Dear Governor Hogan, Secretary Bartenfelder, and the Maryland General Assembly:
As nurses, physicians, pharmacists, other health professionals, and our professional organizations, we urge you to ensure that the Keep Antibiotics Effective Act stays strong. To help safeguard our shrinking arsenal of antibiotics and to ensure they continue to work in treating our patients, we must rein in the overuse of medically important antibiotics in animal agriculture.
Hard-to-treat, drug-resistant infections are on the rise. Already, they strike at least 2 million Americans annually, killing over 23,000 of them.  A recent estimate suggests that the annual number of US deaths due to infection by multi-drug resistant organisms may be 3-7 times higher than the 2013 CDC estimate of 23,000.  A new estimate for annual inpatient deaths of 70,837 is very similar to the estimate of 70,237 deaths due to drug overdose in 2017. 
This epidemic is caused by the spread of bacteria resistant to multiple antibiotics. Antibiotic overuse in both humans and animals exacerbates the problem. The World Health Organization warns, “A post-antibiotic era – in which common infections and minor injuries can kill – far from being an apocalyptic fantasy, is instead a very real possibility for the 21st Century.”  Stronger antibiotic stewardship in hospitals is important. By itself, however, it can’t address the dire warnings. In the U.S., around 64% of all the antibiotics of human importance – including penicillins, tetracyclines, cephalosporins – are sold for use in livestock production, not to treat humans.[5,6] And much of those antibiotics are given routinely to food animals that are not sick, to speed up growth or to compensate for crowding, stress and sometimes less than hygienic conditions. A loophole in the Food and Drug Administration’s (FDA’s) policies allows this use.  In releasing its latest relevant guidelines, in 2017, the World Health Organization urges bluntly: “Stop using antibiotics of medical importance in healthy animals to prevent the spread of antibiotic resistance.” 
The Maryland Department of Agriculture (MDA) has enacted regulations for the Keep Antibiotics Effective Act of 2017 despite concerns from legislators, public health professionals, and advocacy organizations who say the regulations undermine the intent of the law which was to curb the routine use of antibiotics when animals are not sick. In the regulations, the MDA’s definitions of “regular pattern” and “prophylaxis” subverted the intent of the law by only banning activities that were already prohibited by federal law, continuing to allow regular use of antibiotics even when animals are not sick or at risk. MDA’s implementation of the Keep Antibiotics Effective Act of 2017 is insufficient to stop the overuse of antibiotics on Maryland farms because it subverts that law.
The Keep Antibiotics Effective Act of 2019 (SB 471/HB 652) is needed to set MDA straight and specify that for animal meat production in Maryland: (1) antibiotics cannot be used as routine prophylaxis or as standard operating procedure; (2) antibiotics must be reserved for animals that are sick or will receive surgery; (3) reporting will verify compliance with the law and ensure reduction of unnecessary antibiotic use. Without additional legislation to address these issues, MDA’s regulations will continue to undermine this goal, and the overuse of antibiotics in animal agriculture will continue.
We may already have entered a ‘post-antibiotic’ era in that the epidemic of resistance is beginning to cripple the effectiveness of some of our most important tools in health care. The extent of antibiotic resistance is seriously undermining our ability to manage infections in patients undergoing chemotherapy, dialysis, organ transplants, and other surgeries. Increased hospital stays and lost work days all contribute to the $55-70 billion annual cost of these antibiotic-resistant infections nationwide.
We see every day how critical antibiotic stewardship is for our patients and communities. The routine use of antibiotics in livestock provides the selection pressure that helps create and allow resistant bacteria to flourish. They can then disperse from the farm through the air, water, soil, farm workers, or on the meat itself. The American Academy of Pediatrics agrees: “Because of the link between antibiotic use in food-producing animals and the occurrence of antibiotic-resistant infections in humans, antibiotic agents should be used in food-producing animals only to treat and control infectious diseases and not to promote growth or to prevent disease routinely.”
We need to ensure that Maryland’s health care professionals will be able to fight infections with antibiotics that work. We urge you to support the Keep Antibiotics Effective Act of 2019 to halt the routine use of medically important antibiotics in livestock and poultry production.
Maryland Public Health Association
Alliance of Nurses for Healthy Environments
Maryland Nurses Association
Nurse Practitioner Association of Maryland
Robert Sprinkle, MD, PhD, University of Maryland School of Public Policy*
Emily Heil, PharmD, University of Maryland Medical Center*
Kirsten Lyke, MD, University of Maryland Baltimore*
Paul Saleeb, MD, FACP, University of Maryland School of Medicine*
Megan Deming, MD, PhD, University of Maryland*
Anthony Amoroso, MD, University of Maryland School of Medicine*
Paul Luethy, PHD, University of Maryland School of Medicine*
Mary-Claire Roghmann, MD, MS, University of Maryland School of Medicine*
Jacqueline Bork, MD, University of Maryland School of Medicine*
Alison Blackman, PharmD, University of Maryland School of Pharmacy*
Kerri Thom, MD, MS, University of Maryland School of Medicine*
Sarah Henn, MD, MPH, Whitman-Walker Health*
Heather Nace, MD, University of Maryland*
Cindy Liu, MD, PhD, MPH, George Washington University*
Devang Patel, MD, University of Maryland School of Medicine*
Pavan Bhat, MD, University of Maryland*
Richard Bruno, MD, MPH
Naomi Hauser, MD, MPH, University of Maryland*
Shivakumar Narayanan, MD, University of Maryland Medical Center*
Robyn Gilden, PhD, RN, University of Maryland School of Nursing*
Patrick Ryscavage, MD, University of Maryland School of Medicine*
Sarah Schmalzle, MD, University of Maryland School of Medicine*
Kalpana Shere-Wolfe, MD, University of Maryland *
Pat McLaine, DrPH, RN, University of Maryland School of Nursing *
Yinka Bode-George, MHS, Maryland Public Health Association*
Cara Cook, MS, RN, AHN-BC, Alliance of Nurses for Healthy Environments*
Rebecca Rehr, MPH, Maryland Public Health Association*
Ardandia Campbell-Williams, MPH, Maryland Public Health Association*
Neelie Ylagan, RN, University of Maryland School of Nursing*
Katie Huffling, MS, RN, CNM, Alliance of Nurses for Healthy Environments*
E. James Lieberman, M.D., M.P.H., George Washington University*
K Savitha Chengappa, M.D., MS, Annapolis Infectious Disease Associates, LLC*
*affiliation for identification only
 Centers for Disease Control and Prevention (CDC), Antibiotic Resistance Threats in the United States, 2013, http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf (accessed February 23, 2015).
 Burnham JP, Olsen MA, and Kollef MH (2019). Re-estimating annual deaths due to multidrug-resistant organism infections. Infection Control & Hospital Epidemiology 2019, 40, 112-113. Doi: 10.1017/ice.2018.304
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 Avinash Kar and David Wallinga. Blog: Livestock Antibiotic Sales See Big Drop, but Remain High. Natural Resources Defense Council website, 18 December 2018. Retrieved February1, 2019 at https://www.nrdc.org/experts/avinash-kar/livestock-antibiotic-sales-drop-remain-very-high.
 G. Khachatourians, “Agricultural Use of Antibiotics and the Evolution and Transfer of Antibiotic- Resistant Bacteria,” Canadian Medical Association Journal 159 (1998): 1129-1136. T. Jukes, “The Present Status and Background of Antibiotics in the Feeding of Domestic Animals,” Annals of the New York Academy of Sciences 182 (1971): 362-379.
 Natural Resources Defense Council. FDA’s efforts fail to end misuse of livestock antibiotics (fact sheet). http://www.nrdc.org/food/subway/files/fda-guidance-213.pdf. (accessed December 23, 2015),
 World Health Organization press release. Stop Using Antibiotics of Medical Important in Healthy Animals to Stop the Spread of Antibiotic Resistance. 7 November 2017. Retrieved from https://www.who.int/news-room/detail/07-11-2017-stop-using-antibiotics-in-healthy-animals-to-prevent-the-spread-of-antibiotic-resistance.
 Executive Office of the President. President’s Council of Advisors on Science and Technology, Report To The President On Combating Antibiotic Resistance. 2014, p.3, http://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_carb_report_sept2014.pdf (accessed February 23, 2015).
 Chang, Q. et al, “Antibiotics in agriculture and the risk to human health: how worried should we be?” Evolutionary applications, 2014, pp. 1-8.