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Sub-therapeutic use of antibiotics in meat production and antibiotic-resistant bacteria. By Anandi Ehman and Tyler Jacobson

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The sub-therapeutic use of antibiotics in food producing animals is causing an increase in the prevalence of antibiotic- resistant bacteria.

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The issue: Food-borne pathogens account for: 76 million diseases, 325,000 hospitalizations and 5,000 deaths annually in the United States

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This issue and antibiotic resistance: 25000 patients died due to multi-drug resistant bacteria in 2008 in the EU Antibiotic-resistant bacteria are one of the leading causes of a recent increase in infectious disease deaths in the United States(HIV is the other) Trend for Penicillin-Resistant (MIC 2 mg/ml) S. pneumoniae in the US (1988-2002) % of Isolates Resistant to Penicillin

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Antibiotic resistance is widespread:

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Antibiotic Resistance is Common and Increasing:

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Historical Aspects: 3000 BC- use of molds by Ancient Egyptians to treat infection 1674- Anton Von Leeuwenhoek creates lens for microscope 1800s- Germ Theory of Disease 1877- Robert Koch discovers how to best grow cells in culture 1928- Discovery of Penicillin

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1945 - Alexander Flemming claims that the misuse of penicillin could lead to the selection and propagation of mutant forms of bacteria resistant to the drug, 1946 - 14% of staphylococci strains resistant to penicillin Historical Aspects continued:

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1950 - use of antibiotics spread to livestock 1966-1970 - reports showing multi-drug resistant organisms transmissible between humans and animal 1969 - Swann Report in UK bans many antibiotics 1972 - FDA releases statement suggesting sub- therapeutic resistance of in food be stopped 1998 - WHO recommends use of antibiotics as growth promoters be ceased 1998 - Demark bans use of all antibiotics used in humans from use in food animals

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What causes antibiotic resistance? Mutation of bacteria gives rise to resistant forms Treatment with antibiotics strongly selects for resistant bacteria Resistant bacteria become more prevalent

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What causes antibiotic resistance? Over-prescription/over- availability of antibiotics Incomplete dosages of antibiotics Incorrect antibiotics for a particular disease Prophylactic application Use of antibiotics in food producing animals

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Types of resistance mutations:

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How does resistance spread? One major danger 0f antibiotic resistance is how quickly it spreads through bacterial populations Bacteria can transmit resistance between even distantly related species through multiple mechanisms Genes for antibiotic resistance are often housed on plasmids, smaller rings of DNA not part of the bacterial chromosome

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How does resistance spread? Antibiotic resistance can be shared through transformation, transduction, and conjugation.

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How does resistance spread?

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Why worry about resistance in bacteria that infects animals? Antibiotics used in animals are not the same as those used in humans Antibiotics are divided into classes Antibiotics used in animals often come from the same classes as those used in humans Resistance to a specific antibiotic often increases resistance against others in same class because they have similar mechanisms of function

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Who is using sub-therapeutic antibiotics?

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Why keep using antibiotics? Meat industry creates 4.4 million jobs directly, 6.2 million indirectly in the US Meat industry indirectly produces $832 billion per year in the US: 6% of GDP Antibiotics as growth promoters improve the feed efficiency and growth rate of animals Their use helps lower food costs and increase supply Limitations would have little or no effect on prevalence of antibiotic resistant bacteria in humans

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Why keep using antibiotics? Some farmer advocacy groups claim that it allows chickens to be the best they can be Can help developing nations create steady food supply and prevent shortages Antibiotic usage in food animals is not the only source of resistance

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Economic Issues:

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Food production would decrease only slightly Enough food would still be produced, but total costs would increase The cost per European consumer is estimated to be between $4.85 and $9.72 per year

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Economic Issues Cost per consumer is estimated to increase $.05 per pound of pork for US consumers, about $11 per year Total costs in the US per year are estimated to be $748 million Estimated cost of resistance is $4-5 billion per year in 2001 A 1995 Office of Technology Assessment report to Congress concluded that 6 common resistant bacteria cost about 1.3billion per year

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Economics: The economic detriments from sub-therapeutic use of antibiotics are largely externalities Healthcare and missed work costs due to multi-drug resistant bacteria in the EU was 1.5 billion Euros ($2.25 billion USD) Total cost of illness and death from Salmonella in US is $2.5 billion per year

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Economic Costs: Creating a new antibiotics costs between $500 and $800 million per drug

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Externalities associated with antibiotic resistance:

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Scientific Aspects: E. coli resistant to nourseothricin arose within two years of its introduction as a growth promoter in pigs in Eastern Germany Prior to introduction, tests showed no resistance was present E. coli resistant to nourseothricin were found in farmers within 10 years, resulting in higher incidences of urinary tract infections Nourseothricin resistance found in Salmonella and other strains of E. coli, including shiga-toxin producing E. coli within 12 years Other studies have found similar increases

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Political and Cultural Issues: Antibiotics are banned Denmark and Sweden, and many are limited in the EU compared to their use in the US Different cultural attitudes as to whether regulation is the governments job contribute to the differences Companies present in both Canada and the United States have different policies for farms run in each country There are differences even among the opinions and practices of US farmers, such as the growing organic movement

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Moral issues: Infections from multi-drug resistant bacteria have been shown to cause 25000 deaths per year in the EU 1.2 million cases of Campylobacter per year in the US are drug resistant Of these 326,000 are resistant to two or more drugs Is increased profitability worth the health or lives of citizens?

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The Precautionary Principle:

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Potential Solutions: Stop sub-therapeutic application of antibiotics Optimized dosing schedules Monitoring and regulating antibiotic usage Prebiotics, probiotics and competitive exclusion Bacteriocins Exploiting facultative metabolisms of bacteria Bacteriophage therapy Vaccines

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Future Implications: 90.2% of chicken in America tested positive for E. coli in 2009 1.4 million Americans infected with Salmonella per year 2.4 million Americans infected with Campylobacter per year Antimicrobial farms had significantly lower resistance

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Future Implications:

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Continued use of sub-therapeutic levels of antibiotics in food producing animals will only increase the prevalence of antibiotic-resistant bacteria in humans.

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Citations: ALPHARMA Animal Health. Straight Talk About Antibiotic Use in Food Animal Production. (2010, October). For the Record, 9(4), 1-4. Retrieved February 14, 2011, from http://www.alpharma.com/pdf/For_The_Record_Oct2010.pdfhttp://www.alpharma.com/pdf/For_The_Record_Oct2010.pdf AMI. (2010, April). AMI Fact Sheet: The Economic Impact of the Meat Industry in the U.S. In American Meat Industry. Retrieved February 13, 2011, from http://www.meatami.com/ http://www.meatami.com/ Ancient Egypt. (2011, February 16). In Wikipedia. Retrieved February 21, 2011, from: http://en.wikipedia.org/wiki/Ancient_Egypt.http://en.wikipedia.org/wiki/Ancient_Egypt Antibiotic. (2011, February 16). In Wikipedia. Retrieved February 21, 2011, from: http://en.wikipedia.org/wiki/Antibiotic. http://en.wikipedia.org/wiki/Antibiotic Bacteria. (2011, February 16). In Wikipedia. Retrieved February 21, 2011, from: http://en.wikipedia.org/wiki/Bacteria. http://en.wikipedia.org/wiki/Bacteria Banerjee, M. R., & Yesmin, L. (2001). Biotechnology. Encyclopedia of Biotechnology in Agriculture and Food, 116-119. Bischoff, K. M., Callaway, T. R., Edrington, T. S., Genovese, K. J., Crippen, T. L., & Nisbet, D. J. (2005). Antimicrobial Use in Food Animals: Potential Alternatives. Encyclopedia of Animal Science, 45-47.

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Burch, D. (2005, January). Problems of antibiotic resistance in pigs in the UK. In The Pig Site. Retrieved February 13, 2011, from http://www.thepigsite.com/articles/?Display=1266 Cassanova, L.; Sobsey, M.D. Human And Environmental Health Risks from Antimicrobially Resistant Bacteria in Food Animal Production Systems. 2006. 667-720. From: Animal Agriculture and the Environment. Edited by: Rice, J.M.; Caldwell, D.F.; Humenik, F.J. ASABE Press, St. Joseph, MI. 2006. CDC. (2003, August 14). Infectious Disease Mortality in U.S. 1900-1996. In CDC: National Center for Infectious Diseases. Retrieved February 13, 2011, from http://www.cdc.gov/ncidod/osr/site/about/graph.htm. http://www.cdc.gov/ncidod/osr/site/about/graph.htm DiMasi, J. A., Hansen, R. W., & Grabowski, H. G. (2003). The price of innovation: new estimates of drug development costs. Journal of Health Economics, 22, 151-185. Retrieved February 14, 2011, from http://www.ncbi.nlm.nih.gov/pubmed/12606142 Dufresne, M. (2007). Truth Be Told. In Canadian Poultry Magazine. Retrieved February 13, 2011, from http://www.canadianpoultrymag.com/content/view/1947/38/ Germ Theory of Disease. (2011, February 16). In Wikipedia. Retrieved February 21, 2011, from: http://en.wikipedia.org/wiki/Germ_theory_of_disease.http://en.wikipedia.org/wiki/Germ_theory_of_disease Grave, K.; Jensen, V.F.; McEwen, S.; Kruse, H. Monitoring of Antimicrobial Drug Usage in Animals: Methods and Applications. 2006. 375-395. From: Antimicrobial Resistance in Bacteria of Animal Origin. Edited by: Aarestrup, F.M. ASM Press, Washington, D.C. 2006.

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Hayes, D.J.; Jensen, H.H.; Fabiosa, J.F. What would happen if Over-the-Counter Antibiotics were Banned( in Swine Rations)? CARD: Center for Agricultural and Rural Development. (2000). 6(3). Retrieved: February 20, 2011, from: http://www.card.iastate.edu/iowa_ag_review/summer_00/over_the_counter.aspx. Keep Antibiotics Working. (2003, December). The Basics: Antibiotic Resistance. In Keep Antibiotics Working. Retrieved February 13, 2011, from http://www.keepantibioticsworking.com/new/basics.cfm. Lees, P.; Concordet, D.; Aliabadi, F.S; Toutain, P.L. Drug Selection and Optimization of Dosage Schedules To Minimize Antimicrobial Resistance. 2006. 49-71. From: Antimicrobial Resistance in Bacteria of Animal Origin. Edited by: Aarestrup, F.M. ASM Press, Washington, D.C. 2006. Levy, S. B. (2002). The Antibiotic Paradox (2nd ed.). Cambridge, MA: Perseus Publishing. Louis Pasteur. (2011, February 16). In Wikipedia. Retrieved February 21, 2011, from: http://en.wikipedia.org/wiki/Louis_Pasteur#Germ_theory_of_disease. http://en.wikipedia.org/wiki/Louis_Pasteur#Germ_theory_of_disease McGowan, J.E. Economic Impact of Antimicrobial Resistance. CDC: Emerging Infectious Diseases. (March 2001). 7(2). Retrieved: February 11, 2011, from: http://www.cdc.gov/ncidod/eid/vol7no2/mcgowan.htm. Mead, P. S., Slutsker, L., Deitz, V., McCraig, L. F., Bresee, J. S., Shapiro, C., & Griffin, P. M. (1999, September). Food-Related Illness and Death in the United States. Emerging Infectious Diseases. Retrieved February 13, 2011, from http://www.cdc.gov/ncidod/eid/vol5no5/mead.htm.

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"NOAH: The Present." National Office of Animal Health. NOAH, n.d. Web. 20 Feb. 2011. http://www.noah.co.uk/focus/present.htm. Prescott, J. F. "History of Antimicrobial Usage in Agriculture: an Overview." Antimicrobial Resistance in Bacteria of Animal Origin. Copenhagen: Danish Institute for Food and Veterinary Research, 2006. 19-27. Print. Reyes-Herrera, I.; Donoghus, A.M. Novel Strategies for the Preharvest Control of Campylobacter in Poultry. 2010. 11-26. From: Perspective on Food-Safety Issues of Animal-Derived Foods. Edited by: Ricke, S. C. and Jones, F.T. The University of Arkansas Press, Fayetteville, A.K. 2010. Roberts, M.C. The Evolution of Antibiotic Resistant Microbes in Foods and Host Ecosystems. 2009. 231-229. From: Food Borne Microbes-Shaping the Hose Ecosystem. Edited by: Jaykus, LA.; Wang, H.H.; Schlesinger, L.S. ASM Press, Washington DC. 2009. Rogers, L. "The Denmark Experience." Save Antibiotics. The PEW Chartiable Trusts, n.d. Web. 20 Feb. 2011. http://www.saveantibiotics.org/resources/DenmarkExperience.pdf. http://www.saveantibiotics.org/resources/DenmarkExperience.pdf Rollo, S. N., Norby, B., Bartlett, P. C., Scott, H. M., Wilson, D. L., Fajit, V. R., & Linz, J. E. (2010, January 15). Prevalence and patterns of antimicrobial resistance in Campylobacter spp isolated from pigs reared under antimicrobial-free and conventional production methods in eight states in the Midwestern United. Journal of the American Veterinary Medical Association, 236(2). Retrieved February 12, 2011, from http://www.ncbi.nlm.nih.gov/pubmed/20074013.

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Union of Concerned Scientists. (2009, September 12). Antibiotic Resistance and Food Safety. In Union of Concerned Scientists: Citizens and Scientists for Environmental Sollution. Retrieved February 14, 2011, from http://www.ucsusa.org/food_and_agriculture/solutions/wise_antibiotics/food- safety-antibiotics.html. Union of Concerned Scientists. (2009, September 12). Myths and Realities about Antibiotic Resistance: FAQs. In Union of Concerned Scientists: Citizens and Scientists for Environmental Sollution. Retrieved February 14, 2011, from http://www.ucsusa.org/food_and_agriculture/solutions/wise_antibiotics/food- safety-antibiotics.html. U.S. Congress, Office of Technology Assessment, Impacts of Antibiotic-Resistant Bacteria, OTA-H-629 (Washington, DC: U.S. Government Printing Office, September 1995). White, D.G.; McDermott, P.F. Antimicrobial Resistance in Food-Borne Pathogens. 2009. 231-265. From: Food Borne Microbes-Shaping the Hose Ecosystem. Edited by: Jaykus, LA.; Wang, H.H.; Schlesinger, L.S. ASM Press, Washington DC. 2009. World Health Organization. (2011, February). Race against time to develop new antibiotics. In World Health Organization. Retrieved February 13, 2011, from http://www.who.int/bulletin/volumes/89/2/11-030211/en/index.html

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Image Citations: Figure 1: CDC. (2003, August 14). Infectious Disease Mortality in U.S. 1900-1996. In CDC: National Center for Infectious Diseases. Retrieved February 13, 2011, from http://www.cdc.gov/ncidod/osr/site/about/graph.htm Figure 2: Weber, D.J. (n.d.) Trend for Penicillin-Resistant (MIC 2 mg/ml) S. pneumoniae in the US (1988-2002). [Bar Graph retrieved from Slideshow]. University of North Carolina at Chapel Hill. NC, USA. Retrieved from: www.unc.edu/depts/spice/AntibioticResistant- DJW20041112.ppt. Figure 3: Edens, F. W. (2003, August). Antibiotics sensitivity of E. coli and Salmonellae isolated from poults suffering from poult enteritis and mortality syndrome. [Chart] Retrieved from: Edens, F. W. (2003, August). An alternative for antibiotic use in poultry: probiotics. Revista Brasileira de Cincia Avcola, 5(2). doi:10.1590/S1516- 635X2003000200001 Figure 4: M.R.S.A. (n.d.). [Image] In Cartoon Stock. Retrieved February 14, 2011, from http://www.cartoonstock.com/directory/s/superbug.asp

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Figure 5: Burch, D. (2005, January). Development of fluoroquinolone (enrofloxacin) resistance in Escherichia coli from pigs. [Line Graph] Retrieved from: Burch, D. (2005, January). Problems of antibiotic resistance in pigs in the UK. In The Pig Site. Retrieved February 13, 2011, from http://www.thepigsite.com/articles/?Display=1266 Figure 6: Percentage of E. coli Isolates from retail meats resistant to selected antibiotics (Reproduced from NARMS, 2002). (2006). [Table of resistance]. From: Cassanova, L.; Sobsey, M.D. Human And Environmental Health Risks from Antimicrobially Resistant Bacteria in Food Animal Production Systems. 2006. 667-720. From: Animal Agriculture and the Environment. Edited by: Rice, J.M.; Caldwell, D.F.; Humenik, F.J. ASABE Press, St. Joseph, MI. 2006. Figure 7: Increase in Antibiotic Resistance. (March 1, 2011). [Line graph of resistance]. From: Vollmer, S. RTP panels address rogues gallery of multi-drug resistant bacteria. Science in the Triangle. March 1, 2011. Retrieved March 13, 2011, from: http://scienceinthetriangle.org/2011/03/rtp-panels-address-rogues-gallery-of- multidrug-resistant-bacteria/.

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Figure 8: Percentage of isolates from retail meats resistant to selected antibiotics (reproduced from NARMS, 2002). (2006). [Chart of resistance]. From: Cassanova, L.; Sobsey, M.D. Human And Environmental Health Risks from Antimicrobially Resistant Bacteria in Food Animal Production Systems. 2006. 667-720. From: Animal Agriculture and the Environment. Edited by: Rice, J.M.; Caldwell, D.F.; Humenik, F.J. ASABE Press, St. Joseph, MI. 2006. Figure 9: Percentage of E. faecium isolates from retail meats resistant to selected antibiotics (reproduced from NARMS, 2002). (2006). [Chart detailing percentages of resistance]. From: Cassanova, L.; Sobsey, M.D. Human And Environmental Health Risks from Antimicrobially Resistant Bacteria in Food Animal Production Systems. 2006. 667-720. From: Animal Agriculture and the Environment. Edited by: Rice, J.M.; Caldwell, D.F.; Humenik, F.J. ASABE Press, St. Joseph, MI. 2006. Figure 10: Thanks to Penicillin... He will come home. (1944). [Image]. From: Explore PA History. Retrieved February 14, 2011, from: http://explorepahistory.com/displayimage.php?imgId=4243.

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Figure 11: How antibiotic resistance evolves. (2007). [Diagram]. From: Science Blogs. Retrieved February 13, 2011, from: http://scienceblogs.com/mikethemadbiologist/2007/03/a_good_diagram_of_how _antibiot_1.php. Figure 12: Untitled. (January 3, 2008). [Diagram of antibiotic resistance]. From: Answers to Genesis. Retrieved March 12, 2011, from: http://www.answersingenesis.org/articles/nab/is-natural-selection-evolution. http://www.answersingenesis.org/articles/nab/is-natural-selection-evolution Figure 13: Unfortunately, no amount of antibiotics will get rid of your cold. (December 15, 2008). [Image]. From: Microbiology Bytes: The latest news about microbiology. Retrieved February 13, 2011, from: http://www.microbiologybytes.com/blog/category/bacteria/page/4/. Figure 14: Untitled. (2008). [Image of prescription symbol]. From: Smart Now. Retrieved February 23, 2011, from: http://www.smartnow.com/page/4777. Figure 15: Weber, D.J. (n.d.) Mechanisms of resistance. [Diagram retrieved from slideshow]. University of North Carolina at Chapel Hill. NC, USA. Retrieved from: www.unc.edu/depts/spice/AntibioticResistant-DJW20041112.ppt.

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Figure 16: Pearson Education Inc. (Academic Publisher). (2004). [Untitled image depicting bacterial transformation]. Retrieved March 2, 2011, from: http://schoolworkhelper.net/2010/11/prokaryotic-f-factor-transformation- transduction/. Figure 17: [Untitled image depicting specialized and generalized bacterial transduction]. Retrieved March 2, 2011, from: http://schoolworkhelper.net/2010/11/prokaryotic-f- factor-transformation-transduction/. Figure 18: Jones, M.D. (PhD Candidate). (2009). Conjugation[Diagram]. Retrieved March 2, 2011, from: http://en.wikipedia.org/wiki/Bacterial_conjugation. Figure 19: Bacterial cell donating resistance genes. (July 30, 2007). [Image]. From: National Review of Medicine. Retrieved February 10, 2011, from: http://www.nationalreviewofmedicine.com/issue/2007/07_30/4_advances_medici ne_13.html. Figure 20: Untitled. (20110. [Diagram of a plasmid]. From: Medscape Today. Retrieved March 12, 2011, from: http://www.medscape.com/viewarticle/732915_5.

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Figure 21: Dyner, L. (2009). Antibiotic deployment and resistance observed. [Chart from Slideshow]. Stanford University. Retrieved from Slideshow from http://peds.stanford.edu/Tools/documents/AntibioticResistanceLLD.pdf. Figure 22: Pathways for Transferring Antibiotic Resistant Bacteria from Farm Animals to Humans. (2010). [Flowchart]. From: The PEW: Charitable Trusts. Retrieved March 10, 2011, from: http://www.saveantibiotics.org/pathways.html. Figure 23: Untitled. (2006). [Flowchart showing how antibiotic resistant bacteria from agriculture can come into contact with humans]. From: Prescott, J. F. "History of Antimicrobial Usage in Agriculture: an Overview." Antimicrobial Resistance in Bacteria of Animal Origin. Copenhagen: Danish Institute for Food and Veterinary Research, 2006. 19-27. Print. Figure 24: Major classes of antibiotics. (2011). [Chart]. From: Drug Development Technology. Retrieved March 10, 2011, from: http://www.drugdevelopmenttechnology.com/projects/tygacil/tygacil1.html.

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Figure 25: Antibiotics active against enteric pathogens and Enterococcus species. (2006). [Table showing E. coli and Enterococcus resistance]. From: Cassanova, L.; Sobsey, M.D. Human And Environmental Health Risks from Antimicrobially Resistant Bacteria in Food Animal Production Systems. 2006. 667-720. From: Animal Agriculture and the Environment. Edited by: Rice, J.M.; Caldwell, D.F.; Humenik, F.J. ASABE Press, St. Joseph, MI. 2006. Figure 26: MacDonald, J.M. and McBride, W.D. (2009). Average costs and gross returns in 2005, by size if dairy herd. [Line Graph from USDA Survey]. Retrieved from: http://www.ers.usda.gov/Publications/EIB43/EIB43.pdf. Figure 27: MacDonald, J.M. and McBride, W.D. (2009). Percent farms using growth-promoting subtherapeutic antibiotics. [Line Graph from USDA Survey]. Retrieved from: http://www.ers.usda.gov/Publications/EIB43/EIB43.pdf. Figure 28: Untitled. (July 6, 2010). [Image of cows]. From: Friends Eat blog. Retrieved February 13, 2011, from: http://blog.friendseat.com/drug-resistant-bacteria-antibiotics-in- meat/.

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Figure 29: Untitled. (July 16, 2010). [Image of pigs]. From: The United States Agriculture & Food Law and Policy Blog. Retrieved March 10, 2011, from: http://www.agandfoodlaw.com/2010/07/mixed-opinions-on-antibiotic-use-in.html. Figure 30: MacDonald, J.M. and McBride, W.D. (2009). Testing and sanitation substitute for subtherapeutic antibiotics (STAs) in broiler production. [Bar Graph from USDA Survey]. Retrieved from: http://www.ers.usda.gov/Publications/EIB43/EIB43.pdf. Figure 31: Usage in Sweden of AGOs and therapeutic antimicrobials in the period from 1980 to 2003. (2006). [Bar graph of decreasing antibiotic usage]. From: Grave, K.; Jensen, V.F.; McEwen, S.; Kruse, H. Monitoring of Antimicrobial Drug Usage in Animals: Methods and Applications. 2006. 375-395. From: Antimicrobial Resistance in Bacteria of Animal Origin. Edited by: Aarestrup, F.M. ASM Press, Washington, D.C. 2006. Figure 32: Untitled. (December 29, 2010). [Cartoon Image of cow]. From: Environmental, Health and Safety News. Retrieved February 13, 2011, from: http://ehsmanager.blogspot.com/2010/12/80-of-all-antibiotics-were-for.html.

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Figure 32: Declining antibacterial approvals (past 25 years). (2011). [Bar Graph]. From: Heys, J.; Olsen, D.; Guidos, R.J.; Ochs, M. Bad Bugs, No drugs10 New drugs by 2020. Infectious Diseases Society of America. (2011). Retrieved: March 12, 2011, from: http://www.idsociety.org/10x20.htm. Figure 33: Percentage of MDR-TB among new TB cases, 1994-2010. [Image of map]. From: World Health Organization. Retrieved March 12, 2011, from: http://www.who.int/mediacentre/factsheets/fs194/en/index.html. Figure 34: Estimated percent of new TB cases with MDR. (2002). [Image of world map]. From: Davies, P.D.O. and Cooke, R. Mycobacterial Antimicrobial Resistance. Sourced From: Antimicrobial Resistance and Implications for the Twenty-First Century. p.192. Ed. Fong, I.W. and Drlica, K. 2008. Springer Publications, Newark, NJ. Figure 35: Dyner, L. (1999). Cost of Treating Multi-Drug Resistant TB. [Bar Chart from Slideshow]. Stanford University. Retrieved from Slideshow from http://peds.stanford.edu/Tools/documents/AntibioticResistanceLLD.pdf.

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Figure 36: Percent of swine farms showing some resistance to (October 2010). [Bar Graph] Retrieved from: ALPHARMA Animal Health. Straight Talk About Antibiotic Use in Food Animal Production. (2010, October). For the Record, 9(4), 1-4. Retrieved February 14, 2011, from http://www.alpharma.com/pdf/For_The_Record_Oct2010.pdf. Figure 37: Antibiotic Resistance in commensal E. coli from food animals. (2006). [Table of studies on resistance and their findings]. From: Cassanova, L.; Sobsey, M.D. Human And Environmental Health Risks from Antimicrobially Resistant Bacteria in Food Animal Production Systems. 2006. 667-720. From: Animal Agriculture and the Environment. Edited by: Rice, J.M.; Caldwell, D.F.; Humenik, F.J. ASABE Press, St. Joseph, MI. 2006. Figure 38: Untitled. (2011). [Cartoon image of antibiotic resistance]. From: Honeymark. Retrieved February 10, 2011, from: http://www.honeymarkproducts.com/a-solution- to-antibiotic-resistance.aspx. Figure 39: Untitled. (March 27, 2009). [Image of chickens]. From: Main, E. Tough to kill germs found in Chicken and Hog farms. Retrieved from: Marias Farm and Country Kitchen, March 11, 2011, from: http://www.rodale.com/antibiotic-resistance-and-food.

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Figure 40: EU and US organic sectors 2003. (February 2006). [Chart of organic foods]. From: Waves, A. Development of the U.S. and EU Organic Agricultural Sectors. The Pig Site. February 2006. Retrieved March 12, 2011, from: http://www.thepigsite.com/articles/?AREA=FeaturedArticle&Display=1559. Figure 41: Organic Food Sales in the US, 1997-2005. (November 1, 2006). [Bar graph]. From: Organic Foods. IFT Knowledge Center. (November 1, 2006). Retrieved March 12, 2011, from: http://www.ift.org/knowledge-center/read-ift-publications/science- reports/scientific-status-summaries/organic-foods.aspx. Figure 42: Untitled. (2009). [Chart depicting antibiotic resistance]. From: White, D.G.; McDermott, P.F. Antimicrobial Resistance in Food-Borne Pathogens. 2009. 231-265. From: Food Borne Microbes-Shaping the Hose Ecosystem. Edited by: Jaykus, LA.; Wang, H.H.; Schlesinger, L.S. ASM Press, Washington DC. 2009. Figure 43: Precautionary Principle. (n.d.) [Chart depicting rules of the Precautionary Principle]. Wikipedia. Retrieved: March 13, 2011, from: http://en.wikipedia.org/wiki/Precautionary_principle.

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Figure 44: More at stake than steak. (July 2002). [Image of cow with slogan]. Retrieved from: Schmidt, C.W. Antibiotic resistance in livestock: More at Stake than Steak. Environmental Health perspectives. July 2002. 110(7). Retrieved February 13, 2011, from: http://ehp03.niehs.nih.gov/article/fetchArticle.action?articleURI=info:doi/10.1289/e hp.110-a396. Figure 45: Dangerous Bacteria: Percentage of streptococcus pneumonia resistant to the following antibiotics. (n.d.). [Bar graph]. CBS News. (n.d.) Retrieved March 12, 2011, from: http://www.cbsnews.com/htdocs/health/antibiotics/framesource_charts.html. Figure 46: Untitled. (March 11, 2009). [Bar graph of Staphylococcus aureus and Enterococcus faecium]. From: Huang, S.S.; Labus, B.J.; Samuel, M.C.; Wan, D. T.; and Reingold, A.L. Antibiotics Resistance Patterns of Bacterial Isolates from Blood in San Francisco County, California, 1996-1999. CDC: Emerging Infectious Diseases. February 2002. 8(2). Retrieved, March 12, 2011, from: http://www.cdc.gov/ncidod/eid/vol8no2/01- 0102.htm.

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Figure 47: Dyner, L. (2003). Vancomycin-resistant Enterococcus in US hospital intensive care. [Scatter plot from Slideshow]. Stanford University. Retrieved from Slideshow from http://peds.stanford.edu/Tools/documents/AntibioticResistanceLLD.pdf. Figure 48: Weber, D.J. (n.d.). Untitled. [Cartoon Image retrieved from slideshow]. University of North Carolina at Chapel Hill. NC, USA. Retrieved from: www.unc.edu/depts/spice/AntibioticResistant-DJW20041112.ppt.