Dear Governor Hogan and Secretary Bartenfelder,
As physicians, nurses, other health professionals, and their organizations, we urge you to strengthen the regulations for the Keep Antibiotics Effective Act. To help ensure our shrinking arsenal of antibiotics continue to work in treating our patients, we must rein in the overuse of medically important antibiotics in animal agriculture. Here’s why.
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.  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 won’t address the dire warnings. In the U.S., around 70% of all the antibiotics of human importance – including penicillins, tetracyclines, cephalosporins – are sold not to treat humans, but for use in livestock production.[2,3] 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. 
To stop the overuse of antibiotics on farms, the regulations for the Keep Antibiotics Effective Act should clarify that antibiotics cannot be used as prophylaxis or as standard operating procedure. Antibiotics should be reserved for sickness and surgery. As currently drafted, we worry the draft regulations will undermine this goal, and the overuse of antibiotics will continue.
The antibiotic resistance epidemic is beginning to cripple the effectiveness of some of our most important tools in health care, 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 strengthen the draft regulations for the Keep Antibiotics Effective Act to halt the routine use of medically important antibiotics in livestock and poultry production.
Emily Heil, PharmD, Assistant Professor, University of Maryland Medical Center*
Matthew Ferreira, DVM, MPH, Health Professional Action Network*
*for identification only
 World Health Organization, Antimicrobial Resistance: Global Report on Surveillance, 2014, forward,http://apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf?ua=1 (accessed February 23, 2015).
 U.S. Department of Health and Human Services, Food and Drug Administration, Center for Veterinary Medicine, 2011 Summary Report of Antimicrobials Sold or Distributed for Use in Food-Producing Animals, 2011, www.fda.gov/downloads/ForIndustry/UserFees/AnimalDrugUserFeeActADUFA/UCM338170.pdf (accessed February 23, 2015).
 Jerome A. Paulson, Theoklis E. Zaoutis. 2015. Nontherapeutic Use of Antimicrobial Agents in Animal Agriculture: Implications for Pediatrics. Pediatrics DOI: 10.1542/peds.2015-3630 Pediatrics; originally published online November 16, 2015.
 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),
 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).
 “MRSA Revisited,” Critical Link, Maryland Department of Health and Mental Hygiene, Vol. 12, No. 7; July 2008,http://dhmh.maryland.gov/laboratories/docs/july08critlink.pdf (accessed February 23, 2015).
 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.