Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Arlo Guthrie — Thu, 02 Nov 2023 08:40:35 GMT

[quote userid="4181" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242769#242769"]You could say that about homeopathy?[/quote]

The thing I used to argue about homeopathy is that actually, despite being just water, it does harm.

Various reasons, including:

a) It gives people false hope (and in the case of homeopathy, often very vulnerable people), when they would be better advised to come to terms with their illness (if no proven or experimental treatment available).

b) It removes money from people's wallets which could be spent on something else which they will benefit from more. And if there isn't another medical treatment, then the money will probably be better spent on a bottle of wine, or a gift for the grandchild, or whatever!

c) It propagates a mindset which devalues science.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Rob Loxley — Wed, 01 Nov 2023 22:16:42 GMT

[quote userid="12876" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242768#242768"]However I do feel that nutraceuticals at least ‘do no harm’[/quote]

You could say that about homeopathy?

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

helen herinckx — Wed, 01 Nov 2023 20:03:28 GMT

Agree strongly on how do we change the mindset of those using medicines inappropriately - not just Antimicrobials. However I do feel that nutraceuticals at least ‘do no harm’ and therefore are a good alternative in treating diarrhoea, especially when the client feels the need to give ‘something’ to their pet.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Clive Ansell — Mon, 16 Oct 2023 21:00:05 GMT

[quote userid="12337" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242642#242642"]For anyone thinking of using Loperamide:[/quote]

Think twice. I've only taken it one, on a flight from India back to the UK. Made be feel bloated, nauseous and constipated, and far worse than the Delhi belly I was trying to calm. lasted for 3 or 4 days too. Awful.

Also, if using for our patients, don't forget to get those off license use disclaimers signed.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

conorduignan — Mon, 16 Oct 2023 16:05:28 GMT

[quote userid="12930" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242599#242599"]As an aside, I have always been surprised that loperamide is not used more (in breeds where this is reasonable to do) to prevent owners having to clear up messy diarrhoea in the morning - this is what they really want fixed.[/quote]

Thank you for this - I had an 'I wish I'd thought of that...' moment on reading it.

For anyone thinking of using Loperamide: it seems pretty safe at 0.04mg/kg (or one 2mg capsule per 25kg) every 8-12h.

However, avoid in collie (MDR-1) breeds and cats.

www.vettimes.co.uk/.../loperamide-investigating-a-human-medication-toxic-to-pets.pdf

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Rob Loxley — Sat, 14 Oct 2023 21:33:09 GMT

[quote userid="2100" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242618#242618"]a) Measure the scale of prescribing antibiotics on first presentation (have you done it)[/quote]

There have been published data from actual consultation data sources such as savsnet already

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

janine redman — Fri, 13 Oct 2023 19:30:06 GMT

Sadly a large amount of my acute diarrhoea cases are probably stress associated . Highly strung anxious dogs and cats with changes to their food or lifestyle. Unrealistic owner expectations . IBD / IBs due to genetics and inappropriate lifestyle. Kaolin helpful . Long consultation might help but often insurmountable behavioural challenges and the wrong patient in the wrong environment

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Arlo Guthrie — Fri, 13 Oct 2023 07:51:27 GMT

[quote userid="8991" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242592#242592"]So the question isn't why people do it, but what can we do to change behaviour. Whilst these types of studies that you linked are useful they do not turn a should into an ought in that to believe simply producing these studies will lead to a change in behaviour is naive.[/quote]

David Mills Watching this discussion unfold, I wonder whether it would be interesting or helpful to conduct a survey as follows:

a) Measure the scale of prescribing antibiotics on first presentation (have you done it)

b) If yes to a), ask why antibiotics prescribed? (Belief it would be effective / client pressure / employer pressure (to sell stuff, could that be a 'thing'? / anything else?)

c) Ask what participant believes would cause (their own) behaviour change (evidence of lack of efficacy / client education or education materials / alternatives for treatment / anything else?).

(perhaps the survey could also cover probiotics, but that would possibly weaken the focus on the more important issue).

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Rob Loxley — Fri, 13 Oct 2023 07:39:36 GMT

[quote userid="9440" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242615#242615"]most acute diarrhoea cases don’t get seen unless they are unwell as we rarely have appointments available for non urgent cases either.[/quote][quote userid="5012" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242616#242616"]5. Where we do prescribe antibiotics, usually Metronidazole, we usually see a resolution within 24 hours.[/quote]

Personally, I used to use a lot of metronidazole and have moved to using less and less; preferring fenbendazole to rule out giardia; and using more doses/quick courses of steroids. I'm not sure I get the feeling I have any more treatment failures than when using much more antibiotics. Still finding a place for Kaogel on the shelf too. I am genuinely unconvinced that we see any real quantity of cases of salmonella/campylobacter/e.coli/clostridia as primary pathogens that require antibiotic treatment.

I remember the days of routine perioperative antibiotics for clean routine surgery - and most dentistry - and everyone was happy with very low infection rates etc, yet since stopping this we don't see any increase in such, to have justified their use.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Clive Ansell — Fri, 13 Oct 2023 06:13:18 GMT

[quote userid="9440" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242615#242615"]Then at some point you decide to give antibiotics a try and lo and behold things resolve in 12 hours .[/quote]

Agree.

I was talking with colleagues yesterday about this, and we all came up with the same opinions really, in summary:

1. We don't see uncomplicated cases, most clients try 24 hour starvation, a light diet and sometime a probiotic. So often a week down the line before we see them

2. We don't give antibiotics unless unwell or not resolving. When we do it's usually Metronidazole, and we make sure they're up to date with endoparasite control.

3. we offer/advise faecal analysis in cases that are ill or not resolving, almost always declined on costs. That said I have picked up three cases of Giardia recently.

4. Clients don't want to leave empty handed, they seem to feel that "nothing has been done" they want a magic wand quick fix, and are more worried about their carpets. Limited to a 10 or 15 minute appointment, so pressure to hand something out.

5. Where we do prescribe antibiotics, usually Metronidazole, we usually see a resolution within 24 hours.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

janine redman — Thu, 12 Oct 2023 22:35:58 GMT

Having been practicing for a number of years , the original go to was kaobiotic which was actually quite useful because I think the kaolin worked . However over the years you accumulate a number of cases , young and old where you steadfastly try to avoid using antibiotics for days . Sometimes accumulating a large bill for intravenous fluids hospitalisation and other symptomatic options. Then at some point you decide to give antibiotics a try and lo and behold things resolve in 12 hours . Then you have an irate client with a large bill saying - why didn’t you do that earlier !!

Likewise when I started in practice most diarrhoea cases got a dose of dexamethasone and then it went out of favour and now I find myself using it more frequently again. I think the longer you practice the more conundrums you face and with funding getting tight and full investigation being refused , along with intermittent bouts of severe E. coli and Salmonella that occur it is not as easy as it sounds.

most acute diarrhoea cases don’t get seen unless they are unwell as we rarely have appointments available for non urgent cases either.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Clive Ansell — Wed, 11 Oct 2023 19:52:34 GMT

[quote userid="2675" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242605#242605"]Agree on the (probably) very high numbers that don’t get to the vet and actually respond to the rice and chicken. In my area you not going to see the ‘left smear on walk’ crowd- generally the g/ent already a few days old, not responding to bland diet or they can see deterioration- either progressing to vomiting, lethargy or blood in faeces so the clinician isn’t really seeing‘uncomplicated diarrhoea’.[/quote]

I would agree.

Almost all cases I see have already had diarrhoea for several days, have been tried on a bland diet and a probiotic, or the owners have seen blood, or they are clearly unwell and/or vomiting.

I don't treat if they are BAR, t'n , normal appetite, but do if febrile or systemically unwell.

Blunt but honest; I've worked in the low-cost clinic sweatshops in the past, and one has to push them through as quickly as possible, so probiotics and/or antibiotics is the path of least resistance to get them out of the door. 5 minute appointments just don't give time to discuss multiple antimicrobial resistance and the pros and cons of probiotics.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Richard Carter — Wed, 11 Oct 2023 12:57:13 GMT

Agree on the (probably) very high numbers that don’t get to the vet and actually respond to the rice and chicken. In my area you not going to see the ‘left smear on walk’ crowd- generally the g/ent already a few days old, not responding to bland diet or they can see deterioration- either progressing to vomiting, lethargy or blood in faeces so the clinician isn’t really seeing‘uncomplicated diarrhoea’.

So as there no point in culture on first presentation (and the weekend coming up/ going on holiday etc), and ecoli, salmonella and clostridia are real diseases, they get some antibiotics if fever, blood presented.

Hope we not at the stage as in human medicine where children die of septicaemia because the clinician didn’t want to ‘break the rules’

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Mellora Sharman — Wed, 11 Oct 2023 11:19:33 GMT

There has been some research around barriers to / enablers of prescribing antibiotics vs antibiotic stewardship

See - https://pubmed.ncbi.nlm.nih.gov/29573053/

As per their conclusions the key barriers were a lack of AMS governance structures, client expectations and competition between practices, cost of microbiological testing, and lack of access to education, training and AMS resources.

So as well as having guidance / research about rational use, addressing the psychologic aspects from veterinary and client perspectives seems important.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Beats — Wed, 11 Oct 2023 06:43:14 GMT

[quote userid="8663" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics"]why do so many vets nonetheless dispense antibiotics[/quote]

I'm not convinced that many vets do prescribe antibiotics for acute diarrhoea (based on the press release anyway - I haven't read the paper yet). How many cases of simple acute diarrhoea actually get past your receptionist each week?

This study is naturally skewed towards vets inviting clients to bring dogs with simple acute diarrhoea with no complicating factors to the vet - that a relatively high percentage of those vets then prescribe something is perhaps less surprising?

The study misses the data on what I expect to be the silent majority of cases that never get near a vet - you reduce the number being prescribed antibiotics by making sure receptionists don't book them for an over-priced consult for a vet who then feels the need to justify that fee with yet more over-priced antibiotics or probiotics. And if those attending are advised that they will be checked by a vet, but generally no treatment is needed, then they enter the consult room with the appropriate expectation which you simply confirm in a couple of minutes and let them on their way again. The problem is thus expectation on entering the consult room due to poor pre-consult management of expectations.

If a dog has diarrhoea of a day's duration, is bright and otherwise appears normal, has no vomiting and is eating, you do not need to bring it to your vet anymore than you would go to your doctor if you had diarrhoea. Target the public with that message and you will get better results than targeting the vets seeing these dogs. If you really want the public to listen, and antibiotic prescribing to dogs with diarrhoea to decrease, then tell them that vets are fleecing them to a tune of £xxxxxx a year for treatments for self-limiting diarrhoea that don't work.

As an aside, I have always been surprised that loperamide is not used more (in breeds where this is reasonable to do) to prevent owners having to clear up messy diarrhoea in the morning - this is what they really want fixed.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Rob Loxley — Tue, 10 Oct 2023 18:10:46 GMT

Some thoughts: i do remember discussions about immunomodulatory effects of metronidazole though whether we need this in scute diarrhoea is unclear ; also there have been studies to the contrary eg https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/jvim.15664 albeit differences between groups were not statistically significant ; and I do suspect their is a perceived pressure to give something hence also the probiotics (which are heavily marketed).

but I agree David makes a good point about what drives behaviour beyond such papers

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Alasdair Hotston Moore — Tue, 10 Oct 2023 11:14:07 GMT

Yes you're right, that is the question of importance: how do we effect change. Thank you.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Alasdair Hotston Moore — Tue, 10 Oct 2023 11:12:38 GMT

[quote userid="2100" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242591#242591"]Is anyone prescribing nutraceuticals for diarrhoea? [/quote]

On the odd occasion when I'm seeing cases like this (when I have stepped down from my ivory tower and the glamour of 'ears and rears'), I have used probiotics simply because clients want something....

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

David Mills — Tue, 10 Oct 2023 10:47:04 GMT

[quote userid="2100" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics/242591#242591"]

The press release I got about this really led on the lack of benefits of antibiotics, but further down it snuck in the same conclusion about nutraceuticals: https://www.vetsurgeon.org/b/veterinary-news/posts/new-study-finds-antibiotics-offer-no-benefit-for-dogs-with-diarrhoea

Is anyone prescribing nutraceuticals for diarrhoea?

[/quote]

Inherent bias I suspect. Neutraceuticals have long played out in that grey area of "well they don't do any harm and they may do some good". Some of these have been around for decades with no evidence to support their use yet they have the biggest stands at conferences...

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

David Mills — Tue, 10 Oct 2023 10:45:28 GMT

[quote userid="8663" url="~/f/clinical-questions/30786/why-do-our-colleagues-treat-acute-diarrhoea-dogs-with-antibiotics"]why do so many vets nonetheless dispense antibiotics? [/quote]

It is probably something which can be answered by research but it does take a skill set which may be lacking to a degree in veterinary research.

Human EBM has started to do this by using methodologies to assess clinical decision-making. Such requires some knowledge of cognitive psychology and reaserch methods that have been used by social sciences for decades but have traditionally been seen as the poorer relation of 'scientific research'.

As you say people probably know they make little difference but that is a moot point if people are still prescribing them. It is almost paternal - don't do this, here's the evidence, go forth and listen to us. Such an approach rarely alters behaviour. I suspect the increasing division between first opinion and referral levels - the latter produce >95% of research - doesn't help as they are two separate entities. The shorthand of here's the evidence that populates CPD and talks these days - often without critical appraisal - doesn't really help I don't think.

So the question isn't why people do it, but what can we do to change behaviour. Whilst these types of studies that you linked are useful they do not turn a should into an ought in that to believe simply producing these studies will lead to a change in behaviour is naive.

RE: Why do our colleagues treat acute diarrhoea (dogs) with antibiotics?

Arlo Guthrie — Tue, 10 Oct 2023 08:39:10 GMT

Can I add another question, m'lud?

Is anyone prescribing nutraceuticals for diarrhoea?

(Sorry, don't want to divert, I realise antibiotics is the most important thing here, but just interested to know whether nutraceuticals are widely recommended for the same thing).