Antimicrobial Resistance In Healthcare PDF

ANTIMICROBIAL RESISTANCE IN by Dr. Daniel Czyż HEALTHCARE Lecture 1B Lecture Topics Introduction of AMR and different types of Problems associated with AMR in healthcare After completion of this lecture, students should be able to: Define antimicrobial resistan...

ANTIMICROBIAL RESISTANCE IN by Dr. Daniel Czyż HEALTHCARE Lecture 1B Lecture Topics Introduction of AMR and different types of Problems associated with AMR in healthcare After completion of this lecture, students should be able to: Define antimicrobial resistance (AMR) Be able to provide examples of AMR Recognize the problem of AMR in healthcare Antimicrobial Resistance (AMR) The World Health Organization (WHO) defines AMR as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antivirals, and antimalarials) from working against it. As a result, standard treatments become ineffective, infections persist and may spread to others.” Antimicrobial Resistance (AMR) The World Health Organization (WHO) defines AMR as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antivirals, and antimalarials) from working against it. As a result, standard treatments become ineffective, infections persist and may spread to others.”  Antimicrobial Resistance (AMR) The World Health Organization (WHO) defines AMR as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antivirals, and antimalarials) from working against it. As a result, standard treatments Bacteria become ineffective, infections persist and (MRSA) may spread to others.”  Antimicrobial Resistance (AMR) The WorldKNOWLEDGE Health Organization BOX (WHO) defines AMR as “the ability of a microorganism (like bacteria, viruses, and some parasites) One bacterium to stop an antimicrobial (such as antibiotics, Two antivirals, bacteria and antimalarials) Many bacteria from working against it. As a result, standard treatments Bacteria become ineffective, infections persist and (MRSA) may spread to others.”  Antimicrobial Resistance (AMR) The World Health Organization (WHO) defines AMR virus as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antiviral antivirals, and antimalarials) from working against it. As a result, standard treatments Bacteria (MRSA)become ineffective, infections persist and may spread Viruses to others.” (Influenza)  Antimicrobial Resistance (AMR) The World Health Organization (WHO) defines AMR Shutterstock.com fungus as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antifungal antivirals, and antimalarials) from working against it. As a result, standard treatments Bacteria (MRSA)become ineffective, infections persist and may spread Viruses to others.” (Influenza) Fungi (Candida)  Antimicrobial Resistance (AMR) The World Health Organization (WHO) defines AMR parasite as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such asantiparasitic antibiotics, antivirals, and antimalarials) from working against it. As a result, standard treatments Bacteria (MRSA)become ineffective, infections persist and may spread Viruses to others.” (Influenza) Fungi (Candida) Parasites (Malaria)  Pesticide Resistance The World Health Organization (WHO) defines AMR pest as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as pesticide antibiotics, antivirals, and antimalarials) from working against it. As a result, standard treatments Bacteria (MRSA)become ineffective, infections persist and may spread Viruses to others.” (Influenza) Fungi (Candida) Parasites (malaria) Pest (mosquito)  Herbicide Resistance The World Health Organization (WHO) defines AMR weeds as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as herbicide antibiotics, antivirals, and antimalarials) from working against it. As a result, standard treatments Bacteria (MRSA)become ineffective, infections persist and may spread Viruses to others.” (Influenza) Fungi (Candida) Parasites (malaria) Pest (mosquito) Weeds (waterhemp)  Cancer Resistance The World Health Organization (WHO) defines AMR cancer as “the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such aschemotherapy antibiotics, antivirals, and antimalarials) from working against it. As a result, standard treatments Bacteria (MRSA)become ineffective, infections persist and may spread Viruses to others.” (Influenza) Fungi (Candida) Parasites (malaria) Pest (mosquito) Weeds (waterhemp) Humans (cancer) Development of Resistance CDC, Antibiotic Resistance Threats, 2013 AMR: Bacterial & Fungal Infections alone Cause Massive Life Loss CDC, Antibiotic Resistance Threats, 2013 AMR: Bacterial & Fungal Infections alone Cause Massive Life Loss KNOWLEDGE BOX Community-acquired infection: an infection that is acquired from a communal setting, such as gym, swimming pool, subway, etc. CDC, Antibiotic Resistance Threats, 2013 AMR: Bacterial & Fungal Infections alone Cause Massive Life Loss CDC, Antibiotic Resistance Threats, 2013 AMR: Bacterial & Fungal Infections alone Cause Massive Life Loss KNOWLEDGE BOX Nosocomial or hospital-acquired infections (HAIs) are infections that are caught in a healthcare setting (i.e. hospital, clinic, nursing home, etc) CDC, Antibiotic Resistance Threats, 2013 AMR: Bacterial & Fungal Infections alone Cause Massive Life Loss CDC, Antibiotic Resistance Threats, 2013 AMR: Bacterial & Fungal Infections alone Cause Massive Life Loss CDC, Antibiotic Resistance Threats, 2019  How Serious is AMR? 2013 AMR Cases: 2019 2,049,442 2,868,700 23,000 35,000 Death Rate: Death Rate: 1.72% (1.41% FL) 1.12% 1.22% (1.57%)* Last updated: August 10, 2021, 20:33 GMT https://www.worldometers.info/coronavirus/country/us/  How Serious is AMR? 2013 AMR Cases: 2019 2,049,442 2,868,700 23,000 35,000 Death Rate: Death Rate: 1.72% (1.41% FL) 1.12% 1.22% (1.57%)* Last updated: August 10, 2021, 20:33 GMT https://www.worldometers.info/coronavirus/country/us/  US: 328.2 million (‘19) Over 33,000 deaths directly Europe: 746.4 million (‘18) related to AMR in Europe 39% of all deaths related to AMR are due to bacteria that are resistance to last-reserve antibiotics (pan-resistance) Cassini et al. 2018 AMR is a World- wide Problem “Many forms of resistance spread with a remarkable speed” -CDC Healthcare leaders describe AMR as a nightmare that pose a catastrophic threat to the entire world CDC AMR Threats Report 2019 CDC, Antibiotic Resistance Threats, 2019 CDC AMR Threats Report 2019 CDC, Antibiotic Resistance Threats, 2019 CDC AMR Threats Report 2019 CDC, Antibiotic Resistance Threats, 2019 CDC AMR Threats Report 2019 CDC, Antibiotic Resistance Threats, 2019 AMR: Key Facts Antimicrobial Resistance: is one of the biggest threats to global health and food security today can affect anyone, of any age, in any country occurs naturally, but misuse of drugs in humans and animals is accelerating the process leads to longer hospital stays, higher medical costs and increased mortality Source: WHO, Fact Sheet  AMR is a global problem and it is only getting worse The number of ABR infections increases each year While the number of bacterial infections has remained constant (~14M/year), the number of ABR- infections has been constantly increasing Thorpe et al. 2018 Pharmaceuticals & Medical Tech. AMR: Consequences Higher medical costs Prolonged hospital stays Increased mortality Source: WHO, Fact Sheet  AMR: Consequences Higher medical costs: Additional antibiotic prescriptions Prolonged hospitalization Additional diagnostic/lab tests Infectious disease specialist ittipon2002 / iStock Source: Health Aff Abstract Higher Medical Costs It is estimated that on average ABR infections cost ~$1,400 more per person compared to antibiotic-sensitive infections This results in over $2.2B in annual medical costs in the US alone; however, other sources estimate this number to be over $20B (ABR Threats in the US, CDC) Thorpe et al. 2018 Pharmaceuticals & Medical Tech. AMR : Consequences Prolonged hospital stays Estimated US household loss of $35B (2000) to ABR infections due to missed work, hospital costs, and premature deaths  AMR : Consequences Increased mortality Average hospital Stay RVRE: 17 days RMDR P. aeruginosa: 20 days SVSE: 3 days Snon-MDR P. aeruginosa: 10 days Mortality rate RVRE: 33.3% RMDR P. aeruginosa: 21% SVSE: 11.1% Snon-MDR P. aeruginosa: 12% S: Susceptible/sensitive R: Resistant VRE: Vancomycin-resistant Enterococcus VSE: Vancomycin-susceptible Enterococcus MDR: Multidrug-resistant Source: Vergis et al.; Aloush et al.  AMR : Consequences Increased mortality Average hospital KNOWLEDGE BOX Stay AlwaysRitalicize VRE: 17 scientific days names: RMDR P. aeruginosa: 20 days SVSE: 3 species days Snon-MDR P. aeruginosa: 10 days Genus (Pseudomonas Mortality rate aeruginosa) R VRE:to33.3% R But if you want refer to all species: MDR P. aeruginosa: 21% Pseudomonas SVSE: 11.1%spp. Snon-MDR P. aeruginosa: 12% S: Susceptible/sensitive R: Resistant VRE: Vancomycin-resistant Enterococcus VSE: Vancomycin-susceptible Enterococcus MDR: Multidrug-resistant Source: Vergis et al.; Aloush et al. AMR: Scope of the Problem While antibiotic resistance constantly spreads and new resistance mechanisms evolve, the development of novel antibiotics has almost completely ceased. Over the past few years, only a handful of new antibiotics was developed What will happen if we are faced with infections that are not treatable with antibiotics anymore? Schaberle & Hack, 2014 AMR: Failing Drug Efficacy Sisyphus goes to work AMR: From the Introduction to Resistance It takes 8 years on average from the introduction of a new antibiotic to clinical resistance. Schmieder & Edwards, 2012 AMR: Timeline Davis & Davis, 2010 Factors contributing to AMR in Healthcare Antibiotic usage: Underuse: Not finishing prescribed antibiotics Use: increases risk for other infections (i.e. C. difficile) Overuse: it is estimated that 25-75% prescriptions are not necessary Given when not needed Continued when not necessary Wrong dose Wrong antibiotic Lack of antibiotics Poor sanitation and personal hygiene Use of antibiotics in agriculture (covered in Lecture 2) Inadequate infection controls in health care facilities What are some other factors contributing to AMR? Limiting exposure to microbes dampens the immune system Weaken immune system increases chances of developing infection that will require antibiotic treatment In a study of 184 infants whose parents licked the pacifier and put it back in, kids were less likely to develop immune diseases due to stimulation of the immune system by parental microbes – what doesn’t kill you makes you stronger The FDA banned use of antibiotic agents in personal hygiene products Elizabethsalleebauer/Getty Images/RooM RF Hesselmar et al. 2013 Question? Post to the Canvas Discussion Board  ANTIMICROBIAL RESISTANCE IN by Dr. Daniel Czyż AGRICULTURE Lecture 2 Today’s lecture will cover: Antibiotic use in farm animals Evidence of antibiotic resistant bacteria arising from antibiotic use on commercial farms Consequences of using antibiotics in farm animals on human health After completion of this lecture, students should be able to: Recognize the need and drivers of antibiotic use in farm animals Know the consequences of inappropriate antibiotic use in agriculture World population growth, 1750-2100 While the growth rate decreases, the population still rapidly increases www.ourworldindata.org  Population growth of most populated countries Rapid population increase in China and India drives high demand for food www.ourworldindata.org  Increasing global meat production Global meat production has increased 4-5x since 1961. www.ourworldindata.org  Production of poultry, pork, and beef has seen the highest increase Poultry Pork Beef & Buffalo www.ourworldindata.org From population to antibiotic resistance Increase in global population drives increase for food demand Increased food demand drives animal farming Increased animal farming enhances occurrence of transmissible diseases Enhanced occurrence of transmissible diseases increases the use of antibiotics Increase in antibiotic use enhances antibiotic resistance Human exposure to low concentration of antibiotics enhances antibiotic resistance  Why use antibiotics in farming? Growth promoters: antibiotics are known to increase animal weight Infection control: cheaper alternative to hygiene maintenance Consumer Reports Key facts about antibiotic use in farm animals In 1951 the FDA approved first antibiotics for the use in poultry, pork, and beef growth promotion. Industrial farms have been using antibiotics since then It is estimated that ~70% of all antibiotics in the US are used in animals (FDA 2016 Summary Report) In 2016, the UN General Assembly announced that the use of antibiotics in animals is the leading cause of the antibiotic-resistance crisis Van Boeckel et al. 2017 From the farm to the table The use of antibiotics in farm animals selects for antibiotic resistant bacteria Cross contamination leads to human exposure potentially leading to serious infections MicrobeWiki CDDEP 2021 Report Increase in global antibiotic consumption CDDEP 2021 Report Evidence of AMR arising from animal farming The same antibiotic resistant bacterial strains that colonize animals are found in infected humans Enterococcus faecalis are commensal bacteria that colonize the gut of warm-blooded animals, including humans The organism is not normally invasive, but will infect if found outside of the gastro-intestinal tract E. faecalis is the most common Enterococci clinical isolate of urinary tract infections (UTIs), abdominal or pelvic wound infections, and bacteremia. It accounts for ~90% of clinical isolates The infection is usually treated with a combination of antibiotics that includes gentamicin During 2000-2002 a spike of high-level gentamicin- resistant E. faecalis (ST16) was detected in the pig population in Denmark. The causative strain was identified by MultiLocus Sequence Typing (MLST) Larsen et al. 2010 Evidence of AMR arising from animal farming The same antibiotic resistant bacterial strains that colonize animals are found in infected humans Enterococcus faecalis are commensal bacteria that colonize the gut of warm-blooded animals, including humans KNOWLEDGE BOX The organism is not normally invasive, but will infect if found outside of the gastro-intestinal tract E. faecalis MultiLocus Sequence Typingis (MLST) the mostiscommon a clinical isolate of urinary tract infections (UTIs), abdominal or pelvic method of identifying woundbacterial isolates infections, by and bacteremia. It accounts for ~90% of clinical isolates directly measuring the DNA sequence The infection variation in housekeeping is usually genes. For treated with a combination of antibiotics that includes gentamicin example E.During faecalis ST16 2000-2002 a spike of high-level gentamicin- resistant E. faecalis (ST16) was detected in the pig population in Denmark. The causative strain was identified by MultiLocus Sequence Typing (MLST) Larsen et al. 2010 Evidence of AMR arising from animal farming The same antibiotic resistant bacterial strains that colonize animals are found in infected humans Enterococcus faecalis are commensal bacteria that colonize the gut of warm-blooded animals, including humans The organism is not normally invasive, but will infect if found outside of the gastro-intestinal tract E. faecalis is the most common clinical isolate of urinary tract infections (UTIs), abdominal or pelvic wound infections, and bacteremia. It accounts for ~90% of clinical isolates The infection is usually treated with a combination of antibiotics that includes gentamicin During 2000-2002 a spike of high-level gentamicin- resistant E. faecalis (ST16) was detected in the pig population in Denmark. The causative strain was identified by MultiLocus Sequence Typing (MLST) Two patients were diagnosed with infective endocarditis. The causative agent turned out to be community-acquired E. faecalis ST16. Both patients died Larsen et al. 2010 Use of antibiotics in pigs enhances antibiotics resistance Osterberg et al. looked at the antibiotic resistance of E. coli isolated from pigs grown with (conventional) or without (organic) antibiotics E. coli isolated from conventional (antibiotics) farm pigs revealed enhanced resistance to antibiotics compared to organic (no antibiotic) raised animals The study concluded that in each of the four countries studied, antibiotic resistant E. coli from organically-grown pigs were much less common Osterberg et al. 2016 Use of antibiotics on farms enhances transmission of resistance into the Environment A study was designed to assess the spread of i) antibiotics, ii) antibiotic resistance genes, and iii) bacteria via particulate matter from large- scale cattle farms Particulate matter was collected downwind and upwind from 10 cattle farms www.milkmeansmore.org Samples were analyzed for antibiotics, resistance genes, and bacteria The study found that large concentrations of antibiotics, bacteria, and resistance gene were detected in wind-spread particulate matter McEachran et al. 2015 Use of antibiotics on farms leads to emergence of new resistance Polymyxins are peptide antibiotics that target bacterial cell membrane Wide-spread of antibiotic resistance among Gram-negative bacteria leaves polymyxins as a last-reserve antibiotic Resistance to polymyxins is attributed to a chromosomal mutation and therefore does not spread across bacteria A large spike in resistance to colistin (polymyxin) was observed across pig and chicken population in China A strain of E. coli (SHP45) was isolated and was found to carry a colistin resistance gene, mobilized colistin resistance (mcr-1) mcr-1 was found to be encoded on a high mobility plasmid capable of intra and inter-specie transfer, especially to already resistant Gram-negative human pathogens Liu et al. 2016 Using antibiotics in farm animals leads to: Enhanced development of resistance to antibiotics (Osterberg et al. 2016) Transmission of resistant bacteria to humans (Larsen et al. 2010) Contamination of the environment by air particulates that carry antibiotics, resistance genes, and bacteria (McEachran et al. 2015) Emergence of novel antibiotic resistance mechanisms (Liu et al. 2016) Consequences of antibiotic use in farm animals on human health Jalal et al. 2014 Use of Antibiotics in agriculture: 1951 FDA approves the use of antibiotics as growth promoters 1969 UK concludes that antibiotic use in agriculture contributes to AMR 1970 US recommends that some antibiotics be banned from animal use The FDA proposes a ban on penicillin/tetracycline use. The proposal is opposed by 1977 the industry & drugmakers The FDA concludes there is not enough data to support any hazard caused by 1980 antibiotic use in animals The WHO recommends that antibiotics used in humans should not be used as 1997 growth promoters 1999 The EU issues a ban on common human antibiotic use in animals The US Institute of Medicine issues a report on the increased prevalence of 2003 “superbugs” and recommends ban on the use of antibiotic growth promoters in animals 2006 The EU bans the use of antibiotics as growth promoters 2012 The FDA orders limits on cephalosporin use in animals FDA asks pharma companies to voluntarily label their products: not for growth 2013 promotion 2017 The FDA bans the use of antibiotics as growth promoters “Crucial antibiotics still used on US farms despite public health fears” The Guardian (Sept 2018) It’s not easy to eliminate antibiotics from farming The president and COO of Sanderson, said raising chickens without antibiotics would lead to increased mortality and would require expansion of farms to allow more room “We looked at it, and we would need more corn, more water, more soybean meal, more housing, more electricity,” he said. “But sustainability calls for using less of everything.” – Butts A spokesman for Tyson said the company used antibiotics as little as possible. “We’re working with our research partners on antibiotic alternatives, however, until they’re available we currently plan to continue using ionophores,” the spokesman, Gary Mickelson, said. NYTIMES It’s not easy to eliminate antibiotics from farms if anyone can purchase them online Fish antibiotics (i.e., doxycycline) It is not easy to eliminate antibiotic use from farm animals Loss of profit to farm animal companies Uncontrolled access to antibiotics Little control over antibiotic-fed cattle In September 2018, a report on antibiotic use in hamburger meat was generated by the Center for Food Safety, Consumer Reports, Food Animal Concerns Trust, et al. 22 popular fast-food restaurant chains received a failing grade because they used meat from antibiotic- treated animals Wendy’s minimizes the use of antibiotics in their meet, but does not eliminate it Only two chains enforced no-antibiotic meat https://uspirg.org/feature/usp/chain-reaction What Can be Done? Reduction of antibiotic use in food animal production must be addressed on a global basis by: (i) enforcing global regulations to cap antimicrobial use, (ii) adherence to nutritional guidelines leading to reduced meat consumption, and (iii) imposing a global user fee on veterinary antimicrobial use OPTIONAL MOVIE Week 1/Lecture 2/Recommended Material/Antibiotic Resistance in Agriculture https://www.pbs.org/wgbh/frontline/film/trouble-with-antibiotics/ Question? Post to the Canvas Discussion Board  ANTIMICROBIAL RESISTANCE IN THE by Dr. Daniel Czyż ENVIRONMENT Lecture 3A Today’s lecture will cover: Transmission of resistance throughout the environment After completion of this lecture, students should be able to: Explain how antibiotic resistance can travel through the environment Be familiar with different routes of antibiotic resistance transmission Major reservoirs of antibiotic resistance Soil Modified from www.pig333.com Transmission of antibiotic resistance through the environment FARM ANIMALS Modified from Huijbers et al. 2015  Transmission of antibiotic resistance through the environment: Air Aerosol/fluid droplets Solid particles Settles, 2006 www.kasaifilms.com  Transmission of antibiotic resistance through the environment: Air Coxiella burnetii causes Q-fever. The largest Q-fever outbreak sickened over 4,000 people and killed 74 people. Bacteria were disseminated by wind from nearby goat farms Schneeberger et al. 2014 Transmission of antibiotic resistance through the environment: Air Bacteria can enter air from: Soil Leaves Water Humans & animals Fecal matter Wastewater Composting Smets et al. 2016 facilities Modified from Huijbers et al. 2015 Transmission of antibiotic resistance through the environment: Air Bacteria can enter air from: KNOWLEDGE BOX Soil CFU: Colony Forming Unit Leaves A unit used to estimate the number of Water viable bacteria under the assumption that a single bacterium will form a single Humans & colony. Hence 1 bacterium = 1 CFU animals Fecal matter Wastewater Composting Smets et al. 2016 facilities Modified from Huijbers et al. 2015 Transmission of antibiotic resistance through the environment: Soil Antibiotic resistant bacteria occur naturally in soil Credit: Pat Dumas. Creative Commons BY-NC-SA (cropped). Wash & Duffy, 2013 Transmission of antibiotic resistance through the environment: Soil Antibiotic resistant bacteria occur naturally in soil Credit: Pat Dumas. Creative Commons BY-NC-SA (cropped). Wash & Duffy, 2013 Modified from Huijbers et al. 2015 Transmission of antibiotic resistance through the environment: Soil Antibiotic resistant bacteria occur KNOWLEDGE BOX naturally in soil MPN: Most Probable Number Statistical method to estimate number of bacteria in liquid sample based on number of dilutions required to detect no growth Credit: Pat Dumas. Creative Commons BY-NC-SA (cropped). Wash & Duffy, 2013 Modified from Huijbers et al. 2015 Transmission of antibiotic resistance through the environment: Water Credit: shutterstock It’s estimated that 10-90% of antibiotics are excreted in urine and feces leading to constantly increasing concentration of antibiotics in aquatic environments Berkner et al. 2014 Transmission of antibiotic resistance through the environment: Water Bacteria or antibiotics from humans and pet animals enter water systems through ground and waste water Excretions from animal farms enter waste water and are used as manure Both sludge from wastewater and manure are used as fertilizer carrying antibiotics and antibiotic resistant bacteria onto commercial crops Unfortunately, there is no system in place that would monitor antibiotic concentration in water, soil, sewage, or manure Transmission of antibiotic resistance through the environment: Water E. coli Salmonella spp. A list of E. coli outbreaks in 2017 Combination of meat, vegetables, dairy, and other products Berkner et al. 2014 CDC, Outbreaks Transmission of antibiotic resistance through the environment: Water Antibiotic resistant bacteria (i.e. MRSA) are routinely detected in water, including oceans Runoff water being the possible source of contamination Berkner et al. 2014 Modified from Huijbers et al. 2015  Humans can be exposed to antibiotic resistance through: What we eat What we do What we drink Where we live Modified from Huijbers et al. 2015 CDC warns about recreational waters More than 27,000 people get sick from recreational waters that resulted in 8 deaths (2000- 2014) Hotel pools and hot tubs were the major source CDC Question? Post to the Canvas Discussion Board  ANTIMICROBIAL RESISTANCE IN THE by Dr. Daniel Czyż ENVIRONMENT Lecture 3B Today’s lecture will cover: Emerging problem associated with the Citrus Greening Disease After completion of this lecture, students should be able to: Identify the emerging problem associated with citrus production in Florida Predict the consequences of antibiotic use against the Citrus Greening Disease Florida’s Citrus Greening Disease Credit: UF Photography Citrus Greening Disease Asian citrus psyllid, Diaphorina citri Kuwayama is a pest that was first discovered in Florida in 1998 The psyllid is a vector for Candidatus Credit: Jeffrey Lotz Liberibacter asiaticus a causative agent for the Citrus Greening Diseases, also known as Huanglongbing (HLB) – yellow root disease The disease first appeared in Florida in August 2005 and by 2010 was found across the entire state Sechler et al. 2008 iStock Affected Healthy Credit: UF Photography Candidatus Liberibacter asiaticus Citrus Greening Diseases poses a huge threat to Florida economy and the future of the citrus industry CitroBio.com How exactly is this related to antibiotic resistance? There are currently no treatment options available A number of clinically important antibiotics (i.e. streptomycin and tetracycline) can kill these bacteria Application of antibiotics directly on to citrus trees can have disastrous consequences on the emergence of new resistance So what do we do? Question? Post to the Canvas Discussion Board