[The general practitioner perspective of a multimodal intervention for the adequate use of antibiotics in urinary tract infection - a qualitative interview study]

INTRODUCTION

Contrary to current guideline recommendations, second-line antibiotics are still frequently used in the ambulatory treatment of uncomplicated urinary tract infections (UTI), which are associated with a high risk of antibiotic resistance development. The REDARES project (REDuction of Antibiotic RESistance in uncomplicated urinary tract infections by treatment according to national guidelines in ambulatory care), funded by the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA)/Innovation Fund is developing a multimodal intervention for primary care physicians to support them in a guideline-based approach. The intervention consists of the following components: (1) provision of local resistance data of pathogens of uncomplicated UTI (Robert Koch Institute), (2) concise guideline content on the therapy of uncomplicated UTI for patients (paper and online), and (3) prescription feedback on practice level and benchmarking among the study participants (anonymized). In a participatory approach and as part of the process evaluation, representatives of the intended target group were interviewed in advance about the acceptance and feasibility of the intervention.

METHODS

Using guided individual interviews, Thuringian GPs were interviewed before the start of the intervention phase. Following a description of the study concept and the planned components of the intervention, the interviewees were asked about their assessment regarding acceptance and feasibility. The individual interviews were recorded, transcribed verbatim and qualitatively analyzed according to Mayring.

RESULTS

A total of ten interviews with an average duration of 29minutes were conducted and evaluated. 40 per cent of the interviewed GPs were female and, on average, 45 years old. The interviewees described the uncomplicated UTI as an easily manageable condition. The practical nature of the research question was described as a reason to potentially participate in the intervention phase; lack of time or human resources were cited as potential barriers. Regarding the intervention elements, the provision of local resistance data of UTI pathogens was considered beneficial to their own work. The extraction of their own antibiotic prescription data from the practice software was basically assessed as feasible. The interviewees differed in their assessment of whether they would take account of the feedback on their prescribing behavior in their daily work.

DISCUSSION

The interviews generated a detailed picture of the different diagnostic and therapeutic pathways used by respondents for uncomplicated UTI. Overall, they predominantly regarded both the study concept and the intervention components as feasible. Although the study population is small and not representative, some of the results seem to be transferable to other regions in Germany.

CONCLUSION

A research question relating to their daily routine can increase participation of primary care physicians in (intervention) studies. Starting the process evaluation before the intervention seems to be reasonable since the results will be integrated into the design of the intervention. The method of data extraction from practice software by practice teams seems to be promising.

[Survey on the use of antibiotics in exotic pets among Swiss veterinarians]

INTRODUCTION

Monitoring programs and guidelines on the use of antibiotics and antibiotic resistance in human and veterinary medicine have been developed worldwide to promote the prudent use of antibiotics in recent years. However, such information on the use of antibiotics in exotic pets is absent. This fact must be taken into account, since the number of exotic pet patients is constantly increasing and the administration of antibiotics is particular challenging due to the diversity of species and the differences in physiology. The present study reports the results of a survey of frequently used antibiotics and the criteria of antibiotic usage in exotic pets (rabbits, rodents, birds and reptiles) among Swiss veterinarians. These data should form the basis for the development of antibiotic usage guidelines in exotic pets. A total of 61 veterinarians returned the questionnaire. The most important decision-making criteria for antibiotic treatment and antibiotic selection were clinical symptoms (55/59, 93% for antibiotic treatment and 40/59, 68% for antibiotic selection), experience (41/59, 69% and 36/59, 61%, respectively) and textbooks (39/59, 66% and 40/59, 68%). The most important decision-making criteria for dosage and duration of therapy were textbooks (59/59, 100%) and experience (31/59, 53%). The use of a microbial culture was used as a decision criterion for both antibiotic treatment and antibiotic selection by 39% of the participants, sensitivity testing was chosen as a decision criterion by 37% for antibiotic treatment and by 46% for antibiotic selection. Fluoroquinolones were used most frequently, 46/56 (82% of the participants) for rabbits, 49/57 (86%) for rodents, 36/37 (97%) for reptiles and 38/46 (83%) for birds. The vast majority of veterinarians (57/58, 98%) would consult a guide for the use of antibiotics. The frequent use of critical antibiotics in exotic pets underscores the need for a guide to the prudent use of antibiotics. The positive influence of such guidelines has already been proven in dogs and cats.

[Evidence-based homeopathy and veterinary homeopathy, and its potential to help overcome the anti-microbial resistance problem - an overview]

INTRODUCTION

The basic principles of homeopathy, and its legal and scientific foundations, are discussed in an overview to address the positions of the World Health Organization (WHO) and the commission of the European Union (EU) on complementary medicine. According to the WHO, the antimicrobial resistance problem poses a global threat. The EU Commission's current One Health Action Plan requests research in complementary medicine, the WHO urges member states to include complementary medicine in their national health policies. Regarding external evidence on the general use of human and veterinary homeopathy, evidence level 1a studies are reviewed. Focusing on the external evidence on the use of homeopathy in infections, some evidence level 1a, 1b, 2c studies, and a case report, are described in more detail. In conclusion, evidence for the effectiveness of human and veterinary homeopathy in general, and in particular, of homeopathic treatment for infections, is available. Especially, individualized homeopathy demonstrates effects at all quality levels according to Cochrane criteria, even in the methodologically high-quality studies. As in most areas of veterinary medicine and medicine, further good/excellent studies are necessary. In compliance with the principles of homeopathy, further methodologically high-quality trials focusing on the homeopathic treatment of infections are the next logical step. The selection of the simile (individually fitting homeopathic medicinal product) by appropriately trained homeopathic doctors/veterinarians is essential for the effectiveness of homeopathy. Implementation of studies at university facilities is a prerequisite for quality assurance. Consequently, further integration of homeopathy at universities is a necessary requirement for the patients' best interests.

Urinary tract infections in dogs with spontaneous hypercortisolism - frequency, symptoms and involved pathogens

INTRODUCTION

Dogs with hypercortisolism are predisposed to developing bacteriuria associated either with clinical signs of cystitis or without clinical signs (subclinical bacteriuria). Based on current guidelines, dogs with subclinical bacteriuria should not be treated with antibiotics because there is no evidence that treatment improves outcome and because unnecessary treatments should be avoided. Before these guidelines were published in 2019, dogs with hypercortisolism and bacteriuria were commonly treated with antibiotics irrespective of clinical signs. Comprehensive data on the frequency of bacterial cystitis, subclinical bacteriuria and the outcome of antimicrobial treatment in dogs with hypercortisolism is sparse. The aims of this study were to investigate dogs with hypercortisolism for the presence of bacterial cystitis and subclinical bacteriuria, to address the pathogens involved, and to assess the outcome of antibiotic treatment. Dogs newly diagnosed with hypercortisolism between 2005 and 2015 from which a urine bacterial culture was available were included. Statistical analysis was performed with non-parametric tests. Of the 161 client-owned dogs included, 29 (18%) showed bacteriuria, which was subclinical in 24 (83%) cases. Escherichia coli was the most commonly isolated pathogen (58%). Bacteriuria was not associated with sex or neutering status. In 14 dogs, follow-up data was available, of which 13 (93%) were treated with antimicrobials for 14 to 28 days. Follow-up bacterial culture (1 to 118 days after cessation of therapy) was negative in 10 (77%) treated dogs; a negative follow-up culture was not associated with gender, age or duration of treatment. Bacteriuria persisted in three treated dogs and the one untreated dog. The prevalence of positive bacterial urinary culture in dogs with hypercortisolism was lower than previously reported. In the majority of dogs, bacteriuria was subclinical. Most dogs had a negative bacterial culture result after antimicrobial treatment; however, more resistant bacteria were detected in persistently positive urine.

[AntibioticScout.ch: Decision support for the prudent use of antimicrobials: Application in cattle]

INTRODUCTION

The administration of antibiotics in livestock has been criticized for many years, in particular because of an inappropriate use and the appearance of antibiotic residues in the environment, which can promote the emergence and spread of resistant bacteria. However, antibiotics are essential for the successful and sustainable control of bacterial pathogens. With the aim of optimizing the use of antibiotics in food animals and minimizing the prevalence of resistant bacteria, AntibioticScout. ch provides a decision aid for the prudent use of antimicrobial drugs. This approach emphasizes the importance of supportive therapy and the hallmarks of preventive concepts. Procedures to improve animal health and animal welfare in accordance with the principles of good veterinary practice are primary and effective tools to reduce the use of antimicrobial drugs. The necessary reduction in the use of antibiotics must, therefore, be accompanied by appropriate management strategies in animal husbandry. In particular, hygiene, animal welfare and biosecurity measures are crucial to ensure an optimal health status in farm animals.

[AntibioticScout.ch: A decision supporting tool for antimicrobial stewardship: application to companion animal medicine]

INTRODUCTION

Bacterial resistances to antimicrobial drugs pose serious public health challenges. The observed increase of resistances is attributed to the uncontrolled, massive and often unnecessary administration of antibiotics both in human and veterinary medicine. To support the responsible use of antimicrobials in animals and help veterinarians selecting the most suitable antimicrobial drugs, we developed the AntibioticScout.ch as a comprehensive decision supporting tool providing online access to the current knowledge of rational antibiotic prescription practices. User-friendly search functions allow for the fast and efficient retrieval of information that is structured in this database by animal species, organ systems and therapeutic indications. In addition, an online form allows to report treatment failures in order to identify problematic cases as well as ensuing risks and take appropriate mitigation measures. The present report describes the workflow of this decision support system applied to the prudent use of antimicrobials in companion animal medicine.

[AntibioticScout: Online tool for antimicrobial stewardship in veterinary medicine]

INTRODUCTION

Resistances to antimicrobials pose serious public health challenges. This issue concerns both human and veterinary medicine and can only be solved by a multidisciplinary approach. A comprehensive concept is, therefore, being worked out within the StAR (strategy antibiotic resistance) program in order to preserve the effectiveness of antibiotics for humans as well as animals. In this context, the AntibioticScout (www.AntibioticScout. ch) offers a new online tool for the prudent use of antibiotics in veterinary medicine. By involving all stakeholders, the guidelines included in the AntibioticScout will result in a nationwide accepted standard for the treatment of bacterial infections in animals. An additional system for the rapid reporting of cases of suspected lack of efficacy of antimicrobials is integrated to allow early detection of emerging resistance and the immediate launch of risk mitigation measures. A first version of the AntibioticScout for the treatment of dogs, cats and horses is available by the end of 2016. All stakeholders are now invited to contribute to the development of the AntibioticScout decision support.

Methicillin-resistant Staphylococcus aureus isolated from dogs and cats in Switzerland

INTRODUCTION

Twenty-two methicillin-resistant Staphylococcus aureus (MRSA) strains isolated from various infected locations in domestic cats and dogs between June 2008 and September 2014 were analyzed for their genotype, genetic fingerprint, virulence and antibiotic resistance profile. Eighteen strains belonged to the clonal complex (CC) 22 [ST22(MLST)-A(PFGE)-t032(spa)-IV(SCCmec) and ST22-A-t1214-IV], 2 strains to the livestock associated MRSA ST398-t011-IV and two were individual strains of ST5-t002-II and ST1-t001-IV. They contained virulence factors such as γ-hemolysins, β-hemolysin converting phage genes, leukocidins and enterotoxins. Most widespread resistances were observed against β-lactams, trimethoprim and fluoroquinolones, but single strains also exhibited resistance to macrolides, lincosamides, aminoglycosides, tetracycline, chloramphenicol and/or mupirocin. The predominant presence of CC22 MRSA strongly indicates clonal spread of a human associated lineage in Swiss companion animals. It is therefore of public health importance to maintain a low level of MRSA infections in animals to avoid uncontrolled dissemination of MRSA clones in humans and animals.

The effect of the administration of three different antimicrobial premix formulations via the liquid feeding system on the occurrence of Enterobacteriaceae resistant to tetracycline in the liquid feed for pigs

INTRODUCTION

The oral group treatment is still a common procedure in swine production. This project studied the effect of the application of 3 different formulations of antimicrobial premixes (1. chlortetracycline, 2. chlortetracycline + sulfadimidine + tylosin, 3. sulfadimidine + sulfathiazole + trimethoprim) via the liquid feeding system on the occurrence of tetracycline-resistant Enterobacteriaceae (Ent-Tetr) in the liquid feed. 156 and 112 feed samples were collected between April and December 2015 in 13 case and 14 control farms, respectively. The 27 farms were randomly selected pig fattening farms located in different parts of Switzerland. The number of feed samples that contained Ent-Tetr as well as the number of Enterobacteriaceae resistant to tetracycline per sample was significantly higher in the case group than in the control group. The use of any of the 3 antimicrobial combinations turned out to be the main risk factor for the occurrence of Ent-Tetr in the liquid feed. Our results suggest that liquid feed containing antimicrobials is a reservoir of antimicrobial resistant bacteria in swine production.