Practice meeting.. a follow up

Re: Practice meeting.. a follow up

Evelyn Barbour-Hill — Sun, 19 Jan 2014 18:38:11 GMT

[quote user="Virginia Campbell"]

[quote user="Evelyn Barbour-Hill"]

[quote user="Virginia Campbell"]but one of my bosses once read a paper that said scalers over x speed induced bacteriemia in y many animals and so is keen that everything gets antirobe 5 days pre and post dental.[/quote][quote user="Utlendigur"] Tooth root abscesses or those horrible little dogs with rotten mouths get synulox injection pre-op and a course post-op. [/quote]

Why? It's all so unnecessary.

[/quote]

Yup. Do you know any good papers I could quote at my boss to convince him that animals which don't get antibiotics don't suffer any more post dental adverse effects that animals which do? He likes numbers so some statistics to brandish at him would be good.

[/quote]

Not off-hand. I have more than enough to fill my life without memorising and collating references. Anyway, I feel the onus is on the antibioticists to demonstrate that the drugs are necessary.

[quote user="Virginia Campbell"]Does the BVDA have a position statement on this? [/quote]

We prepared one to send to BSAVA, and also published it. Hang on, I can probably dig out the text.

Edit.......

Yes, you'll find it in my "Files and Uploads" on this site.

While I think of it, this is a slightly edited version of what I wrote privately to someone:

"sorry we haven't anything else officially as an association. There's loads of literature but I can't quote chapter and verse. Trust anything by Philippe Hennet, Frank Verstraete or Alex Reiter.

The supposed advantage of clindamycin was debunked many years ago. Amoxi - clav is just as effective. Stomorgyl too has no special advantage for general use.

I dispute that any temporary medication is necessary while the patient is awaiting its dental work. If you feel the need, some chlorhexidine mouthwash would be more logical. If there's pain, some Metacam.

There is no evidence I know of that you have to have some pre-operative antibiotic whenever there is severe periodontal disease. As someone (Frank Verstraete) pointed out, all it does is ensure that the bacteria swilling around at the time of operation are antibiotic-resistant ones.

I rarely use a post-operative antibiotic after, say, an extraction. I know of no evidence in favour. Usually I do with a surgical extraction, which shows that I am not totally logical as I don't think there is any particular evidence in favour. I use a single intramuscular injection of Synulox but any injectable amoxi - clav would do. All that it is necessary to achieve is an adequate antibiotic concentration in the blood which will form the clot. No more is necessary.

If an extraction site "goes wrong" it was the extraction technique to blame."

Re: Practice meeting.. a follow up

Evelyn Barbour-Hill — Sun, 19 Jan 2014 18:33:10 GMT

[quote user="robloxley"]

[quote user="Sammy82"]a greyhound returned with septicaemic shock the same afternoon[/quote]

n=1?

[/quote]

Any evidence whatsoever that the dental procedure was the cause of the septicaemia, and by what mechanism?

Re: Practice meeting.. a follow up

Mark Holmes — Fri, 17 Jan 2014 06:03:36 GMT

[quote user="Michael Woodhouse"]

[quote user="Sammy82"]Well obviously not statisticly significant, but the general practice policy (or tradition?) is to give ABs so I stuck with it . [/quote]

I tend to, but not for very simple things like cat castrates.

We were taught not to at college in lectures and then go into the small animal hospital and everything got IV Zinacef. I fail to see how that's any different to giving a single shot of Betamox LA - other than they were selecting for resistance to a cephlasporin and I use amoxycillin.

It was that discrepancy between what they taught us in lectures and what they did in practice made me happy to carry on the staus quo in practice. We do discuss it from time to time in the practice, but are reluctant to change something that works.

[/quote] But Michael it doesn't work. It makes no difference.

Re: Practice meeting.. a follow up

Michael Woodhouse — Thu, 16 Jan 2014 23:30:08 GMT

[quote user="Sammy82"]Well obviously not statisticly significant, but the general practice policy (or tradition?) is to give ABs so I stuck with it . [/quote]

I tend to, but not for very simple things like cat castrates.

Re: Practice meeting.. a follow up

Matt Hilary — Thu, 16 Jan 2014 23:27:37 GMT

[quote user="Clive Ansell"]

Practice owner commented that "it wouldn't have happened if I'd given the Amox LA".[/quote]

Well done for keeping your cool (assuming you did)!

Re: Practice meeting.. a follow up

Sammy82 — Thu, 16 Jan 2014 22:59:24 GMT

Well obviously not statisticly significant, but the general practice policy (or tradition?) is to give ABs so I stuck with it .

Re: Practice meeting.. a follow up

Utlendigur — Thu, 16 Jan 2014 21:50:37 GMT

[quote user="Julian Earl"]

[quote user="robloxley"]

The other thing about doing diagnostic imaging on healthy patients is the same dilemma of doing routine CT scans on healthy people - say you see an abnormality what are you going to do - tell the owner, biopsy it etc. Just be careful about finding cans of worms...

[/quote]

Blimey, if you can identify worms on ultrasound examination, you're a damn sight better than me! I'm happy to identify the gut wall thickness, never mind the toxacara present!

[/quote]

But probably easier if they are still inside the can - I suspect a metallic FB would show up quite easily

Re: Practice meeting.. a follow up

Julian Earl — Thu, 16 Jan 2014 21:40:10 GMT

[quote user="robloxley"]

[/quote]

Blimey, if you can identify worms on ultrasound examination, you're a damn sight better than me! I'm happy to identify the gut wall thickness, never mind the toxacara present!

Re: Practice meeting.. a follow up

Emily Nightingale — Thu, 16 Jan 2014 18:50:14 GMT

Just incase you might be interested these are the Danish guidelines on antimicrobial use.. (I worked on this before going into general practice)

www.fecava.org/sites/default/files/files/DSAVA_AntibioticGuidelines - v1-1_3(1).pdf

Re: Practice meeting.. a follow up

Virginia Campbell — Thu, 16 Jan 2014 18:43:27 GMT

[quote user="Evelyn Barbour-Hill"]

Why? It's all so unnecessary.

[/quote]

Does the BVDA have a position statement on this?

Re: Practice meeting.. a follow up

Rob Loxley — Thu, 16 Jan 2014 14:57:28 GMT

[quote user="Sammy82"]a greyhound returned with septicaemic shock the same afternoon[/quote]

n=1?

Re: Practice meeting.. a follow up

Mark Hedberg — Thu, 16 Jan 2014 10:52:00 GMT

[quote user="Clive Ansell"]

Practice owner commented that "it wouldn't have happened if I'd given the Amox LA". Damned if you do damned if you don't.

[/quote]

Well, obviously - Amox LA is a miracle drug that encases the dog in a magic barrier of goodness! :p

Re: Practice meeting.. a follow up

Clive Ansell — Thu, 16 Jan 2014 09:37:25 GMT

+1 for no antibiotics for routine clean uncomplicated surgeries.

Although, as a locum I tend to go with the flow and do what the practice normally does. About half give a shot of Amox LA to routine ops. I never know whether to argue my corner and not give it?

I did get burnt October 2012. The practice usually gives Amox LA, but it is accepted I don't to my ops. A SBT spay bled a little under the skin wound after a violent recovery. A body bandage was placed and the client advised to return for check the following morning. Check appt not kept, and dog returned 4 days later with a soaking wet and muddy bandage and an infected would. 7 days antibiotics were prescribed, and again a check appt was not kept. Turned up again 3 weeks later with a large area of necrotic sloughing skin which required debridement. Practice owner commented that "it wouldn't have happened if I'd given the Amox LA". Damned if you do damned if you don't.

Re: Practice meeting.. a follow up

Sammy82 — Thu, 16 Jan 2014 08:52:21 GMT

I stopped using post dental ABs a couple of years ago, until a greyhound returned with septicaemic shock the same afternoon. He only had a scale and polish, some mild gingivitis at the gumline but no gum recession pradontitis or worse. Since then they get their Betamox again.

Re: Practice meeting.. a follow up

Linda Filshie — Thu, 16 Jan 2014 00:02:48 GMT

[quote user="Glenn Hodgson"]

1 I am sure that there is Study out there showing that a jag of amoxy LA does not alter surgical outcome at all In any routine op. I THINK it also showed that a course of amoxyclav had no benefits for experienced surgeon ops,, but did reduce infectio.s in student routine ops.

It's out there somewhere.

[/quote]

Probably this 1988 study

The abstract states: "The administration of antibiotics significantly reduced the frequency of wound infection in clean surgical procedures performed by senior veterinary students but not in clean elective procedures performed by faculty or resident surgeons that required 90 minutes or less to complete."

So if your bitch spays are taking you more than 90 minutes maybe you should be thinking of a jab of beta LA after all!!!

I'm another +1 for no routine antibiotic peri-op/peri-dental

Re: Practice meeting.. a follow up

Evelyn Barbour-Hill — Wed, 15 Jan 2014 23:02:59 GMT

Why? It's all so unnecessary.

Re: Practice meeting.. a follow up

Glenn Hodgson — Wed, 15 Jan 2014 21:51:12 GMT

It's out there somewhere.

Re: Practice meeting.. a follow up

bob lehner — Wed, 15 Jan 2014 21:11:15 GMT

[quote user="Emily Herskind Nightingale"] routine use of antibiotics[/quote]

Good that you had your meeting. All practices should have had an in-house discussion and formulated some sort of policy on their antibiotic usage (post-op for clean routine surgery being a prime example). The BSAVA 'PROTECT' document is a good tool (although EBH might not like the bit on periodontal disease).

It's in the C of PC - tho I suspect 'not a lot of people know that...':

'Antimicrobial and anthelmintic resistance

4.22 The development and spread of antimicrobial resistance is a global public health problem that is affected by use of these medicinal products in both humans and animals. Veterinary surgeons must be seen to ensure that when using antimicrobials they do so responsibly, and be accountable for the choices made in such use.'

With the general twitchiness surrounding the subject of antibiotic resistance by the powers-that-be, up to international government level, I wonder if it is beyond the bounds of possibility that an MRCVS might one day be hauled up on a disciplinary charge for inappropriate use of antibiotics.

Re: Practice meeting.. a follow up

Utlendigur — Wed, 15 Jan 2014 20:55:50 GMT

1. We have discussed this at one or two practice meetings, but as per usual have no actual policy - I know at least one colleague still gives post-op amox la. I stopped using antibiotics for routine neutering several years ago and didn't noticed any problems or increases in wound infections (despite looking back through my ops to sort of audit them).

2. Dentals on a case by case basis. Cats with nasty stomatitis/gingivitis get synulox pre and post dental. Simple descales or extractions don't get any. Tooth root abscesses or those horrible little dogs with rotten mouths get synulox injection pre-op and a course post-op.

3. Not something we tend to do, but on occasions we have scanned something "for interest" eg where it wasn't necessary because we already had a diagnosis and were doing it simply to improve scanning skills, we have just got verbal consent or added to existing consent form.

Re: Practice meeting.. a follow up

Virginia Campbell — Wed, 15 Jan 2014 19:39:35 GMT

1. We stopped using abs for routine cat and dog spays and castrates about 5 years ago and absolutely no problems. The jag of Betamox LA they used to get- after induction- was probably useless anyway ("worse than useless" I think Jill Maddison said at a lecture I attended a few years ago)

2. We occasionally have this fight, sorry I mean discussion, at practice meetings. Having read the opinions of the vetsurgeon.org dentists and those of the VIN dentists, I agree with you, but one of my bosses once read a paper that said scalers over x speed induced bacteriemia in y many animals and so is keen that everything gets antirobe 5 days pre and post dental. Why 5 days? Who knows. Boss #2 is quite a "just in case" type vet so also likes ab use pre and post dental.

3. Doing during recovery is a nice idea so as not to add to GA time, but beware the ex lap air making abdo scan hard to read. If you decide to scan things that aren't getting a coeliotomy anyway- such as the castrates- plan what you're going to say and do in the event that you find something on scan and are trying to work out if it's an artefact, real but incidental, or pathology that is going to cause trouble.

Re: Practice meeting.. a follow up

Evelyn Barbour-Hill — Wed, 15 Jan 2014 19:30:21 GMT

[quote user="ChrisBVSc"]Interesting - so, in what dental situations would you use an antibiotic? (any common examples would be useful!)[/quote]

If you've caused horrible trauma. If it was a mangling RTA that necessitated the procedure. In those cases, antibiotic immediately preceding operation, or intra-operation. Possibly a short course afterward, say three days.

If there is real immunosuppression. I recently did a near-total extraction in a cat with significant leucopaenia (we still haven't diagnosed a cause) and healing did not proceed as it should. After a week I commenced a week's course of clav-amox and a week later all was healing exactly as it should. It might in retrospect have been better to commence the antibiotic immediately after extraction, but I have no regrets about managing it the way that I did.

If there's osteomyelitis, in which case you need to treat it as you would osteomyelitis anywhere. But it's pretty rare, in my experience, and when it is seen it's most usually due to a canine tooth fracture that somebody decided did not need any treatment.

There are I think some BSAVA "guidelines" you can look up – they were contributed by BVDA.

Re: Practice meeting.. a follow up

Rob Loxley — Wed, 15 Jan 2014 19:29:16 GMT

Re: Practice meeting.. a follow up

Rob Loxley — Wed, 15 Jan 2014 19:24:39 GMT

[quote user="Emily Herskind Nightingale"]routine use of antibiotics
Should they be worried??[/quote]

Audit your postop infection rate before and after, if it goes up look at what measures to take (and this may not be just reintroducing abs - see the vicryl rapide thread)

Re: Practice meeting.. a follow up

ChrisBVSc — Wed, 15 Jan 2014 19:14:16 GMT

Interesting - so, in what dental situations would you use an antibiotic? (any common examples would be useful!) And is there anything worth reading that backs up the fact I may have been taught wrong?! (quite happy to change what I'm doing if there's good evidence for it!)

Chris.

Re: Practice meeting.. a follow up

Evelyn Barbour-Hill — Wed, 15 Jan 2014 18:53:29 GMT

Welcome to vetsurgeon, Chris. You'll soon get to know who's what, as it were.........

[quote user="ChrisBVSc"]I know the Antirobe poster probably had some commercial motives behind it,[/quote]

I think we may assume so!

The extra joke is, that if you really wanted an antibiotic drug that would in its characteristics be highly suitable for periodontal disease then clavulanate/amoxycillin would be just as good as clindamycin.

[quote user="ChrisBVSc"]The pre & post dental antibiotic treatment is something I was taught in my first year of practice (2007-8), [/quote]

You wuz taught wrong. Sorry.

All a pre-dental-procedure course is going to do is ensure that the bacteria in the mouth (trillions of 'em) at the time of procedure are the ones resistant to that antibiotic drug.

And a post-procedure course is unnecessary except in special circumstances.