Barriers to and enablers of implementing antimicrobial stewardship programs in veterinary practices

Identifying veterinary surgeons' barriers to, and potential solutions for, improving antimicrobial stewardship among sheep farmers in Northern Ireland

Background

In order to improve antimicrobial stewardship (AMS), including changes in antimicrobial prescribing and use, an enhanced understanding is needed of the barriers that veterinary surgeons (vets) encounter to institute such change.

Methods

A qualitative approach, using grounded theory, was followed. Interviews and discussion groups, with vets and farm industry stakeholders in Northern Ireland (NI), were undertaken to identify and explore attitudes and behaviours surrounding AMS, with a particular emphasis on the barriers vets encountered and the context within which they were working.

Results

Seven inter-related themes associated with improving AMS among their sheep farming clients were identified. The first six addressed barriers were working under commercial and practical constraints, farmer behaviour, multiple medicine sources, poor prescribing practice, a perceived lack of incentive or facilitation to improve AMS and a perceived lack of action by regulators to challenge poor AMS. The seventh theme revealed suggestions vets considered that may improve AMS in NI, including greater state intervention in recording and regulating medicine sales.

Conclusions

Improving AMS will require vets and their client farmers to change behaviour. This will involve concerted effort over an extended period of time to enact and embed change. Veterinary surgeons believe that further action by the industry and state to develop centralised antimicrobial sales recording and by the state to enforce prescribing regulations will aid their efforts. However, critical to achieving this is the development of a sustainable and funded mechanism to create more meaningful farmer-vet consultation around flock health prior to every prescription to improve AMS and sheep welfare.

Why prescribe antibiotics? A systematic review of knowledge, tension, and motivation among clinicians in low-, middle- and high-income countries

Medical professionals such as physicians and veterinarians are responsible for appropriate antimicrobial prescription (AMP) and use. Although seemingly straightforward, the factors influencing antibiotic prescription, a category of antimicrobials, are complex. Many studies have been conducted in the past two decades on this subject. As a result, there is a plethora of empirical evidence regarding the factors influencing clinicians' AMP practices.

AIM

A systematic review of AMR studies on AMP was conducted, condensing findings according to a combination of the Knowledge, Attitude, and Practice (KAP) and Capacity, Opportunity, Motivation-Behavior (COM-B) models. Review findings were then synthesized and analyzed for policy implementation according to the Consolidated Framework for Implementation Research (CFIR).

DESIGN AND METHODOLOGY

A systematic literature review was conducted according to PRISMA guidelines to identify peer-reviewed papers indexed in pre-determined medical science, social sciences, and humanities databases that apply the KAP model in their investigations. Antimicrobial prescription factors were compared and contrasted among low- and middle-income countries (LMICs) and high-income countries (HICs).

FINDINGS

The KAP model is a heuristic and structured framework for identifying and classifying respondents' knowledge. However, other than medical knowledge, factors that influence prescription decision-making can be expanded to include attitudes, perception, personal affinities, professional circumstances, relational pressure, and social norms.

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.

Cross-sectional evaluation of a large-scale antimicrobial stewardship trial in Australian companion animal practices

BACKGROUND

Antimicrobial stewardship programmes (ASPs) are critically important for improving the appropriate use of antimicrobial agents in veterinary practice.

METHODS

One of three ASPs was implemented in 135 Australian general veterinary practices in 2018-2020. The ASP interventions and the perceived impact they had on antimicrobial prescribing were assessed by the veterinarians working in these veterinary practices. An online survey was distributed to all 520 veterinarians working in the trial practices and 267 responses were analysed.

RESULTS

Most veterinarians (174/267, 65%) thought they had an ASP at their clinic and most respondents who said that they were aware that they had an ASP at their clinic indicated that they had changed the way they prescribed antimicrobials because of the trial (125/170, 74%). Antimicrobial prescribing guidelines, the traffic light system for indicating antimicrobial importance, delayed prescribing and antimicrobial stewardship champions were reported to have had the biggest impact.

LIMITATIONS

All practices in the trial belong to a single corporate group, which may impact the external validity of these results when applied to general small animal practice.

CONCLUSION

Antimicrobial stewardship has a positive impact on antimicrobial prescribing in veterinary medicine and future interventions should focus on the implementation of the effective interventions identified in this study.

An Evaluation of the Impact of an OPEN Stewardship Generated Feedback Intervention on Antibiotic Prescribing among Primary Care Veterinarians in Canada and Israel

An interrupted time-series study design was implemented to evaluate the impact of antibiotic stewardship interventions on antibiotic prescribing among veterinarians. A total of 41 veterinarians were enrolled in Canada and Israel and their prescribing data between 2019 and 2021 were obtained. As an intervention, veterinarians periodically received three feedback reports comprising feedback on the participants' antibiotic prescribing and prescribing guidelines. A change in the level and trend of antibiotic prescribing after the administration of the intervention was compared using a multi-level generalized linear mixed-effect negative-binomial model. After the receipt of the first (incidence rate ratios [IRR] = 0.88; 95% confidence interval (CI): 0.79, 0.98), and second (IRR = 0.85; 95% CI: 0.75, 0.97) feedback reports, there was a reduced prescribing rate of total antibiotic when other parameters were held constant. This decline was more pronounced among Israeli veterinarians compared to Canadian veterinarians. When other parameters were held constant, the prescribing of critical antibiotics by Canadian veterinarians decreased by a factor of 0.39 compared to that of Israeli veterinarians. Evidently, antibiotic stewardship interventions can improve antibiotic prescribing in a veterinary setting. The strategy to sustain the effect of feedback reports and the determinants of differences between the two cohorts should be further explored.

Exploring farmer and advisor lameness management behaviors using the COM-B model of behavior change

Introduction

This paper applies the COM-B framework to farmer and farm advisor understandings and responses to lameness in sheep, beef, and dairy systems. It reflects on how farmers' and advisors' capability, opportunity, and motivation (COM-B) influence lameness management practices in these farming systems, and considers the interaction between these three factors, and stakeholders' behavior.

Methods

Interviews with 29 farmers and 21 farm advisors in the north of England were conducted. Thematic analysis was undertaken with results categorized in relation to the COM-B framework focusing on barriers and enablers of lameness management. Use of the COM-B model provides a useful means of understanding the underlying behavioral mechanisms that contribute toward the persistence of lameness. This includes the complexities and interactions which hamper implementation of lameness management best practice.

Results and discussion

The findings highlight three key areas to address with interventions to improve lameness management on farm: (1) removing physical and social barriers for lameness management; (2) improving psychological capability and motivation for lameness management; and (3) facilitating relationships and developing communication between farmers and advisors. In particular, the value of exploring both farmer and advisor perspectives on behavior in the animal health context is demonstrated. Future interventions should look to target these three areas to overcome barriers and focus on factors that enable positive lameness practices to occur.

Quality of Data Recording and Antimicrobial Use in a Municipal Veterinary Clinic in Ghana

The recording of antimicrobial use data is critical for the development of interventions for the containment of antimicrobial resistance. This cross-sectional study assessed whether dissemination activities and recommendations made after an operational research (OR) study in 2021 resulted in better data recording and improved the use of antimicrobials in a rural veterinary clinic. Routinely collected data from treatment record books were compared between 2013 and 2019 (pre-OR) and from July 2021 to April 2023 (post-OR). The most common animals presenting for care in the the pre - and post OR periods were dogs (369 and 206, respectively). Overall, antimicrobial use in animals increased from 53% to 77% between the two periods. Tetracycline was the most commonly used antimicrobial (99%) during the pre-OR period, while Penicillin-Streptomycin was the most commonly used antimicrobial (65%) during the post-OR period. All animals that received care at the clinic were documented in the register during both periods. Whereas the diagnosis was documented in 269 (90%) animals in the post-OR period compared to 242 (47%) in the pre-OR period, the routes and dosages were not adequately recorded during the both periods. Therefore, the quality of data recording was still deficient despite the dissemination and the recommendations made to some key stakeholders. Recommendations are made for a standardized antimicrobial reporting tool, refresher training, and continuous supervisory visits to the clinic.

Perceptions of barriers to providing good cat care in Malaysian clinical practices

Many veterinary practices around the world do not meet basic post-operative cat care, thereby compromising cat welfare. Understanding why the appropriate care is not always given is important. The current study used a mixed methods approach of two phases, to investigate the barriers Malaysian veterinarians face in seeking to provide good cat care in practice. Phase 1 involved a survey consisting of 14 questions which were divided into three sections (demographic details, basic management and barriers experienced by practices) and emailed to 143 Malaysian veterinarians. While for phase 2, 20 interviews were undertaken (recruited from the survey sample) to further elaborate on the results. A Thematic Analysis was conducted to extract the main barriers experienced by participants. A total of 49 veterinarians completed the survey. Over half of the respondents were senior veterinarians (i.e. those with two or more years in practice) (53.1%; n = 26) who were aware of the basic environmental provisions that cats need post-surgery such as bedding and toileting facilities (57.1%; n = 28). Cost (47%; n = 23) was the biggest restriction to good care provision. Interview findings showed that participants were aware of comfortable post-surgery environments helping recovery, but barriers were highlighted: workload factors and a lack of understanding of cat pain behaviours and associated stress. This suggested that participants had the knowledge required to provide good cat care but experienced difficulties putting this into practice. Therefore, to improve cat welfare in veterinary practice, instead of focusing purely on education, interventions to increase good cat care could include targeted elements that support behaviour change to overcome the barriers.

A Spanish Survey on the Perioperative Use of Antimicrobials in Small Animals

Appropriate use of perioperative antimicrobials can significantly reduce the risk of post-operative infections. However, inappropriate antimicrobial use can result in the creation of multidrug-resistant bacteria, increased costs, host flora disruption, side effects and increased risk of hospital-acquired infections. This survey evaluated the current perioperative use of antimicrobials in small animals by Spanish veterinarians using a web-based questionnaire. Responses were represented using descriptive statistics and a statistical analysis of the association between demographic data and perioperative antimicrobial use was performed. Pre-operative antimicrobials were administered in clean surgery by up to 68.3% of participants, 81.0% in clean-contaminated surgery and 71.3% in dirty surgery, while in the post-operative period, antimicrobials were administered by up to 86.3% of participants in clean surgery, 93.2% in clean-contaminated surgery and 87.5% in dirty surgery. Factors considered "very important" for antimicrobial selection were the degree of wound contamination, patient immunosuppression and use of prosthesis. The most frequently used antimicrobial was beta-lactamase-resistant (or potentiated) penicillin. Post-operative antimicrobial use was associated with participants without specific surgical postgraduate training. This study highlights an overuse of antimicrobials in perioperative procedures in small animal surgery in Spain. Therefore, evidence-based guidelines and further education regarding the correct use of antimicrobial prophylaxis are recommended.

Understanding the role of veterinarians in antimicrobial stewardship on Canadian dairy farms: A mixed-methods study

The aim of this study was to describe the factors that influence dairy cattle veterinarians´ antimicrobial prescribing, their attitudes toward reducing antimicrobial use (AMU) in the dairy industry, awareness of antimicrobial resistance (AMR), and perceived barriers to improving antimicrobial stewardship (AMS) on Canadian dairy farms. We used quantitative and qualitative research methods to consider the complexity of the antimicrobial prescription decision-making process. We designed and distributed an online survey, followed by four online focus groups with practicing veterinarians. We used frequency tables and unconditional associations to analyze quantitative data, and thematic analysis to analyze qualitative data. In total, 107 participants from four Canadian provinces responded to the survey, and 26 veterinarians participated in the focus groups. Results from both studies were triangulated to draw our key findings. We found that 1) Veterinarians must weigh numerous intra-personal and contextual considerations that could be conflicting in their decision-making process for prescribing antimicrobials. 2) Although less experienced veterinarians showed greater awareness of AMR and motivation to improve AMS than more experienced veterinarians, they also reported feeling more pressure to adapt their prescribing practices to farmers' wishes than more experienced veterinarians. 3) Some veterinarians experienced conflict between prescribing antimicrobials to maintain animal health, productivity, and welfare, and AMS, which could result in blaming others for inappropriate antimicrobial use and reducing the opportunity to critically review their own prescribing practices. 4) There were strategies and barriers in common between veterinarians and farmers such as collaborative reviews of disease treatment protocols and improving preventive medicine on dairy farms. 5) The main barriers to reducing AMU on dairy farms reported by veterinarians were concerns about animal welfare and AMU on dairy farms without consultation with the veterinarian. Our results can inform the development of AMS programs in the Canadian dairy industry.

Genomic Analysis of Clostridioides difficile Recovered from Horses in Western Australia

Clostridioides difficile poses an ongoing threat as a cause of gastrointestinal disease in humans and animals. Traditionally considered a human healthcare-related disease, increases in community-associated C. difficile infection (CDI) and growing evidence of inter-species transmission suggest a wider perspective is required for CDI control. In horses, C. difficile is a major cause of diarrhoea and life-threatening colitis. This study aimed to better understand the epidemiology of CDI in Australian horses and provide insights into the relationships between horse, human and environmental strains. A total of 752 faecal samples from 387 Western Australian horses were collected. C. difficile was isolated from 104 (30.9%) horses without gastrointestinal signs and 19 (37.8%) with gastrointestinal signs. Of these, 68 (55.3%) harboured one or more toxigenic strains, including C. difficile PCR ribotypes (RTs) 012 (n = 14), 014/020 (n = 10) and 087 (n = 7), all prominent in human infection. Whole-genome analysis of 45 strains identified a phylogenetic cluster of 10 closely related C. difficile RT 012 strains of equine, human and environmental origin (0-62 SNP differences; average 23), indicating recent shared ancestry. Evidence of possible clonal inter-species transmission or common-source exposure was identified for a subgroup of three horse and one human isolates, highlighting the need for a One Health approach to C. difficile surveillance.

Factors influencing dairy farmers' antibiotic use: An application of the COM-B model

In dairy farming, mastitis treatment is the most common reason for antimicrobial use. The overuse or misuse of antibiotics in agriculture has been associated with the development and spread of antimicrobial resistance (AMR). Traditionally, blanket dry cow therapy (BDCT), in which all cows receive antibiotic treatment, was used prophylactically to prevent and manage disease spread. In recent years, there has been a move toward selective dry cow therapy (SDCT), in which only clinically infected cows are treated with antibiotics. This study aimed to explore farmer attitudes toward antibiotic use (ABU), using the COM-B (Capability-Opportunity-Motivation-Behavior) model as a framework, to identify predictors of changing behavior toward SDCT and suggest interventions to encourage its uptake. Participant farmers (n = 240) were surveyed online between March and July 2021. Five items were found to be significant predictors of farmers having stopped BDCT: (1) having lower knowledge of AMR, (2) greater awareness of AMR and ABU (Capability), (3) feeling social pressure to reduce ABU (Opportunity), and (4) having greater professional identity, and (5) having positive emotions associated with stopping BDCT (Motivation). Direct logistic regression found that these 5 factors explained between 22 and 34.1% of the variance in making changes to BDCT practices. Additionally, objective knowledge was not correlated with current positive antibiotic practices, and farmers often perceived their antibiotic practices as more responsible than they actually were. A multifaceted approach, encompassing each of the predictors highlighted, should be taken to encourage farmer behavior change in relation to stopping BDCT. Additionally, as farmers' perceptions of their own behaviors may not align with their actual practices, awareness raising of what constitutes "responsible" behavior should be targeted at dairy farmers to motivate them to take action and adopt more responsible antibiotic practices.

Antibiotic prescription patterns and non-clinical factors influencing antibiotic use by Ecuadorian veterinarians working on cattle and poultry farms: A cross-sectional study

Understanding antibiotic prescription patterns and non-clinical factors influencing antibiotic use is essential for implementing strategies to promote appropriate antibiotic use. There is, however, limited research exploring these issues with Ecuadorian veterinarians. Therefore, a questionnaire was developed and applied cross-sectionally to veterinarians (n = 173) from two professional organizations to explore the antibiotic prescription patterns and non-clinical factors (e.g., attitudes and perceptions) influencing antibiotic use, and to identify strategies to reduce antibiotic use. The response rate was 78.4%. Responses were compared between veterinarians working mainly on cattle and poultry farms using Mann-Whitney U tests. The most important attitudes, beliefs and perceptions towards antimicrobial resistance (AMR) and antibiotic use were identified with the Relative Importance Index (RII). Veterinarians showed high awareness of AMR and its implications for public health, as well as the necessity of reducing antibiotic use. However, some veterinarians appear to underestimate the potential contribution of veterinary antibiotic use on AMR in humans. Veterinarians self-reported high prescription (> 20%) of antibiotics for cattle and poultry that are critically important for human medicine, such as 3rd and 4th generation cephalosporins, polymyxins and quinolones. Further, antibiotic therapy was not tailored to disease type. Cattle and poultry veterinarians perceived similar barriers to increasing antibiotic stewardship including: poor biosecurity measures, animal confinement, low feed quality, farmers' behaviors (such as stopping antibiotic treatment, storing antibiotics on farms, buying antibiotics in veterinary supply stores), and sales agents' roles as non-professional prescribers of antibiotics. Overall, veterinarians were broadly supportive (>90%) of most strategies to promote appropriate antibiotic use. They saw more merit in improving biosecurity of farms and implementing educational programs for farmers and veterinarians. This study provides insight into the complexity of antibiotic use on Ecuadorian farms and the need for holistic strategies in a One Health context, to achieve antibiotic stewardship.

‘Brave Enough’: A Qualitative Study of Veterinary Decisions to Withhold or Delay Antimicrobial Treatment in Pets

Veterinarians sometimes prescribe antimicrobials even when they know or suspect that they are unnecessary. The drivers of this behaviour must be understood to design effective antimicrobial stewardship interventions. Semi-structured interviews were conducted with 22 veterinarians who treated companion animals in Australia. The Theory of Planned Behaviour was used to organise interview themes, focusing on a decision to withhold antimicrobial therapy in the absence of a clear indication. Many background factors influenced antimicrobial-withholding decisions, including the veterinarian’s communication skills, general attitudes towards antimicrobial resistance (AMR), habits and energy levels. Client awareness of AMR and the veterinarian–client relationship were also important. Beliefs about the consequences of withholding antimicrobials (behavioural beliefs) were dominated by fears of the animal’s condition deteriorating and of failing to meet client expectations. These fears, weighed against the seemingly distant consequences of AMR, were major barriers to withholding antimicrobials. Normative beliefs were primarily focused on the expected approval (or disapproval) of the client and of other veterinarians. Control beliefs about the difficulty of withholding antimicrobials centred around client factors, most importantly, their capacity to adequately monitor their animal, to pay for further investigations, or to undertake non-antimicrobial management, such as wound care, at home. The use of antimicrobials by companion animal veterinarians in the absence of a clear indication is often powerfully driven by behavioural beliefs, chiefly, fears of clinical deterioration and of failing to meet client expectations.

Exploring veterinarians' behaviour relating to antibiotic use stewardship on Irish dairy farms using the COM-B model of behaviour change

Employing a theoretical model of human behaviour (COMB), the current study explores the factors influencing veterinarians' engagement with antibiotic use stewardship on Irish dairy farms. One-to-one semi structured interviews were carried out by telephone with 12 veterinarians whose daily work focused on dairy cattle. A thematic analysis approach was undertaken. The identified themes and sub-themes were then mapped to the COM-B model. This study identified challenges faced by veterinarians when trying to prescribe responsibly which included lack of training to encourage farmer behaviour change, issues with laboratory testing, pressures from farmers to prescribe antimicrobials, concern for animal welfare and farmers going elsewhere for prescriptions. Having a good knowledge of AMR, peers as an advice source, potential financial benefits for farmers as a result of reduced antimicrobial costs and accepting a shared responsibility for AMR, facilitate veterinarians in their role as antimicrobial stewards. The barriers and facilitators identified as influencing veterinarians' capability, opportunity and motivation to responsibly prescribe antimicrobials formed the basis for a number of practical recommendations which should be considered by advisory and policy making teams. Recommendations include; continuous training for veterinarians on AMR and alternatives to overcome the barriers faced when trying to promote reduced AMU, veterinarian peer support groups to improve confidence in their knowledge and decision making to minimise the effect of client pressures/expectations, setting up collaborative farmer and veterinarian working groups to promote a transparent working relationship and the development of affordable and efficient diagnostic and susceptibility testing.

Trust, agreements, and occasional breakdowns: Veterinarians' perspectives on farmer-veterinarian relationships and use of antimicrobials for Swedish dairy cattle

Studies have shown that farmer-veterinarian relationships influence antimicrobial use (AMU) in livestock, though how they do so is unclear. On the one hand, research shows that well-established veterinarian-farmer relationships are positive for implementation of antibiotic stewardship and restrictive AMU. On the other hand, studies also show that farmer demands can increase antimicrobial prescribing and that prescribing antimicrobials can strengthen the veterinarian's relationship with farmer clients. In the present study, we focus on veterinarians' perspectives on the relationships between dairy cattle farmers and veterinarians in Sweden and explore what characterizes these relationships when restrictive AMU is described as unproblematic and when AMU becomes a matter of tension or conflict. The study draws on semistructured interviews with 21 veterinarians working with livestock in Sweden. Interviews were analyzed thematically. The study shows that from the perspectives of veterinarians, well-established veterinarian-farmer relationships generally facilitate restrictive AMU in 3 slightly different but related ways: (1) they create trust in the veterinarian and their prescribing decisions; (2) they create shared understanding concerning when antimicrobials are needed and not needed; and (3) they facilitate constructive discussions between veterinarians and farmers on AMU. To make the farmer feel listened to and to come to an agreement on AMU was described as central for the veterinarians. However, the veterinarians described agreements on restrictive AMU as sometimes requiring strategic work, such as discussions to motivate the farmer and leave the door open for antimicrobials later if needed. Such work takes time and energy and is easier within well-established relationships according to the veterinarians. We also identified examples where veterinarians explained that they occasionally make compromises with farmers concerning antimicrobials-compromises that, according to the veterinarians, facilitate the relationship with the farmer, which in turn facilities restrictive AMU in the longer term. The examples in our interviews where antimicrobials became a matter of tension and even conflict between veterinarians and farmers could, with a few exceptions, be traced to absence of well-established relationships. However, some veterinarians also described AMU as a matter of tension within well-established relationships, especially with older farmers who do not trust new treatment strategies. We also found a small number of examples where disagreements on antimicrobials made a relationship with specific farmers impossible. Thus, even though the interviewed veterinarians generally meant that their restrictive antimicrobial prescribing did not threaten the relationship with the farmer, our study also, to some extent, confirms research showing that restrictive AMU can harm the relationship with some clients who simply choose another, less restrictive, veterinarian. In summary, our study supports that decisions on AMU cannot be reduced to the individual prescriber's behavior, nor to a strict medical judgment. Antimicrobial use for dairy cattle needs to be understood as taking form in relationships in which both veterinarians and farmers are active parts.

Prescribing and sales of intramammary antimicrobials in Ireland in 2019 and 2020: the role of milk purchasers

Background

In Ireland between 2008 and 2022, intramammary antimicrobial (AM) products could be prescribed by a veterinary practitioner under what was known as Schedule 8 (or remote) prescribing. Under this prescribing route, an annual herd visit was not required when criteria were met as outlined in Animal Remedies Regulation 2007 to 2017 (statutory instruments No. 786/2007 and 558/2017). Under this prescribing route, the responsibilities of the milk purchaser, the farmer and the veterinary practitioner were each outlined, and a written mastitis control programme (MCP) was required. Milk purchasers implemented MCPs on participating farms (so-called MCP herds) with support from veterinary practitioner(s) who undertook Schedule 8 prescribing of intramammary AM tubes. This study seeks a clearer understanding of the role of milk purchasers in the prescribing and sale of intramammary AM products in Ireland during 2019 and 2020, whilst this Regulation was in force. Specifically, the study sought insights into the role of milk purchasers in the prescribing and sale of intramammary AM products in the Irish dairy industry during 2019 and 2020, using anonymised and highly aggregated milk purchaser data. The study also provided insights into milk quality among supplying herds during this period.

Methods

For this study, we had access to anonymised, highly aggregated data from all milk purchasers that operated a MCP on at least some of their supplying herds during 2019 or 2020. Data collection was undertaken by the Department of Agriculture, Food and Marine. Data analysis was primarily descriptive.

Results

Data were available on 11 milk purchasers (64.7% of all) and 13,251 supplying herds. Of these, 52% were MCP herds. The quality of milk from supplying herds varied significantly by month, year and milk purchaser. During 2019 and 2020, there was a single Schedule 8 prescriber (a private veterinary practitioner prescribing intramammary AMs as part of a MCP), on average, for 549.3 herds. The sale of intramammary AM products through milk purchasers represented 15.2% and 26.9% of national sales in in-lactation and dry cow tubes, respectively. There was an overall 2% increase in sales through milk purchasers between 2019 and 2020. Few European Medicines Agency (EMA) category B (‘Restrict’) intramammary AM products were sold by milk purchasers. For both in-lactation and dry cow tubes, there was a statistically significant association between EMA classification and route of sale (through milk purchasers or otherwise).

Conclusions

The study findings provide important insights into mastitis control and intramammary AM stewardship in the Irish dairy industry. Significant differences between milk purchasers were observed in the quality of milk, as measured through somatic cell count (SCC) values, from supplying herds. This warrants further research. In the context of intramammary AM prescribing, veterinary oversight under the Animal Remedies Regulation 2007 to 2017 was very limited during 2019 and 2020. There were also significant associations between EMA classification and route of sale during 2019 and 2020, reinforcing the need for Irish veterinary practitioners to move away from EMA category B intramammary AMs. Higher quality data are needed to address important industry questions. Specifically it is recommended that national bulk tank SCC data are made available for public good research. Past experiences with Schedule 8 prescribing (no longer permitted from 28 January 2022) may influence current efforts towards improved intramammary AM stewardship.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13620-022-00227-4.

Attitudes towards Use of High-Importance Antimicrobials—A Cross-Sectional Study of Australian Veterinarians

The timely implementation of antimicrobial stewardship interventions could delay or prevent the development of higher levels of antimicrobial resistance in the future. In food-producing animals in Australia, high-importance antimicrobials, as rated by the Australian Strategic and Technical Advisory Group (ASTAG), include virginiamycin and third-generation cephalosporins (in individual pigs or cattle). The use of high-importance antimicrobials in companion animals is more widespread and less regulated. There is no national antimicrobial use surveillance system for animals in Australia. Consequently, there is a gap in the knowledge about reasonable use across all sectors of veterinary practice. This study explored attitudes towards the use in veterinary medicine of antimicrobials with high importance to human health, and determined levels of agreement about the introduction of restrictions or other conditions on this use. An online survey was distributed via social media and email from June to December 2020 to veterinarians working in Australia. Of the 278 respondents working in clinical practice, 49% had heard of the ASTAG rating system, and 22% used a traffic light system for antimicrobial importance in their practice. Overall, 61% of participants disagreed that veterinarians should be able to prescribe high-importance antimicrobials without restrictions. If there were to be restrictions, there was most agreement amongst all respondents for only restricting high-importance antimicrobials (73%). There is a need for education, guidance, and practical support for veterinarians for prescribing high-importance antimicrobials alongside any restrictions.

Veterinary Practitioners' Standpoints and Comprehension towards Antimicrobial Use-Are There Opportunities for Antimicrobial Stewardship Improvement?

The main subject of the research is the assessment of the knowledge, attitudes and behaviors of veterinarians regarding the use of antibiotics (AMU) and antimicrobial resistance (AMR) through a questionnaire conducted among veterinarians in the northern region of Serbia. A total of 62 respondents completed the questionnaire, which represents a response rate of 44.3%. Male veterinarians are less likely to be in the group of veterinarians with insufficient knowledge (p < 0.05). Veterinarians engaged in mixed practice (small and large animals) (p < 0.001) and veterinarians who have over 100 patients per month (p < 0.005) are also less likely to be in the group with insufficient knowledge of antimicrobial resistance. The proportion of those with insufficient knowledge is growing among veterinarians whose source is the Internet (p < 0.01), while the proportion of those with insufficient knowledge about antimicrobial resistance is declining among veterinarians whose source of information is continuous education (p < 0.05). The majority of the respondents (n = 59, 95.2%) completely agreed that AMR is a very big issue in the global health sector right now. Unfortunately, there are crucial gaps in the knowledge and attitudes of the surveyed participants. They do not appear to be aware of the importance of AMU in veterinary medicine and its influence on overall AMR, or the crucial part that non-prescribed antibiotics have in all of it. Positively, many veterinarians use good practice AMU guidelines in their everyday practice and in line with the global trend of AMU reduction, respondents have also decreased their AMU compared to the previous year.

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

BACKGROUND

Antimicrobial stewardship is a cornerstone of efforts to combat antimicrobial resistance. We evaluated the impact of a formal discussion of antimicrobial stewardship for dogs and cats on systemic antimicrobial prescribing behaviours among companion animal veterinarians.

METHODS

Electronic health records including information about the prescription of antimicrobials were collected from a multisite UK veterinary practice between 2017 and 2020. We undertook interrupted time series analysis using a quasi-Poisson model to compare the pre- and postintervention change in level and slope for multiple outcomes.

RESULTS

After the intervention, there were sustained reductions in the prescription rate of cefovecin to cats and metronidazole to dogs and increases in amoxicillin-clavulanic acid prescribing. There was no evidence for an immediate change in overall prescribing rates in either species, although rates increased over the 12 months after the intervention. There was a transient increase in the proportion of dogs who had their weight recorded at the time of prescription. Results suggest decreases in the prescription of off-licence antimicrobials in both species and the likelihood of underdosing in dogs.

CONCLUSIONS

Discussion of antimicrobial stewardship is more likely to influence the antimicrobial choice than whether to prescribe or not. Interventions may benefit by focusing on appropriate antimicrobial selection rather than overall prescription frequency.

Assessing Knowledge, Beliefs, and Behaviors around Antibiotic Usage and Antibiotic Resistance among UK Veterinary Students: A Multi-Site, Cross-Sectional Survey

Antimicrobial resistance (AMR) is a profound threat to human and animal health. Antimicrobial prescribing behaviours are influenced by psychological factors such as knowledge, beliefs, and emotions. As future antimicrobial prescribers, it is important to understand beliefs about AMR and stewardship among veterinary (vet) students. This cross-sectional online survey assessed vet students’ self-reported behavior, knowledge, and beliefs in specific relation to antibiotic resistance (ABR) and antibiotic usage. Participants were early years (first- and second-year; n = 460) and later-years (third- and fourth-year; n = 113) undergraduate vet students from three UK universities. Self-reported antibiotic-related behaviors were responsible among most students. Knowledge about ABR and stewardship was moderate among early years students and good among later years students. Vet students typically believed that vets had less responsibility for both causing and preventing ABR than other groups (animal owners, human medics, and the public). This study offers evidence that vet students (along with other groups) tend to lay greater responsibility for ABR/AMR outside of their own profession, which may impact their future prescribing behaviors. It is vital that AMR and antimicrobial stewardship are embedded across veterinary curricula, and that the One Health nature of the challenge posed by AMR is emphasized to encourage shared responsibility across all stakeholder groups, thereby helping to reduce ‘other-blaming’ for AMR.

Factors Associated with Antimicrobial Stewardship Practices on California Dairies: One Year Post Senate Bill 27

BACKGROUND

The current study is aimed at identifying the factors associated with antimicrobial drug (AMD) use and stewardship practices on conventional California (CA) dairies a year after CA Senate Bill 27.

METHODS

Responses from 113 out of 1282 dairies mailed a questionnaire in 2019 were analyzed to estimate the associations between management practices and six outcomes including producer familiarity with medically important antimicrobial drugs (MIADs), restricted use of MIADs previously available over the counter (OTC), use of alternatives to AMD, changes in on-farm management practices, changes in AMD costs, and animal health status in dairies.

RESULTS

Producers who reported having a veterinarian-client-patient relationship (VCPR) and tracking AMD withdrawal intervals had greater odds of being familiar with the MIADs. Producers who began or increased the use of preventive alternatives to AMD in 2019 had higher odds (OR = 3.23, p = 0.04) of decreased use of MIADs previously available OTC compared to those who did not. Changes in management practices to prevent disease outbreak and the use of diagnostics to guide treatment were associated with producer-reported improved animal health. In addition, our study identified record keeping (associated with familiarity with MIADs), use of alternatives to AMD (associated with management changes to prevent diseases and decreased AMD costs), and use of diagnostics in treatment decisions (associated with reported better animal health) as factors associated with AMD stewardship.

CONCLUSIONS

Our survey findings can be incorporated in outreach education materials to promote antimicrobial stewardship practices in dairies.

Cattle farmer psychosocial profiles and their association with control strategies for bovine viral diarrhea

Bovine viral diarrhea (BVD) is endemic in the United Kingdom and causes major economic losses. Control is largely voluntary for individual farmers and is likely to be influenced by psychosocial factors, such as altruism, trust, and psychological proximity (feeling close) to relevant “others,” such as farmers, veterinarians, the government, and their cows. These psychosocial factors (factors with both psychological and social aspects) are important determinants of how people make decisions related to their own health, many of which have not been studied in the context of infectious disease control by farmers. Farmer psychosocial profiles were investigated using multiple validated measures in an observational survey of 475 UK cattle farmers using the capability, opportunity, motivation-behavior (COM-B) framework. Farmers were clustered by their BVD control practices using latent class analysis. Farmers were split into 5 BVD control behavior classes, which were tested for associations with the psychosocial and COM-B factors using multinomial logistic regression, with doing nothing as the baseline class. Farmers who were controlling disease both for themselves and others were more likely to do something to control BVD (e.g., test, vaccinate). Farmers who did not trust other farmers, had high psychological capability (knowledge and understanding of how to control disease), and had high physical opportunity (time and money to control disease) were more likely to have a closed, separate herd and test. Farmers who did not trust other farmers were also more likely to undertake many prevention strategies with an open herd. Farmers with high automatic motivation (habits and emotions) and reflective motivation (decisions and goals) were more likely to vaccinate and test, alone or in combination with other controls. Farmers with high psychological proximity (feeling of closeness) to their veterinarian were more likely to undertake many prevention strategies in an open herd. Farmers with high psychological proximity to dairy farmers and low psychological proximity to beef farmers were more likely to keep their herd closed and separate and test or vaccinate and test. Farmers who had a lot of trust in other farmers and invested in them, rather than keeping everything for themselves, were more likely to be careful introducing new stock and test. In conclusion, farmer psychosocial factors were associated with strategies for BVD control in UK cattle farmers. Psychological proximity to veterinarians was a novel factor associated with proactive BVD control and was more important than the more extensively investigated trust. These findings highlight the importance of a close veterinarian-farmer relationship and are important for promoting effective BVD control by farmers, which has implications for successful nationwide BVD control and eradication schemes.

Knowledge and perceptions of Australian postgraduate veterinary students prior to formal education of antimicrobial use and antimicrobial resistance

Antimicrobial resistance (AMR) is widely perceived as a threat to human and animal health and a significant One Health issue with extensive and complex factors contributing to its occurrence and spread. Previous studies have surveyed human and animal health professionals to determine their perceptions regarding AMR and antimicrobial use (AMU). There are limited studies exploring the understanding of veterinary students despite their critical role as future antimicrobial prescribers. A cross-sectional survey was administered to an entire cohort of Doctor of Veterinary Medicine Year 2 (DVM2) students (n = 136) to investigate their knowledge and perceptions regarding AMR and AMU prior to formal education on this issue. Ninety students (66.2% of the cohort) completed the survey. There was overwhelming agreement regarding the immediacy of the problem, with 84.4% of students indicating that ‘We must take action on AMR’. Despite more than 94.4% of students correctly defining AMR, specific knowledge regarding AMR impact, contributory causes to AMR and strategies to solve the challenge of AMR was variable. Most students perceived livestock producers to have a significant role in the perpetuation of AMR due to AMU for prophylaxis (71.1% substantial/moderate contribution) and treatment (56.7% substantial/moderate contribution). Over a third of respondents (37.8%) were unsure if AMR could spread from animals to humans. Respondents perceived that various groups (dentists, doctors, veterinarians, professional organisations) are all important in ameliorating the issue of AMR. The implementation of restrictive measures to reduce veterinary prescription of antimicrobials was viewed as less important than strategies involving education, hygiene, surveillance, and guideline development/availability. To encourage the development of good antimicrobial stewardship (AMS) practices, professional veterinary education needs to foster an understanding of the scientific, behavioural and social issues that contribute to AMR and inappropriate AMU, as well as prescribers' personal contribution to AMR perpetuation and amelioration.

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Reports on perceptions of postgraduate veterinary students regarding factors responsible for AMR prior to formal instruction in a DVM program

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Students were unsure about routes of transfer of AMR between humans and animals, and antimicrobial use for routine veterinary procedures

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Students had high agreement that antimicrobial use in livestock contributed to AMR

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Students, like qualified veterinarians, do not like the concept of government restricting their ability to prescribe antimicrobials

Knowledge, Attitudes, and Common Practices of Livestock and Poultry Veterinary Practitioners Regarding the AMU and AMR in Bangladesh

Current evidence indicates that more than half of all antimicrobials are used in the animal food-producing sector, which is considered a significant risk factor for the development, spread, and existence of antimicrobial resistance (AMR) pathogens in animals, humans, and the environment. Among other factors, clinical etiology and the level of knowledge, attitudes, and practices (KAP) of veterinarians are thought to be responsible for inappropriate prescriptions in the animal-source protein production sector in lower-resource settings like Bangladesh. We performed this cross-sectional study to assess factors associated with veterinarians’ antimicrobial prescription behavior and their KAP on antimicrobial use (AMU) and AMR in Bangladesh. Exploratory and multivariate logistic models were used to describe an association between knowledge, attitudes, and practices of AMU and AMR and demographic characteristics of veterinarians. The results demonstrated that when selecting an antimicrobial, there was no to minimal influence of culture and susceptibility tests and patients’ AMU history but moderate to high influence of the farmer’s economic condition and drug instructions among the veterinarians. The results also demonstrated that more than half of the veterinarians had correct KAP regarding AMU and AMR, while the rest had moderate or lower levels of KAP. The factor score analysis revealed that age, level of education, years of experience, gender, and previous training on AMU and AMR were the key influencing factors in their level of KAP. Adjusted logistic regression analysis showed that respondents’ age, current workplace, and previous training on AMU and AMR had a positive association with increased KAP. Considering the results, it is imperative to include AMR issues on vet curricula, and to provide post-education training, awareness campaigns, easy access to, and dissemination of AMR resources. Increasing the veterinary services to the outreach areas of the country and motivating veterinarians to follow the national AMR guidelines could be some other potential solutions to tackle the over-prescriptions of antimicrobials.

Farm Animal Veterinarians' Knowledge and Attitudes toward Antimicrobial Resistance and Antimicrobial Use in the Republic of Serbia

Antimicrobial resistance (AMR) is considered one of the most prevalent global health issues in both veterinarian and human medicine. This complex problem requires a "One Health" approach with the cooperation of all healthcare sectors, as well as agriculture, finance, and consumers. We conducted a survey with the objective to assess the knowledge and attitudes of farm animal veterinarians toward AMR and antimicrobial use in the Republic of Serbia with a small focus on mastitis therapy. A total of 110 respondents completed the questionnaire, which represents a response rate of 27.3%. The majority of our respondents (n = 102, 92.7%) completely agreed that AMR currently represents severe concern in the health sector. Unfortunately, less than one-third (n = 34, 30.9%) of the respondents had only heard about antimicrobial stewardship. Participants showed a positive attitude toward prudent antimicrobial use and were open to solutions to the AMR crisis. We noticed a certain gap between farm veterinarians' desire to improve and perform better in daily practice, while at the same time feeling like they did not have enough guidance, help, and resources.

A VetCompass Australia Study of Antimicrobial Use in Dog-to-Dog Bite Wounds (1998-2018)

Although dog-to-dog bite wounds (DBW) are a common presentation to veterinary clinics, antimicrobial prescribing habits of Australian clinics have not been reported. This study determined the frequency and results of DBW cultures; antimicrobial selection; and importance class of antimicrobials prescribed relative to wound severity, geographic location, or year. A systematic sample of 72,507 patient records was retrieved from the VetCompass Australia database. Records for 1713 dog bite events involving 1655 dogs were reviewed for presenting signs, results of culture and susceptibility testing (C&S), antimicrobial treatment, geographical location, and outcome. A crossed random effects multivariable logistic regression model was used to determine if antimicrobial importance was associated with wound severity, year, and location, and to assess the differences in antimicrobial prescription between geographical locations, clinics, and veterinarians. Antimicrobials were prescribed in 86.1% of DBW. Amoxicillin-clavulanic acid was prescribed in 70% (1202/1713) with underdosing in 15.8% (191/1202). High-importance antimicrobial use was associated with wound severity (p < 0.001), year category (p = 0.007), and surgery (p = 0.03). C&S testing was recorded as having been performed in only one case. Differences in individual veterinarian prescribing habits were stronger than the clinic culture, suggesting that education utilizing clinic-wide antimicrobial guidelines may aid in improving antimicrobial stewardship.

Narratives of veterinary drug use in northern Tanzania and consequences for drug stewardship strategies in low-income and middle-income countries

INTRODUCTION

Awareness-raising campaigns play a central role in efforts to combat drug resistance. These campaigns assume that knowledge deficits drive poor practices that increase resistance. Therefore, increasing awareness will promote prudent practices and reduce resistance. However, most awareness campaigns have been developed and evaluated in high-income and public health settings. Consequently, it is not clear whether these campaigns are effective in low-income and middle-income countries and/or within animal health settings.

METHODS

Focus group discussions and in-depth interviews were used to collect narratives of veterinary drug use among Maasai pastoralists (n=70), animal health professionals (n=10) and veterinary drug sellers (n=5). Thematic analysis was used to identify recurring themes across narratives and groups.

RESULTS

Narratives of Maasai and animal health professionals indicated that Maasai treated their livestock with limited input from the professional sector and that non-prudent treatment practices were observed (eg, using antimicrobials as 'energizers'). Professionals linked these practices to knowledge and attitudinal deficits among the Maasai, while Maasai narratives highlighted the importance of climatic uncertainties and cultural beliefs surrounding veterinary care.

CONCLUSION

Narratives of veterinary drug use from animal health professionals are consistent with the knowledge deficit assumption guiding awareness-raising efforts. In contrast, Maasai narratives highlight how animal health practices are patterned by cultural norms interacting with factors largely outside of Maasai control, including a constrained professional veterinary sector. If these cultural and structural contexts remain unconsidered in awareness-raising strategies, current campaigns are unlikely to motivate practices necessary to limit drug resistance, especially within low-income and middle-income settings.

OUP accepted manuscript

Background

Antimicrobial stewardship programmes (ASPs) have been widely implemented in medical practice to improve antimicrobial prescribing and reduce selection for multidrug-resistant pathogens.

Objectives

To implement different antimicrobial stewardship intervention packages in 135 veterinary practices and assess their impact on antimicrobial prescribing.

Methods

In October 2018, general veterinary clinics were assigned to one of three levels of ASP, education only (CON), intermediate (AMS1) or intensive (AMS2). De-identified prescribing data (1 October 2016 to 31 October 2020), sourced from VetCompass Australia, were analysed and a Poisson regression model fitted to identify the effect of the interventions on the incidence rates of antimicrobial prescribing.

Results

The overall incidence rate (IR) of antimicrobial prescribing for dogs and cats prior to the intervention was 3.7/100 consultations, which declined by 36% (2.4/100) in the implementation period, and by 50% (1.9/100) during the post-implementation period. Compared with CON, in AMS2 there was a 4% and 6% reduction in the overall IR of antimicrobial prescribing, and a 24% and 24% reduction in IR of high importance antimicrobial prescribing, attributable to the intervention in the implementation and post-implementation periods, respectively. A greater mean difference in the IR of antimicrobial prescribing was seen in high-prescribing clinics.

Conclusions

These AMS interventions had a positive impact in a large group of general veterinary practices, resulting in a decline in overall antimicrobial use and a shift towards use of antimicrobials rated as low importance, with the greatest impact in high-prescribing clinics.

Assessing knowledge, attitude, and practices of veterinarians towards antimicrobial use and stewardship as drivers of inappropriate use in Abuja, Nigeria

INTRODUCTION

Antimicrobial resistance (AMR) has recently gained worldwide recognition, as the emergence of multi-drug resistant organisms has led to increased mortality and economic burden. This study aimed to assess knowledge, attitudes, and practices of veterinarians towards rational antimicrobial prescribing and identify factors influencing use.

METHODS

We interviewed veterinary doctors in Abuja, Nigeria using a 50-point questionnaire distributed via WhatsApp mobile application. The questionnaire inquired about their experiences, knowledge, attitudes, and practices towards AMR and stewardship. We analyzed the data by calculating frequencies and proportions.

RESULTS

Of 220 registered veterinarians, 144 (65.5%) participated in the survey. Most (52.8%) were within the age group 30 - 39 years; males (72.2%), with a Master's degree (42.4%) and worked in public service (44.4%). Three-quarters (75.7%) had good knowledge of antimicrobials; 47.2% had received training on stewardship while 88.9% reported that they believed that overuse of antimicrobials was the major contributory factor towards AMR. Antimicrobial stewardship regulations are important in veterinary practice. Veterinarians were aware of the occurrence of resistant pathogens and agreed that restricting antimicrobial use in animal health care was necessary to reduce AMR.

CONCLUSION

Most respondents referred to the veterinary formulary (VF) when in doubt of the appropriate antimicrobial agent to administer. We recommend that the VF be updated following the WHO list of critically-important-antimicrobials (CIA) and veterinarians educated not to use these CIAs in the treatment of food animals.

Antimicrobial use in agriculture: critical review of the factors influencing behaviour

Antimicrobial resistance (AMR) is a global health emergency affecting humans and animals, diminishing the effectiveness of medication used to treat illness. The agri-food sector has attracted increased attention for imprudent antimicrobial use (AMU) and its contribution to AMR. Thus, ascertaining farmers' and veterinarians' behaviours surrounding AMU is essential to address imprudent AMU and generate behaviour change within the agri-food sector. Therefore, the aim of this critical review is to investigate, assess and collate the current body of evidence to identify psychosocial factors including knowledge, understanding, perceptions, attitudes and behaviours surrounding AMU. Database searches were limited to articles utilizing qualitative and quantitative methodologies, available in English with no restriction on publication year. Of the 1156 articles identified, 103 were retained for this review. Findings on the psychosocial aspects were thematically analysed. Five key themes emerged from the data: (i) knowledge and awareness of antimicrobials; (ii) attitudes towards antimicrobials; (iii) influential relationships; (iv) resources; and (v) factors influencing AMU. Results indicated that to overcome barriers experienced by key stakeholders, a carefully considered, evidence-based approach, incorporating behaviour change theory, is required when designing intricate interventions/strategies, in order to elicit successful and sustained AMU behaviour change.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Restrictive but not restricted: Perspectives on antimicrobial use and antimicrobial resistance among Swedish dairy veterinarians

BACKGROUND AND AIMS

In Europe, the antimicrobial use (AMU) for food-producing animals has decreased rapidly. However, studies indicate that a too strict policy, with too restrictive AMU, is potentially problematic for veterinarians because it threatens animal welfare and creates tensions between farmers and veterinarians. The AMU in Sweden is among the lowest in Europe, and regulation of AMU in farm animals is strict. The aim of our study was to explore how Swedish veterinarians describe the relations between (1) being restrictive with antibiotics due to the risk of AMR and (2) concerns for animal welfare and/or the veterinarian-client relationship.

METHODS

Semi-structured interviews with 21 veterinarians, working with dairy cattle, were performed. The transcripts were analysed, and a number of dominant patterns which recurred in all, or most of, the interviews were identified.

RESULT

The interviewed veterinarians described AMR prevention and tackling the threat AMR poses towards public health, as central for their profession and as influencing their everyday practice and decisions on AMU. Importantly, veterinarians described accounting for AMR in everyday practice as fairly unproblematic, both in relation to animal welfare as well as in relation to farmers. The veterinarians generally perceived that they could treat animals with antibiotics when justified, and being restrictive with antibiotics was described as an expression of professional skill and not as challenging as animal welfare. Moreover, they stated that restrictive AMU seldom or never caused conflicts with farmers.

CONCLUSION

Strict AMU policy and restrictive AMU do not necessarily put veterinarians in a problematic position where they are caught between conflicting demands and risks.

Understanding Antibiotic Use in Companion Animals: A Literature Review Identifying Avenues for Future Efforts

Addressing antibiotic use is essential to tackle antimicrobial resistance, a major human and animal health challenge. This review seeks to inform stewardship efforts in companion animals by collating research insights regarding antibiotic use in this group and identifying overlooked avenues for future research and stewardship efforts. The development of population-based methods has established that antibiotics are frequently used in companion animal care. Research insights are also contributing toward an in-depth comprehension of the contexts to antibiotic use. Qualitative approaches, for example, have enabled a nuanced understanding in four key areas: interactions with owners, clinical and financial risk management, time pressures, and clinic dynamics. This review identifies that much of the existing research frames antibiotic use as the result of choices made by the individuals at the interface of their use. Future research and policy endeavours could look beyond the moment of prescribing to consider the societal structures and networks in which companion animal antibiotic use is entangled. A diversification in research approaches and frameworks through which antibiotic use is understood will facilitate the identification of additional targets for stewardship initiatives beyond providing information and awareness campaigns.

Evaluation of antimicrobial prescriptions in dogs with suspected bacterial urinary tract disease

Background

Antimicrobials are commonly used to treat urinary tract disease in dogs. Understanding antimicrobial use is a critical component of antimicrobial stewardship efforts.

Hypothesis/Objectives

To evaluate antimicrobial prescriptions for dogs diagnosed with acute cystitis, recurrent cystitis, and pyelonephritis.

Animals

Dogs prescribed antimicrobials for urinary tract disease at veterinary practices in the United States and Canada.

Materials and Methods

A retrospective review of antimicrobial prescriptions was performed.

Results

The main clinical concerns were sporadic bacterial cystitis (n = 6582), recurrent cystitis (n = 428), and pyelonephritis (n = 326). Amoxicillin/clavulanic acid (2702, 41%), cefpodoxime (1024, 16%), and amoxicillin (874, 13%) were most commonly prescribed for sporadic bacterial cystitis. The median prescribed duration was 12 days (range, 3‐60 days; interquartile range [IQR], 4 days). Shorter durations were used in 2018 (median, 10 days; IQR, 4 days) compared to both 2016 and 2017 (both median, 14 days; IQR, 4 days; P ≤ .0002).

Amoxicillin/clavulanic acid (146, 33%), marbofloxacin (95, 21%), and cefpodoxime (65, 14%) were most commonly used for recurrent cystitis; median duration of 14 days (range, 3‐77 days; IQR, 10.5 days). Amoxicillin/clavulanic acid (86, 26%), marbofloxacin (56, 17%), and enrofloxacin (36, 11%) were most commonly prescribed for pyelonephritis; however, 93 (29%) dogs received drug combinations. The median duration of treatment was 14 days (range, 3‐77 days; IQR, 11 days).

Conclusions and Clinical Importance

Decreases in duration and increased use of recommended first‐line antimicrobials were encouraging. Common drug choices and durations should still be targets for antimicrobial stewardship programs that aim to optimize antimicrobial use, concurrently maximizing patient benefits while minimizing antimicrobial use and use of higher tier antimicrobials.

Patterns of antimicrobial drug use in veterinary primary care and specialty practice: A 6-year multi-institution study

BACKGROUND

Combatting antimicrobial resistance requires a One Health approach to antimicrobial stewardship including antimicrobial drug (AMD) use evaluation. Current veterinary AMD prescribing data are limited.

OBJECTIVES

To quantify companion animal AMD prescribing in primary care and specialty practice across 3 academic veterinary hospitals with particular focus on third-generation cephalosporins, fluoroquinolones, and carbapenems.

ANIMALS

Dogs and cats presented to 3 academic veterinary hospitals from 2012 to 2017.

METHODS

In this retrospective study, AMD prescribing data from 2012 to 2017 were extracted from electronic medical records at each hospital and prescriptions classified by service type: primary care, specialty practice or Emergency/Critical Care (ECC). Hospital-level AMD prescribing data were summarized by species, service type, AMD class, and drug. Multivariable logistic full-factorial regression models were used to estimate hospital, year, species, and service-type effects on AMD prescribing. Estimated marginal means and confidence intervals were plotted over time.

RESULTS

The probability of systemic AMD prescribing for any indication ranged between 0.15 and 0.28 and was higher for dogs than cats (P < .05) apart from 2017 at hospital 1. Animals presented to primary care were least likely to receive AMDs (dogs 0.03-0.15, cats 0.03-0.18). The most commonly prescribed AMD classes were aminopenicillins/β-lactamase inhibitors (0.02-0.15), first-generation cephalosporins (0.00-0.09), fluoroquinolones (0.00-0.04), nitroimidazoles (0.01-0.06), and tetracyclines (0.00-0.03). Among the highest priority classes, fluoroquinolones (dogs 0.00-0.09, cats 0.00-0.08) and third-generation cephalosporins (dogs 0.00-0.04, cats 0.00-0.05) were most frequently prescribed.

CONCLUSIONS AND CLINICAL IMPORTANCE

Antimicrobial drug prescribing frequencies were comparable to previous studies. Additional stewardship efforts might focus on fluoroquinolones and third-generation cephalosporins.

Dairy veterinarians' perceptions and experts' opinions regarding implementation of antimicrobial stewardship on dairy farms in the western United States

OBJECTIVE

To explore veterinarians' perceptions and veterinary experts' opinions regarding antimicrobial stewardship (AMS) on dairy farms in the western United States.

SAMPLE

20 dairy veterinarians and 9 AMS experts.

PROCEDURES

3 focus group discussions involving 20 dairy veterinarians from California, Idaho, and Washington and an expert opinion study involving 9 North American AMS experts were conducted. During focus group discussions, participants were asked open-ended questions regarding implementation of AMS programs on dairy farms. Discussions were recorded and transcribed for thematic analysis. An asynchronous nominal group process was used for the expert opinion study. Participants were asked to complete a series of 3 online surveys consisting of open-ended questions. Expert opinion data underwent thematic analysis and were compared with results obtained from focus group discussions.

RESULTS

Veterinarian-perceived barriers to implementation of AMS on dairy farms included variable relationships with clients and farm employees, ensuring AMS provided value to the farm, and uncertainty about regulations for monitoring on-farm antimicrobial use (AMU). Veterinarians were willing to accept additional responsibility for AMU provided that protocols were adopted to ensure them more complete control of on-farm AMU and they were compensated. The AMS experts indicated that effective implementation of AMS on dairy farms requires producer buy-in and tools to facilitate treatment protocol development and monitoring.

CONCLUSIONS AND CLINICAL RELEVANCE

Additional veterinary oversight of AMU on dairy farms will require engagement by both veterinarians and producers and practical value-added methods for AMS. Continuing education programs should address treatment protocol development, AMU monitoring strategies, and employee training.

Examining the Effect of Context, Beliefs, and Values on UK Farm Veterinarians' Antimicrobial Prescribing: A Randomized Experimental Vignette and Cross-Sectional Survey

Antimicrobial resistance (AMR) is a pressing threat to public and animal health. There is evidence that antimicrobial prescribing and stewardship behaviors by veterinarians (vets) are influenced by non-clinical factors, such as psychological, social, and environmental factors. This study explored the role of context, beliefs, and values on vets' antimicrobial prescribing decisions. UK-based practicing farm vets (n = 97) were recruited to an online study. Using an experimental vignette methodology, vets were randomly assigned across four conditions, to examine the effects of different contexts (pressure on farm economics, the farmer, or the vet-farmer relationship, compared to a control condition) on vets' likelihood of prescribing antibiotics. Vets' beliefs about different groups' responsibility for causing and preventing AMR and vets' values were also measured. Key findings were that context alone, values, and beliefs about groups' responsibilities for causing AMR were not predictive of vets' likelihood of prescribing antibiotics. However, vets' beliefs about groups' responsibilities for preventing AMR were predictive of an increased likelihood of prescribing antibiotics, when vets were exposed to the experimental condition of the vignette in which the vet-farmer relationship was under pressure. Farm vets also believed that different groups have different levels of responsibility for causing and preventing AMR. Results should be interpreted cautiously, given the smaller than planned for sample size, and the possibility for both false negatives and false positives. Further research is needed to explore how these findings could inform antimicrobial stewardship interventions in veterinary medicine.

Antibiotic prescription practices and opinions regarding antimicrobial resistance among veterinarians in Kentucky, USA

Background

Inappropriate antimicrobial use (AMU) is a global concern. Opinions of veterinarians regarding AMU and its role in the development of antimicrobial resistance (AMR) may influence their prescription practices. It is important to understand these opinions, prescription practices and their potential impact on the development of AMR in order to guide efforts to curb the problem. Therefore, the objective of this study was to investigate the antimicrobial prescription practices and opinions of veterinarians in Kentucky regarding AMU and AMR.

Methods

This cross-sectional study used a 30-question survey questionnaire administered to veterinarians who were members of the Kentucky Veterinary Medical Association. Survey responses from 101 participants were included in the study. Descriptive statistics were computed and associations between categorical variables assessed using Chi-square or Fisher’s exact tests. Firth logistic models were used to investigate predictors of “Compliance with prescription policies” and “Cost of antimicrobial affects prescription decisions”.

Results

Almost all (93%) respondents indicated that improper AMU contributed to selection for AMR. A total of 52% of the respondents believed that antimicrobials were appropriately prescribed, while the remaining 48% believed that antimicrobials were inappropriately prescribed. Significant predictors of compliance with prescription policies were availability of prescription policy at the veterinary facility (Odds Ratio (OR) = 4.2; p<0.001) and over-prescription (OR = 0.35; p = 0.025). Similarly, significant predictors of cost of antimicrobials affecting prescription decisions were lack of post-graduate training (OR = 8.3; p = 0.008) and practice type, with large animal practices having significantly lower odds of the outcome (OR = 0.09; p = 0.004) than small animal practices.

Conclusion

Most veterinarians indicated that improper AMU contributed to selection for AMR. Since the odds of compliance with prescription policies were 4-times higher among veterinarians working at facilities that had prescription policies compared to those at facilities that didn’t, more veterinary facilities should be encouraged to adopt prescription policies to help improve compliance and reduce AMR. Veterinarians would also benefit from continued professional education to help improve prescription practices, antimicrobial stewardship and curb AMR.

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.

Towards a Better and Harmonized Education in Antimicrobial Stewardship in European Veterinary Curricula

Education in antimicrobial stewardship (AMS) in veterinary medicine is essential to foster responsible antimicrobial use and control of antimicrobial resistance (AMR) in animals. AMS is listed by the EU and international organizations among the basic 'Day One Competences' required of veterinary students upon graduation. Our aim was to evaluate the quality of education of European veterinary students in AMS. We distributed a 27-item survey addressing the perceptions of preparedness and acquired skills on key topics related to AMS to final-year veterinary students in Europe. We collected 3423 complete answers from 89 veterinary schools in 30 countries. Selection of treatment strategies and awareness of emerging AMR problems were markedly different between countries. Overall, only one in four students was familiar with guidelines for antimicrobial use. The students perceived a medium-high impact of veterinary antimicrobial use on AMR in humans. Notably, 75% of the students felt the need for improved teaching on AMS, half of which also demanded more teaching on general antimicrobial therapy. Our results highlight several possible strategies to improve the quality of education, ranging from a better link between clinical rotations and the theory taught in pre-clinical modules, to a more effective introduction into best practices for antimicrobial use.

Designing a National Veterinary Prescribing Champion Programme for Welsh Veterinary Practices: The Arwain Vet Cymru Project

Antimicrobial use in agriculture has been identified as an area of focus for reducing overall antimicrobial use and improving stewardship. In this paper, we outline the design of a complex antimicrobial stewardship (AMS) intervention aimed at developing a national Veterinary Prescribing Champion programme for Welsh farm animal veterinary practices. We describe the process by which participants were encouraged to design and deliver bespoke individualised AMS activities at practice level by forging participant “champion” identities and communities of practice through participatory and educational online activities. We describe the key phases identified as important when designing this complex intervention, namely (i) involving key collaborators in government and industry to stimulate project engagement; (ii) grounding the design in the literature, the results of stakeholder engagement, expert panel input, and veterinary clinician feedback to promote contextual relevance and appropriateness; and (iii) taking a theoretical approach to implementing intervention design to foster critical psychological needs for participant motivation and scheme involvement. With recruitment of over 80% of all farm animal practices in Wales to the programme, we also describe demographic data of the participating Welsh Veterinary Prescribing Champions in order to inform recruitment and design of future AMS programmes.

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.

Survey of perceptions and attitudes of an international group of veterinarians regarding antibiotic use and resistance on dairy cattle farms

Veterinarians are the main source of information for farmers regarding the responsible use of antibiotics in farm animals and how to reduce the risk of antibiotic resistance. Consequently, understanding how veterinarians perceive their clients' and colleagues' antibiotic use and their own beliefs about the development of antibiotic resistance is essential to determining areas in which antibiotic use practices can be improved to minimize the emergence of antibiotic resistance. An international cross-sectional study was carried out using a questionnaire designed to elucidate perceptions, attitudes, and concerns of dairy veterinarians regarding antibiotic use and the emergence of antibiotic resistance in dairy farming. The questionnaire was initially administered to veterinarians attending the International Bovine Mastitis Conference in Milano, Italy, 2018, followed by veterinarian members of the National Mastitis Council, and all conference registrants. A total of 71 participants from 21 countries participated in the survey, the majority were from the United States and member countries of the European Union. Logistic regression analysis was conducted to identify predictors of veterinarians' level of concern about the development of antibiotic resistance on their clients' farms. Associations were described with odds ratios (ORs) and the associated 95 % confidence intervals (95 % CIs). Free text responses where participants shared their views on the reason for overprescribing antibiotics by veterinarians were analyzed using thematic analysis. Participants perceived that nearly half of their clients overuse or inappropriately use antibiotics, and nearly half of their colleagues overprescribe or inappropriately prescribe antibiotics. After controlling for other factors, the odds of veterinarians being concerned about antibiotic resistance on dairy farms they served decreased by a factor of 0.91 for each additional year of participants' experience working with dairy cattle (OR = 0.91, 95 % CI = 0.84-0.99). Participants concerned about antibiotic resistance on clients' dairy farms were also more likely to consider better adherence to drug labelling as important for reducing farmers' antibiotic use (OR = 6.86, 95 % CI = 1.21-38.93). Thematic analysis revealed four themes surrounding the perceived reasons for veterinarians' overprescribing of antibiotics: (i) knowledge, (ii) attitudes, (iii) barriers, and (iv) rules and regulations. The study findings will aid in the development of strategies to improve antibiotic use in dairy farming and educational initiatives looking to enhance the communication between veterinarians and farmers about judicious use of antibiotics.

Knowledge, attitudes and influencers of North American dog-owners surrounding antimicrobials and antimicrobial stewardship

OBJECTIVES

To quantify the individual influences of antimicrobial cost, method of administration and drug importance in human medicine on dog-owner antimicrobial preference, and determine knowledge, attitudes and influencers of dog-owners surrounding antimicrobials and antimicrobial stewardship.

MATERIALS AND METHODS

Data were collected through an online survey targeting three dog-owner participant groups. These consisted of individuals residing in: (1) Canada, (2) USA and (3) any country recruited through an educational social media site. USA and Canadian participants were financially compensated. Conjoint analysis was used to quantify the influence of antimicrobial cost, method of administration and drug importance in human medicine. Descriptive and analytical statistics were used for data evaluation.

RESULTS

A total of 809 surveys were completed. Antimicrobial cost accounted for 47% of dog-owner preferences, followed by method of administration (31%) and drug importance in human medicine (22%). All groups preferred lower cost drugs that were administered once by injection. Participants were more likely to prefer drugs considered "very important" in human medicine, except for the social media participants, who preferred drugs that were "not at all important." Most respondents (86%) reported antimicrobial resistance as important in human medicine and 29% believed antimicrobial use in pets posed a risk for antimicrobial resistance in humans. Participants recruited through social media, and those in the highest education category, were significantly more likely to report antimicrobial use in pets as a risk to people.

CLINICAL SIGNIFICANCE

Cost was the most important factor in dog-owner antimicrobial preferences. There is a need for dog-owner antimicrobial stewardship education.

An efficient cephalosporin stewardship programme in French swine production

By 2010, systems set up to monitor the antimicrobial resistance of pathogenic bacteria and antimicrobial usage identified a sustained increase regarding third‐ and fourth‐generation cephalosporin resistance in French pig production. This sector mobilised and collectively committed to responsible action in the following months. This led to a multi‐professional voluntary stewardship programme that was started in 2011. A consensus of veterinary opinion led to the definition of restrictive rules on the prescription of the third‐ and fourth‐generation cephalosporins targeted by the antimicrobial stewardship programme (ASP). All pig sector professionals, including farmers, were informed. Existing monitoring systems for usage and resistance were supplemented by data from the records of veterinarians' cephalosporin deliveries and from individual pig farm surveys investigating antimicrobial usage. The second step, from 2014, entailed regulatory measures that consolidated the programme by setting quantitative reduction objectives and specifying the terms and conditions for prescribing and dispensing a list of critical antimicrobial molecules including cephalosporins. All the data sources confirmed a significant fall of more than 90% in cephalosporin usage in the French pig production sector between 2010 and 2016. Monitoring systems recorded that the resistance of commensal and pathogenic Escherichia coli isolates also tended to decrease over the same period. The stewardship programme proved highly effective in reducing usage and containing resistance, illustrating the efficiency of a well‐defined multi‐professional strategy.

In-Water Antibiotic Dosing Practices on Pig Farms

Pigs reared on many farms are mass-medicated for short periods with antibiotics through their drinking water to control bacterial pathogen loads and, if a disease outbreak occurs, to treat pigs until clinical signs are eliminated. Farm managers are responsible for conducting in-water antibiotic dosing events, but little is known about their dosing practices. We surveyed managers of 25 medium to large single-site and multi-site pig farming enterprises across eastern and southern Australia, using a mixed methods approach (online questionnaire followed by a one-on-one semi-structured interview). We found wide variation in the antibiotics administered, the choice and use of dosing equipment, the methods for performing dosing calculations and preparing antibiotic stock solutions, the commencement time and duration of each daily dosing event, and the frequency of administration of metaphylaxis. Farm managers lacked data on pigs’ daily water usage patterns and wastage and the understanding of pharmacology and population pharmacometrics necessary to optimize in-water dosing calculations and regimens and control major sources of between-animal variability in systemic exposure of pigs to antibiotics. There is considerable scope to increase the effectiveness of in-water dosing and reduce antibiotic use (and cost) on pig farms by providing farm managers with measurement systems, technical guidelines, and training programs.

Survey of production animal veterinarians' prescription practices, factors influencing antimicrobial drug use, and perceptions of and attitudes toward antimicrobial resistance

OBJECTIVE

To assess production animal medicine veterinarians' prescription practices and identify factors influencing their use of antimicrobial drugs (AMDs) and their perceptions of and attitudes toward antimicrobial resistance (AMR).

SAMPLE

157 production animal veterinarians in the United States.

PROCEDURES

An online cross-sectional survey and digital diary were used to gather information regarding perceptions on AMD use and AMR and on treatment recommendations for production setting-specific disease scenarios. Results were compared across respondents grouped by their selected production setting scenarios and reported years as veterinarians.

RESULTS

The most commonly selected production setting disease scenarios were dairy cattle (96/157 [61.1%]), backgrounding cattle (32/157 [20.4%]), and feedlot cattle (20/157 [12.7%]). Because few respondents selected swine (5/157 [3.2%]) or poultry (4/157 [2.5%]) scenarios, those responses were excluded from statistical analysis of AMD prescription practices. Most remaining respondents (147/148 [99.3%]) reported that they would recommend AMD treatment for an individual ill animal; however, responses differed for respondents grouped by their selected production setting scenarios and reported years as veterinarians when asked about AMD treatment of an exposed group or high-risk disease-free group. Most respondents reported that government regulations influenced their AMD prescribing, that owner and producer compliance was a veterinary-related factor that contributed to AMR, and that environmental modifications to prevent disease could be effective to mitigate AMR.

CONCLUSIONS AND CLINICAL RELEVANCE

Results of the present study helped fill important knowledge gaps pertaining to prescription practices and influencing factors for AMD use in production animal medicine and provided baseline information for future assessments. This information could be used to inform future interventions and training tools to mitigate the public health threat of AMR.

Non-Clinical Factors Determining the Prescription of Antibiotics by Veterinarians: A Systematic Review

The misuse of antibiotics in humans, animals, and plants is related to the spread of resistant antibiotic strains among humans and animals. In this paper, we carry out a bibliographic search of Medline, Web of Knowledge, and Cab Abstracts with the main objective of ascertaining the available evidence on non-clinical factors and attitudes that could influence the prescription of antibiotics by veterinarians. A total of 34 studies fulfilled the inclusion criteria. Whereas, veterinary health professionals' prescribing habits did not appear to be influenced by their socio-demographic characteristics, they were influenced by different attitudes, such as fear (identified in 19 out of 34 studies), self-confidence (19/34), business factors (19/34), and by complacency (16/34). Certain owner-related factors, such as lack of awareness (16/34) and demand for antibiotics (12/34), were also important, as were concurrent factors, ranging from a lack of appropriate regulations (10/34) to the expense and delays involved in performing culture and sensitivity tests (10/34) and inadequate farm hygiene (8/34). Our results appear to indicate that the non-clinical factors are potentially modifiable. This may be useful for designing interventions targeted at improving antibiotic use in animals, as part of an overall strategy to reduce the global spread of multi-resistant strains.