Ensuring access to working antimicrobials - Science and Technology Committee Contents

2  Stewardship

7. Clinicians currently have access to a vast array of antimicrobials. But some antimicrobials, particularly antibiotics, have become less effective due to the development of drug resistance among the target pathogen populations. Although, to our current knowledge, antimicrobial resistance cannot be entirely prevented, it is a problem that is exacerbated by inappropriate use and poor stewardship of antimicrobials. For example, by prescribing antibiotics to a patient whose symptoms are caused by a virus, rather than bacteria, a patient's natural, and beneficial, bacterial population would be unnecessarily exposed to an antibiotic, allowing the opportunity for bacteria in the gut to develop resistance to that particular antibiotic which may later pass to pathogenic organisms.

8. During the course of the inquiry some themes emerged from the evidence surrounding stewardship of our current antibiotics and inadequacies in practice that were not sufficiently addressed by the Government's 2013-2018 Strategy. This chapter considers what good medical practice should look like in relation to antibiotics, the need for awareness throughout the NHS, the need for practice and policy to be based on good information and how use of veterinary antibiotics relate to resistance in human pathogens.

Good medical practice

Patient demand for antibiotics

9. In the UK, access to antibiotics is largely controlled through prescription by medical practitioners. Nevertheless, we were told that instances of inappropriate antibiotic use remain. Dr Michael Moore, Royal College of General Practitioners, believed that fears of "complications" encouraged unnecessary antibiotic prescribing practices, referring to the potential media coverage of a patient that had not received antibiotics and then "died as a result of pneumonia".[13] He said that one of the drivers of prescribing was being "risk averse" and that more sophistication was needed in "spotting the people who really need" antibiotics. [14] He said that "80% to 90% of the time, a prescription for antibiotics is still issued" when patients present with distressing symptoms regardless of whether, or not, that prescription might prove to be of clinical value.[15]

10. A critical point in the control of antibiotic prescriptions is the interaction between the clinician and patient. Professor Kessel, Director of Public Health Strategy at Public Health England, told us that clinicians can be under pressure to prescribe antibiotics during very short consultations.[16] The Academy of Medical Sciences expressed concern that antibiotics were often prescribed simply to achieve a placebo effect.[17] One suggestion to assist GPs under pressure, came from Dr Moore who told us about the delayed prescription, whereby a doctor would "say to somebody, 'You do not need an antibiotic now, but, if you do not get better in four or five days' time, you do not have to come back and see me but you can take this prescription at that point.' That reduces prescribing in sore throats, say, from 90% down to about 40%". Dr Moore also emphasised the:

    urgent need to look for alternative ways of providing symptom relief. People go to their doctor with symptoms and they anticipate getting something to help them. At the moment there is not much in the cupboard and people go to antibiotics, although we really are pretty sure that they do not make any difference—or very little difference—to the duration of symptoms.[18]

As part of the solution, the University of Southampton Medical School and the University College London Hospitals NHS Foundation Trust stated that the "promotion of safe and appropriate self-care should be investigated";[19] meaning things like rest, paracetamol and increased fluid intake.[20] The Department of Health told us that NICE would be developing guidance (directed at members of the public) that would "provide evidence-based advice on situations where self-care, non-antimicrobial treatment and seeking medical advice would be appropriate".[21]

Public awareness of antimicrobial resistance

11. The Academy of Medical Sciences suggested that an increase in public awareness of antimicrobial resistance would play a "significant role in its control".[22] Despite previous Government information campaigns to highlight the issue, Dr Hopkins, Royal College of Physicians, referring to the results of the 2013 Eurobarometer Survey,[23] was concerned that only "one in two people in the UK knew that antibiotics were not right for colds, flu and viruses".[24] Professor Kessel, Director of Public Health Strategy at Public Health England, agreed that there needed to be "greater" public awareness of the matter[25] and that greater public awareness would result in "fewer unnecessary" or "inappropriate demands, for antibiotics".[26]

12. One of the current methods used to raise public awareness about antibiotic stewardship is the "European Antibiotic Awareness Day" (EAAD), which is "an annual European public health initiative that takes place on 18 November to raise awareness about the threat to public health of antibiotic resistance and prudent antibiotic use".[27] The Department of Health said that its evaluation found that EAAD was an "excellent platform" for raising awareness about "appropriate antibiotic use".[28] This positive view was supported by the Academy of Medical Sciences, which said that EAAD was "a cheap and effective way of increasing public awareness of antibiotic resistance and proper use".[29] However, the Department of Health admitted that "understanding is not universal and sustained campaigns are required to educate new generations".[30]

13. The Government has been considering initiatives for raising public awareness. Key Area 3 of the Strategy indicated that actions would include:

    facilitating public debate to shift the societal view to raise awareness of antibiotics and ways to limit their use. This could include considering the potential for restricting the use of antibiotics for low risk self-limiting infections and/or restricting antibiotic use more widely to affect behaviour change.[31]

Professor Kessel considered that the Strategy itself provided a good opportunity for raising public awareness.[32]

14. Various contributors to this inquiry commented on what an effective awareness campaign could look like. Imperial College London wrote that "fragmenting the population appropriately will help inform better targeted campaigns and interventions for the public and patients".[33] Jean-Yves Maillard, of Cardiff University, pointed to public campaigns like the "e-bug project"[34] intended to ensure that "every child in Europe leaves school with an understanding of the issues related to antibiotic resistance and the basic principles of hygiene".[35] The Chief Medical Officer told us that she had asked Public Health England, "who hold the expertise for social marketing as well as the budget, to prepare plans" for a public awareness campaign, to be ready for November 2014 (and the next EAAD).[36]

15. Professor Kessel told us that Public Health England had started to look into how a campaign could be conducted in a "targeted" and "cost effective" way. He said that research had drawn on work by the World Health Organisation to create targeted antimicrobial resistance campaigns. The initial stage would require "qualitative work to find out where such a campaign might be most effective," looking at, for example, "age groups" and "schools or residential sectors". This stage would be followed by "running a tailored campaign accordingly".[37]

16. We are convinced that greater public awareness surrounding the necessity for stewardship of antibiotics is crucial in reducing pressure on practitioners to prescribe antibiotics. We welcome the awareness of the Government of the need for sustained campaigns to educate new generations. However, the previous Strategy would appear to have had insufficient impact in achieving a high enough public awareness and the current Strategy has no definitive targets or measures of success. We recommend that the Action Plan set challenging targets for improvement of public awareness against which success may be measured and reported. These targets should be re-evaluated, and communicated to this Committee, once a rigorous evaluation of the 2014 European Antibiotic Awareness Day has been conducted.


17. Several witnesses called for improvements to be made to medical education and training to ensure that clinicians' knowledge of antimicrobial resistance was improved and maintained throughout their career. The Academy of Medical Sciences considered that "more extensive education of medical students and doctors in training on antimicrobial resistance issues would highlight the negative impact of bad antimicrobial prescribing practice for a future cadre of doctors".[38] Professor Laura Piddock, British Society for Antimicrobial Chemotherapy, told us that "one of the problems we perceive […] is that undergraduate and postgraduate education in microbiology, in particular antibiotic prescribing, is relatively weak, so physicians with a very ill patient will tend to err on the side of caution".[39] Professor Holmes, Imperial College London, pointed out that "[UK Clinical Research Collaboration]-funded work has just demonstrated the enormous variability in the education provided in our medical schools, from a range of five hours to over 240 hours".[40]

18. Dr Susan Hopkins, Royal College of Physicians, who had reviewed courses for medical students, explained that the curriculum for medical students, as regulated by the General Medical Council, included "some training in microbiology" and that there was also a requirement to "understand the principles of infection prevention and control, and antibiotic prescribing". [41] However, Professor Holmes, was of the opinion that "we can do a lot more to improve [education]" and "how we teach as well".[42] There was also a need to ensure that adequate education was also extended to pharmacists and nurses. Professor Holmes said that there should be "some kind of core principles, and then, on top of that, different types of education depending on the profession and the type of development the individual needs".[43] The British Pharmacological Society (BPS) said that it was working with the Medical Schools Councils "to provide the Prescribing Safety Assessment (PSA) to enable medical students to demonstrate their competencies in safe and effective prescribing (a key theme of clinical pharmacology)",[44] which covers effective antibiotic prescribing. The BPS had also developed an online learning tool for medical students called "Prescribe."[45] The Academy of Medical Sciences drew attention to the "Imperial Antibiotic Prescribing Policy (IAPP) smartphone app" which "provides clinical decision support about antibiotics for clinicians at the point of care".[46] It said that "this application has been warmly welcomed and adopted by clinicians, 96% of whom said it influenced their prescribing practice".[47] Witnesses highlighted that continuing education and support are also being addressed. The Royal College of General Practitioners developed an antibiotics toolkit, called TARGET,[48] which Dr Moore, representing the Royal College of General Practitioners, described as "a collection of educational tools for GPs to teach them about more rational prescribing".[49]

19. The Department of Health released prescribing guidelines, "Start smart-then focus" which aimed to "provide an outline of evidence-based antimicrobial stewardship in the secondary healthcare setting"[50] and the need to develop education for clinicians was also clearly recognised in the UK Five Year Antimicrobial Resistance Strategy 2013-2018. The Strategy said that Health Education England, "jointly with equivalent organisations in the Devolved Administrations, will lead improvement in the education and training of healthcare workers and have a role in helping strengthen curricula on antimicrobial resistance, responsible prescribing, infection prevention and control and develop e-learning tools to support this".[51] Dr Moore said that "the Strategy is helpful" but that "these are words on paper in Government offices and they do not really filter down to the man or woman behind the desk with the prescribing pad."[52]

20. Given the focus on antibiotic resistance since 2000, we found it difficult to understand how the Government has failed to act decisively to address the issue of inappropriate prescription of antibiotics. We recommend that, as a matter of public interest, the Government drives the development of clinically proven alternative, safe and effective strategies to ease the demand placed on General Practitioners by people with acute infections so that they can develop an appropriate response to these requests without creating further antimicrobial resistance. We support calls for better education of medical students and greater focus on antimicrobial resistance during clinical career development. It is essential that the Government, as a matter of urgency, puts measures in place to drastically reduce the unnecessary prescription of antibiotics.

NHS structure

21. Accountability for antimicrobial resistance within the NHS was outlined for us by Dr Hopkins of the Royal College of Physicians. She told us that the Health and Social Care Act 2008,[53] as amended in 2012, placed responsibility for "health care-associated infections, antimicrobial resistance and antimicrobial stewardship" on Chief Executives.[54] Professor Holmes, Imperial College London, informed us that "within acute care and acute hospitals […] there is a director of infection prevention and control who reports directly to the chief executive, with the responsibility of addressing infection prevention and antibiotic stewardship".[55]

22. One of the major concerns that became apparent through this inquiry, was how the major restructure of the NHS might affect antimicrobial resistance. Concern was raised by Imperial College London that "the new NHS and public health structure (post April 2013) poses many challenges as well as opportunities for cross sector working. Understanding new leadership roles within this structure and drivers for appropriate and efficient prescribing need to be consistent with AMR reduction".[56] Dr Moore also criticised NHS re-structuring, saying that:

    a big organisational change is disruptive, so I do not think at the moment we are quite clear how to influence GPs. They are contracted through the area teams, which is NHS England working through the area teams. […] I anticipate that in time they will be looking at things like antimicrobial stewardship, but at the moment that is not at the top of their priority list.[57]

The Minister[58] was keen to emphasise that the "new architecture" of the NHS had been fully considered in the design of the Government's 2013-2018 Strategy. She outlined the responsibilities of the various agencies and organisations within the NHS in terms of antimicrobial resistance:

·  The Department of Health would have a clear role, for example co-ordinating leadership and research.[59]

·  NICE would be responsible for setting "clear governance guidelines".[60]

·  Public Health England would have a surveillance role, as well as some practical delivery roles around things like developing tools to aid health workers to better manage the use of antibiotics and the development of resistance.[61]

·  NHS England would have a role to implement solutions as well as looking at how they implement those through primary and secondary care.[62]

·  Health Education England would contribute within their role to provide education and training.[63]

The Minister indicated that ultimate responsibility rested with central government:

    The leadership is coming from the top; it is coming from central Government. […] although there is a great deal of localism about the way we deliver health, the architecture, in terms of setting the strategy through things like the mandate, remains something that we drive from the centre in terms of setting national standards.[64]

She recognised, however, that the sheer size of the NHS would make it difficult to enforce an effective command economy:

    this is a big, complex health economy, and it would always be difficult to drive change across such a big organisation. I think there is greater clarity around some of the roles—for example, Public Health England—and we will continue to work with them to get clarity around their role across a range of things, including [antimicrobial resistance], but actually I think there are opportunities, as well as the obvious challenges, in the changes".[65]

23. It is inevitable that strategic goals such as stewardship of antimicrobials will get lost in the daily tactical decisions made by healthcare staff. We consider it necessary that there are clear responsibilities within all levels of the NHS for better antimicrobial stewardship and we recommend that the Government outline, in its Action Plan for the Strategy, how they will embed those responsibilities across all roles within the NHS and how compliance with the Strategic goals will be monitored and reported. We have concerns that the implementation of new structures and chains of command may exacerbate those difficulties in the short term.


24. Developing new diagnostics forms part of Key Area 4 for future action in the Government's 2013-2018 Strategy.[66] According to AstraZeneca, the Government's new Antimicrobial Resistance Strategy contained a "clear recognition of the need for [...] diagnostics".[67] Projects to develop novel diagnostic techniques have also attracted investment from the EPSRC, which established an "£11 million interdisciplinary research centre in University College London to create [...] early-warning sensing systems for diagnosis"[68] in May 2013. George Eustice MP, Parliamentary Under-Secretary for farming, food and marine environment, supported the development of "pen side diagnostics"[69] and stated that there was "some research being done in the private sector on veterinary rapid diagnostics".[70]

25. What is required from a diagnostic may depend on the circumstance. Witnesses told us that when a doctor first sees a patient with symptoms of an infection, he or she "does not know the type of organism involved and its likely susceptibility to particular antibiotics, leading to inappropriate use and the unnecessary development of resistance".[71] Evidence suggested that current diagnostic techniques could be improved in two main ways:

i)  Increased accuracy: GlaxoSmithKline highlighted the need for diagnostic tests that would "accurately identify the pathogens and/or presence of resistance mechanisms".[72]

ii)  Increased speed: Rapid diagnostic tests were called for by the Royal College of Physicians, so that unnecessary antibiotic consumption could be halted promptly.

26. The use of diagnostics would be different depending on which part of the healthcare system a patient was attending when the infection occurred. In primary care, the infections encountered by doctors are likely to be wide ranging but often of a non-life-threatening nature such as colds. Rapid diagnostics at this point of engagement may indicate the relative lack of value in prescribing antibiotics, a point supported by results from the HAPPY AUDIT, [73] an EU funded project on respiratory tract infections in general practice,[74] which "indicated that increasing the use of diagnostics, as well as raising awareness decreased the amount of antibiotics in use".[75]

27. In secondary care, there is likely to be more knowledge of potential routes of infection and the immediate availability of laboratory facilities. The patient is also within the observation of clinical staff for prolonged periods of time allowing for the quick refinement drug based intervention if diagnostic information is available. However, the EPSRC[76] Interdisciplinary Research Collaboration told us that "current gold standard diagnostic tests (e.g. RT-PCR and bacterial culture) are slow and require samples to be sent to specialist laboratories. This leads to inherent delays between tests, results and clinical interventions".[77] This was a problem that could be exacerbated by the "closure of hospital laboratories and loss of on site microbiologists".[78] GlaxoSmithKline called for tests that would identify the "resistance mechanisms" of pathogens within "20 minutes".[79] The Royal College of Physicians described the requirement for "point of care"[80] tests, which could be used when a patient entered the healthcare environment, thereby minimising delays on diagnosis.

28. The British In Vitro Diagnostics Association (BIVDA) encouraged Government action to ensure that existing diagnostics were taken up "more widely" in the NHS.[81] Doris Ann Williams, representing BIVDA told us that:

    one of the barriers is the financial flows around the NHS systems […], it is very difficult to introduce a new technology that will be slightly more expensive but means that the patient could get the right antibiotic therapy within five hours of being admitted.[82]

BIVDA's written evidence further speculated that the lack of take-up may be due to a lack of awareness of diagnostic tests available, budget restraints and the lack of availability of diagnostic tests on the NHS.[83] The Chief Medical Officer highlighted the need for cheap diagnostics. She said that "if we get an expensive one, it will be difficult, because people will start to do the trade-off, which is not the right trade-off, between cheap antibiotics and an expensive test".[84] GlaxoSmithKline suggested that a global fund should be created to develop cheap diagnostic tests. It advocated "consolidating funds from multiple public partners[85] and governments to create a global prize for a transformational diagnostic that will diagnose the causative pathogen of pneumonia within 20 minutes of a physician consult".[86] It suggested a substantial prize of "of $50-100M". [87]

A diagnostics catapult centre

29. The Society of Biology criticised the Strategy for focusing only on those diagnostics "already in development" and emphasised the need for "maintaining and expanding the pipeline" of new diagnostic technologies.[88] In written evidence, witnesses reported on a planned Catapult centre[89] for "Diagnostics for Stratified Medicine". Doris Ann Williams, representing the BIVDA, was enthusiastic about the catapult centre, saying that BIVDA members:

    were delighted […] that the TSB recognised the importance of having a Catapult to get diagnostics used, and that stratified medicine is across the whole health care continuum, diagnosing, ruling out, monitoring and managing disease as well. I would be highly in favour of that continuing along the plans that they have got going at the moment.[90]

Sir John Savill, Research Councils UK, informed us that the name of the Catapult Centre had been amended to "precision medicine" saying that the change "makes sense" because "we need precision medicine when treating bacterial infection".[91] Professor Dame Sally Davies, Chief Medical Officer, raised concerns that when most people hear the terms "precision medicine" and "stratified medicine", they "think first and foremost about cancer and cancer drugs". Her concern was that if it was funded as precision medicine that it might "then end up supporting just cancer and therapeutics" rather than "where we need it in rapid diagnostics for [antimicrobial resistance]".[92]

30. Diagnostics are a key tool in limiting and targeting use of antibiotics. The Government should indicate in its response to this report how it intends to ensure better use of current diagnostic facilities, how it intends to speed up diagnostic provision and how it will ensure that the Catapult for Precision Medicine delivers diagnostics for infectious diseases.

Preventing infection

31. Infection Prevention Control (IPC) is already an important task in hospital settings. The Royal College of Nursing said that "emerging threats and IPC risks continue to develop"[93] and Professor Laura Piddock, British Society for Antimicrobial Chemotherapy, told us that outside the hospital environment, people were not aware of what good IPC practice meant. She thought that "involving the public more and involving all health care professionals in good infection control practices and what they mean to their area would be well warranted".[94]

32. The Government's 2013-2018 Strategy identified "improving infection prevention and control practices in human and animal health" as one of the key areas for future action. However, Imperial College said that the Strategy needed to be "explicitly linked with the wider infection control agenda, which in turn is integral to the patient safety agenda".[95] There was concern within the Royal College of Nursing that the "prominence of IPC within the Strategy" was "low" and there was currently "no clear national IPC strategy in place".[96] It considered that "a multi-disciplinary national IPC strategy" was needed to "ensure sustained improvements in clinical IPC practice and to strengthen the relationship between IPC and public health".[97]

33. We are concerned that Infection Prevention and Control (IPC) does not appear to be delivered in a coherent fashion within the National Health Service. Our key concern is that the integration of antimicrobial resistance measures will be more difficult in the absence of a coherent IPC policy across the NHS.


34. Healthcare associated infection (HCAI) targets,[98] currently focus on a small number of predominantly gram-positive,[99] resistant infections, such as methicillin-resistant Staphylococcus aureus (MRSA). These targets have attracted criticism during our inquiry. A group of experts on antibiotic resistance and healthcare associated infection reported that "prescribing behaviours […] are being driven by existing MRSA [Blood Stream Infection] BSI and C. difficile infection objectives/targets" and explained:

    whilst avoiding the use of certain antibiotics is sensible in patients at high risk of MRSA or C. difficile infection, antibiotic prescribing has become too concentrated on a limited number of drugs. There is evidence that such intensive use of few antibiotics, rather than using a wide range of agents, can lead to the emergence of resistance, particularly in problematic Gram-negative pathogens.[100]

The Association of the British Pharmaceutical Industry (ABPI) said that although "current national performance measures for MRSA and C. difficile have successfully lowered infection rates, they have also led to perverse prescribing behaviours that are driving an over-reliance on critical, last-line antibiotics".[101]

35. Professor Dame Sally Davies, Chief Medical Officer (CMO), told us that HCAI targets had made a "dramatic impact" on the reducing the incidence of these infections but she was aware of the "rising concern" that targets were increasing the use of critically important antibiotics, like carbapenems.[102] Although, the CMO added that she found this phenomenon "worrying", she was not aware of receiving "formal advice that [targets] should change at this point". She told us that the scientists would need to "make the case to Government" for this to take place.[103] The Minister, echoed the CMO's comments and indicated that the Government was "very much open" to moving away from "specific indicators to a more comprehensive approach".[104] The Strategy identified the Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection as responsible for identifying "emerging AMR research needs".[105]

36. We acknowledge the success that introducing Healthcare Associated Infection Targets has achieved in reducing the incidence rates of infectious diseases like MRSA and C. difficile. However, it is now time to design a more sophisticated approach to infection prevention and control that avoids undue reliance on particular antibiotics, thus exacerbating the problem of antibiotic resistance.

The need for a broader evidence base


37. Witnesses to the inquiry highlighted the importance of knowing more about what happens to antibiotics after they are prescribed. Dr Pat Goodwin, Society of Biology, pointed out that "patients do not always take their medicines as prescribed, and if they do not take their antibiotics properly they could be causing an environment which selects for resistant strains". She thought that this was particularly problematic because now there are "so many more elderly, frail and other groups that are vulnerable to infection, who also may have difficulty in following the instructions for taking their drugs".[106] The British Society for Antimicrobial Chemotherapy wrote that "under the current system there is often the belief that 'no news' or failure to request further tests is an indicator of a treatment success. Accurate data on treatment failure is lacking".[107]

38. The EPSRC Interdisciplinary Research Council proposes that patients should have a greater involvement in monitoring their own antibiotic usage. It noted that "mobile health technologies" were "linked to a much larger trend in patients taking on much more interest and responsibility in their own health. For example, handheld glucose monitoring devices with data linkage to doctors are the standard of care for patients with diabetes".[108] It suggested that a similar concept could be applied to monitoring antimicrobial consumption:

    Mobile tests for AMR could also facilitate two-way interfaces, providing patients with advice on treatment (e.g. encouraging compliance to antibiotic treatment programmes) and relaying public information in the event of a serious outbreak.[109]

39. The Government's 2013-2018 Strategy acknowledged that:

    information on the impact of antibiotic use on patient outcome and development of resistance is limited. Antibiotic prescription data for humans are only collected centrally for primary care. Work is underway to address these needs and strengthen surveillance arrangements.[110]

The British Society of Antimicrobial Chemotherapy criticised the Strategy for focusing on antibiotic resistance, which was "causing infection in hospitalised patients rather than those outside in the wider community". It drew attention to the fact that, in the UK, "much of the current problem with antibiotic resistant pathogens" was seen in "community patients" where there is less information available.[111]

40. It is essential that the Department of Health develop a system for monitoring post-prescription behaviour of patients who have been prescribed a course of antibiotics. That system should be outlined in the Government's Action Plan for Antimicrobial Resistance and should include data from community-based patients.


41. Professor Laura Piddock, British Society of Antimicrobial Chemotherapy, raised the issue of how waste disposal contributes to antibiotic resistance, noting that "we are […] now putting antibacterial compounds back into the environment, via water".[112] David Graham, Newcastle University agreed that antimicrobial resistance "is being significantly fuelled by inadequate waste management and inconsistent sanitation around the world".[113] A POSTNote[114] on antibiotics and the environment said that "resistant bacteria from human sources have been detected in all stages of the sewage treatment process, including in treated water released to the environment and sludge applied to farmland", noting that "the highest concentrations of antibiotics and resistant bacteria have been recorded in effluent released from hospitals and drug manufacturing sites in developing countries".[115] Professor Piddock said that "some of the resistances we are now dealing with in human medicine have come out of environmental bacteria which are then transferred into bacteria that are pathogenic to us".[116] She told us that when:

    [contaminated] waters go on to fields where animals are being reared for food production, or there are crops that enter the food chain […] they can be contaminated either with the bacteria that have come through that route, which then enter the food chain again, or they can select antibiotic-resistant bacteria in that environment.[117]

However, Dr William Gaze, Senior Lecturer from the European Centre for Environment and Human Health, University of Exeter Medical School,[118] added that there was:

    still very little data on whether AMR [antimicrobial resistance] genes are spreading between bacteria as a result of environmental pollution, how AMR persists over time in environmental bacterial populations, what the risk of human exposure to AMR bacteria is through environmental transmission routes and what the contribution of environmental transmission has in the overall burden of resistant infections seen in the clinic.[119]

42. The Strategy defines its approach to antimicrobial resistance as "collaborative multi-disciplinary work at local, national, and global levels to attain optimal health for people, animals and the environment".[120] Witnesses, however, were generally critical of the lack of consideration allocated to environmental factors in the Strategy.[121]

43. Sally Wellsteed, Antimicrobial Resistance and Healthcare Associated Infections Team Leader, Department of Health, said, with regard to environmental policies to address antimicrobial resistance:

    We did look at them and we did not find very much evidence, but the strategy flags up the environment as an area to be investigated. It is one of our gaps—how resistance genes transmit between humans, the environment and animals. Those people are quite correct: it does not really go into the detail, but that is because we could not find very much to put in, and there is not that much activity in the UK on it. But it is not an area that we want to ignore; it is just that we need to build up our evidence base more.[122]

Talking about future plans to investigate the effects of the environment on antimicrobial resistance, Ms Wellsteed told us that "the MRC funders forum is getting all the research councils together and is having a much stronger look at working with the environment" and that the Wellcome Trust would also be involved.[123] She told us there is "not a pot of money ring-fenced solely for the environment," although the research platform "has a certain amount of money, so good proposals can be put in and a bid can be made".[124]


44. Professor John Threlfall, Society for Applied Microbiology, criticised the Strategy, for failing to mention "antimicrobial substances other than antibiotics" in particular "the extensive use of biocides, which can in fact, if not used properly, promote antibiotic resistance".[125] In contrast, Jean-Yves Maillard, Cardiff University, indicated that microbicidal products could have a beneficial role in the fight against resistance and that "recommendations and exploration of other non-chemotherapeutic antimicrobials [microbicidal products] to prevent the spread of resistant strains are not being fully considered".[126] He identified a number of unanswered questions relating to the effect of microbicidal products on antimicrobial resistance, such as:

    What type of microbicides and usage applications are most likely to lead to the spread or maintenance of AMR genetic determinants?

    To what extent and what types of microbicidal products are regularly used in the healthcare settings in the UK?[127]

While microbicides can contribute to cleaner surroundings, he acknowledged that exposure to them may give microbes the opportunity to develop resistance.[128] Dr William Gaze, Exeter Medical School, said that: "We know that biocides and detergents can exert indirect selection by selecting for biocide resistance genes which are situated on the same mobile bits of DNA which carry antibiotic resistance genes".[129]

45. The Government recognises that there is a lack of information concerning environmental drivers of antimicrobial resistance. We recommend that the Government publish, in its Action Plan, a research programme that will recruit expertise across the UK to fill the knowledge gaps on how antimicrobial resistance exists and may be transmitted via environmental routes. Hoping that research grant applications to research councils will serendipitously gather this necessary information leaves too much to chance. Research council funding should be, in this important field of study, complementary to Government directed, and funded, research programmes.

Veterinary antibiotics

46. The same antibiotic products are used to treat both animal and human infections. Although, John Fitzgerald, Secretary General of the Responsible Use of Medicines in Agriculture Alliance, told us there was not "much evidence" that antimicrobial resistance was a problem when treating animal infection (except in cases of pig dysentery, where resistance had developed to the "main" antimicrobial treatment) there have been concerns that overuse of antibiotics in animals could undermine efforts to prevent the spread of antimicrobial resistance.[130]

47. Dr Goodwin, Society of Biology, highlighted how better infection control, which was "virtually absent in animal husbandry",[131] could reduce infection rates and stated that much more needed to be done to "tighten up" in this area.[132] However, other witnesses stressed the importance of antibiotics to veterinary medicine. Catherine McLaughlin, National Farmers Union, told us that the "UK poultry industry voluntarily banned the use of some critically important antibiotics at about this time last year" and consequently, had to raise their hygiene standards to be "better than hospitals", to reduce the increased mortality rate in young chicks.[133] She pointed out that, although a high standard of hygiene could be achieved in a "closed environment, that type of hygiene would not be possible in the more extensive outdoor-type systems".[134] Furthermore, she said that if a ban were introduced on adding antibiotics to feed and water, then "it would make pig production in the UK pretty much impossible".[135] George Eustice MP, Under-Secretary of State for farming, food and marine environment, indicated that the Veterinary Medicines Directorate "funds a number of projects looking at antimicrobial resistance", two of which have an "element" looking at "alternative treatments".[136] He added that sometimes though these treatments are "anecdotally" reported to have "some impact", they tend to "fall" at the "final hurdle" of clinical trials.[137]


48. The extent to which antibiotic resistance can move from bacterial populations in animals to those in humans is not clear. Witnesses from National Office of Animal Health (NOAH) and the Responsible Use of Medicines in Agriculture Alliance (RUMA) presented evidence that suggested limited transmission rates. NOAH highlighted a study by Mather (published in Science in 2013), which found that "salmonella and its resistance genes were largely maintained within animal and human populations separately and that there was limited transmission, in either direction".[138] John Fitzgerald, RUMA, told us that researchers, such as de Been, who had originally proposed that resistance problems in humans had been caused by poultry had, more recently, "changed position strongly", announcing that they had "looked more deeply into this" and could not support their original conclusion.[139] Mr Fitzgerald pointed out that the process of transmission was steeped with obstacles:

    The bacteria from that animal have to develop resistance, and they then have to transfer from the animal to the human in some way, and not be destroyed by things like cooking. With any bacteria from animals that get into humans, there are so many ways that the pathway can be interrupted—by cooking, by good hygiene.[140]

Conversely the Alliance to Save our Antibiotics said that "farm antibiotic use contributes significantly to the human resistance problem".[141] Cóilín Nunan, representing the Alliance to Save our Antibiotics told the Committee about an example where "poultry producers decided that they would voluntarily stop using" a particular antibiotic called "ceftiofur" and consequently argued that evidence from Denmark suggested that there was transmission.[142] The World Health Organisation, in its 2011 report entitled Tackling antibiotic resistance from a food safety perspective in Europe, said that "resistance in the foodborne zoonotic bacteria Salmonella and Campylobacter is clearly linked to antibiotic use in food animals, and foodborne diseases caused by such resistant bacteria are well documented in people".[143]

49. The Strategy recognised that more "research" would be required to "provide a more detailed understanding" of "transmission pathways" between "the environment, humans, animals and the food supply chain".[144] However, it took the stance that "increasing scientific evidence suggests that the clinical issues with antimicrobial resistance that we face in human medicine are primarily the result of antibiotic use in people, rather than the use of antibiotics in animals".[145] Many witnesses supported this sentiment, including the Alliance to Save our Antibiotics and RUMA which agreed that "the main cause of resistance in humans is the overuse/inappropriate use of antibiotics in human medicine".[146] Although Coilin Nunan said "The only study that I have ever seen that looked directly at the impact of food on the E. coli in the human gut was an experiment carried out by French scientists. They compared some volunteers for several weeks before they went on to a sterile diet, and then for several weeks after they went on to a sterile diet. What the French scientists found was a remarkable fall in the level of E. coli resistant bacteria in the human gut. We know that the overwhelming majority of E. coli infections start off from E. coli in the human gut getting into the urinary tract and causing a urinary tract infection, and that if it is not readily treatable by antibiotics it may develop into blood poisoning. This is a huge problem at the moment. The idea that we should be downgrading the impact that farm animals are having on that is, I find, a bit irresponsible"[147] and he continued "There is certainly not consensus regarding what John FitzGerald might say about E. coli, and salmonella, campylobacter, enterococci and those sorts of things".[148]

50. It is worrying that since the United Kingdom banned the use of tetracycline antibiotics and penicillin as growth promoters,[149] the total veterinary use of tetracylines has increased nearly tenfold and that of penicillin type antibiotics has increased nearly fivefold[150]. Antibiotic use in pigs and poultry in the Nordic countries is 3 to 5 times lower than it is in the United Kingdom. These countries have much lower levels of resistance in food poisoning bacteria than that found in many EU countries.

51. There is circumstantial evidence that antimicrobial resistance can be transmitted from animal pathogens to human pathogens although the evidence base is incomplete. The Government needs to ensure that this is addressed. We recommend that this is an additional focus of research in the action plan and that in the meantime, the Government takes action to ensure the use of antibiotics in farm animals is strictly required for therapeutic use.


52. Witnesses expressed concern about the lack of data on veterinary antimicrobial resistance in the UK. Cóilín Nunan, Principal Scientific Adviser, Alliance to Save our Antibiotics, said that the UK was "still lacking basic data on which antibiotics are being used in which animals, and where the resistance problems are. Some countries have been collecting this data for 15 years, but the UK still has very basic data, and we need much more precise data if we are actually to understand the problem".[151] He also told us that "we do not have the number of doses" of antibiotics given to animals, "those figures do not exist […] it is done in terms of the weight of the active ingredient".[152] John FitzGerald, RUMA, agreed that the "data is pretty scarce, and can be fairly crude in terms of the simple weights of antibiotic active ingredient that is sold into any particular country, based on authorised product sales reported by the companies".[153] Phil Sketchley, NOAH, mentioned the ESVAC project in Europe, which John FitzGerald described as "trying to get more co-ordinated production of this type of information".[154]

53. Catherine McLaughlin pointed out that a lot of information was held by farms. She said "every farm has a legal obligation to keep a medicine record" that was "inspected at least annually" by "probably five different independent inspectors" including "trading standards", "farm insurance assessors", "the [Rural Payments Agency[155]], vets and retailers under contract".[156] The medical records describe which animals had been treated, why they were treated, the "type of consultation" including "the mode of action, the dosage and treatment regime".[157] She thought that all this information could be "useful".[158] Cóilín Nunan, Alliance to Save our Antibiotics, said that "we need prescription data or sales data, because antibiotics are frequently sold for use in more than one species, so we do not know how they are actually being used".[159] NOAH considered it "essential to gather additional data about the usage of antibiotics at an individual vet practice and farm level in an efficient, user friendly and low cost manner".[160]

54. Phil Sketchley, NOAH, highlighted work that was already ongoing in this area:

    the Veterinary Medicines Directorate (VMD) have been sending out reports, […] for coming up to 10 years. This information gives a lot of detail in terms of the types or classes of antibiotics that are used, and the livestock species that they go into—whether it be beef, cattle, sheep, pigs and so on. There is a lot of information in that document. The latest report looks into the detail of the individual pathogens and the resistance profiles.[161]

Two initiatives, in particular, were described to us:

·  "The Target Pathogen Monitoring Programme"[162], which Phil Sketchley described as a "Europe-wide initiative"[163] that was "going through consultation with industry and the Heads of Medicines Agencies (HMA)[164], in which the VMD takes quite a significant role";[165] and

·   CEESA (European Animal Health Study Centre), which had a lot of "information on pathogen resistance through a dataset called VetPath".[166] [167]

55. NOAH said that the veterinary sector was "different" from the human sector in that there was no single source for "the majority of the required data".[168] The Veterinary Medicines Directorate agreed that, "there is not a mechanism established in the veterinary field for the collection and analysis of prescription data to allow an understanding of which different animal species have been treated, the treatment given, the purpose of the treatment and the outcome".[169] It considered that this information would be "powerful" for "improving responsible and optimal antibiotic use" as well as providing a "more meaningful comparison to human use".[170] There was support for the creation of a central repository for veterinary information on antimicrobial use in the animal sector. John FitzGerald, RUMA, told us that Denmark had a "centrally co-ordinated" system, where veterinarians report prescription data and usage on-farm. He commended this initiative saying that Denmark was "able to produce much better and more accurate data on how antimicrobials are actually being used on Danish farms".[171]

56. With regard to the transmission of resistance from animal to human pathogens it is clear that the Government does not hold and is not collating the necessary information. The Action Plan should detail how the Government intends to collect, collate and share this data and have target dates for when this will be achieved.


57. The Strategy highlighted the RUMA guidelines[172] "to promote the responsible use of antibiotics in animals" among veterinarians and animal carers and give "advice on all aspects from application and responsibilities of the farmer and veterinary surgeon, to strategies for reduced usage" of antimicrobials.[173] John FitzGerald, RUMA, told us that the general message behind the guidelines was "you should use medicines as little as possible and as much as necessary"; he used the phrase "right medicine, right animal, right time".[174] Catherine McLaughlin, National Farmers Union described the guidelines as an "extremely useful tool" and confirmed that "farmers do use them. They are using them as a teaching aid for a lot of their stockmen, and they are now widely being picked up in agricultural colleges as well, so it is part of the agricultural student curriculum".[175]

58. However, Cóilín Nunan told the Committee that "the guidelines do not necessarily make much of a difference" and that they are "frequently" not followed.[176] Phil Sketchley, NOAH, said that "like any guidelines, they will work if they are abided by" but acknowledged that it was "not in legislation that vets, or indeed farmers, have to use the RUMA guidelines".[177] When asked how useful the guidelines were for reducing antimicrobial resistance in animals, John FitzGerald said that he could not provide "empirical evidence", because there had been "no surveys that measured it in any way, other than to say that, if you look at the surveillance reviews of resistance in livestock across Europe, you generally find that the UK is at the lower end of the resistance that has been found in animals".[178]

59. Nigel Gibbens, Chief Veterinary Officer, DEFRA, told us that "the Strategy will build on quite a lot of work to pursue best practice guidelines to make sure that veterinary medicine is properly licensed and properly used".[179] He said that there was "mandatory continuing professional development" for veterinarians, but that there was no "mandatory antimicrobial resistance element". However, he agreed there was a need for behaviour change amongst vets and famers, towards "minimising" the use of antibiotics and "maximising good practice in husbandry".[180] For example, the Academy of Medical Sciences said that "stewardship campaigns should also be extended to veterinary surgeons and animal keepers".[181] When discussing the role of veterinarians and antibiotics, George Eustice MP, Under-Secretary of State for farming, food and marine environment, said that "we have to make sure that it is done the right way round, that the vet linked to the farm actually prescribes" antibiotics, rather than a feed company telling a farmer to "just get your vet to sign off a bit of paper".[182] He emphasised the need to "make sure that the controls are right".[183]

60. It is essential that responsible antimicrobial stewardship is practised in the animal sector. The Government should, in the Action Plan, outline its plans to ensure that veterinarians, farmers and other animal carers have a stronger focus on antimicrobial resistance.

13   Q50 [Dr Moore] Back

14   Ibid. Back

15   Q47 [Dr Moore] Back

16   Q66 [Professor Kessel]  Back

17   AMR0054 [Academy of Medical Sciences] Back

18   Q47 [Dr Moore] Back

19   AMR0024 [University of Southampton and University College London Hospital] Back

20   Ibid. Back

21   AMR0069 [Department of Health supplementary] Back

22   AMR0054, Para 12 [Academy of Medical Sciences] Back

23   A Europe-wide survey about antimicrobial resistance. http://ec.europa.eu/public_opinion/archives/ebs/ebs_407_en.pdf Back

24   Q76 [Dr Hopkins] Back

25   Q47 [Professor Kessel] Back

26   Q47 [Professor Kessel] Back

27   European Antibiotic Awareness Day http://ecdc.europa.eu/en/EAAD/Pages/AboutTheDay.aspx Back

28   AMR0043, Para 53 [Department of Health] Back

29   AMR0054, Para 12 [Academy of Medical Sciences] Back

30   AMR0043, Para 53 [Department of Health] Back

31   Department of Health, Department of Rural Affairs, UK Five Year Antimicrobial Resistance Strategy 2013 to 2018, September 2013, p.35 Back

32   Q47 [Professor Kessel] Back

33   AMR0034, Para 3.2.5 [Imperial College London Centre for Infection Prevention and Management] Back

34   www.e-bug.eu Back

35   AMR0052 [Jean-Yves Maillard] Back

36   Q264 [Professor Dame Sally Davies] Back

37   Q76 [Professor Kessel] Back

38   AMR0054, Para 14 [Academy of Medical Sciences] Back

39   Q9 [Professor Piddock] Back

40   Q47 [Professor Holmes] Back

41   Q45  Back

42   Q47 [Professor Holmes] Back

43   Ibid. Back

44   AMR0032, Para 5 [British Pharmacological Society] Back

45   British Pharmacological Society, Prescribe e-learning, accessed June 2014 http://www.bps.ac.uk/details/aboutPage/855685/Prescribe_e-learning.html?cat=bps12a5cac2541 Back

46   AMR0054, Para 18 [Academy of Medical Sciences] Back

47   Ibid. Back

48   Royal College of General Practitioners, TARGET Antibiotics toolkit, accessed June 2014, http://www.rcgp.org.uk/targetantibiotics/ Back

49   Q42  Back

50   Department of Health's Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection, Antimicrobial Stewardship: Start Smart - Then Focus, November 2011, para 1.5 Back

51   Department of Health, Department of Rural Affairs, UK Five Year Antimicrobial Resistance Strategy 2013 to 2018, September 2013 Back

52   Q54 Back

53   Health and Social Care Act 2008 Back

54   Q40 [Dr Hopkins] Back

55   Q40 [Professor Holmes] Back

56   AMR0034, Para 3.7.3 [Imperial College London Centre for Infection Prevention and Management] Back

57   Q43  Back

58   Jane Ellison MP, Parliamentary Under-Secretary for Public Health Back

59   Q333 Back

60   Q333 Back

61   Q333 Back

62   Q333 Back

63   Q334 Back

64   Q337 Back

65   Q336 Back

66   Department of Health, Department of Rural Affairs, UK Five Year Antimicrobial Resistance Strategy 2013 to 2018, September 2013, p.35 Back

67   AMR0018, Para 29 [AstraZeneca] Back

68   AMR0012, Para 13 [Research Councils UK] Back

69   Q355 {George Eustice] Back

70   Ibid.  Back

71   AMR0030, Para 4 [John Innes Centre] Back

72   AMR0029, Para 3.7 [GlaxoSmithKline (GSK)] Back

73   Health Alliance for Prudent Prescribing, Yield and Use of antimicrobial Drugs in the Treatment of Respiratory Tract Infections, http://www.happyaudit.org Back

74   Ibid. Back

75   AMR0037 [British In Vitro Diagnostics Association] Back

76   Engineering and Physical Sciences Research Council Back

77   AMR0038, Para 3.2 [EPSRC IRC in Early Warning Sensing Systems for Infectious Diseases] Back

78   AMR0023, Para 3 [Ian Gould] Back

79   AMR0029, Para 3.7 [GlaxoSmithKline (GSK)] Back

80   AMR0053, Para 3 [Royal College of Physicians] Back

81   AMR0037, Para 5.2 [The British In Vitro Diagnostics Association] Back

82   Q105 Back

83   AMR0037 [The British In Vitro Diagnostics Association] Back

85  84   e.g. Medical Research Council (MRC), Defence Threat Reduction Agency (DTRA), Biomedical Advanced Research and Development Authority (BARDA), National Institutes of Health (NIH), Innovative Medicines Initiative (IMI), Wellcome, Defense Advanced Research Projects Agency (DARPA)  Back


86   AMR0029, Para 6.6 [GlaxoSmithKline (GSK)] Back

87   Ibid. Back

88   AMR0041, Para 28 [Society of Biology] Back

89   A Catapult is a physical centre where the very best of the UK's businesses, scientists and engineers work side by side on late-stage research and development - transforming 'high potential' ideas into new products and services to generate economic growth. https://www.innovateuk.org/-/catapult-centres# Back

90   Q101 Back

91   Q176 [Sir John Savill] Back

92   Q352 [Professor Dame Sally Davies] Back

93   AMR0067, Para 3.2 [Royal College of Nursing] Back

94   Q6 [Professor Piddock] Back

95   AMR0034, Para 3.6.4 [Imperial College London Centre for Infection Prevention and Management] Back

96   AMR0067, Para 3.1 [Royal College of Nursing] Back

97   Ibid. Back

98   National Audit Office, Reducing Healthcare Associated Infections in Hospitals in England, June 2009, para 3 Back

99   One way of classifying bacteria is to determine whether or not they take up a dye (called a Gram Stain after its inventor). Bacteria that do not (gram negative) tend to have more complex cell walls and are also less susceptible to most current antibiotics.  Back

100   AMR0060 [Expert Group on Antimicrobial Resistance] Back

101   AMR0014 [Association of the British Pharmaceutical Industry (ABPI)] Back

102   Q346 [Professor Dame Sally Davies] Back

103   Q346 [Professor Dame Sally Davies] Back

104   Q346 [Jane Ellison] Back

105   Department of Health, Department of Rural Affairs, UK Five Year Antimicrobial Resistance Strategy 2013 to 2018, September 2013 Back

106   Q7 [Dr Goodwin] Back

107   AMR0016 [British Society for Antimicrobial Chemotherapy] Back

108   AMR0038, Para 4.5.7 [EPSRC IRC in Early Warning Sensing Systems for Infectious Diseases] Back

109   Ibid. Back

110   Department of Health, Department of Rural Affairs, UK Five Year Antimicrobial Resistance Strategy 2013 to 2018, September 2013, para 4.18 Back

111   AMR0016 [British Society for Antimicrobial Chemotherapy] Back

112   Q13  Back

113   AMR0009 [Professor David Graham] Back

114   The Parliamentary Office for Science and Technology (POST) is Parliament's in-house source of independent, balanced and accessible analysis of public policy issues related to science and technology. Their primary output are four page briefings called POSTNotes.  Back

115   Parliamentary Office of Science and Technology, Antibiotic Resistance in the Environment - POST Note, October 2013, p.2 Back

116   Q13 Back

117   Ibid.  Back

118   University of Exeter Medical School, European Centre for Environment & Human Health, accessed June 2014 http://www.ecehh.org/?s=antimicrobial Back

119   AMR0042 [William Gaze] Back

120   Department of Health, Department of Rural Affairs, UK Five Year Antimicrobial Resistance Strategy 2013 to 2018, September 2013, p.39 Back

121   For example AMR0009 [Professor David Graham] and AMR0042 [Dr William Gaze, University of Exeter Medical school ] Back

122   Q296  Back

123   Q297 Back

124   Q300 Back

125   Q6 [Professor Threlfall] Back

126   AMR0052 [Jean-Yves Maillard] Back

127   AMR0052 [Jean-Yves Maillard] Back

128   Ibid. Back

129   AMR0042 [William Gaze] Back

130   Q113 [John FitzGerald] Back

131   Q6 [Dr Goodwin] Back

132   Ibid. Back

133   Q140 [Catherine McLaughlin] Back

134   Ibid. Back

135   Q129 Back

136   Q311 [George Eustice] Back

137   Ibid. Back

138   AMR0019, Para 8.2 [National Office of Animal Health Ltd] Back

139   Q119 [John FitzGerald] Back

140   Q126  Back

141   AMR0035 [Alliance to Save Our Antibiotics] Back

142   Q119 [Cóilín Nunan] Back

143   World Health Organization, Tackling antibiotic resistance from a food safety perspective in Europe, 2011 Back

144   Department of Health, Department of Rural Affairs, UK Five Year Antimicrobial Resistance Strategy 2013 to 2018, September 2013, para 4.22 Back

145   Department of Health, Department of Rural Affairs, UK Five Year Antimicrobial Resistance Strategy 2013 to 2018, September 2013, para 2.1 Back

146   AMR0045, Para 9.4 [Responsible Use of Medicines in Agriculture Alliance (RUMA)] Back

147   Q127 Back

148   Q128 [Cóilín Nunan] Back

149   Swann MM, Baxter KL, Field HI, et al. Published by HMSO, Report of the Joint Committee on the Use of Antibiotics in Animal Husbandry and Veterinary Medicine, Cm 4190, November 1969 Back

150   Veterinary Medicines Directorate, Sales of antimicrobial products authorised for use as veterinary medicines in the UK in 2011, (2012), accessed 2 July 2014 Back

151   Q115 [Cóilín Nunan] Back

152   Q145 Back

153   Q147 Back

154   Ibid. Back

155   Rural Payments Agency http://rpa.defra.gov.uk/rpa/index.nsf/home Back

156   Q149 Back

157   Ibid. Back

158   Ibid. Back

159   Q150 [Cóilín Nunan] Back

160   AMR0019, Para 8.5 [National Office of Animal Health Ltd] Back

161   Q118 [Phil Sketchley] Back

162   Veterinary Medicines Directorate, How we monitor resistance in bacteria found in animals, accessed June 2014 http://www.vmd.defra.gov.uk/vet/antibiotic_surveillance.aspx Back

163   Q148 [Phil Sketchley] Back

164   Heads of Medicines Agency http://www.hma.eu/index.php?id=283 Back

165   Q148 [Phil Sketchley] Back

166   VetPath http://www.vetpath.com.au/ Back

167   Q148 [Phil Sketchley] Back

168   AMR0019, Para 8.5 [National Office of Animal Health Ltd] Back

169   AMR0047, Para 9 [Veterinary Medicines Directorate] Back

170   Ibid. Back

171   Q147 [John FitzGerald] Back

172   Responsible Use of Medicines in Agriculture Alliance, ruma Antimicrobials Guidelines, accessed June 2014 http://www.ruma.org.uk/antimicrobials.htm Back

173  Ibid. Back

174   Q120 [John FitzGerald] Back

175   Q121  Back

176   Q120 [Cóilín Nunan] Back

177   Q120 [Phil Sketchley] Back

178   Q120 [John FitzGerald] Back

179   Q243 Back

180   Q263 Back

181   AMR0054, Para 1.5 [Academy of Medical Sciences] Back

182   Q347 [George Eustice] Back

183   Ibid. Back

previous page contents next page

© Parliamentary copyright 2014
Prepared 7 July 2014