These figures are from the Smith and Coast 2013 BMJ paper
This analysis is based on Smith and Coast BMJ 2013 paper and their 2012 report.
The ‘crude estimate’ is from the recent Lancet Infectious Disease commission paper. The OIE point (the OIE is the World Organisation for Animal Health) is from the presentation given (on the record) by Bernard Vallet, the Director General of the OIE, at the Chatham House conference I went to. The reason so many countries have no control over farm antibiotic use is often because they have no regulations (eg. you don’t need a prescription, which is why it they are ‘sold like food or any commodity’ in the words of Bernard Vallet), but also when they do have regulations they are not applied as they don’t have the capacity to ensure that the rules are applied.The 49% AGP point is also from OIE presentation. In the 51% of countries that have banned AGPs, many have no way of ensuring rules applied in practice.
This slide and the last slide are very heavily based on Smith and Coast, and you should mention this in presentation.
This slide is just a suggestion. You could use it to illustrate that increasing resistance leads to more infections, including more severe infections like bacteraemia, as mentioned in the last slide. Otherwise you could just omit it.
The True Cost of Antibiotic
Overuse in Food Production
Antibiotic resistance – the problem
Last 25 years –
• Major new types of antibiotic resistance (about) 10 – with
hundreds of variations
• New Antibiotic Classes 1
• New Gram-negative classes 0
Last new major class of antibiotics developed in 1986 – next
to nothing significant in the pipeline
• Becoming very much harder to develop new antibiotics –
‘Peak Antibiotics’ was in the 1950s
• Existing antibiotics - ‘the best we will ever have’
• Antibiotic resistance inevitable, but speed of rise linked to
overuse and misuse
Consequences of resistance
• Prolonged duration of disease
• Increased number of infections as bugs which resist
antibiotic treatment have more time to spread
• Increased severity of infections, e.g. more bloodstream
• More and longer hospitalisation/ isolation
• Increased frequency of treatment failures
• Greater mortality
• Some pig herds with swine dysentery destroyed
because infection resistant to all antibiotics
The true cost of resistance
• US – Estimates of $5 bn, $26 and $55 billion pa:
increased hospital costs $20 billion pa, other
costs to society in lost wages, etc. $35 bn (CDC)
• An MRSA outbreak can cost $500,000
• UK estimates - range £3-11 billion a year - EU –
only estimate €1.5 billion (ECDC and EMEA), but
only includes infections where data available
• For surgery resistance increases hospital costs
dramatically – median $51,000 per patient, plus
extra $1,800 for drugs (Evans et al 2007)
Why such a low priority till now?
• Highest US estimate of $55 billion a year (from
CDC) –still low c/w other health costs.
• Cardiovascular disease $380 billion
pa, musculoskeletal conditions $300 billion,
• motor vehicle accidents $270 billion,
• mental disorders $260 billion,
• substance abuse $195 billion,
• cancer $185 billion,
• diabetes ($145 billion) and alzheimers ($70
However, all costs in literature are
• Most look at impact on medical costs for
resistant c/w sensitive infections
• As we may never get more really good
antibiotics we are moving towards breakdown
of current health systems: no safe
surgery, cancer chemotherapy and
transplantation, treatment of preterm
babies, caesarians etc. All this could be
• Also close to untreatable STDs and superbugs
Example: hip replacement
• At present, antibiotics are used preventatively and
infection rate is 0.5-2% and those who are infected can
normally be treated.
• Without antibiotics, scientists estimate that infection rate
would be 40-50%, and 30% of those infected would die.
• Hip replacement rates would therefore fall
dramatically, which would result in large costs to society.
• This analysis by British scientists Richard Smith and
Joanna Coast shows that the rise of resistance will impact
on patients who are not even suffering from infectious
How much due to farm use?
• Crude estimates suggest worldwide more than half all
antibiotics are used in farming. In US, about 60-80% used in
animals, in UK now 45% and 5% companion animals
• OIE says that 120 of 178 member countries have no control
over farm antibiotic use. Sold like food or any commodity.
• About 90% of farm antibiotics are added to the feed or
water of groups of intensively farmed animals, particularly
pigs and poultry.
• 49% of countries allow antibiotics to be used as growth
promoters. Those that don’t usually permit routine
preventative use. Some countries allow antibiotics to be
used to treat plants including organic apples in the US even
though antibiotics not allowed to treat all organic animals!
Spread of resistance from farms to
• Farm antibiotic use doesn’t contribute to resistance for
many human infections, but…
• Most resistance in human Salmonella and
Campylobacter infections is of farm-animal origin.
• A large proportion of resistance in human E. coli
infections comes from farm animals.
• Some resistance in human enterococci and now also
MRSA comes from farm animals.
• Farm use of critically important antibiotics for human
medicine has contributed to resistance in human
Research still needed
• Source of AMR – how much hospital, how
much GPs, how much farm animals, how
much fruit, how much companion animals?
• How much will it cost national economies if
modern treatments: hip and knee
replacements, cancer chemotherapy, organ
transplants open heart surgery no longer
• Other ways to treat bacterial infections
• Contribution of food
• Contribution of the environment
• Link between increasing resistance and
increasing levels of infections
• Ban all use for growth promotion worldwide
• Ban all preventative use in healthy animals
except for surgery
• Make low antibiotic use a cross-compliance
criteria for subsidies – EU especially
• Tax antibiotics
• Research and encourage non-antibiotic
treatments and systems with low usage
True cost of resistance
• Low estimates of costs for resistance have led to political
inaction. Awareness needs to be increased to level of
• Resistance is not just an infectious disease issue, it’s a
cancer issue, a surgical issue, a health-system issue.
• With resistance increasing, we should consider the
economic cost of completely losing antibiotics and the
impact this would have on modern medicine.
• Research is needed to estimate cost of losing antibiotics
completely, or nearly completely.
• Reducing antibiotic use in humans and animals should be
been seen as an insurance policy against this catastrophic
More resistance more serious
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
E. coli bacteraemia in England, Northern Ireland and Wales
E. coli bacteraemia in England, Northern Ireland and Wales Fluoroquinolone resistance
E. coli bacteraemia in England, Northern Ireland and Wales 3rd generation cephalosporin resistance
E. coli bacteraemia in England, Northern Ireland and Wales Gentamicin resistance
ReAct Facts 2007. Economic Aspects of Antibiotic Resistance
Cormican M, Vellinga A. Existing classes of antibiotics are probably the best we will ever
have. BMJ 2012;344