Antimicrobial stewardship in small animal veterinary practice: from theory to practice

Overview on antimicrobial prescription habits in cats at different clinical services of the Veterinary Teaching Hospital of Parma

Antimicrobials are frequently administered for therapeutic and prophylactic purposes in companion animals. Their use is closely monitored as related to antimicrobial resistance both in human and veterinary medicine. This retrospective study aimed to describe antimicrobial prescription by different clinical services in cats visited at the Veterinary Teaching Hospital of the University of Parma (VTH-UP) between January 2021 and December 2023. The antibiotic classes were divided according to the categorization of antibiotics adopted by the European Medicines Agency (EMA); EMA categories A and B were classified as Critically Important Antimicrobials (CIAs). Overall, 43.8%, 35.0%, and 35.0% of visited cats received an antimicrobial prescription in 2021, 2022, and 2023, respectively. Most of the prescriptions were Category C "Caution" antibiotics (49.0%, 54.0%, and 55.0% in 2021, 2022, and 2023, respectively). Category B "restrict" antibiotics represented 13.0%, 12.0%, and 11.0% of the total antimicrobials prescribed in 2021, 2022, and 2023, respectively. Penicillins associated with beta-lactam inhibitors were the most common antibiotics prescribed each year at the VTH-UP (32.0%, 31.3%, and 23.7% of total prescriptions in 2021, 2022, and 2023, respectively). Among CIAs, quinolones were the most common, with 12.1%, 11.2%, and 10.1% of the total prescriptions in 2021, 2022, and 2023, respectively. Culture and sensitivity tests (CSTs) were performed for 18.1% (85/470), 17.4% (73/420), and 23.0% (96/417) of the total prescriptions in 2021, 2022, and 2023, respectively. Considering only CIA prescriptions, CSTs were performed in 70.0% (49/70), 66.7% (38/57), and 70.9% (39/55) of CSTs in 2021, 2022, and 2023, respectively. Antimicrobial use varies considerably depending on the clinical service. The use of "restrict" antibiotics was very limited, and attention should be given to therapeutic and prophylactic use.

Non-invasive physical plasma improves conventional wound management of cut and bite wounds in wild European hedgehogs

Non-invasive physical plasma (NIPP) has been used effectively for wound healing in human medicine for over two decades. The advantages are that NIPP has few side effects, is painless and gentle on the tissue. The therapeutic effect is mediated by reactive oxygen species (ROS). Based on the biomedical effects known to date, it can be assumed that NIPP can also be used for wound treatment in non-human mammals. In this prospective, non-randomized monocentric clinical trial, 43 European hedgehogs with cut and bite wounds were treated with conventional wound management (CWM: 21 patients) and compared with 22 patients with CWM plus NIPP treatment (CWM + NIPP). Under NIPP treatment, patients showed no signs of pain, stress or discomfort, even after several applications. In 76% of CWM + NIPP patients, three or four NIPP applications were sufficient. In patients in the CWM + NIPP group, wound treatment was completed statistically significantly 6 d earlier (CWM: 19.0 d versus CWM + NIPP: 13.2 d; p = 0.0008). This wildlife clinical trial demonstrates that NIPP can be used to improve wound healing in wild European hedgehogs. It is conceivable that NIPP therapy could also lead to positive effects in other injured wild animals, domestic animals or livestock.

Assessing Illinois companion animal veterinarians' antimicrobial prescription practices and the factors that influence their decisions when treating bacterial infections in dogs and cats

AIMS

Judicious antimicrobial use in companion animal practice is critical for maintaining the effectiveness of antimicrobial agents against bacterial infections and reducing the selection of antimicrobial-resistant bacteria. This study aimed to provide insights into companion animal veterinarians' antimicrobial treatment recommendations for common bacterial infections in dogs and cats and describe the factors influencing their prescription choices.

METHODS AND RESULTS

An online survey using QualtricsXM® software was administered between September and November 2022 to companion animal veterinarians who were Illinois State Veterinary Medical Association members. Descriptive and text analyses were conducted to assess the participants' responses. A total of 78 surveys were included in the analysis. Skin infections were ranked as the most common bacterial infections for which veterinarians prescribed antimicrobial agents, followed by ear, urinary tract, respiratory, and enteric infections. The severity of clinical symptoms and the results of bacterial culture and susceptibility tests were the most influential factors for veterinarians when making antimicrobial prescription choices. Veterinarians were aware of the current antimicrobial prescription guideline recommendations when prescribing antimicrobials empirically to nine hypothetical scenarios of bacterial infections. According to the results of the text analysis that assessed veterinarians' responses to an open-ended question, regarding their challenges when prescribing antimicrobial agents, the pairwise correlation of word frequencies within each response showed the highest correlations between the words 'owner' and 'compliance', 'administration' and 'route', 'cost' and 'culture', and 'patients' and 'acceptance'.

CONCLUSIONS

The study results can support animal health stakeholders in the development of antimicrobial stewardship programmes to promote appropriate antimicrobial use and limit the emergence of antimicrobial resistance.

Veterinary support staff knowledge and perceptions of antimicrobial drug use, resistance, and stewardship in the United States

Antimicrobial drug use (AMU) in veterinary medicine may contribute to antimicrobial resistant (AMR) infections in both animals and people. Efforts to improve AMU in companion animal medicine are underway and should include all members of the veterinary team, including veterinary support staff. Our objective was to describe knowledge and attitudes regarding AMU, AMR, and antimicrobial stewardship (AMS) in companion animal medicine among veterinary support staff professionals in the United States using an anonymous, online questionnaire. Additionally, we sought to explore veterinary support staff perceptions of their role in the antimicrobial drug (AMD) prescribing process. Veterinary technicians, nurses, assistants, client care representatives, and hospital managers (n = 337) considered AMR a global concern (83.4%), and 40% reported receiving AMR education from their employer. Few (18.3%) were aware of AMS, with only 6.4% indicating that their clinic had an AMS program. Frequent involvement in the AMD prescribing process was reported (43.4%), but only 19.7% perceived involvement with AMS interventions. Approximately one-third of participants (34.9%) said that advice regarding the need for AMDs was routinely provided by staff to pet owners prior to veterinary consultation. Participants estimated that 82.6% of all AMD prescriptions were filled at the clinic as opposed to an outside pharmacy. Given their direct involvement in the AMD prescribing process and frequent interactions with pet owners, AMS should be emphasized to all veterinary staff. Involving support staff in AMS interventions is necessary to improve AMU in companion animal medicine.

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.

Successful management of pulmonary edema secondary to accidental electrocution in a young dog

BACKGROUND

Human records describe pulmonary edema as a life-threatening complication of electric shock. Successful management requires prompt recognition and intensive care. However, in companion animals, electrocutions are rarely reported, even though domestic environments are full of electrical devices and there is always the possibility of accidental injury. Therefore, it is important for veterinarians to know more about this condition in order to achieve successful patient outcomes.

CASE PRESENTATION

A 3-month-old male Labrador Retriever was presented with a history of transient loss of consciousness after chewing on a household electrical cord. On admission, the puppy showed an orthopneic position with moderate respiratory distress. Supplemental oxygen via nasal catheter was provided, but the patient showed marked worsening of respiratory status. Point-of-care ultrasound exams suggested neurogenic pulmonary edema due to electrical shock close to the central nervous system and increased B-lines without evidence of cardiac abnormalities. Mechanical ventilation of the patient was initiated using volume-controlled mode with a tidal volume of 9 to 15 ml/kg until reaching an end-tidal carbon dioxide ≤ 40 mm Hg, followed by a stepwise lung-recruitment maneuver in pressure-controlled mode with increases of the peak inspiratory pressure (15 to 20 cm H2O) and positive end-expiratory pressure (3 to 10 cm H2O) for 30 min, and return to volume-controlled mode with a tidal volume of 15 ml/kg until reaching a peripheral oxygen saturation ≥ 96%. Weaning from the ventilator was achieved in six hours, and the patient was discharged two days after admission without neurological or respiratory deficits.

CONCLUSIONS

We present a rather unusual case of a neurogenic pulmonary edema subsequent to accidental electrocution in a dog. Timely diagnosis by ultrasound and mechanical ventilation settings are described. Our case highlights that pulmonary edema should be considered a potentially life-threatening complication of electrical shock in small animal emergency and critical care medicine.

Six-Year Prescription Pattern of Antimicrobial Use in Cats at the Veterinary Teaching Hospital of the University of Pisa

The use of antimicrobials has greatly contributed to improving animal health. However, their inappropriate use reduces their effectiveness in treating bacterial infections and contributes to the selection of resistance. This study aimed to retrospectively evaluate the six-year pattern (2017-2022) of antimicrobial use in cats visiting the Veterinary Teaching Hospital (VTH) of the University of Pisa (Italy). The total number of prescribed antimicrobials, the number of animals for which an antimicrobial was prescribed, and the total number of antimicrobial prescriptions showed a significant time trend decrease during the study period, except for the fixed-dose combinations. The most frequently prescribed antimicrobials were amoxicillin-clavulanic acid (Synulox) (39.1%) followed by enrofloxacin (29.8%). These antimicrobials were mostly prescribed to treat infections affecting the genitourinary tract (~30%), followed by the gastrointestinal tract, skin, and respiratory system affections. Antimicrobials in empirical associations represented 13.0% of the total antimicrobial prescriptions, and the combination of amoxicillin-clavulanic acid (Synulox) with enrofloxacin accounted for the majority. The oral route represented the main route of administration of prescribed antimicrobials, followed by parenteral and topical ones. Amoxicillin-clavulanic acid (Synulox) (37.2%), ceftriaxone (2.7%), and tobramycin (2.8%) were the most prescribed antimicrobials for the oral, parenteral, and topical routes, respectively. Antimicrobial prescriptions complied with prudent use recommendations in terms of availability of diagnosis, respect to the dose range, duration of treatment, and the use of medicinal products approved for the species. On the contrary, antimicrobial susceptibility tests were used infrequently (5.2%), lacking compliance with the existing guidelines observed in companion animal practice. Overall, additional interventions are required not only to improve the responsible use of antimicrobials in our feline practice but also to implement antimicrobial stewardship programs, enhancing diagnostics such as culture and sensitivity testing in the future.

Validation, visibility, vagueness and variation: A qualitative assessment of existing veterinary guidelines for antimicrobial use in cattle and sheep in the UK

Antimicrobials are essential in veterinary medicine to treat and control bacterial disease in animals. Their prudent use in food-producing animals has been encouraged to reduce the development and spread of antimicrobial resistance. National and international guidelines for responsible antimicrobial use have been developed as tools to guide and rationalise antimicrobial prescribing decisions by veterinarians and usage decisions by farmers. Yet, there is little understanding of whether these existing guidelines are fit for purpose. Accordingly, this study rigorously assessed 128 veterinary guidelines for antimicrobial use in ruminants in the UK, following established qualitative methodologies. Findings revealed four pertinent themes: validation of the veterinarian as the prescriber, visibility of responsible use realities, vagueness in interpretation and variation in directing behaviour. These themes encompassed the roles and responsibilities of the veterinarian and the realities of prescribing scenarios, alongside concerns relating to the specificity within and variation between guidelines. Resultant recommendations to inform and support the future development of guidelines include establishing species-specific and disease-specific guidelines, expanding guidelines to include disease prevention measures, including definitions to resolve vagueness and promoting congruence in interpretation, encouraging the development of practice-level guidelines to endorse collaboration and ownership, and fostering active working between stakeholders to align priorities and messaging.

Does Nitrofurantoin Improve the Portfolio of Vets against Resistant Bacteria in Companion Animals?

In clinical practice in dogs and cats, antimicrobials are frequently used, sometimes overused or misused, increasing antimicrobial resistance (AMR). In order to limit the phenomenon, laws have been enacted and guidelines for prudent and rational use of antibiotics have been developed. Interestingly, old molecules such as nitrofurantoin could be used to achieve therapeutic success and overcome AMR. To better understand the suitability of this molecule in veterinary medicine, the authors performed a revision of the literature, searching on PubMed and entering the following keywords: nitrofurantoin, veterinary medicine, dog, and cat connected by the Boolean operator "and", without restrictions on the date of publication. Thirty papers were finally selected. It is possible to appreciate that papers dealing with nitrofurantoin have been written from the early 1960s to the middle of the 1970s, and then a long period passed without publications. Only at the beginning of the new century, nitrofurantoin was included or was sometimes the focus of papers dealing with its efficacy in veterinary medicine, mainly in the treatment of urinary tract infections. One recent paper dealt with pharmacokinetic features, and none was dedicated to pharmacokinetic/pharmacodynamic integration or modeling. Nitrofurantoin appears to be still effective against several pathogens that rarely develop resistance to this molecule.

Knowledge and Attitudes of Small Animal Veterinarians on Antimicrobial Use Practices Impacting the Selection of Antimicrobial Resistance in Dogs and Cats in Illinois, United States: A Spatial Epidemiological Approach

Inappropriate antimicrobial use in animals and humans has been associated with the emergence of antimicrobial resistance, which has become a global public health concern. Veterinarians’ practice locations and their knowledge and opinions on antimicrobial resistance may influence their antimicrobial prescription practices, which could impact the emergence of antimicrobial-resistant bacteria. This study used a spatial modeling approach to identify areas where veterinarians are knowledgeable about factors that impact the selection of antimicrobial resistance. In addition, we sought to identify regions with higher- and lower-than-expected response rates to our survey to aid future antimicrobial stewardship efforts. A total of 83 veterinarians who treated dogs and/or cats across 34 different Illinois counties responded to our online survey. Most of the responders (90.9%) considered that insufficient doses or duration of antibiotic treatments contribute the most to the selection of antimicrobial resistance. A high proportion of veterinarians (78.7%) attended educational programs on antimicrobial use and resistance; however, only 46.2% were knowledgeable about the current antimicrobial resistance profiles of prevalent bacteria in their area. A mean knowledge score for each county was calculated based on the responses of veterinarians to the survey questions. Local Moran’s I statistic was used to identify counties with high and low knowledge scores. A high knowledge score area in the northeast region and a low knowledge score area in the southeast of Illinois were identified. Using scan statistics with a Poisson model that accounted for the estimated number of veterinarians in a county, a higher-than-expected response rate area was identified in central-east Illinois and a lower-than-expected area in the northeast. This study showed the effectiveness of using geographic analysis and spatial statistics to identify locations where future antimicrobial stewardship programs should focus.

The Use of Antibiotics and Antimicrobial Resistance in Veterinary Medicine, a Complex Phenomenon: A Narrative Review

As warned by Sir Alexander Fleming in his Nobel Prize address: “the use of antimicrobials can, and will, lead to resistance”. Antimicrobial resistance (AMR) has recently increased due to the overuse and misuse of antibiotics, and their use in animals (food-producing and companion) has also resulted in the selection and transmission of resistant bacteria. The epidemiology of resistance is complex, and factors other than the overall quantity of antibiotics consumed may influence it. Nowadays, AMR has a serious impact on society, both economically and in terms of healthcare. This narrative review aimed to provide a scenario of the state of the AMR phenomenon in veterinary medicine related to the use of antibiotics in different animal species; the impact that it can have on animals, as well as humans and the environment, was considered. Providing some particular instances, the authors tried to explain the vastness of the phenomenon of AMR in veterinary medicine due to many and diverse aspects that cannot always be controlled. The veterinarian is the main reference point here and has a high responsibility towards the human–animal–environment triad. Sharing such a burden with human medicine and cooperating together for the same purpose (fighting and containing AMR) represents an effective example of the application of the One Health approach.

[Antibiotic resistance - what can be done? A review]

Serious work is being carried out in the world in the field of combating antibiotic resistance: reducing the prescribing of antibiotics, banning the use of antibiotics as stimulators of animal growth, improving infection control. Antimicrobial resistance is systematically monitored not only in every medical center, but also at the national level. The collected data is successfully used to implement local and national recommendations on the optimal use of antibiotics.

"If You Do Not Take the Medicine and Complete the Dose…It Could Cause You More Trouble": Bringing Awareness, Local Knowledge and Experience into Antimicrobial Stewardship in Tanzania

Antimicrobial resistance (AMR) is a global health issue disproportionately affecting low- and middle-income countries. In Tanzania, multi-drug-resistant bacteria (MDR) are highly prevalent in clinical and community settings, inhibiting effective treatment and recovery from infection. The burden of AMR can be alleviated if antimicrobial stewardship (AMS) programs are coordinated and incorporate local knowledge and systemic factors. AMS includes the education of health providers to optimise antimicrobial use to improve patient outcomes while minimising AMR risks. For programmes to succeed, it is essential to understand not just the awareness of and receptiveness to AMR education, but also the opportunities and challenges facing health professionals. We conducted in-depth interviews (n = 44) with animal and human health providers in rural northern Tanzania in order to understand their experiences around AMR. In doing so, we aimed to assess the contextual factors surrounding their practices that might enable or impede the translation of knowledge into action. Specifically, we explored their motivations, training, understanding of infections and AMR, and constraints in daily practice. While providers were motivated in supporting their communities, clear issues emerged regarding training and understanding of AMR. Community health workers and retail drug dispensers exhibited the most variation in training. Inconsistencies in understandings of AMR and its drivers were apparent. Providers cited the actions of patients and other providers as contributing to AMR, perpetuating narratives of blame. Challenges related to AMR included infrastructural constraints, such as a lack of diagnostic testing. While health and AMR-specific training would be beneficial to address awareness, equally important, if not more critical, is tackling the challenges providers face in turning knowledge into action.

An Overview of Antimicrobial Stewardship Optimization: The Use of Antibiotics in Humans and Animals to Prevent Resistance

Antimicrobials are a type of agent widely used to prevent various microbial infections in humans and animals. Antimicrobial resistance is a major cause of clinical antimicrobial therapy failure, and it has become a major public health concern around the world. Increasing the development of multiple antimicrobials has become available for humans and animals with no appropriate guidance. As a result, inappropriate use of antimicrobials has significantly produced antimicrobial resistance. However, an increasing number of infections such as sepsis are untreatable due to this antimicrobial resistance. In either case, life-saving drugs are rendered ineffective in most cases. The actual causes of antimicrobial resistance are complex and versatile. A lack of adequate health services, unoptimized use of antimicrobials in humans and animals, poor water and sanitation systems, wide gaps in access and research and development in healthcare technologies, and environmental pollution have vital impacts on antimicrobial resistance. This current review will highlight the natural history and basics of the development of antimicrobials, the relationship between antimicrobial use in humans and antimicrobial use in animals, the simplistic pathways, and mechanisms of antimicrobial resistance, and how to control the spread of this resistance.

Carbapenem prescribing at a veterinary teaching hospital before an outbreak of carbapenem-resistant Escherichia coli

OBJECTIVES

Carbapenems are a critically important class of antimicrobials used to treat infections caused by multi-drug-resistant bacteria. Following an outbreak of a carbapenemase (NDM-5)-producing strain of Escherichia coli at our veterinary institution, we opted to describe the use of carbapenems in our institution and the role that drug contraindications in patients may have played when culture and susceptibility testing identified alternative drug options.

MATERIALS AND METHODS

Medical record reviews of all cases where a carbapenem was prescribed were performed, and indications for use, timing of prescribing relative to culture and susceptibility reports, and alternative possible antimicrobial treatments were extracted. Contraindications to alternative antimicrobials were also documented.

RESULTS

Carbapenems were prescribed infrequently: from 2013 to 2018, they accounted for 0.47% of all antimicrobial prescriptions and were administered to 108 of 56,776 (0.2%) patients seen at our institution. They were prescribed empirically in slightly more than half of the patients (57.6%). Among cases where a carbapenem was prescribed after culture and susceptibility results were available, alternative antimicrobials could have been used in 68.3% of cases.

CLINICAL SIGNIFICANCE

Variability in use of these drugs within an institution highlights the need to develop well-defined use guidelines, including when to use these drugs empirically and how to safely de-escalate or choose alternative drugs guided by culture and susceptibility results.

Implications of Veterinary Medicine in the comprehension and stewardship of antimicrobial resistance phenomenon. From the origin till nowadays

•

Antibiotic resistance is a well-known phenomenon with several implications

•

The contribution of Veterinary Medicine is underestimated.

•

It was believed that only livestock was responsible for antibiotic resistance.

•

Companion animals, wild animals and environment are more involved than estimated.

•

Educational tools for public and more veterinary specialists are needed.

Antimicrobial resistance (AMR) is defined by the entire scientific community as the major threat for human health and it is responsible for an increase in morbidity and mortality rates. The reasons behind this phenomenon are complex and the solution is achievable only considering the One Health approach, that encompasses the integration and implementation of human health, veterinary medicine and environmental status. Authors aimed to write this review to summarize to readers the three milestones of One-Health, underlying the most important topics in which veterinary medicine is mostly involved. Therefore, a short introduction about the history of AMR in veterinary medicine is provided, then more detailed aspects about the impact of AMR related to pets, food producing animals, wild animals and environment are discussed. Finally, some critical aspects about current and future issues are considered.

Prevalence of coagulase-positive methicillin-resistant Staphylococcus aureus and Staphylococcus pseudintermedius in dogs in Bangladesh

Background

The emergence of methicillin‐resistant Staphylococcus aureus (MRSA) and methicillin‐resistant Staphylococcus pseudintermedius (MRSP) have a significant health impact on people with direct or supportive occupations in veterinary medicine including veterinarians, animal handlers, laboratory personnel and pet owners.

Objectives

This cross‐sectional survey was conducted to determine the prevalence of and risk factors for S. aureus, S. pseudintermedius, MRSA and MRSP in dogs in Bangladesh.

Methods

A total of 358 swab samples were collected from different body sites of 150 dogs attending a university teaching veterinary hospital between January and June 2018. Standard bacteriological procedures were followed to isolate Staphylococcus, and identification was confirmed to the species level by PCR to detect the nuc gene. MRSA and MRSP were confirmed by the presence of the mecA gene.

Results

The prevalence of coagulase‐positive S. aureus and S. pseudintermedius in dogs were 16% and 45.3%, respectively. S. aureus and S. pseudintermedius isolates displayed the highest resistance against nalidixic acid (95.2% and 91%, respectively) and erythromycin (89.3% and 84.7%, respectively). Notably, all the staphylococcal isolates showed resistance to ≥3 antimicrobial classes. The prevalence of MRSA and MRSP in dogs was 8.7% and 6%, respectively. Multivariable logistic regression analysis identified the following variables as risk factors for MRSA colonisation in dogs: dogs with dermatitis (odds ratio [OR], 12.24, 95% CI: 3.12–57.33; p < 0.001) and history of antibiotic use (OR 8.73, 95% CI: 2.23–43.10; p < 0.001). Presence of otitis (OR 14.22; 95% CI: 1.64–103.58; p = 0.008) and oral lesions (OR 9.48, 95% CI: 1.14–64.82; p = 0.002) were identified as the significant risk factors for the carriage of MRSP.

Conclusions

The circulation of multidrug‐resistant S. aureus and S. pseudintermedius is a serious concern to dogs and humans. To our knowledge, this is the first report of S. pseudintermedius and MRSP affecting dogs in Bangladesh.

Assessment of Antibiotic Stewardship Components of Certification Programs in US Animal Agriculture Using the Antibiotic Stewardship Assessment Tool

Antibiotic stewardship programs (ASPs) are meant to promote appropriate use of antibiotics and to help maintain the effectiveness of antibiotics. For the United States (US) animal agriculture industry, multiple resources exist to guide antibiotic stewardship practices. Animal management certification programs can promote on-farm compliance with antibiotic stewardship through the incentive of achieving certification. The goal of this project was to determine whether the stewardship-related requirements of US-based certification programs align with identified core components of antibiotic stewardship in food animal agriculture using the Antibiotic Stewardship Assessment Tool (ASAT). We applied the ASAT to publicly available information from four different US animal agriculture certification programs that incorporate some level of antibiotic stewardship. In part due to varying scopes, the programs demonstrated a great deal of variability in meeting the metrics of the ASAT, with one program meeting all the required metrics and the other three only meeting the metrics to varying degrees (ranging from 3 to 67%). We identified several areas as opportunities for enhancing and promoting ASP implementation on farms. The area with the most opportunity for improvement is evaluation. Evaluation can help ensure effective outcomes of stewardship practices and ensure accountability for following recommended antibiotic stewardship guidelines. While evaluation currently may fall outside the scope of some certification programs, the incorporation of more specific antibiotic stewardship evaluation details within certification program content could serve as an important mechanism for promoting voluntary on-farm compliance with antibiotic stewardship guidelines.

Development and Pilot of an Interactive Online Course on Antimicrobial Stewardship in Companion Animals

A holistic approach to antimicrobial use (AMU) and prescribing is needed to combat the problem of antimicrobial resistance (AMR). Previously, an antimicrobial stewardship programme (ASP) was developed, introduced, and evaluated in 44 Dutch companion animal clinics, which resulted in an optimization of AMU. As a follow-up to this, an online course was developed to promote awareness of AMU, AMR, and responsible antimicrobial prescribing. The aim of this paper is to describe the development and pilot, including evaluation, of this course, which will be disseminated more widely among Dutch companion animal veterinarians. The interactive programme consists of a major e-learning component and two online, face-to-face meetings. The course comprises five different parts corresponding with five consecutive weeks. Theory on several topics is offered, for example on AMU and AMR in general, Dutch regulations and guidelines on veterinary AMU, behavioural change, and possible methods to quantify AMU. Additionally, several assignments are offered, for example to reflect upon one’s own current antimicrobial prescribing behaviour. Interactive discussion and peer-to-peer learning are promoted. Since September 2020, the course has been offered in a pilot phase, and the feedback is promising. Evaluation of the pilot phase will result in recommendations for further optimization and dissemination.

Prescription Pattern of Antimicrobial Use in Small Animal Veterinary Practice in Cameroon

Retrospective data on antimicrobial use (AMU) within the period ranging from January 2012-December 2015 was collected to assess the antimicrobial prescription patterns in pets (cats and dogs) treated by 16 veterinary private practitioners in the 2 main urban cities of Cameroon (Douala and Yaounde). The vet practitioners were interviewed in order to analyze prescribing behavior and factors influencing antimicrobial prescription. Out of a total of 3928 antimicrobial prescriptions, 3673(93.5%) were recorded in dogs and 255 (6.5%) in cats during the study period in 7 veterinary clinics. The most prescribed antimicrobials were sulfamethoxypyridazine-trimethoprim (dog: 31.2%; cat: 28.6%), benzylpenicillin-streptomycin (dogs:19.0%; cat:21.9%) and marbofloxacin (dogs:18.3%; cats:16.1%). Almost, 64.6% of antimicrobial prescription in dogs was categorized as highly important antimicrobials and 34.9% as critically important antimicrobial agents. In cats, 77.9% of antimicrobial prescription was categorized as highly important antimicrobials and 22.1% as critically important antimicrobial agents. Antimicrobials were mostly used for gastro-intestinal disorders (31.9%) and skin diseases (24. 1%) in dogs while they were mostly applied for surgical problems (29.8%), musculo-skeletal disease (20.4%) and gastro-intestinal tract diseases (19.6%) in cats. Fluoroquinolones were administered as first option instead of third option. Antimicrobials were associated with other veterinary drugs (anti-inflammatory, internal and external parasite therapy) in 75.3% of cases. The prescription of antimicrobials was based on clinical diagnosis (symptom-based), ease of drug administration, owner's purchasing power and antibiogram. This study highlights the necessity to promote antimicrobial stewardship in pet medicine in Cameroon. Confirmatory diagnosis and antibiotic susceptibility testing before antibiotic prescription should be encouraged. The uncontrolled use of critically important antimicrobials for human medicine and especially their indiscriminate use may favor the occurrence of AMR public health issues.

Antibiotic Stewardship for Canine and Feline Acute Urinary Tract Infection: An Observational Study in a Small Animal Hospital in Northwest Italy

Antimicrobial stewardship programs (ASPs) have been suggested to reduce antimicrobial resistance phenomena in veterinary medicine, as antibiotics are commonly used without microbiological confirmation. The aim of the present study is to design a specific working flow for a tailored antimicrobial treatment in the case of canine and feline urinary tract infections (UTIs). Urine samples were collected by cystocentesis from 16 dogs and 12 cats presenting acute signs of UTI. The therapy was decided according to the minimal inhibitory concentration, and it was possible to monitor 14 dogs and 11 cats. Rescue therapy (amoxicillin and clavulanic acid) was included in emergency cases. Escherichia coli, Proteus mirabilis, and Streptococcus canis were isolated in dogs, and Escherichia coli, Staphylococcus pseudintermedius, and Staphylococcus aureus were isolated in cats. No multidrug-resistant strains were detected, but all Staphylococci were methicillin resistant. Only one cat received rescue therapy, and only one dog was recruited. Dogs were treated with tetracycline (1/14), fluoroquinolones (6/14), beta-lactams (6/14), and gentamicin (1/14), while cats received fluoroquinolones (3/11), nitrofurans (1/11), clindamycin (1/11), and beta-lactams (6/11). The success rate was very high. Our findings are interesting because this is the first ASP in Italy, and it may be used as a model to develop ASPs for other pathologies.

Breaking new ground in antimicrobial stewardship in companion animal veterinary practice

Singleton and colleagues publish in Nature Communications an intervention study to reduce antimicrobial usage in companion animal practice. They identify significant reductions in antimicrobial usage with their more active intervention group over approximately a 6-month period. The study offers an exciting way forward to explore further the trial interventions and assess alternative methods to improve antimicrobial stewardship in veterinary practice.

[Use of antimicrobials in acute canine diarrhea - overview of potential risks, indications and alternatives]

In Germany, antibiotics are frequently used in dogs with gastrointestinal disorders such as acute diarrhea. In line with global efforts to limit antibiotic use, this literature review aims to provide a guideline for the rational and judicious use of antibiotics in acute canine diarrhea. Antibiotics can lead to gastrointestinal side effects and may exert a negative influence on the intestinal microbiota in addition to increasing the occurrence of resistant bacteria. There is also evidence that chronic immunological diseases may be triggered by the administration of antibiotics. Therefore, these should not be administered in uncomplicated acute diarrhea without signs of sepsis or systemic inflammatory reaction. In addition, enteropathogenic bacteria usually do not play a role in the etiology of acute diarrhea. For select clinical entities such as acute hemorrhagic diarrhea syndrome, antibiotic therapy should only be recommended in cases displaying signs of bacterial translocation with subsequent sepsis. In the case of parvovirosis, on the other hand, the administration of antibiotics is unavoidable due to the immunological incompetence of the dog caused by the accompanying severe neutropenia.

Implementation of an antimicrobial stewardship program in a veterinary medical teaching institution

Widespread use of antimicrobials in human and veterinary medicine drives the emergence and dissemination of resistant bacteria in human, animal, and environmental reservoirs. The AVMA and FDA Center for Veterinary Medicine have both taken public positions emphasizing the importance of incorporating antimicrobial stewardship in veterinary clinical settings; however, a model for implementing a comprehensive antimicrobial stewardship program in veterinary practice is not readily available. In 2015, The Ohio State University College of Veterinary Medicine began developing a veterinary antimicrobial stewardship program modeled on existing programs in human health-care institutions and the 7 core elements of a successful hospital antimicrobial stewardship program, as defined by the CDC. The program includes comprehensive antimicrobial use guidelines, active environmental surveillance, and enhanced infection control procedures in The Ohio State University Veterinary Medical Center, along with routine monitoring and reporting of antimicrobial prescribing practices and antimicrobial susceptibility patterns of common pathogens isolated from patients and the hospital environment. Finally, programs have been developed to educate clinicians, staff, and students on antimicrobial resistance and appropriate antimicrobial prescribing practices. The antimicrobial stewardship program has been designed to help clinicians and students confidently make judicious antimicrobial use decisions and provide them with actionable steps that can help them act as strong stewards while providing the best care for their patients. This report describes our program and the process involved in developing it, with the intent that the program could serve as a potential model for other veterinary medical institutions.

Overview and Evaluation of Existing Guidelines for Rational Antimicrobial Use in Small-Animal Veterinary Practice in Europe

Antimicrobial stewardship guidelines (ASGs) represent an important tool to help veterinarians optimize their antimicrobial use with the objective of decreasing antimicrobial resistance. The aim of this study was to map and qualitatively assess the ASGs for antimicrobial use in cats and dogs in Europe. Country representatives of the European Network for Optimization of Veterinary Antimicrobial Treatment (ENOVAT) were asked to identify ASGs published in their countries. All collated ASGs updated since January 2010 containing recommendations on antimicrobial therapy for at least three conditions affecting different organ systems in cats and dogs underwent detailed review including AGREE II analysis. Out of forty countries investigated, fifteen ASGs from eleven countries met the inclusion criteria. Several critical principles of antimicrobial use were identified, providing a framework that should assist development of stewardship guidance. The AGREE II analysis highlighted several methodological limitations of the currently available ASGs. This study sheds light on the lack of national ASGs for dogs and cats in multiple European countries and should encourage national bodies to prioritize guideline development in small animals. A greater awareness of the need to use a structured approach to guideline development could improve the quality of ASGs in the future.

Development of a method for creating antibiograms for use in companion animal private practices

OBJECTIVE

To identify a method for developing antibiograms for use in companion animal private practices (PPs).

SAMPLES

Reports (n = 532) of aerobic bacterial culture and antimicrobial susceptibility testing performed between January 1, 2018, and December 31, 2018, at 11 PPs and 1 academic primary care practice (APCP).

PROCEDURES

Data extracted from reports included patient identification number, laboratory accession number, patient signalment, collection method, body site, and results of bacterial culture and antimicrobial susceptibility testing. A custom antibiogram was then constructed with the help of commonly available software by adapting methods used by human hospitals. Susceptibility patterns of bacteria isolated by PPs and the APCP were compared to identify challenges associated with collating data from multiple laboratories.

RESULTS

4 bacterial species (Escherichia coli, Proteus mirabilis, Pseudomonas aeruginosa, and Staphylococcus pseudintermedius) and 3 bacterial groups (Enterobacteriaceae, Enterococcus spp, and coagulase-positive Staphylococcus spp) met the minimum requirement of ≥ 15 isolates for construction of an antibiogram. For urine samples, 3 bacterial species and 2 bacterial groups met the minimum requirement of ≥ 10 isolates. For samples from skin, 2 bacterial species and 2 bacterial groups met the minimum requirement of ≥ 10 isolates. Patient signalment, sample source, and distribution of bacterial isolates were similar between PP and APCP patients.

CONCLUSIONS AND CLINICAL RELEVANCE

Results demonstrated that it was feasible to adapt existing guidelines for developing antibiograms in human medicine to the veterinary outpatient setting. Use of antibiograms could aid in empirical antimicrobial drug selection in a manner that supports antimicrobial stewardship principles.

Antimicrobial resistance in companion animals - Veterinarians' attitudes and prescription drivers in Portugal

Antimicrobial resistance transmitted from companion animals is a threat to public health increased by the pet's relationship with humans. This study aims to understand the attitude and drivers of antimicrobial (AM) prescription among companion animal veterinarians in Portugal and identify actions to combat antimicrobial resistance (AMR). This cross-sectional study is based on a questionnaire with 417 respondents representing the Portuguese veterinary population. The results allowed grouping the respondents according to the attitude of prescription. Two types of veterinarians were identified: those who prefer to prescribe treatments based on the animals' signs and their own experience - empirical-oriented type - and those who refer to a guidance protocol to assist the prescription decision - protocol-oriented type. Respondents working in hospitals displayed a positive association with the use of guidance protocols. Efficacy was the main driver of prescription for both groups, suggesting that no matter the attitude in prescribing, the veterinarian's aim is achieving positive clinical results. Most respondents prefer empirical-oriented prescriptions, declare the absence of protocols for the prudent use of AM at the workplace and do not refer to AMR issues nor the need for hygiene reinforcement measures with owners. Owners are less likely to request AMs from veterinarians aged over 43 years old. It was discovered that communication between owners and veterinarians about risks associated with AMR was poor and must be improved and the adoption of a national guideline for the adequate use of AM directed for companion animals would be beneficial.

Antimicrobial resistance increased over an 8-year period in Enterobacteriaceae cultured from canine urine samples

OBJECTIVES

The aims of the present study were to describe the prevalence of positive urinary bacterial culture in dogs, to identify the most commonly isolated microorganisms and to analyse changes in antimicrobial susceptibility patterns over time.

MATERIAL AND METHODS

A retrospective case series was performed using culture and susceptibility results from canine urine samples collected between January 2010 and December 2017. The presence or absence of infection, identity of the bacterium with heaviest growth, and susceptibility profile were recorded for each sample. Trends in the frequency of positive culture and antimicrobial resistance were assessed by Poisson regression modelling. Prevalence rate ratio and 95% confidence interval were reported for resistance to each antimicrobial.

RESULTS

A positive urine culture was documented in 771 (22.5%) of 3420 samples. Escherichia coli was the most commonly isolated microorganism. There was no significant increase in the frequency of positive bacterial culture over the study period (prevalence rate ratio 0.98; 95% confidence interval: 0.92 to 1.0). Overall, there was an increase in antimicrobial resistance within Enterobacteriaceae from 5.2 to 35.6%. The prevalence of multidrug-resistant bacteria varied from year to year throughout the study period. However, the Poisson regression model identified a significant increase in the frequency of multidrug-resistant Enterobacteriaceae over this period, averaging approximately 22% per year (prevalence rate ratio 1.22, 95% confidence interval: 1.06 to 1.42).

CLINICAL SIGNIFICANCE

The significant increase in antimicrobial resistance observed in this study is concerning and may have implications for veterinary and public health. Appropriate measures, such as antibiotic stewardship programmes, should be implemented to address increasing antimicrobial resistance.

White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in the animal sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks

BACKGROUND

The JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks have joined efforts to formulate a set of target actions to link the surveillance of antimicrobial usage (AMU) and antimicrobial resistance (AMR) with antimicrobial stewardship (AMS) activities in four different settings. This White Paper focuses on the veterinary setting and embraces the One Health approach.

METHODS

A review of the literature was carried out addressing research questions in three areas: AMS leadership and accountability; AMU surveillance and AMS; and AMR surveillance and AMS. Consensus on target actions was reached through a RAND-modified Delphi process involving over 40 experts in infectious diseases, clinical microbiology, AMS, veterinary medicine and public health, from 18 countries.

RESULTS/DISCUSSION

Forty-six target actions were developed and qualified as essential or desirable. Essential actions included the setup of AMS teams in all veterinary settings, building government-supported AMS programmes and following specific requirements on the production, collection and communication of AMU and AMR data. Activities of AMS teams should be tailored to the local situation and capacities, and be linked to local or national surveillance systems and infection control programmes. Several research priorities were also identified, such as the need to develop more clinical breakpoints in veterinary medicine.

CONCLUSIONS

This White Paper offers a practical tool to veterinary practitioners and policy makers to improve AMS in the One Health approach, thanks to surveillance data generated in the veterinary setting. This work may also be useful to medical doctors wishing to better understand the specificities of the veterinary setting and facilitate cross-sectoral collaborations.

Linking antimicrobial resistance surveillance to antibiotic policy in healthcare settings: the COMBACTE-Magnet EPI-Net COACH project

OBJECTIVES

To systematically summarize the evidence on how to collect, analyse and report antimicrobial resistance (AMR) surveillance data to inform antimicrobial stewardship (AMS) teams providing guidance on empirical antibiotic treatment in healthcare settings.

METHODS

The research group identified 10 key questions about the link between AMR surveillance and AMS using a checklist of 9 elements for good practice in health research priority settings and a modified 3D combined approach matrix, and conducted a systematic review of published original studies and guidelines on the link between AMR surveillance and AMS.

RESULTS

The questions identified focused on AMS team composition; minimum infrastructure requirements for AMR surveillance; organisms, samples and susceptibility patterns to report; data stratification strategies; reporting frequency; resistance thresholds to drive empirical therapy; surveillance in high-risk hospital units, long-term care, outpatient and veterinary settings; and surveillance data from other countries. Twenty guidelines and seven original studies on the implementation of AMR surveillance as part of an AMS programme were included in the literature review.

CONCLUSIONS

The evidence summarized in this review provides a useful basis for a more integrated process of developing procedures to report AMR surveillance data to drive AMS interventions. These procedures should be extended to settings outside the acute-care institutions, such as long-term care, outpatient and veterinary. Without proper AMR surveillance, implementation of AMS policies cannot contribute effectively to the fight against MDR pathogens and may even worsen the burden of adverse events from such interventions.

Acute Ulcerative Enterocolitis With Severe Protein Loss Due to Mucosal Invasion With Enterococcus spp. in a Dog With Exocrine Pancreatic Insufficiency: A Case Report

We describe an unusual case of severe acute protein-losing enteropathy in a dog, which presented with a systemic inflammatory response syndrome. This dog's condition could not be categorized as any well-known canine intestinal condition. Instead, components of several enteropathies like acute hemorrhagic diarrhea syndrome (AHDS), chronic inflammatory enteropathy (CIE), and ulcerative and granulomatous colitis were present. Thorough investigations identified concurrent exocrine pancreatic insufficiency (EPI) and hypocobalaminemia. On histopathology, marked diffuse chronic-active ileitis and ulcerative colitis with fibroplasia and neovascularization were present. Intestinal biopsy cultures identified E.coli and multiresistant Enterococcus spp. The latter was identified as mucosally invasive using fluorescent in situ hybridization (FISH). Protracted clinical signs following the acute presentation required intensive care including enteral and parenteral feeding for a successful outcome, but eventually stabilized with antibiotics and immunosuppressive doses of glucocorticoids. This case highlights a potentially previously unrecognized condition, suspected to be a form of CIE manifesting acutely after bacterial mucosal invasion. In this case, this might have been facilitated by EPI-induced dysbiosis. The use of FISH and mucosal culture in this context provided important clinical information and should be considered more frequently in CIE and non-responsive AHDS.

Evaluation of the Resistance Profile of Bacteria Obtained From Infected Sites of Dogs in a Veterinary Teaching Hospital in Brazil: A Retrospective Study

The aim of this study was to evaluate the prevalence and antimicrobial resistance profile of bacterial species isolated from infected sites of canines. All samples were collected from canine patients who received clinical or surgical care at the veterinary teaching hospital between March 2016 and November 2017. The samples were analyzed in a private pathology laboratory. A descriptive analysis of 295 antimicrobial susceptibility test reports was performed. Staphylococcus spp. (104/295 [35.25%]), Escherichia coli (100/295 [33.90%]), Proteus spp. (44/295 [14.92%]), Pseudomonas spp. (25/295 [8.47%]), and Klebsiella spp. (20/295 [6.78%]) were more frequently isolated, and a high incidence of multidrug resistance was observed (69,83% [206/295]). Methicillin-resistant Staphylococcus spp. accounted for 33% (33/100) of the Staphylococcus strains. Enterobacteriaceae cefotaxime resistance constituted 22.82 ± 4.49% and Enterobacteriaceae imipenem resistance constituted 5% (1/20) for Klebsiella spp., 5% (5/100) for E coli, and 6.82% (3/44) for Proteus spp. Pseudomonas spp. strains accounted for 8% (2/25) of imipenem resistance and 45.45% (10/22) of polymyxin B resistance. Our findings revealed a high rate of multidrug-resistant bacteria involvement in the infectious process of dogs. From the perspective of the One Health scenario, our results showed alarming data, given the high risk of resistant-strain dissemination between animals, owners, and healthcare professionals. There is an urgent need for strategies to control and prevent the evolution of new multidrug-resistant bacteria in veterinary hospitals. It is also crucial to understand and emphasize the role of veterinary professionals in this public health battle.

Effect of antimicrobial stewardship on antimicrobial prescriptions for selected diseases of dogs in Switzerland

BACKGROUND

Antimicrobial stewardship programs (ASPs) are important tools to foster prudent antimicrobial use.

OBJECTIVE

To evaluate antimicrobial prescriptions by Swiss veterinarians before and after introduction of the online ASP AntibioticScout.ch in December 2016.

ANIMALS

Dogs presented to 2 university hospitals and 14 private practices in 2016 or 2018 for acute diarrhea (AD; n = 779), urinary tract infection (UTI; n = 505), respiratory tract infection (RTI; n = 580), or wound infection (WI; n = 341).

METHODS

Retrospective study. Prescriptions of antimicrobials in 2016 and 2018 were compared and their appropriateness assessed by a justification score.

RESULTS

The proportion of dogs prescribed antimicrobials decreased significantly between 2016 and 2018 (74% vs 59%; P < .001). The proportion of prescriptions in complete agreement with guidelines increased significantly (48% vs 60%; P < .001) and those in complete disagreement significantly decreased (38% vs 24%; P < .001) during this time. Antimicrobial prescriptions for dogs with AD were significantly correlated with the presence of hemorrhagic diarrhea in both years, but a significantly lower proportion of dogs with hemorrhagic diarrhea were unnecessarily prescribed antimicrobials in 2018 (65% vs 36%; P < .001). In private practices, in 2018 a bacterial etiology of UTI was confirmed in 16% of dogs. Prescriptions for fluoroquinolones significantly decreased (29% vs 14%; P = .002). Prescriptions for antimicrobials decreased significantly in private practices for RTI (54% vs 31%; P < .001).

CONCLUSION

Antimicrobials were used more prudently for the examined indications in 2018 compared to 2016. The study highlights the continued need for ASPs in veterinary medicine.

Small and Large Animal Veterinarian Perceptions of Antimicrobial Use Metrics for Hospital-Based Stewardship in the United States

Background: Robust measurement and tracking of antimicrobial use (AMU) is a fundamental component of stewardship interventions. Feeding back AMU metrics to individual clinicians is a common approach to changing prescribing behavior. Metrics must be meaningful and comprehensible to clinicians. Little is known about how veterinary clinicians working in the United States (US) hospital setting think about AMU metrics for antimicrobial stewardship. Objective: To identify hospital-based veterinary clinicians' attitudes toward audit and feedback of AMU metrics, their perceptions of different AMU metrics, and their response to receiving an individualized prescribing report. Methods: Semi-structured interviews were conducted with veterinarians working at two hospitals in the Eastern US. Interviews elicited perceptions of antimicrobial stewardship in veterinary medicine. Respondents were shown a personalized AMU Report characterizing their prescribing patterns relative to their peers and were asked to respond. Interviews were recorded, transcribed, and analyzed using the framework method with matrices. Results: Semi-structured interviews were conducted with 34 veterinary clinicians (22 small animal and 12 large animal). Respondents generally felt positive about the reports and were interested in seeing how their prescribing compared to that of their peers. Many respondents expressed doubt that the reports accurately captured the complexities of their prescribing decisions and found metrics associated with animal daily doses (ADDs) confusing. Only 13 (38.2%) respondents felt the reports would change how they used antimicrobials. When asked how the impact of the reports could be optimized, respondents recommended providing a more detailed explanation of how the AMU metrics were derived, education prior to report roll-out, guidance on how to interpret the metrics, and development of meaningful benchmarks for goal-setting. Conclusions: These findings provide important insight that can be used to design veterinary-specific AMU metrics as part of a stewardship intervention that are meaningful to clinicians and more likely to promote judicious prescribing.

[Bacterial urinary tract infection and subclinical bacteriuria in the dog: a current review]

Bacterial urinary tract infection (UTI) is a common clinical presentation in dogs and a frequent reason for the prescription of antimicrobial drugs. UTI refers to adherence, multiplication and persistence of an infectious agent within the urogenital system. This causes an associated inflammatory response as well as the pertaining clinical signs. Depending on the site of infection, UTI's may be classified as bacterial cystitis, prostatitis or pyelonephritis. In contrast, subclinical bacteriuria (SB) is defined as the presence of a significant number of bacteria in the urine of an individual not showing clinical signs referrable to UTI. UTI's typically occur as a consequence of ascending pathogen migration from the host's own fecal or distal urogenital microbial flora. The most commonly isolated pathogen in cases of UTI and SB is Escherichia coli. The diagnosis is based on clinical signs and the results of urine examination and culture. The recently revised guidelines of the International Society for Companion Animal Infectious Diseases provide detailed recommendations for diagnosis and management of different forms of bacterial UTI's in dogs. Adherence to treatment guidelines will improve treatment success and is imperative in avoiding further deterioration of the antimicrobial resistance situation.

Mapping knowledge and comprehension of antimicrobial stewardship and biosecurity among veterinary students

OBJECTIVES

As an important public health concern, antimicrobial resistance (AMR) is related to lack of knowledge among healthcare professionals. Since the Global Action Plan on AMR highlights the importance of training all healthcare professionals, it is essential to focus our attention on the education related to judicious antimicrobial use. The current study was the first attempt in southeastern Europe to quantify the knowledge about antimicrobial usage and biosecurity measure among veterinary students.

METHODS

This questionnaire-based study was performed between April and May of 2019 on 213 veterinary students of the University of Novi Sad, Serbia and the University of Zagreb, Croatia.

RESULTS

Veterinary students appeared to be little aware of antimicrobial use in veterinary medicine contribution to overall AMR since only 56.8% have chosen strong contribution as the answer. Of the students surveyed, only 22.1%/35.7% of them strongly agreed/agreed that the amount of teaching time for pharmacology was about right. Students who denied having good knowledge of the pharmacology of antimicrobials showed higher knowledge about systemic use of antimicrobials in different clinical scenarios (p = 0.002). High importance of some antimicrobials for human medicine was not recognized by surveyed students. Only 8.5% of them identified gentamicin correctly, as first-line therapy. Students expected to graduate later were more likely to identify the importance of rating antimicrobials correctly than those who thought they would graduate earlier (p = 0.002). More than half of students gave correct answer at scenario regarding a dog with recurrent pyoderma by choosing culture and susceptibility (C & S) testing. Our students who think they will graduate sooner have higher knowledge level on C & S testing sample submission for range of clinical scenarios (p = 0.004). Moreover, appropriate use of PPE (personal protective equipment) procedure and biosecurity measure were reported for two thirds of our students in case of only for two clinical scenarios.

CONCLUSION

This study reveals that among veterinary students from Croatia and Serbia improved undergraduate education is needed on the AMR with emphasis on antimicrobial stewardship (AMS) and appropriate biosecurity.

Antimicrobial prescriptions in cats in Switzerland before and after the introduction of an online antimicrobial stewardship tool

BACKGROUND

Antimicrobial stewardship activities are essential to improve prudent antimicrobial use. The aim of the present study was to evaluate changes in antimicrobial prescriptions in cats after the introduction of prudent use guidelines promoted by an online antimicrobial stewardship tool (AntibioticScout.ch) in Switzerland. Data from 792 cats presented to two university hospitals and 14 private practices in 2018 were included and compared to 776 cases from 2016. Cats were diagnosed with acute upper respiratory tract disease (aURTD), feline lower urinary tract disease (FLUTD) and abscesses. Clinical history, diagnostic work-up and antimicrobial prescriptions (class, dosage, duration) were assessed. Type and proportions [95% confidence intervals] of antimicrobial prescriptions were compared between the two evaluation periods and a mixed effects logistic regression model was applied to evaluate compliance with Swiss prudent use guidelines.

RESULTS

From 2016 to 2018, the proportion of antimicrobial prescription in all included cases decreased from 75.0% [71.8-78.0] to 66.7% [63.3-69.9]; this decrease was most pronounced for treatments at university hospitals (67.1% [59.5-74.0] to 49.3% [40.9-57.8]) and for cats with FLUTD (60.1% [54.6-65.4] to 48.8% [43.2-54.4]). Use of 3rd generation cephalosporins in private practices declined from 30.7% [26.5-35.1] to 22.1% [18.4-26.2], while overall use of non-potentiated aminopenicillins increased from 19.6% [16.4-23.0] to 27.8% [24.1-31.9]. In cases where antimicrobial therapy was indicated, compliance with guidelines did not increase (33.3% [26.6-40.6] to 33.5% [27.2-40.2]), neither at universities nor in private practices. On the other hand, antimicrobial treatment was more often withheld in cases with no indication for antimicrobial therapy (35.6% [30.1-41.4] to 54.0% [47.6-60.4]); this was found for private practices (26.7% [20.8-33.4] to 46.0% [38.4-53.7]) and for aURTD cases (35.0% [26.5-44.2] to 55.4% [44.7-65.8]).

CONCLUSIONS

Overall proportions of antimicrobial prescription, unjustified antimicrobial therapy and, in private practices, use of 3rd generation cephalosporins decreased from 2016 to 2018 for the investigated feline diseases. However, overall compliance with Swiss prudent use guidelines was still low, implying that further efforts are required to foster prudent antimicrobial use in cats.

Diagnostic evaluation of a point-of-care test for culture and microbial susceptibility testing in canine dermatological infections in clinical practice

Background and Aim

Empirical antimicrobial therapy is frequently given in superficial bacterial folliculitis (SBF) and otitis externa (OE) in dogs, especially for the initial clinical presentation. Culture and subsequent antimicrobial susceptibility testing (AST) are generally limited to chronic cases with poor response to initial therapy. Several factors contribute to the failure to implement the use of AST in veterinary practice, i.e., long laboratory turnaround time or special requirements for sample shipping. Point-of-care (PoC) testing might reduce laboratory turnaround time and costs and the risk of emergence of multidrug-resistant pathogens. This study evaluated the Speed Biogram™ PoC test in canine SBF and OE compared with conventional methods for culture and AST.

Materials and Methods

Thirty-four canine samples were analyzed: eleven from SBF, seven from bacterial OE, four from mixed OE, six from Malassezia spp. OE, and six negative controls. Sensitivity (Se) and specificity (Sp) of the PoC test and the agreement between the PoC test and conventional methods were evaluated.

Results

Se and Sp of PoC test in discriminating between healthy and unhealthy subjects were 100% (95% confidence interval [CI] 87.66-100.00) and 100% (95% CI 54.1-100.0), respectively. For bacterial identification, the k value was 0.532. Se and Sp of PoC tests for AST were 81.73% (95% CI 72.95-88.63) and 93.10% (95% CI 88.86-96.98), respectively with a total good agreement between tests (mean k=0.714), but major (8/27) and very major (19/27) errors were observed in 55% of bacterial conventional culture-positive samples.

Conclusion

PoC test can identify dogs with SBF and OE, but AST is not sufficiently accurate. The lack of susceptibility testing for methicillin makes this test inappropriate for use in small animal practice.

What Would the Screen-and-Treat Strategy for Helicobacter pylori Mean in Terms of Antibiotic Consumption?

Several guidelines recommend the screen-and-treat strategy, i.e. active search for the presence of Helicobacter pylori infection and its eradication to prevent the possibility of gastric cancer. It is thought that a relatively short duration antibiotic regimen given once in a lifetime would not significantly increase overall antibiotic consumption. However, this would mean offering antibiotic treatment to the majority of the population in countries with the biggest burden of gastric cancer who would, therefore, have the greatest benefit from such a strategy. So far, no country has implemented an eradication strategy. With an example based on the current situation in Latvia, we have estimated the increase in antibiotic consumption if the screen-and-treat strategy was applied. Depending on the scenario that might be chosen, clarithromycin consumption would increase up to sixfold, and amoxicillin consumption would double if the recommendations of the current guideline in the local circumstances was applied. It appears that an increase in commonly used antibiotic consumption cannot be justified from the viewpoint of antibiotic stewardship policies. Solutions to this problem could be the use of antibiotics that are not required for treating life-threatening diseases or more narrow selection of the target group, e.g. young people before family planning to avoid transmission to offspring. Additional costs related to the increase in resistome should be considered for future cost-effectiveness modelling of the screen-and-treat strategy.

Occurrence of Escherichia coli in captive psittaciformes: antimicrobial susceptibility and virulence genes

Abstract Captive Psittaciformes may harbor Gram-negative bacteria in their digestive tract, mainly due to poor hygienic conditions and confinement. The present study was carried out with the objective of isolating and identifying Escherichia coli in samples collected from Psittaciformes cages in 50 commercial establishments in the metropolitan region of Goiania, with subsequent antimicrobial susceptibility testing and detection of virulence genes. A total of 141 samples of excreta and swab samples from feeders and water bowls were collected, totaling 423 samples. Escherichia coli was isolated from 9.7% (41/423) samples: 12% (17/141) in excreta, 8.5% (12/141) in feed, and 8.5% (12 /141) in waterers. To determine the susceptibility profile of E. coli isolates, resistance to ciprofloxacin 4.9% (2/41), gentamicin 17.0% (7/41), doxycycline 34.1% (14/41), florfenicol 34.1% (14/41), trimethoprim 39.0% (16/41), tetracycline 41.5% (17/41), enrofloxacin 43.9% (18/41), amoxicillin 48.8% (20/41), neomycin 61.0% (25/41), and sulfonamide 90.2% (37/41) was determined. In 20 isolates, resistance was determined at 4 or more antimicrobials, seven of excreta (7/17), five of feed (5/12), and eight of waterers (8/12). One of the isolates from the waterers showed resistance to all antimicrobials. The iss gene was detected in three isolates, the tsh gene in three, the papC gene in two, traT and eae genes were not detected. In this study, it can be concluded that Psittaciformes commercialized as pet are carry E. coli isolates resistant to most commonly used antimicrobials, mainly sulfonamides and neomycin, besides having virulence and serum resistance genes, which highlights the possibility of the to cause disease in humans.

A clinical approach to multidrug-resistant urinary tract infection and subclinical bacteriuria in dogs and cats

Multidrug-resistant bacteria are increasingly isolated from the urinary tract of pets, particularly those that suffer from concurrent conditions, have been hospitalised, or were treated with antimicrobials in the recent past. Many of the multidrug-resistant bacteria encountered are resistant to all commonly used oral antibiotics. This poses both a therapeutic dilemma in the individual pet and a threat to public health. This article begins with an overview of multidrug resistance in organisms that are commonly isolated from the urinary tract of pets. This is followed by a proposed clinical approach to managing multidrug-resistant urinary bacteria, which summarises current knowledge regarding appropriate sampling and analysis, reviews the current guidelines regarding appropriate antimicrobial use and discusses treatment options that might be considered. The article highlights several shortcomings of the current knowledge to be considered when planning future clinical research and developing policies.

Posters Have Limited Utility in Conveying a Message of Antimicrobial Stewardship to Pet Owners

Pet owners frequently administer antimicrobials to their pets and therefore have an important role to play in promoting antimicrobial stewardship in veterinary medicine. However, best methods of educating pet owners about antimicrobial stewardship have yet to be defined. While visual materials such as brochures and posters are often used in health promotion campaigns, their effectiveness in veterinary medicine is unknown. The objective of this study was to determine whether pet owners noticed and retained the message of a poster with an antimicrobial stewardship message placed in veterinary clinic exam rooms. A total of 111 pet owners from five veterinary clinics (three general practices, two low-cost clinics) in the greater Philadelphia area participated in the study. Participants completed a survey asking whether they noticed the poster and if they could paraphrase its message. In a follow-up survey, an antibiotic knowledge score was calculated from answers to questions assessing their knowledge of the poster message. Baseline knowledge was assessed by asking participants to define antibiotic resistance. At the end of the study, veterinarians at participating clinics were interviewed about their experiences with the poster. Only 51 (46.4%) participants noticed the poster, and only 11 (9.9%) could partially or completely reproduce its message. No demographic or clinic-level factors were significantly associated with noticing the poster or recalling its message. Antibiotic knowledge scores were highly correlated (ρ = 0.87, p < 0.001) with baseline knowledge and not affected by viewing the poster (p = 0.955). Veterinarians expressed skepticism that the poster was effective in conveying a message of judicious antibiotic use to clients and noted no difference in the frequency with which they discussed antibiotic resistance or felt pressured to prescribe antibiotics by their clients. Posters alone will likely have limited impact in conveying a message of judicious antibiotic use to pet owners. However, they might be useful as part of an active, multi-modal education strategy, especially if complemented by veterinarian actions.

Implementation and evaluation of an antimicrobial stewardship programme in companion animal clinics: A stepped-wedge design intervention study

BACKGROUND

To curb increasing resistance rates, responsible antimicrobial use (AMU) is needed, both in human and veterinary medicine. In human healthcare, antimicrobial stewardship programmes (ASPs) have been implemented worldwide to improve appropriate AMU. No ASPs have been developed for and implemented in companion animal clinics yet.

OBJECTIVES

The objective of the present study was to implement and evaluate the effectiveness of an ASP in 44 Dutch companion animal clinics. The objectives of the ASP were to increase awareness on AMU, to decrease total AMU whenever possible and to shift AMU towards 1st choice antimicrobials, according to Dutch guidelines on veterinary AMU.

METHODS

The study was designed as a prospective, stepped-wedge, intervention study, which was performed from March 2016 until March 2018. The multifaceted intervention was developed using previous qualitative and quantitative research on current prescribing behaviour in Dutch companion animal clinics. The number of Defined Daily Doses for Animal (DDDAs) per clinic (total, 1st, 2nd and 3rd choice AMU) was used to quantify systemic AMU. Monthly AMU data were described using a mixed effect time series model with auto-regression. The effect of the ASP was modelled using a step function and a change in the (linear) time trend.

RESULTS

A statistically significant decrease of 15% (7%-22%) in total AMU, 15% (5%-24%) in 1st choice AMU and 26% (17%-34%) in 2nd choice AMU was attributed to participation in the ASP, on top of the already ongoing time trends. Use of 3rd choice AMs did not significantly decrease by participation in the ASP. The change in total AMU became more prominent over time, with a 16% (4%-26%) decrease in (linear) time trend per year.

CONCLUSIONS

This study shows that, although AMU in Dutch companion animal clinics was already decreasing and changing, AMU could be further optimised by participation in an antimicrobial stewardship programme.

In vitro antimicrobial activity of narasin and monensin in combination with adjuvants against pathogens associated with canine otitis externa

BACKGROUND

The emergence of antimicrobial resistance represents a serious human and animal health risk. Good antimicrobial stewardship is essential to prolong the lifespan of existing antibiotics, and new strategies are required to combat infections in man and animals.

HYPOTHESIS/OBJECTIVES

To determine the in vitro interaction of ionophores (narasin or monensin) with antimicrobial adjuvants (N-acetylcysteine (NAC), Tris-EDTA or disodium EDTA) against bacterial strains representing pathogens associated with canine otitis externa (OE).

ANIMAL/ISOLATES

American Type Culture Collection (ATCC) strains Staphylococcus aureus 29213, Pseudomonas aeruginosa 27853 and P. aeruginosa biofilm producer PAO1, and a clinical isolate of Proteus mirabilis from a case of canine OE were tested.

METHODS AND MATERIALS

A 2D microdilution checkerboard method was used, allowing calculation of fractional inhibitory concentration index (FICI), dose reduction index (DRI) and plotting of isobolograms.

RESULTS

The combination of narasin with either Tris-EDTA or disodium EDTA produced additive effects (FICI = 0.75) against P. aeruginosa ATCC 27853 and P. aeruginosa biofilm producer ATCC PAO1. An additive effect (FICI = 0.53-0.75) was found against S. aureus ATCC 29213 when narasin or monensin were combined with NAC. The highest DRI (32-fold) was found with monensin/NAC where the MIC of monensin was reduced from 4 to 0.125 μg/mL.

CONCLUSIONS AND CLINICAL IMPORTANCE

The combination of narasin with Tris-EDTA or disodium EDTA is a promising strategy to inhibit the intrinsic resistance elements of Gram-negative bacteria. These novel combinations potentially could be useful as a multimodal approach to treat mixed infections in canine OE.