Animal drug shortages limit veterinary therapeutic options and introduce artifacts in antimicrobial sales reporting

Supply chain issues disrupt veterinary care and cause downstream consequences that alter the practice of veterinary medicine. Antimicrobials are just 1 class of pharmaceuticals that have been impacted by supply chain issues over the last couple of years. Since February 2021, 2 sponsors/manufacturers of penicillin products have reported shortages in the active pharmaceutical ingredient. With the release of the 2021 Summary Report on Antimicrobials Sold or Distributed for Use in Food-Producing Animals by the FDA, a key finding was a 19% decrease in penicillin sales and distribution from 2020 to 2021. Herein, we provide our clinicians' professional perspective regarding how drug shortages, specifically that of penicillin, might contribute to misconstrued patterns in antimicrobial use and what can be done by veterinarians and the FDA to minimize the impact of an antimicrobial drug shortage on animal health and well-being.

Biodegradation, photolysis, and sorption of antibiotics in aquatic environments: A scoping review

The presence of antibiotics in surface waters is a potential driver of antibiotic resistance and thus of concern to human and environmental health. Key factors driving the potential impact of antibiotics are their persistence and transport in rivers and lakes. The goal of this study was to describe the peer-reviewed published literature on the photolysis (direct and indirect), sorption, and biodegradation of a selected group of antibiotic compounds following a scoping review methodology. Primary research from 2000 to 2021 was surveyed to compile information on these processes for 25 antibiotics from 6 classes. After compilation and assessment of the available parameters, the results indicate that information is present to predict the rates of direct photolysis and reaction with hydroxyl radical (an indirect photolysis process) for most of the selected antibiotics. There is insufficient or inconsistent information for including other indirect photolysis processes, biodegradation, or removal via sorption to settling particles for most of the targeted antibiotic compounds. Future research should focus on collecting fundamental parameters such as quantum yields, second-order rate constants, normalized biodegradation rates, and organic carbon or surface area normalized sorption coefficients rather than pseudo-first order rate constants or sorption equilibrium constants that apply only to specific conditions/sites.

Prevalence of antibiotic use for dogs and cats in United States veterinary teaching hospitals, August 2020

BACKGROUND

Awareness of prescribing practices helps identify opportunities to improve antibiotic use (AU).

OBJECTIVES

To estimate AU prevalence in dogs and cats in U.S. veterinary teaching hospitals (VTHs) and identify antibiotic drugs commonly prescribed, indications for use, and evidence of bacterial infection.

ANIMALS

Medical record data were collected from dogs and cats examined at 14 VTHs.

METHODS

Data were collected from VTH medical records of dogs and cats examined by primary care, urgent care, emergency and critical care, internal medicine, and surgery services on a single day during August 13-September 3, 2020. Data included signalment; clinical service; inpatient or outpatient status; clinical conditions; diagnostic tests; evidence of bacterial infection; intended reason for AU; name and route of antibiotics prescribed.

RESULTS

Of 883 dogs and cats, 322 (36.5%) were prescribed at least 1 antibiotic. Among 285 antibiotics administered systemically intended for treatment of infection, 10.9% were prescribed without evidence of infection. The most common class of antibiotics presribed for systemic administration was potentiated penicillin for dogs (115/346, 33.3%) and cats (27/80, 33.8%). For dogs and cats, first-generation cephalosporins (93/346, 26.9% and 11/80, 13.8%, respectively) and fluoroquinolones (51/346, 14.7% and 19/80, 23.8%, respectively) was second or third most-prescribed. Common AU indications included skin, respiratory, and urinary conditions, and perioperative use.

CONCLUSIONS AND CLINICAL IMPORTANCE

Collaborative data collection provides a sustainable methodology to generate national AU prevalence estimates and bring attention to areas requiring additional research and detailed data collection. These efforts can also identify practice improvement opportunities in settings where future veterinarians are trained.

Minnesota One Health Antibiotic Stewardship Collaborative: A Reproducible Approach to Facilitate Antimicrobial Stewardship Progress

The Minnesota One Health Antibiotic Stewardship Collaborative (MOHASC) was launched in 2016 with the mission of providing a collaborative environment to promote judicious antibiotic use and antibiotic stewardship (AS) and to reduce the impact of antibiotic-resistant pathogens of human, animal, and environmental health importance. MOHASC goals include improving AS programs in healthcare and veterinary medicine, advancing understanding of environmental impacts of antibiotic use, and promoting a One Health (OH) approach to AS. These goals are accomplished through quarterly meetings of 4 work groups, field trips, collaborative research, an annual member meeting, and public education events. This novel OH approach has strengthened multidisciplinary relationships within Minnesota and led to procurement of funding to enhance AS initiatives beyond the Collaborative. This perspective serves as a blueprint for other jurisdictions, and we advocate for use of this reproducible OH strategy to facilitate broad AS goals.

A quarterly Survey of antibiotic prescribing in small animal and equine practices-Minnesota and North Dakota, 2020

Antimicrobials are critical for medicine, but the problem of antimicrobial resistance (AMR) threatens the effectiveness of these valuable drugs. In USA, there are no national- or state-level programs or policies in place to track antibiotic use (AU) in dogs, cats, and horses, despite acknowledgement of this sector's importance to both the AMR problem and its solution. AU measurement is a key part of antibiotic stewardship and AMR prevention. This study aimed to fill existing gaps in the veterinary professions' knowledge of antibiotic prescribing in small animals and horses. To address this aim, medical record data were collected on a single day per quarter for 1 year from 19 Minnesota and North Dakota small animal and equine practices, totaling 1,899 veterinarian consults of dogs, cats, and horses. Overall, 25.8% of all canine, feline, and equine consults involved an antibiotic prescription. Third-generation cephalosporins were the most commonly prescribed systemic antibiotic drug class, and the long-acting injectable drug, cefovecin, was the most commonly prescribed antibiotic for cats (34.5%). Topical antibiotic preparations were prescribed frequently, especially in dogs (42.5% of canine prescriptions), though systemic antibiotics were often prescribed concurrently. Common general indications, based on problem or diagnosis recorded in the medical record, for antibiotics in all species combined were skin conditions (24.4%), otitis (22.1%), ophthalmic (9.4%), gastrointestinal (8.3%), respiratory (8.3%), and urinary tract (7.6%) diseases. While 44.2% of patients for which antibiotics were prescribed had cytology performed, only 3.9% had bacterial culture and susceptibility performed. In a pre-study survey, veterinarians' recommendations for AU differed from actual prescribing, suggesting collection of AU data provides more accurate assessments of veterinary prescribing behaviour than surveys. This study shows feasibility of AU measurement in small animals and horses. The data collection tool and standard operating procedures described prove suitable for national AU data collection.

Antimicrobials in Animal Agriculture in the United States: A Multidisciplinary Overview of Regulation and Utilization to Foster Collaboration: On Behalf Of the Society of Infectious Diseases Pharmacists

Given the complexity of antimicrobial resistance and the dire implications of misusing antimicrobials, it is imperative to identify accurate and meaningful ways to understand and communicate the realities, challenges, and opportunities associated with antimicrobial utilization and measurement in all sectors, including in animal agriculture. The objectives of this article are to (i) describe how antimicrobials are regulated and used in US animal agriculture and (ii) highlight realities, challenges, and opportunities to foster multidisciplinary understanding of the common goal of responsible antimicrobial use. Recognition of the realities of medicine, practice, and policy in the agricultural setting is critical to identify realistic opportunities for improvement and collaboration.

Serial point-prevalence surveys to estimate antibiotic use in a small animal veterinary teaching hospital, November 2018 to October 2019

Background

There is no standardized methodology to measure antibiotic drug use (AU) in small animal veterinary hospitals.

Objectives

To estimate AU prevalence in a small animal veterinary teaching hospital and characterize usage by indication and evidence of infection. To establish an AU measurement methodology for veterinary settings.

Animals

Electronic medical records of cats and dogs seen by primary care, urgent care, emergency and critical care, internal medicine, and surgery services during November 2018 to October 2019.

Methods

On 1 day each month, data (signalment, visit reason, diagnostics, and antibiotic details, including indication) were collected for all animals seen on study services.

Results

Of 168 inpatient dogs and 452 outpatient dogs, 98 (58.3%) and 107 (23.7%,) were receiving at least 1 antibiotic on the day of data collection, respectively. For cats 15/49 (30.6%) inpatients and 29/187 (15.5%) outpatients were receiving at least 1 antibiotic. Common drug classes prescribed for dogs were potentiated penicillins (28.7%), first‐generation cephalosporins (22.1%), and nitroimidazoles (14.7%), and for cats, common drug classes administered were potentiated penicillins (26.9%), fluoroquinolones (13.5%), and penicillins (11.5%). Common indications for antibiotics included skin, respiratory, gastrointestinal, perioperative, aural, and urinary conditions.

Conclusions and Clinical Importance

Serial point‐prevalence surveys (PPS) can estimate AU in a large specialty hospital setting and identify targets for antimicrobial stewardship. The methodology developed during this study can be adapted for use in private practice, including large animal practice. Mirroring methods used in human healthcare, the data collection tool can also be used to describe AU nationally through completion of national PPS.

One Health and antimicrobial resistance, a United States perspective

Antimicrobial drugs are a precious resource, responsible for saving millions of lives since their discovery. Unfortunately, some antimicrobials are rapidly losing their effectiveness due to the development and spread of antimicrobial resistance (AMR), a multi-faceted and complex problem affecting humans, animals, plants and the environment. While AMR is a global problem, in this paper, the authors briefly highlight some ongoing efforts in the United States of America aimed at integrating a One Health approach into policies and programmes that address this important health threat.

Invasive group A Streptococcus infections associated with liposuction surgery at outpatient facilities not subject to state or federal regulation

IMPORTANCE

Liposuction is one of the most common cosmetic surgery procedures in the United States. Tumescent liposuction, in which crystalloid fluids, lidocaine, and epinephrine are infused subcutaneously before cannula-assisted aspiration of fat, can be performed without intravenous or general anesthesia, often at outpatient facilities. However, some of these facilities are not subject to state or federal regulation and may not adhere to appropriate infection control practices.

OBJECTIVE

To describe an outbreak of severe group A Streptococcus (GAS) infections among persons undergoing tumescent liposuction at 2 outpatient cosmetic surgery facilities not subject to state or federal regulation.

DESIGN

Outbreak investigation (including cohort analysis of at-risk patients), interviews using a standardized questionnaire, medical record review, facility assessment, and laboratory analysis of GAS isolates.

SETTING AND PARTICIPANTS

Patients undergoing liposuction at 2 outpatient facilities, one in Maryland and the other in Pennsylvania, between July 1 and September 14, 2012.

MAIN OUTCOMES AND MEASURES

Confirmed invasive GAS infections (isolation of GAS from a normally sterile site or wound of a patient with necrotizing fasciitis or streptococcal toxic shock syndrome), suspected GAS infections (inflamed surgical site and either purulent discharge or fever and chills in a patient with no alternative diagnosis), postsurgical symptoms and patient-reported experiences related to his or her procedure, and emm types, T-antigen types, and antimicrobial susceptibility of GAS isolates.

RESULTS

We identified 4 confirmed cases and 9 suspected cases, including 1 death (overall attack rate, 20% [13 of 66]). One instance of likely secondary GAS transmission to a household member occurred. All confirmed case patients had necrotizing fasciitis and had undergone surgical debridement. Procedures linked to illness were performed by a single surgical team that traveled between the 2 locations; 2 team members (1 of whom reported recent cellulitis) were colonized with a GAS strain that was indistinguishable by laboratory analysis of the isolates from the case patients. Facility assessments and patient reports indicated substandard infection control, including errors in equipment sterilization and infection prevention training.

CONCLUSIONS AND RELEVANCE

This outbreak of severe GAS infections was likely caused by transmission from colonized health care workers to patients during liposuction procedures. Additional oversight of outpatient cosmetic surgery facilities is needed to assure that they maintain appropriate infection control practices and other patient protections.

Notes from the field: rapidly growing nontuberculous Mycobacterium wound infections among medical tourists undergoing cosmetic surgeries in the Dominican Republic--multiple states, March 2013-February 2014

In August 2013, the Maryland Department of Health and Mental Hygiene (MDHMH) was notified of two persons with rapidly growing nontuberculous mycobacterial (RG-NTM) surgical-site infections. Both patients had undergone surgical procedures as medical tourists at the same private surgical clinic (clinic A) in the Dominican Republic the previous month. Within 7 days of returning to the United States, both sought care for symptoms that included surgical wound abscesses, clear fluid drainage, pain, and fever. Initial antibiotic therapy was ineffective. Material collected from both patients' wounds grew Mycobacterium abscessus exhibiting a high degree of antibiotic resistance characteristic of this organism.

Risk factors for exposure to influenza a viruses, including subtype H5 viruses, in Thai free-grazing ducks

Free-grazing ducks (FGD) have been associated with highly pathogenic avian influenza (HPAI) H5N1 outbreaks and may be a viral reservoir. In July-August 2010, we assessed influenza exposure of Thai FGD and risk factors thereof. Serum from 6254 ducks was analysed with enzyme-linked immunosorbent assay (ELISA) to detect antibodies to influenza A nucleoprotein (NP), and haemagglutinin H5 protein. Eighty-five per cent (5305 ducks) were seropositive for influenza A. Of the NP-seropositive sera tested with H5 assays (n = 1423), 553 (39%) were H5 ELISA positive and 57 (4%) suspect. Twelve per cent (74 of 610) of H5 ELISA-positive/suspect ducks had H5 titres ≥ 1 : 20 by haemagglutination inhibition. Risk factors for influenza A seropositivity include older age, poultry contact, flock visitors and older purchase age. Study flocks had H5 virus exposure as recently as March 2010, but no HPAI H5N1 outbreaks have been identified in Thailand since 2008, highlighting a need for rigorous FGD surveillance.