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I’ve written (ranted?) about this before. Usually, it’s followed by a deluge of nasty emails along with a bunch of curious requests for links to fish antibiotic sellers (8% kickback available!).
Another sponsorship request came in this am, prompting my rant. I guess it was a poorly programmed bot or someone who didn’t even carefully read the title, let alone the content.
Anyway, in some ways, this is small potatoes in the grand scheme of the ‘silent pandemic’ of antimicrobial resistance (AMR), something that impacts millions of people and costs billions of dollars, but still flies largely under the radar. But, small potatoes are still something we need to address for a problem like this.
Why is it an issue of any degree?
Anytime an antibiotic is used, there are various risks….adverse effects, treatment failure, resistance… So, when we use them, we need to make sure we maximize the benefits and minimize the costs. The more we remove medical (human/veterinary) advice and control, the more risks and the fewer benefits.
What are ‘fish antibiotics’?
Basically, they’re the same antibiotics we use in people and other animals, but with ‘fish’ slapped on the label. They’re marketed that way to try to fly under the regulatory radar (even though it’s still illegal in some countries where they are sold this way). If you look at fish antibiotic websites, you’ll see the same drugs and same formations (same tablet sizes and shapes) as are used in other species. Websites are smart enough now not to explicitly say you can use them yourself or in other species, but that’s pretty well known so they don’t have to and product reviews show other people what’s being done.
Do many people actually buy fish antibiotics?
It’s hard to say. One study of internet reviews reported that 2.4% of reviews suggested they were purchased for use in people.
That’s presumably an underrepresentation since I’d guess that most people that buy fish antibiotics to use on themselves or their kids don’t write that in a review. A larger percentage probably bought them for use on dogs or cats.
Is the ability to buy and divert fish antibiotics actually causing damage?
Who knows? However, there are various potential issues.
Adverse effects: Antibiotics are not innocuous. There’s always some risk of various adverse effects. Some situations and some drugs pose higher risk.
Product safety: Who knows what’s actually in these products. A 500 mg ciprofloxacin tablet could contain 500 mg of cipro. However, I suspect it often doesn’t. It could contain more or less (both potentially being an issue) or contain contaminants. I’m not going to have much confidence in quality control for a product that’s being produced for dodgy or illegal sale.
Inadequate treatment: Some reviews I’ve seen talk about use for things where there’s not much hope of the antibiotic working. People using it themselves have to know the right drug, the right dose and the right duration. I doubt that’s common.
Resistance: Anytime an antibiotic is used, there’s pressure for bacteria to become resistant or to select for resistant bacteria that are already present. At the individual level, it’s a small risk but the more it’s done, the more that risk becomes relevant.
Why is this done?
A general principle of antibiotic stewardship and good medicine is that antibiotics should be available only by prescription (human or animal). That makes sure they are used when needed, not used when not needed and used properly (right drug, dose, duration and any other necessary treatments).
It’s easy to say ‘just stop it’. We need to think about why it’s done.
Some people are looking for the cheap option, even though they can afford a proper product. However, what’s the true cost savings if the antibiotic they buy online isn’t necessary, is the wrong drug, is harmful or isn’t used properly?
Some people truly can’t afford a proper product. Access to treatments needs to be a right, not a privilege.
Lack of access to healthcare is an issue. At the core of antibiotic stewardship is a need to improve human and animal health systems. Whether it’s because they can’t afford healthcare, don’t have access to a doctor or vet in their area, have tenuous employment where they can’t get time to go see a doctor or vet, some people may truly have barriers to getting antibiotics through the proper pathways. We need to improve those pathways so that people can get antibiotics when needed and get proper healthcare to avoid needing them.
Education is another issue. If someone can buy something that is labelled the same and looks the same as a product licensed for people or pets, it’s easy to see why they’d think it’s fine. We need more general education about antibiotics, antibiotic use and antibiotic resistance.
So, what about fish antibiotics…what can be done?
When there are companies based in countries where it’s illegal to market products like this, it’s simply an enforcement issue. Selling over the counter fish antibiotics is illegal in the US and many of these companies list US addresses. So, it’s a matter of someone deciding to crack down. That doesn’t address the broader internet issue of black market drugs being imported but it’s at least a start.
Even some ‘main stream’ companies are involved, probably inadvertently, but it’s something they need to look at. For example, I looked at Walmart’s PetRx website and there are reviews that indicate diversion of pet meds. I’m not sure how rigourous some of the US online vet pharmacies are in their ‘vetting’ of prescriptions and purchases, but some effort to minimize diversion would be good (at a minimum, removing reviews that show it being done and therefore might encourage others is a no-brainer).
Undoubtedly, small improvements in antibiotic use in human healthcare, veterinary medicine and food production would have much more of an impact than completely eliminating diversion of fish antibiotics. However, the scourge of AMR is a complex, multifactorial problem. There will never be a simple, single solution. We need a toolbox of many different interventions that on their own only contribute a little, but put together and over time will have an impact. Low hanging fruit like this needs to be part of that.
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