A global perspective on the use, sales, exposure pathways, occurrence, fate and effects of veterinary antibiotics (VAs) in the environment

Antimicrobials are valuable therapeutics whose efficacy is seriously compromised by the emergence and spread of antimicrobial resistance. The provision of antibiotics to food animals encompasses a wide variety of nontherapeutic purposes that include growth promotion. The concern over resistance emergence and spread to people by nontherapeutic use of antimicrobials has led to conflicted practices and opinions. Considerable evidence supported the removal of nontherapeutic antimicrobials (NTAs) in Europe, based on the "precautionary principle." Still, concrete scientific evidence of the favorable versus unfavorable consequences of NTAs is not clear to all stakeholders. Substantial data show elevated antibiotic resistance in bacteria associated with animals fed NTAs and their food products. This resistance spreads to other animals and humans-directly by contact and indirectly via the food chain, water, air, and manured and sludge-fertilized soils. Modern genetic techniques are making advances in deciphering the ecological impact of NTAs, but modeling efforts are thwarted by deficits in key knowledge of microbial and antibiotic loads at each stage of the transmission chain. Still, the substantial and expanding volume of evidence reporting animal-to-human spread of resistant bacteria, including that arising from use of NTAs, supports eliminating NTA use in order to reduce the growing environmental load of resistance genes.

Food Animals and Antimicrobials: Impacts on Human Health

The health-care facility environment is rarely implicated in disease transmission, except among patients who are immunocompromised. Nonetheless, inadvertent exposures to environmental pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and varicella-zoster virus) can result in adverse patient outcomes and cause illness among health-care workers. Environmental infection-control strategies and engineering controls can effectively prevent these infections. The incidence of health-care--associated infections and pseudo-outbreaks can be minimized by 1) appropriate use of cleaners and disinfectants; 2) appropriate maintenance of medical equipment (e.g., automated endoscope reprocessors or hydrotherapy equipment); 3) adherence to water-quality standards for hemodialysis, and to ventilation standards for specialized care environments (e.g., airborne infection isolation rooms, protective environments, or operating rooms); and 4) prompt management of water intrusion into the facility. Routine environmental sampling is not usually advised, except for water quality determinations in hemodialysis settings and other situations where sampling is directed by epidemiologic principles, and results can be applied directly to infection-control decisions. This report reviews previous guidelines and strategies for preventing environment-associated infections in health-care facilities and offers recommendations. These include 1) evidence-based recommendations supported by studies; 2) requirements of federal agencies (e.g., Food and Drug Administration, U.S. Environmental Protection Agency, U.S. Department of Labor, Occupational Safety and Health Administration, and U.S. Department of Justice); 3) guidelines and standards from building and equipment professional organizations (e.g., American Institute of Architects, Association for the Advancement of Medical Instrumentation, and American Society of Heating, Refrigeration, and Air-Conditioning Engineers); 4) recommendations derived from scientific theory or rationale; and 5) experienced opinions based upon infection-control and engineering practices. The report also suggests a series of performance measurements as a means to evaluate infection-control efforts.

Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

In 1994, CDC published the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in HealthCare Facilities, 1994. The guidelines were issued in response to 1) a resurgence of tuberculosis (TB) disease that occurred in the United States in the mid-1980s and early 1990s, 2) the documentation of several high-profile health-care--associated (previously termed "nosocomial") outbreaks related to an increase in the prevalence of TB disease and human immunodeficiency virus (HIV) coinfection, 3) lapses in infection control practices, 4) delays in the diagnosis and treatment of persons with infectious TB disease, and 5) the appearance and transmission of multidrug-resistant (MDR) TB strains. The 1994 guidelines, which followed statements issued in 1982 and 1990, presented recommendations for TB infection control based on a risk assessment process that classified health-care facilities according to categories of TB risk, with a corresponding series of administrative, environmental, and respiratory protection control measures. The TB infection control measures recommended by CDC in 1994 were implemented widely in health-care facilities in the United States. The result has been a decrease in the number of TB outbreaks in health-care settings reported to CDC and a reduction in health-care-associated transmission of Mycobacterium tuberculosis to patients and health-care workers (HCWs). Concurrent with this success, mobilization of the nation's TB control programs succeeded in reversing the upsurge in reported cases of TB disease, and case rates have declined in the subsequent 10 years. Findings indicate that although the 2004 TB rate was the lowest recorded in the United States since national reporting began in 1953, the declines in rates for 2003 (2.3%) and 2004 (3.2%) were the smallest since 1993. In addition, TB infection rates greater than the U.S. average continue to be reported in certain racial/ethnic populations. The threat of MDR TB is decreasing, and the transmission of M. tuberculosis in health-care settings continues to decrease because of implementation of infection-control measures and reductions in community rates of TB. Given the changes in epidemiology and a request by the Advisory Council for the Elimination of Tuberculosis (ACET) for review and update of the 1994 TB infection control document, CDC has reassessed the TB infection control guidelines for health-care settings. This report updates TB control recommendations reflecting shifts in the epidemiology of TB, advances in scientific understanding, and changes in health-care practice that have occurred in the United States during the preceding decade. In the context of diminished risk for health-care-associated transmission of M. tuberculosis, this document places emphasis on actions to maintain momentum and expertise needed to avert another TB resurgence and to eliminate the lingering threat to HCWs, which is mainly from patients or others with unsuspected and undiagnosed infectious TB disease. CDC prepared the current guidelines in consultation with experts in TB, infection control, environmental control, respiratory protection, and occupational health. The new guidelines have been expanded to address a broader concept; health-care--associated settings go beyond the previously defined facilities. The term "health-care setting" includes many types, such as inpatient settings, outpatient settings, TB clinics, settings in correctional facilities in which health care is delivered, settings in which home-based health-care and emergency medical services are provided, and laboratories handling clinical specimens that might contain M. tuberculosis. The term "setting" has been chosen over the term "facility," used in the previous guidelines, to broaden the potential places for which these guidelines apply.

/pdf/guidelines-for-preventing-the-transmission-of-mycobacterium-4h27m134c1.pdf

Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005

Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).

Antimicrobial residues in animal waste and water resources proximal to large-scale swine and poultry feeding operations

ContextWashington State has a relatively low incidence rate of tuberculosis
(TB) infection. However, from May to September 1997, 3 cases of pulmonary
TB were reported among medical waste treatment workers at 1 facility in Washington.
There is no previous documentation of Mycobacterium tuberculosis transmission as a result of processing medical waste.ObjectiveTo identify the source(s) of these 3 TB infections.Design, Setting, and ParticipantsInterviews of the 3 infected patient-workers and their contacts, review
of patient-worker medical records and the state TB registry, and collection
of all multidrug-resistant TB (MDR-TB) isolates identified after January 1,
1995, from the facility's catchment area; DNA fingerprinting of all isolates;
polymerase chain reaction and automated DNA sequencing to determine genetic
mutations associated with drug resistance; and occupational safety and environmental
evaluations of the facility.Main Outcome MeasuresPrevious exposures of patient-workers to TB; verification of patient-worker
tuberculin skin test histories; identification of other cases of TB in the
community and at the facility; drug susceptibility of patient-worker isolates;
and potential for worker exposure to live M tuberculosis cultures.ResultsAll 3 patient-workers were younger than 55 years, were born in the United
States, and reported no known exposures to TB. We did not identify other TB
cases. The 3 patient-workers' isolates had different DNA fingerprints. One
of 10 MDR-TB catchment-area isolates matched an MDR-TB patient-worker isolate
by DNA fingerprint pattern. DNA sequencing demonstrated the same rare mutation
in these isolates. There was no evidence of personal contact between these
2 individuals. The laboratory that initially processed the matching isolate
sent contaminated waste to the treatment facility. The facility accepted contaminated
medical waste where it was shredded, blown, compacted, and finally deactivated.
Equipment failures, insufficient employee training, and respiratory protective
equipment inadequacies were identified at the facility.ConclusionProcessing contaminated medical waste resulted in transmission of M tuberculosis to at least 1 medical waste treatment facility
worker.

https://jamanetwork.com/journals/jama/articlepdf/193136/joc00379.pdf

Transmission of Mycobacterium tuberculosis from medical waste.

In 2000, shigellosis traced to a commercially prepared dip developed in 406 persons nationwide. An ill employee may have inadvertently contaminated processing equipment. This outbreak demonstrates the vulnerability of the food supply and how infectious organisms can rapidly disseminate through point-source contamination of a widely distributed food item.

/pdf/multistate-shigellosis-outbreak-and-commercially-prepared-m83ut6dyrq.pdf

Kammy R. Johnson

Papers

Antimicrobial residues in animal waste and water resources proximal to large-scale swine and poultry feeding operations

Transmission of Mycobacterium tuberculosis from medical waste.

Multistate shigellosis outbreak and commercially prepared food, United States.

Diffuse and point source mercury inputs to the Mississippi, Minnesota, and St. Croix Rivers