Antibiotic overuse in animals and humans, resistant gonorrhea in UK

1. a recent NY Times article ​noted the continued overuse of antibiotics in cattle and other animals to increase their weight, thereby contaminating ground water, drinking water, and leading to increased antiobiotic-resistant bugs (see https://www.nytimes.com/2018/03/23/business/cattle-antiobiotics.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=second-column-region®ion=top-news&WT.nav=top-news​  ).

Details: 
--80-90% of antibiotics produced are used in animal agriculture: the US Agriculture Dept confirms the 80% number
--the antibiotic tylosin is given daily to cattle. tylosin is a macrolide antibiotic active against a broad array of gram-positive and gram-negative organisms, as well as mycoplasma bovis and staph aureus (and tylosin resistance is associated with macrolide-class resistance)
--more than 1/2 of samples of ground turkey, pork chops, and ground beef in supermarkets countain bacteria resistant to antibiotics, per the NY Times
--the Environmental Working Group on 2/5/18 published a report that 81% of ground turkey, 69% of pork chops, 55% of ground beef and 39% of chicken breasts/wings/thighs had antibiotic-resistant bacteria (see https://www.ewg.org/meateatersguide/superbugs/ ). [this group is partially funded by Applegate, which sells organic and antibiotic-free meats]
--anti-microbial resistant chicken has been found in fresh whole chickens sold in Britain, as well as MRSA in pork products
--other data suggest that 9% of chicken had antibiotic-resistant salmonella (74% of the salmonella they found were resistant, vs 50% in 2002) and 26% antibiotic-resistant campylobacter
--and a report from the US Geological Survey in 2016 found antibiotics in streams, groundwater, and drinking water in the early 2000s, including MRSA in Great Lake beaches. Antibiotics were detected in 60% of beef, 100% of swine/poultry/dairy, and antibiotic resistant genes were frequently found in livestock (see https://www.hhs.gov/sites/default/files/carrie-givens-fin-remediated.pdf​ )​
--the food industry response is that antibiotics keep animals healthy, though it seems that most farmers and others would argue that antibiotics promote growth and reduce costs
--public health officials are pretty uniform in commenting that consumption of meat laced with antibiotics contributes to antibiotic resistance in humans​
--one concern (also expressed in prior blogs: see http://gmodestmedblogs.blogspot.com/2016/11/reduced-antibiotic-susceptibility-of.html ) is that some of the bacterial resistance generated in one bacteria can pass to other and scarier ones (eg through plasmids). the NY Times notes that enterococcus feacalis and faecium, which easily develop resistance, are the 3rd leading cause of infections in ICUs​​

Commentary:
--this is really a looming (and increasingly present) huge issue, especially in light of the dearth of new classes of antibiotics on the horizon (in general, drug companies like to produce expensive drugs that one needs to take for a very long time, not the 7-day courses). and this issue is likely to get worse as governments overall are seemingly quite hesitant to enact rigid regulations:
    --in the US, the FDA is promoting "judicious use of medically important antimicrobial drugs in food animals" specifically opting for a voluntary approach by industry, since they stated a regulatory action would take much more time and require more resources. see https://www.fda.gov/animalveterinary/guidancecomplianceenforcement/guidanceforindustry/ucm216939.htm 
    --in European, some countries in the EU ban the use of routine antibiotics in animal husbandry (eg the Nordic countries), others do not (eg Spain), see http://www.ema.europa.eu/docs/en_GB/document_library/Report/2017/01/WC500220032.pdf​ 

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 2. another article in the Washington Post highlighted a "super-resistant" gonorrhea strain reported in the UK (see http://edition.pagesuite.com/popovers/article_popover.aspx?guid=cb64ca7d-0411-4b2c-9ad9-c26f2c824787​​​) 

Details:

--​a man had symptoms consistent with gonorrhea after contact with a woman in Southeast Asia, was treated with azithromycin and ceftriaxone, but subsequently had persistent symptoms and was found to have antibiotic-resistant GC. Other reports state that he is now being treated with IV ertapenem, results pending (see http://time.com/5222180/super-gonorrhea-drug-resistant-uk/ )

Commentary:

--this case is not surprising: in 2016 the MMWR came out with a report noting increasing antibiotic-resistant gonorrhea (see http://gmodestmedblogs.blogspot.com/2016/07/gonorrhea-resistance-increasing.html ). this blog reviews the CDC report and comments on the prior WHO report from 2014 finding that >25% of gonorrhea strains were resistant to 3rd generation cephalosporins in 3 of the 6 regions of the world.

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3.and, another article just came out on antibiotic overtreatment of sinusitis (see antibiotic overuse sinusitis jamaintmed2018 in dropbox, or doi:10.1001/jamainternmed.2018.0407​).

Details:

--the Clinical Practice Guideline for acute rhinosinusitis treatment by the Infectious Disease Society of America (see sinusitis abx guidelines IDSA 2012 in dropbox, or DOI: 10.1093/cid/cir1043) suggested:

    --treatment only if persistent symptoms and nonimproving for >10 days or severe symptoms (T>102, purulent discharge, facial pain) for >3-4 days, or "double-sickening" (getting better, then worse) after 3-4 days.

    --treat for 5-7 days

--the current study was from 2016, using the National Disease and Therapeutic Index, a random sample of US office-based physicians in private practice detailing all patient contacts for 2 randomly selected consecutive workdays

Results:

--3,696,976 visits where antibiotics were prescribed; 70% were for 10 days or longer (excluding azithromycin, 92% were for 10 days or longer, 8% 7 days, and 0.5% for 5 days). azithromycin, per the guidelines, should not be empiric therapy given the high resistance rates to S. pnuemoniae of about 30%, but hangs around in the tissues longer, so shorter courses are typically prescribed.

Commentary:

--sinusitis is the most common outpatient conditon leading to antibiotic prescription (bronchitis is close)

--though the duration of therapy was much higher than recommended, the overwhelming issue is that about 90% of patients with sinusitis do not need antibiotics. and there are studies suggesting that even shorter antibiotic courses, 3-7 days, works just fine in those who need them

--in terms of azithromycin, as noted it is not recommended because of resistance. i would add that it is a significant microbiome toxin (see https://www.nature.com/articles/s41598-017-06862-0 ).  and azithro was almost 100% of the cases in the above study where antibiotics were given for 7days or less

--there have been several other articles of note showing that overall about 50% of outpatient antibiotics are not necessary clinically, >80% of patients with acute rhinosinusitis get antibiotics mostly unnecessarily, >70% with acute uncomplicated bronchitis get antibiotics, etc: see http://gmodestmedblogs.blogspot.com/2016/01/antibiotic-overprescribing-and-acute.html , and http://gmodestmedblogs.blogspot.com/2015/07/antibiotic-overprescribing.html  ; http://gmodestmedblogs.blogspot.com/2017/07/take-full-course-of-antibiotics.html

Overall, doesn't look good....