14. Bon Appétit’s Policy on AntibioticsUse in Food Animals, November 18,2003. Available at:http://www.bamco.com/pressrelease/pdfs/antibioticpolicymaster1032003.pdf.Accessed July 7, 2004.

15. Numerous such suppliers, for example,are listed at www.EatWellGuide.org.

A. ResponsibilitiesTo minimize inappropriate use ofantibiotics, personnel involved in foodpurchasing decisions will use theseguidelines when making food-purchasingdecisions involving meat, poultry, dairy,and seafood.

B. Purchasing GuidelinesIn complying with this policy,[INSTITUTION] will strive to makepurchases as follows:

1. [Institution] will regularly andconsistently inform suppliers of meat,poultry, dairy, and seafood products oftheir preference for purchasingproducts that have been producedwithout nontherapeutic use ofantibiotics, particularly those thatbelong to classes of compoundsapproved for use in human medicine.

2. Opportunities will be prioritized asfollows:

a. Unless these products are notavailable to the institution becauseof local supply constraints, chickenwill only be purchased if it hasbeen produced:

i. without the nontherapeuticuse of antibiotics that belongto classes of compoundsapproved for use in humanmedicine; and

ii. without any use offluoroquinolone antibiotics.

b. Poultry other than chicken willreceive a purchase preference if ithas been produced without thenontherapeutic use of antibiotics,particularly those that belong toclasses of compounds approved foruse in human medicine.

c. Meat, dairy, and seafood productswill receive a purchase preferenceif they have been producedwithout the nontherapeutic use ofantibiotics, particularly those thatbelong to classes of compoundsapproved for use in humanmedicine.

3. [INSTITUTION] will also encourageits meat, poultry, dairy, and seafoodsuppliers to minimize use ofantibiotics, particularly those thatbelong to classes of compoundsapproved for use in human medicine,for disease therapy and non-routinedisease prevention to the extentpracticable.

DefinitionsAntibiotic: This policy uses the termantibiotic to have the same meaning asthe more technical term "antimicrobial."Antimicrobials are substances of naturalor synthetic origin that kill or inhibit thegrowth or multiplication of bacteria(adapted from American Veterinary MedicalAssociation Judicious Therapeutic Use ofAntimicrobials, http://www.avma.org/scienact/jtua/jtua98.asp). However, theterm antibiotic does not includeionophores or other compounds fromclasses of drugs not used in humanmedicine that are used as coccidiostats.

Nontherapeutic: This policy uses theterm "nontherapeutic" to meanadministration of antibiotics to an animalor groups of animals for purposes otherthan disease therapy or non-routinedisease prevention as defined herein.

Disease Therapy: This policy uses theterm "disease therapy" to mean the use ofantibiotics, under the direction of acertified veterinarian, for the specificpurpose of treating animals with an

established disease or illness. Once thetreatment is over and the animal is cured,the application of the antibiotic ceases.(Adapted from the World VeterinaryAssociation's Prudent Use of AntibioticsGlobal Basic Principles and CanadianCommittee on Antibiotic Resistance,http://www.ccar-ccra.org/agriglos-e.htm.)

Non-routine Disease Prevention: Thispolicy uses the term "non-routine diseaseprevention" to mean the use of antibioticswhere it can be shown that a particulardisease is present on the premises or islikely to occur because of a specific non-customary situation. (Adapted fromWHO Global Principles for the Containmentof Antimicrobial Resistance in AnimalsIntended for Food, http://www.who.int/emc/diseases/zoo/who_global_principles.html.)

This publication is part of Going Green: A Resource Kit for PollutionPrevention in Health Care. For additional copies of this or other publi-cations included in the kit, or to find out how to get a complete kit, visitHealth Care Without Harm on the Web at www.noharm.org/goinggreen.

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SAMPLE FOOD PROCUREMENT GUIDELINESPurchasing Meat, Poultry, Dairy and Seafood Produced Without Inappropriate Antibiotic Use