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Consumer groups scorched nearly every fast-food burger chain in the country for continuing to buy beef raised using antibiotics in ways that make them less effective on humans.

Only two small but up-and-coming chains, Shake Shack and BurgerFi, received A grades in an annual report card issued Wednesday by a coalition of five consumer and environmental groups.

Wendy’s received a grudging D-minus for sourcing 15 percent of its beef from a supplier that has reduced use of one antibiotic, tylosin. The remaining 22 top burger chains failed.

Overuse of antibiotics by both the food industry and human medicine has led to the proliferation of drug-resistant superbugs that kill 23,000 people in the U.S. and increase healthcare costs by $20 billion annually, according to the Centers for Disease Control and Prevention.

A 2007 study, for instance, showed that use of tylosin in poultry flocks left strains of campylobacter bacteria that were resistant to a human equivalent of the drug.

This year’s Chain Reaction food report marks a pivot for the coalition of national consumer, environmental and health groups known as Keep Antibiotics Working, which had previously highlighted progress in eliminating antibiotic use in poultry.

Over the last decade, pressure from consumers and activist shareholders, as well as market competition, has pushed major poultry companies toward raising flocks without routinely administering antibiotics.

Perdue Foods halted the use of antibiotics in 2014 and was soon followed by Foster Farms, Tyson Foods and Pilgrim’s Pride. Sanderson Farms remains the only top poultry company to buck the trend, even as 40 percent of its shareholders this year backed a proxy measure to curtail the use of antibiotics.

“Once Perdue offered it and consumers bought it and the fast-food chains went for it, the rest of the companies followed,” said Jean Halloran, director of food policy initiatives at Consumers Union and a contributor to the report.

Following the lead of Panera Bread and Chipotle Mexican Grill, industry leaders such as Chick-fil-A, McDonald’s, Burger King, Taco Bell, KFC and others instituted broad policies limiting antibiotic use in poultry.

Those trends help explain a sharp reversal in antibiotic purchases by the food animal industry – the U.S. Food and Drug Administration reported a 10 percent annual drop in 2016, after sales had risen 11 percent in the previous five years.

The beef and pork industries, which have stopped using antibiotics solely to enhance growth of otherwise healthy animals, have balked at further limits. They argue that using low doses preventively – mostly in younger, low-weight animals – can avoid more widespread application if illnesses break out.

“The beef industry promotes the judicious use of antibiotics to keep potential risk of developing antibiotic-resistant bacteria extremely low,” the National Cattlemen’s Beef Assn. said. “In addition, the beef community has invested significantly in research and education programs like Beef Quality Assurance to maintain high standards of animal care and health.”

Last year, the FDA tightened its guidelines to require veterinary “oversight or consultation” for measures “considered necessary for assuring animal health,” including administering antibiotics.

Those guidelines leave a substantial loophole, activists say.

“A veterinarian can prescribe for months on end for extremely large numbers of animals,” Halloran said. “We’re not opposed to treatment of sick animals, but that’s not the way antibiotics are used.”

After faintly praising McDonald’s with a C-minus in last year’s report, the groups flunked the fast-food titan this year because of lingering concerns that McDonald’s has not set firmer deadlines to eliminate antibiotics in its beef supplies.

McDonald’s has said that it is committed to more ethical and judicious use of antibiotics but that curbing their use could conflict with its broader animal welfare goals.

“Treating sick animals is consistent with the company’s long-standing commitment to animal health and welfare,” the company said in a written policy. “Engaging farmers, producers and veterinarians in the responsible use of antibiotics is key to achieving our vision of preserving antibiotic effectiveness for both humans and animals.”

McDonald’s shift away from antibiotics in its U.S. poultry supply chain, which began about three years ago, was a turning point for the industry given the fast-food chain’s enormous footprint and influence. McDonald’s also had announced it would buy only eggs raised in facilities that don’t confine chickens to small cages.

The U.S. Public Interest Research Group, which has spearheaded the antibiotics campaign, plans to focus consumers’ attention on McDonald’s, as it previously did on KFC’s owner, Yum Brands, which pledged to go antibiotic-free last year.

Consumer Reports said its polling shows that 60 percent of respondents would pay more for a burger if it were certified to come from cows that were not fed antibiotics. A vast majority of those polled also said they favored making companies reveal the names and quantities of antibiotics they use on animals.

About 1 in 5 drug-resistant infections in humans comes from food and animals, according to the CDC, which has pushed for more conservative policies on antibiotic prescription by both veterinarians and physicians. The CDC also found that 1 in 3 prescriptions by physicians is not needed.

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