Action Plan — The Focus Areas:
II. Prevention (Issues D-E)

D.	Issue: Prevention and control of drug resistance in agriculture and veterinary medicine is important to promoting animal and plant health, as well as in preventing AR transmission to humans through the food supply or through contact with infected animals or the environment.
	1.	Goal: Improve understanding of the risks and benefits of antimicrobial use, and ways to prevent the emergence and spread of drug resistance, in agricultural and veterinary settings.
		a.	Action Items
			49.	Evaluate the nature and magnitude of the impact of using various antimicrobial drugs as growth promotants in different species, using current animal husbandry practices. Use this information to assist in risk-benefit assessments of such use. Coordinator: USDA Collaborators: CDC, FDA Timeline: Begin within one to two years
			50.	Conduct additional research to further define the effects of using various veterinary drugs on the emergence of resistant bacteria that infect or colonize food animals of different species, using various animal husbandry practices. Identify risk factors and preventive measures. Assess the associated risk of:
					Transmission of AR infections to humans;
					Clinical disease in humans; and
					Transfer of resistance factors from animal flora to human flora. Coordinators: CDC, USDA, FDA Timeline: Initiated
			51.	Conduct epidemiologic and laboratory studies to assess the risk of development and transfer of resistance related to the use of antimicrobial drugs in food and nonfood plants, and identify risk factors and potential preventive measures. Coordinator: USDA Collaborators: CDC, FDA, EPA Timeline: Initiated
			52.	Develop rapid tests for inspecting fresh commodities like fruit for evidence of contamination with bacteria that are resistant to antibiotics. Coordinator: USDA Collaborators: EPA, FDA, CDC Timeline: Begin within one to two years
			53.	Evaluate the effect of current food processing and distribution methods on the emergence and spread of drug-resistant organisms. Coordinator: USDA Collaborators: CDC, FDA Timeline: Begin within one to two years
			54.	Identify and evaluate new food pasteurization strategies. Coordinator: USDA Collaborators: FDA, CDC Timeline: Begin within three to five years
			55.	Assess the risk of AR emergence and spread due to environmental contamination by antimicrobial drugs or by resistant bacteria in animal and human waste. Collect information on whether environmental contamination by antimicrobial drugs can lead to the development of resistance in bacteria that live in the soil or in water. (Related Action Item: Surveillance #19) Coordinators: USDA, CDC, EPA, FDA Timeline: Initiated
			56.	Assess the impact of antimicrobial use in companion animals (pets) on colonization and infection with drug-resistant organisms in the animals and their human household contacts. Coordinator: CDC Timeline: Begin within three to five years
	2.	Goal: Promote appropriate antimicrobial use in agricultural and veterinary settings.
		a.	Action Items
			57.	Work with veterinary and agricultural communities to help educate users of veterinary and agricultural antimicrobials about AR issues, and promote the implementation and evaluation of guidelines that address these issues:
					Appropriate antimicrobial use in agricultural and veterinary settings;
					Performance and interpretation of antimicrobial susceptibility tests performed on specimens from different species of animals; and
					Point-of-care tests for infection, including AR infections. Coordinators: USDA, CDC, FDA Collaborator: EPA Timeline: Initiated
			58.	TOP PRIORITY ACTION ITEM — In consultation with stakeholders, refine and implement the proposed FDA framework (30) for approving new antimicrobial drugs for use in food-animal production and, when appropriate, for re-evaluating currently approved veterinary antimicrobial drugs. The proposed framework includes the following major steps:
					Categorize antimicrobial drugs according to their importance in human medicine. Timeline: Initiated
					Develop an approach to the establishment of thresholds for drug resistance in selected pathogens. Timeline: Initiated
					Revise requirements for the industry's submission of drug use data. Timeline: Initiated
					Develop procedures to assess microbial safety of antimicrobial drug use in food-producing animals. Timeline: Initiated
				In support of the concepts articulated in the framework document:
					Conduct risk assessments on the human health impact of using selected antimicrobials important in human medicine in food-producing animals Timeline: Initiated
					Initiate appropriate steps to address any unacceptable human health impact, if identified by the risk assessments, for drugs categorized as being of critical importance in human medicine Timeline: Begin within one to two years Coordinator: FDA
			59.	Strongly encourage involvement of veterinarians in decisions regarding the use of systemic antimicrobial drugs in animals, regardless of the distribution system through which the drug is obtained (e.g., regardless of whether a prescription is required to obtain the drug). Coordinators: FDA, USDA Timeline: Initiated
			60.	Evaluate the potential impact of making all systemic veterinary antimicrobial drugs available by prescription only. Coordinators: FDA, USDA Timeline: Begin within three to five years
			61.	Convene an expert group to consider how to incorporate AR issues into regulations governing the registration and use of antimicrobials and antibiotic pesticides. Invite external experts, stakeholders, and the public to provide input. Coordinator: EPA Timeline: Begin within one or two years
E.	Issue: Efforts to prevent and control AR emergence and spread must be comprehensive and multifaceted, involve a wide variety of nonfederal partners and the public, and become a part of routine practice nationwide.
	1.	Goal: Ensure input from nonfederal experts on federal efforts to combat antimicrobial resistance.
		a.	Action Item
			62.	Establish an ongoing mechanism to obtain periodic input from external experts on AR issues. This process will include ensuring input from stakeholders and partners (b) (e.g., state and local health agencies, the private sector, and the public) in developing and reviewing federal efforts to address antimicrobial resistance. Coordinators: CDC, FDA, NIH Collaborators: USDA, EPA, DoD, DVA, AHRQ, HRSA, HCFA Timeline: Begin within one to two years
	2.	Goal: Develop and evaluate comprehensive demonstration programs to prevent and control AR.
		a.	Action Item
			63.	TOP PRIORITY ACTION ITEM — Support demonstration projects to evaluate comprehensive strategies that use multiple interventions to promote appropriate drug use and reduce infection rates. These projects will include the following steps:
					Assess how interventions found effective in research studies can be applied routinely and most cost-effectively on a large scale;
					Evaluate the use of these programs in health care systems (federal and nonfederal), in the community, and in agricultural and veterinary settings; and
					Involve partnerships with local and state agencies, health care systems, professional societies, community organizations, schools, private industry, and the public. Coordinator: CDC Collaborators: FDA, DVA, DoD, HRSA, HCFA, USDA Timeline: Initiated
	3.	Goal: Incorporate into routine clinical practice AR prevention strategies and programs that have been found to be beneficial in research and demonstration projects.
		A.	Action Item
			64	Utilize federal health care systems (e.g., DoD, DVA) as models for AR surveillance and prevention and control activities involving appropriate drug use, optimized diagnostic testing, infection control, and vaccination practice. Coordinators: CDC, DVA, DoD, HCFA, HRSA Timeline: Begin within three to five years
			65.	For all health care systems for which federal funds are provided, identify and promote strategies to establish AR prevention and control activities as part of quality monitoring programs. Coordinators: CDC, DVA, DoD, HCFA, HRSA Timeline: Initiated
			66.	Encourage nationally recognized accrediting agencies such as the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to include accreditation standards that promote efforts to prevent and control AR, including appropriate antimicrobial use, infection control, vaccine use, and diagnostic testing. These standards may draw on the findings of existing data and demonstration programs and AHRQ Evidence-Based Practice Centers. Coordinator: CDC Collaborators: HCFA, AHRQ Timeline: Begin within one to two years

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