Department of Medicine & Epidemiology, University of California-Davis, Davis, CA, USA
The expansion of antimicrobial-resistant bacterial populations that contribute to infections in small animal practice is of increasing concern to practitioners, academicians, and public health officials. The isolation of antimicrobial-resistant pathogens is associated with poorer patient outcomes, higher costs of treatment, and longer hospital stays. Some of these organisms are capable of infecting humans in contact with infected or colonized pets.
In the United States, several efforts have been made to try to reduce the overall quantity of antimicrobial drugs used and to help practitioners select the most appropriate antimicrobial drug for a particular infection. These efforts include the development of specific antimicrobial use guidelines for different infections by the International Society for Companion Animal Infectious Diseases (ISCAID),1,2 an American College of Veterinary Internal Medicine (ACVIM) consensus statement on antimicrobial use,3 and the assignment of an Antimicrobial Stewardship Taskforce for Companion Animal Practice to develop a stewardship program by the American Veterinary Medical Association (AVMA)4. It should be noted that some of the recommendations in these guidelines as well as the following notes include treatments that are off-label but are based on their known in vitro or in vivo activity against specific pathogens, as well as consideration of drug pharmacokinetics and adverse effects.
Activities of the AVMA task force have included:
1. Performing a survey of practitioners’ thoughts on antimicrobial use5
2. Performing a survey of laboratory practices relating to susceptibility testing
3. Developing a “do’s and don’ts” list for antimicrobial use
4. Supporting the development of local and regional antibiograms (An antibiogram provides information on the prevalence of resistance to certain antimicrobials in different populations of bacteria and can help guide practitioners’ decisions in selecting antimicrobials in their local area)
5. Providing a comparison of susceptibility test results across multiple veterinary teaching hospitals
6. Creation of a core stewardship document and associated educational materials and resources for practitioners and clients addressing appropriate antimicrobial use
What Is Antimicrobial Stewardship?
Antimicrobial stewardship is an effort to consider the benefit of antibiotic use to the patient while minimizing the development of antibiotic resistance and adverse effects in the patient from unnecessary therapy.
Antimicrobial Stewardship Programs in Human Health
In human hospitals, antimicrobial stewardship programs are multi-pronged efforts that include prescriber education, hospital formulary restriction; a requirement for antibiotic use approval for certain drugs before dispensing, streamlining, or de-escalating therapy; and computer-assisted programs that track use and antimicrobial resistance while providing clinician guidance. These programs have generally led to a reduction in the percentage of antibiotic-resistant organisms in hospitals, improved patient outcomes, and reduced costs.
Antimicrobial Stewardship Programs for Veterinary Practices
For smaller veterinary practices, an antimicrobial stewardship program can be much simpler. At a minimum, an antimicrobial stewardship program in a companion animal practice is simply an attitude toward antimicrobial use that effects reflection on their appropriate use. Whenever antibiotics are considered for a patient, alternative therapies should be considered and the necessity of antibiotic use should be substantiated. Then, for every antibiotic dispensed, the name, dose, route, and duration of treatment should be noted in the record, as well as the indication for the antibiotic. Of relevance, a study that looked at prescribing behavior by referring veterinarians for the year before patient referral to a veterinary teaching hospital in the United States found that for 197 of 549 cases examined, the duration of administration of antibiotics that had been prescribed was not noted in the record and that dose and route of administration were frequently not included.6 After 48–72 hours, a “timeout” should be taken (i.e., a period of reconsideration) to re-evaluate the need for an antibiotic; the dose, frequency, duration, and indication; and whether its de-escalation or discontinuation is indicated.
In summary, there needs to be an emphasis on not only reduced use of antimicrobials but also improved use of antimicrobials in order to battle the emergence of resistant bacterial populations. Veterinary practitioners are urged to become familiar with guidelines documents produced by ISCAID, ACVIM, and AVMA to guide rational antimicrobial therapy in companion animal practice.
1. Weese JS, Blondeau JM, Boothe D, et al. Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: antimicrobial guidelines working group of the international society for companion animal infectious diseases. Vet Med Int. 2011;2011:263768.
2. Hillier A, Lloyd DH, Weese JS, et al. Guidelines for the diagnosis and an antimicrobial therapy of canine superficial bacterial folliculitis (Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases). Vet Dermatol. 2014;25:163–175, e142–163.
3. Weese JS, Giguere S, Guardabassi L, et al. ACVIM consensus statement on therapeutic antimicrobial use in animals and antimicrobial resistance. J Vet Intern Med. 2015;29:487–498.
4. Bender JB, Barlam TF, Glore RP, et al. The AVMA Task Force for Antimicrobial Stewardship in Companion Animal Practice responds. J Am Vet Med Assoc. 2015;246:727–728.
5. Grayzel SE, Bender JB, Glore RP, et al. Understanding companion animal practitioners’ attitudes toward issues of antimicrobial stewardship. J Am Vet Med Assoc. 2015;247(8):883–884.
6. Baker SA, Van-Balen J, Lu B, et al. Antimicrobial drug use in dogs prior to admission to a veterinary teaching hospital. J Am Vet Med Assoc. 2012;241:210–217.