Effect of an antimicrobial stewardship intervention on the prescribing behaviours of companion animal veterinarians: A pre-post study

Efficacy of continuous education and determinants of antimicrobials prescription behavior in companion animal veterinarians from Quebec, Canada

Highly important antimicrobial use in veterinary companion animal medicine is frequent and in some cases unjustified. Establishing cautious and evidence-based prescription practices in veterinary companion animal medicine should be one of the key objectives of One Health antimicrobial stewardship initiatives. We aimed to (1) develop a training program on antimicrobial use in veterinary companion animal medicine in Quebec, Canada, (2) quantify the impact of this training on the use of highly important antimicrobials, and (3) identify the factors that could limit such an impact. A total of 54 veterinarians from 35 veterinary facilities participated in the study. Antimicrobials were identified from electronic medical records, prescription rates were calculated and a difference-in-differences estimation was used to compare prescription rates pre- and post-training in 2023, controlling for seasonal trends during the same period in 2022. Participating veterinarians prescribed on average 11.7 antimicrobial treatments per 100 consultations. Two thirds of the systemic antimicrobials prescribed by participants were antimicrobials of very high medical importance, according to Health Canada. Amoxicillin-clavulanic acid was the most often prescribed antimicrobial and accounted for approximately 22 % of all prescriptions. The training had a limited impact on overall prescription rates. However, a reduction of 55 % in prescription rate was observed for metronidazole, which is most often prescribed in canine patients with acute diarrhea. Interviews were conducted with 11 participating veterinarians to identify obstacles to the implementation of recommended prescription practices. The main obstacles identified were pet owner expectations, fear of therapeutic failure, lack of confidence in the recommendations and unavailability of therapeutic alternatives.

Antimicrobial Prescribing Practices Among Sri Lankan Veterinarians for Common Medical Conditions in Companion Animals

Veterinarians are essential in antimicrobial stewardship. Companion animal (CA) practitioners have recently received more attention. There are few relevant studies on CA antimicrobial prescribing practices in South Asia. A cross-sectional survey on the antimicrobial prescribing practices of Sri Lankan veterinarians associated with six common CA infections and factors associated with bacterial culture and antimicrobial susceptibility testing (AST) was conducted. A survey of antimicrobial prescribing practices was distributed via email or professional events among veterinarians treating CAs. There were 127 respondents. Most were from CA-only practices (63%); the remainder worked in government, mixed, or other practices. Based on the World Health Organization's criteria, 1.7% (13/783) of cases were treated with drugs authorized for human use only; 23.9% (187/783) were treated with highest-priority critically important antimicrobials; 4.7% (37/783) were treated with critically important antimicrobials, and 66.8% (523/783) were treated with highly important antimicrobials. The antimicrobial treatment of abscesses, skin, urinary, and ear infections was usually empirical, with only 12.4% (72/579) of cases utilizing AST to guide diagnosis and treatment. The use of AST was significantly associated with the type of antibiotic prescribed, the medical condition, the practice type, and continuing professional development, with the latter recognized as a pathway toward improved veterinary antimicrobial stewardship and the implementation of a One Health approach.

Antimicrobial stewardship: a definition with a One Health perspective

Antimicrobial stewardship (AMS) is a commonly advocated approach to address antimicrobial resistance. However, AMS is often defined in different ways depending on where it is applied, such that a range of definitions is now in use. These definitions may be functional and well-structured for a given context but are often ill-adapted for collaborative work, creating difficulties for intersectoral communication on AMS and complicating the design, implementation, and evaluation of AMS interventions from a One Health perspective. Using boundary object theory, we identified three key elements common to AMS in different settings in the human and animal health sectors-a sense of collective and temporal responsibility, flexibility in scale and scope, and contextual contingency. Based on these findings, we propose a definition for antimicrobial stewardship applicable to the human and animal health sectors, intended to facilitate intersectoral communication and cooperation. Further directions of this work could include the application of the definition to develop indicators for evaluating stewardship interventions and the extension of the definition to incorporate elements pertinent to plant and ecosystem health.

Effect of institutional antimicrobial stewardship guidelines on prescription of critically important antimicrobials for dogs and cats

BACKGROUND

Veterinary hospital antimicrobial stewardship (AMS) guidelines might help combat antimicrobial resistance (AMR).

OBJECTIVES

Determine the conditions and types of infection for which antimicrobial drugs (AMDs) deemed critically important (CIA) by the World Health Organization (WHO) were prescribed and assess the effect of hospital AMS guidelines on adherence to International Society for Companion Animal Infectious Diseases published guidelines for the treatment of superficial bacterial folliculitis, respiratory tract disease and urinary tract infection in these cases.

ANIMALS

Dogs and cats managed at an academic veterinary hospital from 1/21 to 6/21 and 9/21 to 6/22.

METHODS

Prescriptions of cephalosporins (third or fourth generation), glycopeptides, macrolides/ketolides, polymyxins, and quinolones were identified. Data on culture and susceptibility (C/S) testing and previous AMD exposure were collected. Frequencies were compared between time periods using Fisher's exact test with Bonferroni corrections.

RESULTS

In animals prescribed ≥1 WHO-CIA AMD, fluoroquinolones were the most frequently prescribed WHO-CIA class in dogs (567/1724, 32.9%) and cats (192/450, 42.7%). No animals were prescribed carbapenems, dihydrofolate reductase inhibitors/sulfonamides, or polymyxins. No cats were prescribed aminoglycosides or amphenicols. Institutional guidelines were followed in 57.8% (324/561) cases. The most frequent causes of nonadherence were failure to perform C/S testing 46.0% (109/237) and unnecessary use of a higher-tier AMD 43.0% (102/237). Bacterial C/S testing was more frequently performed after AMS guideline institution (59.7% vs. 46.8%, P = 0.0006).

CONCLUSIONS AND CLINICAL IMPORTANCE

Adherence to published guidelines remained poor despite an increase in C/S testing. There were no changes in the frequencies of confirmed infections, positive cultures or AMD resistance between time periods.

Patient weight has diverse effects on the prescribing of different antibiotics to dogs

Introduction

Various factors including body weight-associated treatment cost may influence the probability of dispensing antibiotics to dogs in first-opinion practice, but their effect on specific drug choice remains unclear.

Methods

Multiple membership regression modeling was used to investigate the probability of dispensing 12 different antibiotics to dogs of different weights in the context of various disease presentations, using anonymized data obtained from electronic health records of 18 clinics between 2020 and 2022. Data from 14,259 dogs were analyzed.

Results

Treatment choice varied significantly with animal weight. Higher body weight was associated with an increased likelihood of dispensing lower cost antimicrobials such as amoxicillin and trimethoprim sulfonamide, while use of higher cost antimicrobials such as cefovecin was strongly biased to smaller animals. However, these effects were limited when restricted treatment options were available for the target condition.

Conclusion

This work demonstrates that anticipated financial costs may result in different treatment choices for canine patients depending on their body weight. Further work is needed to understand the impact of financial pressures on veterinarians' treatment choices, and the implications for the optimization of antimicrobial stewardship in first opinion practice.

A multinational survey of companion animal veterinary clinicians: How can antimicrobial stewardship guidelines be optimised for the target stakeholder?

Antimicrobial stewardship initiatives are widely regarded as a cornerstone for ameliorating the global health impact of antimicrobial resistance. Within companion animal health, such efforts have largely focused on development and dissemination of antimicrobial stewardship guidelines (ASGs). However, there have been few attempts to understand veterinarian attitudes towards and knowledge of ASGs or to determine how awareness regarding ASGs might best be increased. An online survey regarding ASGs was formulated for veterinarians who treat companion animals. The survey was distributed across 46 European and associated countries between 12 January and 30 June, 2022. In total, 2271 surveys were completed, with 64.9% of respondents (n = 1474) reporting awareness and usage of at least one ASG. Respondents from countries with greater awareness of ASGs tended to report more appropriate use of antimicrobials (Spearman's rank coefficient = 0.6084, P ≤ 0.001), with respondents from countries with country-specific ASGs tending to score highest across both awareness and appropriate use domains. Respondents prioritised guidance around antimicrobial choice (82.0%, n = 1863), duration of treatment (66.0%, n = 1499), and dosage (51.9%, n = 1179) for inclusion in future ASGs, with 78.0% (n = 1776) of respondents preferring ASGs to be integrated into their patient management system. Awareness of ASGs and their use in companion animal veterinary practice appears to be greater than previously reported, with respondents tending to report antimicrobial prescription decision making broadly in line with current clinical recommendations. However, further initiatives aimed at maximising accessibility to ASGs both within countries and individual veterinary practices are recommended.

Examining the Veterinary Electronic Antimicrobial Prescriptions for Dogs and Cats in the Campania Region, Italy: Corrective Strategies Are Imperative

Companion animals are increasingly being recognised as important contributors to the spread of antimicrobial-resistant bacteria. The present work aimed to measure the antimicrobial drug prescribing in dogs and cats in the Campania Region, Italy by analysing the Veterinary Electronic Prescriptions (VEPs) between 2019 and 2020. The medical records associated with antimicrobial drug prescriptions were collected according to the drug administration (systemic or topical) and the rationale for the treatment chosen. In the period under investigation, 166,879 drugs were prescribed of which 129,116 (73.4%) were antimicrobial. A total of 83,965 (65%) antibiotics were prescribed to dogs, 40,477 (31.4%) to cats, and 4674 (3.6%) to other companion animals. In dogs, 90.5% of VEPs prescribed for systemic treatment included an antimicrobial Critically Important or Highly Important or Important for human medicine (WHO, 2018). The most widely prescribed class was fluoroquinolones. The antimicrobials prescribed were mainly metronidazole-spiramycin (29.7%), amoxicillin-clavulanic (19.6%), enrofloxacin and cephalexin in dogs (16.5%) and enrofloxacin (22.6%) and amoxicillin-clavulanic acid (21.4%) in cats. Based on the results, the widespread use of broad-spectrum antimicrobials and the use of molecules for which limitations should be observed according to the EMA guidelines has emerged.

Disturbance Ecology Meets Bovine Tuberculosis (bTB) Epidemiology: A Before-and-After Study on the Association between Forest Clearfelling and bTB Herd Risk in Cattle Herds

Disturbance ecology refers to the study of discrete processes that disrupt the structure or dynamics of an ecosystem. Such processes can, therefore, affect wildlife species ecology, including those that are important pathogen hosts. We report on an observational before-and-after study on the association between forest clearfelling and bovine tuberculosis (bTB) herd risk in cattle herds, an episystem where badgers (Meles meles) are the primary wildlife spillover host. The study design compared herd bTB breakdown risk for a period of 1 year prior to and after exposure to clearfelling across Ireland at sites cut in 2015-2017. The percent of herds positive rose from 3.47% prior to clearfelling to 4.08% after exposure. After controlling for confounders (e.g., herd size, herd type), we found that cattle herds significantly increased their odds of experiencing a bTB breakdown by 1.2-times (95%CIs: 1.07-1.36) up to 1 year after a clearfell risk period. Disturbance ecology of wildlife reservoirs is an understudied area with regards to shared endemic pathogens. Epidemiological observational studies are the first step in building an evidence base to assess the impact of such disturbance events; however, such studies are limited in inferring the mechanism for any changes in risk observed. The current cohort study suggested an association between clearfelling and bTB risk, which we speculate could relate to wildlife disturbance affecting pathogen spillback to cattle, though the study design precludes causal inference. Further studies are required. However, ultimately, integration of epidemiology with wildlife ecology will be important for understanding the underlying mechanisms involved, and to derive suitable effective management proposals, if required.