1 hour challenge: Antimicrobial stewardship in companion animal practice
As part of my ACVPM training, I am required to pump out a number of essays (at a rate of 1 per hour). To try and facilitate this, I am going to adhere to getting a frequent blog on various subjects on veterinary careers to get into the zone. Feel free to comment on our Facebook page or whatever pathways you can reach me. At some point, we’ll open up the comments section in this website. The main aim is to pump out a one-pager that is concise and engaging. So what better way than to start than something that is quite close to my heart (at least in clinical practice). I’ll be setting these challenges myself, but if anyone has any requests, I’ll be happy to take them up.¬†
Challenge: Antimicrobial stewardship is quickly being adopted within human hospitals to encourage judicious use of antibiotics. Veterinary hospitals and clinics have been a¬†little slower in the uptake. The Journal of Internal Veterinary Medicine has recently released its guidelines on Antimicrobial use for the treatment of respiratory tract disease in dogs and cats. The has been produced by the International Society for Companion Animal Infectious Diseases.¬†
The Australian Veterinary Association has a selection of antimicrobial resources including the Australasian Infectious Diseases Advisory Panel (AIDAP), safe handling of antimicrobials and animals, a list of antimicrobials for veterinary use that prioritises according to human health and guidelines for personal biosecurity. The Australian Department of Agriculture and Water Resources has collaborated with the Department of Health to establish a One Health National Antimicrobial Resistance Strategy (2015-2019).
Your assignment is to¬†write a letter to the editor¬†targeting small animal veterinarians to encourage them to review their use of antimicrobials, with a focus on the treatment of respiratory disease as well as encourage the establishment of antimicrobial stewardship in companion animal hospitals and clinics.¬†
Antimicrobial Stewardship in companion animal practice – no sneezing matter
In early 2017, the Journal of Internal Veterinary Medicine released its latest guidelines for antimicrobial use in the treatment of respiratory tract diseases in dogs and cats. This was a collaborative effort from the Antimicrobial working group from the International Society for Companion Animal Infectious Diseases. Whilst each medical case seen by a veterinarian should be approached in a first principles manner,¬†using all diagnostic tools available including culture and sensitivity tests, guidelines are critical for veterinarians to be up to date with recommended empirical therapies.
I would recommend every companion animal veterinarian as well as mixed practitioners to review these latest guidelines and assess whether the recommendations match with the prescribing habits of your clinic. Do your habits or the habits of your associate veterinarians match with these guidelines?
Antimicrobial resistance is a critical issue for the health of not only our patients but also human health as well.
Just recently the WHO published a list of 12 bacterial species that were regarded as antibiotic-resistant “priority pathogens”:
The WHO list:
Priority 1: Critical
1.¬†Acinetobacter baumannii, carbapenem-resistant
2.¬†Pseudomonas aeruginosa, carbapenem-resistant
3.¬†Enterobacteriaceae, carbapenem-resistant, ESBL-producing
Priority 2: High
4.¬†Enterococcus faecium, vancomycin-resistant
5.¬†Staphylococcus aureus, methicillin-resistant, vancomycin-intermediate and resistant
6.¬†Helicobacter pylori, clarithromycin-resistant
8. Salmonellae, fluoroquinolone-resistant
9.¬†Neisseria gonorrhoeae, cephalosporin-resistant, fluoroquinolone-resistant
Priority 3: Medium
10.¬†Streptococcus pneumoniae, penicillin-non-susceptible
11.¬†Haemophilus influenzae, ampicillin-resistant
In clinical veterinary practice we may encounter a number of these bacterial species¬†in our own patients – either as pathogens¬†that may be explicitly affecting our patients, or as commensals that are existing as the natural flora. Yet how many of them are identified with the resistance profiles that are described by the WHO? There are a few papers out there, however they do carry a bias due to often being produced by specialist centres or universities. In day-to-day, companion animal general practice, the¬†capacity for bacterial resistance surveillance is reliant on the finances of our clients. My personal preference is to always offer a culture and sensitivity profile on the majority of each suspect/confirmed bacterial infection. Yet, when presented with an estimate that often ranges between $100-200, a significant number of clients will baulk and request for empirical therapy. And this is the worth of the above-mentioned guidelines.
Moving to a clinic-wide approach, the release of the ISCAID guidelines on respiratory tract infections should serve as a talking point within the veterinary team to ensure that there is consistency with how empirical antibiotics are prescribed. Such discussions could serve as a perfect launching point to raise the subject of antimicrobial stewardship within the clinic/hospital.
Within the US human hospitals, antimicrobial stewardship seek to improve antibiotic use with goals to optimise appropriate antibiotic selection, dose and duration of therapy. Often the stewardship team is made up of the following individuals:
- A lead physician
- A pharmacist
- Infection prevention and control¬†staff
- Laboratory staff
- and Information Technology representatives
Given the size of many veterinary clinics, what can be done by our practitioners?
- Encourage a culture of stewardship amongst the whole team – include the veterinarians, nurses, practice managers and reception staff.
- Establish a champion of stewardship within the clinic.
- Establish clinic policies and protocols – differentiate between the¬†non-antibiotic diseases that can be managed with supportive therapy vs those that will require appropriate antibiotics. Various tools are available to do that including the in-clinic PROTECT poster
- Promote a culture of Infection, Prevention and Control (IPC). Place a veterinary nurse in charge of IPC and establish metrics to identify areas for improvement and success.
- Establish appropriate in-clinic surveillance, monitoring and feedback systems to ensure that the stewardship program is operating well. Some metrics that could be used may include clinic antibiograms (these can be sourced from your diagnostic laboratory), the frequency of culture and sensitivity submissions and clinician notes on the selection process.
Over the coming years, more formalised stewardship programs will be released. This is the way of the future for veterinary practice and it is critical that we prepare to play our role in preventing the rise of antibiotic-resistant bacteria.
Ok, that’s done… 1hr and 10min… Granted I was writing this whilst plugging in links and checking my work. Probably not something I can get away with in the exam. I think next time, I’ll write and then for the sake of the blog, I’ll populate it with links. ¬†Reviewing this, I think I lost my way in the middle there, probably didn’t need the WHO list or a ramble about costs of culturing. Plus, I probably should have established a shorthand for some words, for example, C&S for culture and sensitivity. The inclusion of the hospital team make up was also superfluous unless I provided more details on the roles and how they operated together.¬†
For further details, and if you are an AVA member, feel free to log into the website and go to this link to watch a webinar the AVPH ran at the end of 2016.