Be an Antibiotic Guardian?

Re: Be an Antibiotic Guardian?

Evelyn Barbour-Hill — Mon, 20 Oct 2014 14:40:05 GMT

[quote user="Ian Battersby"]

[quote user="Evelyn Barbour-Hill"]I agree. But the explanation lies to a considerable degree in the medicines licensing legislation and the "cascade".[/quote]

Below I have copied and pasted a summary statement from the VMD on ABi and the cascade put out earlier this year. Which may be applicable to this discussion

Responsible antibiotic use under the cascade

Summary Position Statement:

[/quote]

Yeah yeah sure. But that doesn't answer John Flynn's points about pouring valuable antibiotics down dogs' ears.

Re: Be an Antibiotic Guardian?

Ian Battersby — Mon, 20 Oct 2014 10:28:42 GMT

[quote user="Evelyn Barbour-Hill"]I agree. But the explanation lies to a considerable degree in the medicines licensing legislation and the "cascade".[/quote]

Below I have copied and pasted a summary statement from the VMD on ABi and the cascade put out earlier this year. Which may be applicable to this discussion

Responsible antibiotic use under the cascade

Summary Position Statement:

UK veterinary surgeons have raised concerns over a perceived tension in balancing

the responsible use of antibiotics with the legislative requirement to use a UK

authorised veterinary medicinal product (VMP) before applying the cascade.

The VMD supports and encourages the responsible use of antibiotics. Responsible

use requires veterinary surgeons to take into consideration not only the most

appropriate active substance(s) but also the most appropriate formulation, the

posology, the current pattern of resistance in their locality, an awareness of how to

reduce selection pressure (considering MICs and clinical breakpoints when available)

and related factors (e.g. good biosecurity and husbandry/hygiene, avoiding surgical

sepsis etc). If a veterinary surgeon can demonstrate that these steps have been

taken, then cascade use of antibiotics is supported.

The VMD therefore considers that it is justified, on a case-by-case basis, to prescribe

an antibiotic on the cascade in the interests of minimising the development of

resistance, particularly where culture and sensitivity data indicate that a particular

antibiotic active substance is effective against a bacterial pathogen and where

knowledge of pharmacokinetics indicates that the selected product is likely to be safe

and effective for the animal species and condition being treated; i.e. prescription of a

narrow spectrum antibiotic on the cascade over a broad spectrum antibiotic that has

a specific indication for that condition.

The VMD strongly urges professional bodies, veterinary schools, research institutions

and other interested parties, to work together to aid veterinary surgeons by

considering options and proposing measures to compile the necessary up-to-date

evidence and guidance to enable them to make a more informed choice (based on

current scientific finding and peer reviewed data) when prescribing medicines on the

cascade. Veterinary surgeons are encouraged to maintain an awareness of guidance

already provided by organisations such as the British Veterinary Association (BVA),

British Small Animal Veterinary Association (BSAVA), British Equine Veterinary

Association (BEVA), Pig Veterinary Society (PVS) and the Responsible Use of

Medicines in Agriculture (RUMA) as well as discussions co-ordinated by the European

Platform for the Responsible Use of Antimicrobials (EPRUMA), and the Federation of

Veterinarians in Europe, (FVE).

Re: Be an Antibiotic Guardian?

Michael Woodhouse — Sat, 18 Oct 2014 23:13:37 GMT

[quote user="Hannah Wynne Richards"] The biggest veterinary problem is the use of antibiotics in farm animals. Farmers are allowed to keep modern antibiotics in stock - and to decide when, what dosage and what length of course to use them.[/quote]

In our practice the antibiotics handed out tend to be amoxycillin, oxytet and pen/strep. We are constantly talking to people about best products for specific conditions, dose rates, route etc. We flatly refuse to hand out fluoroquinolones to animals we haven't seen, and even then we use them very rarely (I might get through 6 X 100ml bottles per year doing 90+% cattle work). The cephalosporins are used by farmers in specific circumstances for specific problems, but remain too expensive for routine use.

The majority of farm vets I speak to are very responsible when it comes to prescribing. Not always the case with some small animal vets handing out Baytril like smarties....

Re: Be an Antibiotic Guardian?

Evelyn Barbour-Hill — Sat, 18 Oct 2014 15:26:59 GMT

[quote user="John Flynn"]Additionally, why would one pour useful systemic antibacterials down the ear anyway? I keep reading reports of this and it really bugs me. Surely the point of a useful systemic antibacterial is that it can kill bugs at blood levels that won't kill you and therefore reach infections that couldn't be treated otherwise. If the bugs are living in an area where one can kill them with effective antibacterial agents such as silver-sulphadiazine, acetic acid, alcohols, chlorhexidine, iodine etc etc that are too toxic to be given systemically should you have a lung/prostate infection etc, then why would one use a systemic antibacterial on them in the first place?[/quote]

I agree. But the explanation lies to a considerable degree in the medicines licensing legislation and the "cascade".

Re: Be an Antibiotic Guardian?

Hannah Wynne Richards — Sat, 18 Oct 2014 11:12:19 GMT

The biggest veterinary problem is the use of antibiotics in farm animals. Farmers are allowed to keep modern antibiotics in stock - and to decide when, what dosage and what length of course to use them. Very often these are used to treat production diseases, which have been caused by over-intensive agriculture - and therefore by the demand from the public for unrealistically cheap food. Both animal welfare, and antibiotic resistance would be vastly improved if farm gate prices were at least trippled - and there was a concurrent tightening up on farmer's ability to treat without far greater veterinary involvement.

Wynne

Re: Be an Antibiotic Guardian?

John Flynn — Thu, 16 Oct 2014 23:30:47 GMT

Lists of 1st/2nd/3rd line antibiotics are available from certain organisations e.g. BEVA, BSAVA

I found this:

http://www.bsava.com/Portals/4/knowledgevault/resources/files/Protect_Poster.pdf

but I think there would be a lot of vets that would read this (including some that actually knew what they are talking about unlike me) and completely disagreed with the suggestions being made.

According to this, fusidic acid is totally appropriate to apply topically for pyoderma or otitis! While trimethoprim or erythromycin are not appropriate for systemic use for the same (unless MRSA/MRSP is confirmed in the case of trimethoprim), though sustained-release cefovecin is?!

Apparently pouring ceftazidime, ticarcillin, enrofloxacin or marbofloxacin down a dog's ear is appropriate!?!?

And they use a LOT of clavulanate which I really doubt is going to limit resistance developement - quite the opposite I would have guessed.

I feel fairly comfortable that I am not the only vet reading this and thinking "that's nuts", hardly a yardstick that I would consider measuring up against regarding whether my prescribing habits were responsible or not as I don't think some of those recommendations are remotely responsible in the first place. If I'm to be encouraged to change my habits, then I need more explanation than I have found on that website to date to explain why these are responsible choices - I appreciate that science moves on at quite a rate and they may well be sensible guidelines on responsible antibiotic use, but I just don't follow myself.

[quote user="SilverstarDJ"]Surely drug companies much know the half life of their drugs?[/quote]

[quote user="SilverstarDJ"]And the following has a lot of half lives on it for dogs (84 mins for cephalexin)[/quote]

Cephacare (AnimalCare) reports a half-life of 2.5-3hrs

"Cefalexin is excreted in the urine in high concentrations and has an elimination half life (T_1/2) of approximately 2.5–3 hours." ( looking at its UK SPC on http://www.vmd.defra.gov.uk/ProductInformationDatabase/Default.aspx )

Are you still sure the drug companies know the half lives of their drugs?

[quote user="SilverstarDJ"]How else would they know how many mg/kg/day are recommended ? I assume this is based on some science[/quote]

*cough* - maybe I'm just an old cynic but I really don't put a lot of trust in anything spouted by a pharmaceutical company unless I can evaluate the data on which it is based, and even then I have a high degree of skepticism.

Re: Be an Antibiotic Guardian?

John Flynn — Thu, 16 Oct 2014 20:45:44 GMT

I appreciate you taking the time to share your insights, Ian.

[quote user="Ian Battersby"]comparing 3 days of a FQ with 14 days of amoxi-cla in bacterial cystistis in dogs; there was no difference but I would have been more interested to see 3 days of amoxiclav given its pharmokinectics it is highly concentrated in urine.[/quote]

Surely the inclusion of clav only increases selection-pressure for ESBL strains? I would be more interested to see work on basic, commonly-used antibacterials in this situation such as amoxicillin, trimpethorpim and oxytetracycline before moving to more fancy ones. I suspect this study, like most published, was funded by the same pharmaceutical industry flogging the more pricey drugs? Additionally, it would be really useful to make more easily available the data that is out there - I just took a look and couldn't easily lay my hand on any data regarding the urine concentration of clavulanate achieved after oral dosing in the dog, I'm not denying the info is out there, but if an average vet like myself can't find it then better publicity of data like this might help with intelligent antibacterial prescribing?

[quote user="Ian Battersby"]Absolutely not using in self limiting conditions is a primary place to start and by developing a practice policy including when Abi are not indicated can help with this.[/quote]

I personally think it is more important to restrict/abolish/not-introduce the use of "important" antibacterials in the human field. I struggle to believe that the use of oxytet for5 days in dogs with "kennel cough" is nearly so much a crime as culturing a pretty-resistant bug, doing a sensitivity and then using a carbapenem, fluoroquinolone, 3rd-generation cephalosporin etc for a few weeks.

I reckon if developing a practice policy, then focus on which antibacterials will be used at all is more important than how often short courses of the "less-important" ones are prescribed (though I appreciate that restricting the latter will help preserve their efficacy).

[quote user="Ian Battersby"]Agree the culture and sensitivities are based on expected serum concentrations of the drugs so you can interprete them in like of the area you are trying to treat. So if used topically you may overcome the resistance ( or reduced susceptibility) as you can reach much higher concentration,[/quote]

The production of sensitivities that say "resistant" to polymixin B or fusidic acid from an ear swab are surely meaningless? Surely the only use of suspectibility testing is if systemic antibacterials are to be administered?

Additionally, why would one pour useful systemic antibacterials down the ear anyway? I keep reading reports of this and it really bugs me. Surely the point of a useful systemic antibacterial is that it can kill bugs at blood levels that won't kill you and therefore reach infections that couldn't be treated otherwise. If the bugs are living in an area where one can kill them with effective antibacterial agents such as silver-sulphadiazine, acetic acid, alcohols, chlorhexidine, iodine etc etc that are too toxic to be given systemically should you have a lung/prostate infection etc, then why would one use a systemic antibacterial on them in the first place? I can't see much point in culture and sensitivity (or at least not with the testing done by some UK labs) of the average case of otitis externa for instance.

Finally, somewhere previously in this thread I think I read the comment that a general rule was to use more narrow spectrum antibacterials to be more responsible. Again I don't follow this. That would suggest to the reader that oxytetracycline, amoxicillin, chloramphenicol and trimethoprim should be replaced by fusidic acid, metronidazole, rifampicin, azithromycin etc when feasible. While I appreciate the sentiment is probably "all other things being equal", I think as a general "rule" this has little application and whatever limited applications are there are probably easier to spell out specifically?

Re: Be an Antibiotic Guardian?

No Name — Thu, 16 Oct 2014 20:09:48 GMT

[quote user="John Flynn"]

[quote user="SilverstarDJ"]My understanding is that we need to be using older antibiotics (more resistance in human medicine since they have been out for longer) and reserving the newer ones as a last resort, especially those that are used in human medicine.[/quote]

I think this makes sense, but just try drawing up a list and getting folk to agree on it.

[/quote]

Lists of 1st/2nd/3rd line antibiotics are available from certain organisations e.g. BEVA, BSAVA if I am not mistaken (I have seen some in poster format in vet practices) - I think there is some evidence to suggest that practices who have such charts/protocols prescribe fewer FQs. Of course some people won't want to change, but you have to start somewhere...

[quote]

[quote user="SilverstarDJ"]I agree that there should be more data on common disease and efficacy of different classes of antimicrobials across a whole range in population, which should be reviewed regularly but sadly this sort of data isn't readily available[/quote]

I'm talking really basic data here such as the pharmacokinetics/pharmacodynamics of such commonly-used drugs as clavulanate. Have a look for something really basic such as the half-life of cephalexin in the dog and it ain't even clear to me.

And I moaned about this in another thread, but the last "consensus" paper I read on antibacterial treatment of bacterial urinary tract infections contained all sorts of wacky drugs a general practitioner would never consider while failing to even mention oxytetracycline (even to say "not recommended" and give an explanation - not that I know what that explanation might possibly be).

[/quote]

Surely drug companies much know the half life of their drugs? How else would they know how many mg/kg/day are recommended ? I assume this is based on some science or is this extrapolated from humans?

Regarding cephalaxin half lives I found a paper which may interest you :

http://www.ncbi.nlm.nih.gov/pubmed/10597534
Absorption kinetics and bioavailability of cephalexin in the dog after oral and intramuscular administration.
Carli S1, Anfossi P, Villa R, Castellani G, Mengozzi G, Montesissa C.

And the following has a lot of half lives on it for dogs (84 mins for cephalexin) http://www.merckmanuals.com/vet/pharmacology/antibacterial_agents/cephalosporins_and_cephamycins.html

You mention a good point about limitations of C&S though.

Re: Be an Antibiotic Guardian?

Bob Russell — Thu, 16 Oct 2014 13:44:23 GMT

Vets should be doing our bit but we also should be realistic.

http://www.theguardian.com/society/2014/oct/10/doctors-antibiotics-prescriptions

Doctors are prescribing more, dentists a lot more and some of the reasoning is public pressure. If we don't give clients what they want, they go somewhere else and will get their own way. I am happy to see these people walk but do find explaining generally works well. If your GP refuses to give antibiotics where else do people go?

If antibiotics are being given to fob people off and get rid of them quickly then something in the system is pretty broken! A good source of revenue for the NHS though. £8.05 prescription charge for 50p of antibiotics!

Re: Be an Antibiotic Guardian?

Ian Battersby — Thu, 16 Oct 2014 13:29:07 GMT

Great to see a discussion developing , just thought I would bullet point a few things regarding some of the posts so far

Great to hear re university teaching. You are right in scandinavia there are a lot more restriction for vets a number of which the vets voluntarily engaged in. IN sweden I understand a vet is only allowed to prescribe a FQ after a culture and senisitivity demonstrates it is the only drug that will work.

I suspect that the longer an antibacterial course is administered the longer the selection pressure on the various bugs living on/in the patient occurs

This is correct the longer the course of antibiotic the greater the slection pressure for resistance strains. This is the primary model for resistance develpement . there are other factors such as hypermutable states that bacteria enter when antibiotics are not quite high enough to kill them as well. Duration of course is an interesting topic. Looking at the human side tradition course recommendations don’t have that much evidence to back them up. Even less in veterinary and we have adapted recommendations in some cases.

There is expanding research looking at shorter courses to get a clinical cure in humans. There was a recent cochrane review of a number of studies l;ooking at bacterial cystitis in women ( uncomplicated). A number of studies ( with 10,000 pateints) showed no difference between 3-4 days of antibiotics and 7-10 days of antibiotics in times to clinical cure and also relapse. Interestingly one study showed with 4 days Abi , pateints would improve but still had bacteruria on urinanalysis that then resolved ( i.e. the immune system finsihed the job) . Other examples would be pyelonephritis in which 1 week course was found to be effective. There are also studies looking at shorter courses being effective for community acuired pneumonia in people, septic joints even meningitis. So an interesting area and certainly an area that should be looked at more in veterinary species. The only one I am aware of is comparing 3 days of a FQ with 14 days of amoxi-cla in bacterial cystistis in dogs; there was no difference but I would have been more interested to see 3 days of amoxiclav given its pharmokinectics it is highly concentrated in urine.

I picked up on your post from the SAMSoc forum, and have run a story here

Cheers Arlo – great to spread the word on this one

And that we should remember the importance of hygiene - one of the biggest help of reducing MRSA in human hospitals has been correct HAND WASHING between patients!

Couldn’t agree more; antibiotic stewardship is part of the strategy which should be combined with infection control policy/hygiene policies and also passive surveillance of what bugs are being cultured so you can watch for trends.

Next up, is probably the empirical courses of antibacterials prescribed. These may well be unnecessary, as aluded to previously in posts, in which case on rapid clinical recovery of the patient cessation of any remaining antibacterial prescribed would be more appropriate than maintaining a selection pressure on the gut/skin bugs etc.

Then we have other patients where antibacterials are administered not even in an attempt to clear a primary bacterial infection, but for "other" reasons. For example the poplular use of metronidazole in cases of chronic diarrhoea - the more you use the more the selection pressure.

Absolutely not using in self limiting conditions is a primary place to start and by developing a practice policy including when Abi are not indicated can help with this. The challenge is changing habits and appreciating all our contributions to the resistance issues. i.e. “ I break the rules in this case it wont matter”. But also changing habits is hard particularly if we have one case that didn’t go well despite the 100 others that were fine without Abi.

I think C&S is useful certainly, but it has its limitations:

Agree the culture and sensitivities are based on expected serum concentrations of the drugs so you can interprete them in like of the area you are trying to treat. So if used topically you may overcome the resistance ( or reduced susceptibility) as you can reach much higher concentration, or again depending on pharmacokinectics coming back to the b lactam’s reach much higher concentrations in the urine than in the serum

Re: Be an Antibiotic Guardian?

Arlo Guthrie — Thu, 16 Oct 2014 10:59:42 GMT

[quote user="John Flynn"][quote user="Arlo Guthrie"]it is really important with antibiotics to make sure your pet finishes the course[/quote]

I'm not sure that this is a useful piece of wisdom to be sharing necessarily.[/quote]

Well there we go, exposing my ignorance!

My simplistic understanding was that the problems in human medicine are largely caused by a) medics dishing out antibiotics like candy, in response to patient pressure and b) patients not finishing the course, leading to the survival or resistant strains.

[quote user="John Flynn"]I think that may make sense for the sort of infection you are talking about, but by far the biggest use of useful systemic antiboitics in my experience in small animal practice appears to be for pyoderma/otitis, where the idea of removing all infection is not really practical. [/quote]

I hadn't thought of that, or its implications in human medicine.

The point I was trying to make, though, is just that the veterinary profession is in a good position to influence / educate a significant proportion of the public about their own use of antibiotics, and not just their pets'.

Re: Be an Antibiotic Guardian?

John Flynn — Thu, 16 Oct 2014 00:44:51 GMT

[quote user="SilverstarDJ"]I think the point is that a owner might stop giving antibiotics (or a human patient stop taken them) because they think their animal is feeling a bit better BUT before the infection is completely cleared (or at a point where the body may be able to cope with what is left).[/quote]

I think that may make sense for the sort of infection you are talking about, but by far the biggest use of useful systemic antiboitics in my experience in small animal practice appears to be for pyoderma/otitis, where the idea of removing all infection is not really practical. I can see the argument that perhaps treating for a long enough course so the skin's defences have recovered might make sense, indeed in my undergraduate days I was encouraged to treat for a good 3 weeks with systemic antibacterials(!) after clinical resolution, but a constant selection pressure like this makes me think that more likely to allow proliferation of eg MRSP. As there will be Staph.P. left on the dog at the end of the course no matter how long, the greater the selection pressure, then the greater the selection for resistance. Obviously the gut bugs are getting a healthy selection pressure for resistance at the same time.

I'm really left only with primary (or some secondary I guess) bacterial infections, perhaps an uncomplicated urinary tract infection in a bitch to take the most common example I reckon. I can see the argument that a longer course of antibacterial to ensure better chance of full resolution may seem prudent, but I'm not convinced that this is actually necessarily the case (and incidentally, whatever happened to the notion of asymptomatic bacteriuria). Even if it is, the courses prescribed by vets tend to be pretty empirical at the best of times and I'm unconvinced that the owner truncating these on the resolution of clinical signs will lead to more transferable bacterial resistance than them completing an often arbitrary course length.

I guess what I'm objecting to is simply the notion that if one starts an arbitrary course of antibacterial tablets then finishing that course of antibacterial tablets is the best way to minimise antibacterial resistance. This may well be the case where complete bacteriological cure of a truly infectious organism such as TB in humans is the aim, but in day-to-day small animal practice I am far from convinced.

I think this makes sense, but just try drawing up a list and getting folk to agree on it.

You'll find some think is perfectly normal to use an important anti-staphylococcal antibacterial such as fusidic acid on a routine basis for minor conjunctivitis or superficial pyoderma while soap-boxing about the profligate use of a single amoxicillin injection pre-operatively for "clean" surgery.

Others will funnel metronidazole into dogs with diarrhoea like it's going out of fashion while criticising those who think extended-spectrum fluoroquinolones are excellent for aspiration pneumonia.

Yet others will consider pouring useful systemic antibacterial drugs down a dog's ear a worthy use while suggesting that kennel cough shouldn't get any oxytet.

And have you seen the price of chloramphenicol these days!!!

[quote user="SilverstarDJ"]use culture&sensitivity more[/quote]

I think C&S is useful certainly, but it has its limitations:

Getting a representative sample.

Many labs report meaningless results - one clinic I worked in took a lot of C&S on ears which was often a total waste of time. The lab reported such specific findings as "non-lactose fermenting coliform ++" and then proceeded to give unhelpful sensitivies (which I can only assume are based on irrelevant data based on the achievable serum levels of things such as polymixin B).

But I genuinely am open to be educated on the topic, if there's clear well-accepted sensible-sounding guidance that I can apply and measure my prescribing habits against, I just haven't found it yet. I see a lot of stuff saying to be more responsible, but I see little sensible advice on my basic day-to-day questions of what being more responsible actually is in detail rather than vague concepts. Perhaps starting a thread to discuss teh specficis of matters of antibacterial responsible use would help?

Re: Be an Antibiotic Guardian?

No Name — Wed, 15 Oct 2014 22:46:23 GMT

[quote user="John Flynn"]

[quote user="Arlo Guthrie"]it is really important with antibiotics to make sure your pet finishes the course[/quote]

I'm not sure that this is a useful piece of wisdom to be sharing necessarily. While I appreciate that there are instances where this will be advisable to reduce the chances of selecting for resistant infection in a patient, in general I suspect that the longer an antibacterial course is administered the longer the selection pressure on the various bugs living on/in the patient occurs - for the "average" GP vet I somewhat suspect that advising owners NOT to complete their antibacterial "course" would lead to less selection of (transmissible) bacterial resistance.

[/quote]

I think the point is that a owner might stop giving antibiotics (or a human patient stop taken them) because they think their animal is feeling a bit better BUT before the infection is completely cleared (or at a point where the body may be able to cope with what is left). So then the infection may 'come back' as bacteria start to multiple again, meaning you then are back to square one PLUS you have more resistant bacteria so then have to switch to a different class of antibiotics.... and if this happens again then you soon end up with a population resistant to multiple classes.

But I'm open to be educated.

[quote user="John Flynn"]

I find the biggest barrier to responsible antibacterial use is agreement on what is important (and really basic quantifiable information such as knowledge on the PK/PD of that drug in that species) - if there's no consensus then it is rather hard to measure one's level of responsibility against it. When I read "consensus" statements, they don't tend to appeal to my common sense or conflict with other "knowledge" I think I had already received.

[/quote]

My understanding is that we need to be using older antibiotics (more resistance in human medicine since they have been out for longer) and reserving the newer ones as a last resort, especially those that are used in human medicine. We need to stop prescribing antibiotics to self limiting diseases and mild viral diseases. And that we should be using more narrow spectrum of antibiotics if possible and use culture&sensitivity more especially in cases that aren't getting better.

And that we should remember the importance of hygiene - one of the biggest help of reducing MRSA in human hospitals has been correct HAND WASHING between patients!On an interesting note, a friend told me that they read some paper that have suggested resistance to chlorohexidine!!

I agree that there should be more data on common disease and efficacy of different classes of antimicrobials across a whole range in population, which should be reviewed regularly but sadly this sort of data isn't readily available

Re: Be an Antibiotic Guardian?

John Flynn — Wed, 15 Oct 2014 20:43:06 GMT

[quote user="Arlo Guthrie"]it is really important with antibiotics to make sure your pet finishes the course[/quote]

But I'm open to be educated.

Re: Be an Antibiotic Guardian?

Arlo Guthrie — Wed, 15 Oct 2014 19:15:39 GMT

[quote user="Ian Battersby"]Resistance to antibiotics is a massive issue (and a soap box of mine as some of you know) and there is a campaign to raise awareness by encouraging everyone ( weather you prescribe them or given them) to become antibiotic guardians. [/quote]

Hi Ian,

I picked up on your post from the SAMSoc forum, and have run a story here:

http://www.vetsurgeon.org/blogs/veterinary_news/archive/2014/10/15/122679.aspx

Tweeted here:https://twitter.com/_VetSurgeon

and here: https://twitter.com/_VetNurse

and on facebook here: https://www.facebook.com/pages/VetSurgeonorg/143873598965199

and here: https://www.facebook.com/pages/VetNursecouk/183078125056338

I too think this is a really important issue!

I'm not sure how important responsible use of antibiotics is in companion animals, but isn't there a far bigger and more important point about all this, which is the role of veterinary professionals in using animals to educate pet owners why responsible antibiotic use is important in humans.

i.e. Mr Client, it is really important with antibiotics to make sure your pet finishes the course, or you could cause the bug to become resistant, and then it's curtains for poochums. It's the same for people.

Re: Be an Antibiotic Guardian?

No Name — Wed, 15 Oct 2014 18:07:23 GMT

At vet school lecturers are really hammering into us the responsible use of antimicrobials - especially emphasising that we shouldn't be using fluroquinolones & 3rd/4th gen cephalosporins as first line drugs, suggestioning we should do more culture and sensitivity, etc.. They have told us that the UK may end up like some countries where the use of antibiotics is severely restricted (one of the Scandinavian countries I think, can't recall which one), where you need to prove there is in infection and that only the vet can administer the drug to farm animals - but the data also shows that they have the lowest rates of antimicrobial resistance (although probably a combination of policies). It doesn't matter if doctors have a bigger role to play than vets, what matters more is what the politicians think of vets/farmers and their antibiotic use!

On EMS I have certainly seen vets prescribe antibiotics to animals with self limiting disease (to keep the owner happy?), or even no obvious disease (blood work had increased WBCs but normal clinical exam and the animal was well in itself). Or farmers who decide to underdose animals to save money.

Antibiotic resistance is inevitable, but it is important to slow this process down. Of course it is a multi factorial problem and will involve a lot of different parties to work together: doctors, vets, researchers & governments are needed to slow this process down and develop new classes of drugs, not just in the UK but worldwide.

Re: Be an Antibiotic Guardian?

Bob Russell — Wed, 15 Oct 2014 15:07:57 GMT

I use a very limited number of antibiotics but have fallen into the amox/clav trap. Recently I have reordered ampicillin and so far not seen an obvious difference. This suggests that there is little need to use the posher penicillins routinely or I am giving out antibiotics unnecessarily!

I suspect food animal antibiotic use is the key veterinary risk area but even that pales into insignificance compared to medical use.

Re: Be an Antibiotic Guardian?

Robin Grimmer — Wed, 15 Oct 2014 12:19:23 GMT

Are antibiotics still used as growth promoters for cattle in some countries? This is a global problem so going to be tough to solve if some countries aren't playing ball. Much like the topic of emissions. China and the USA account for almost half of the world's CO2 emissions!

Re: Be an Antibiotic Guardian?

Ian Battersby — Wed, 15 Oct 2014 12:10:01 GMT

Great to see there is a discussion developing. This is a big complex topic to try and summarise into a succinct post is hard so just thought I would try and highlight a few points that may add to the discussion on the points so far.

Massive issue. - A few picked up on me using the word massive. I guess that depends on your perspective as to what terms you use. I think this is an important global One Health issue that we all need to work on now to prevent problems in the future. There are increasing numbers of multi resistant bacteria in human hospitals but there are multiresistant bugs beginning to emerging in veterinary practice. these are reported in abstracts at CPD meetings but I know from personal experience of cases referred to me but also I get phone calls about them

No new class of antibiotic has been discovered or developed since the late eighties ( research and development was reduced significantly at that time). Following work by groups such as Antibiotic Action, research is on new antibiotic classes is starting but theses products will take time to develop. So we have an opportunity to start modifying our prescribing patterns now to slow down resistance emergence whilst new products are developed.

Multi resistant bacteria in veterinary species. – I have a small animal bias so I cant comment on larger species. MRSA infections in pets have been reported , but Staph Aureus doesn’t colonise dogs well. But there are increasing levels of MRSP ( Staph pseudo intermedius) cultured from dogs patients. In particular dermatological cases that have received lots of antibiotics to control secondary infections ( some dermatology centres reported 20% colonisation, I have heard someone suggest in some of the centres in the USA this figure was much higher) . What is worrying is that the resistance profile in MRSP is often more extensive than isolates of MRSA.

Animal prescribing affecting our patients and the affect on humans

· BVA and BSAVA and other veterinary societies have been actively campaigning to put the veterinary side across and argue against restriction ( I have been to some of the meetings). There has in the past been a lot of attention on veterinary prescribing e.g. in 2008 the UK CMO suggested a ban of veterinary prescribing of FQ and cephasporins. There are infrequent reports of MDR bugs being transferred from pets to human. But there is the other aspect of resistance reservoir for human colonising species ( see below).

· The EMA has commissioned a report looking at the affect of animal prescribing on human health that will be reported to the EU later this year. What implications this will have for veterinary prescribing I cant say we will have to wait and see. But as said before BVA, BSAVA et al have been very active putting the veterinary professions side across to defend our prescribing privileges. What we need to do as a profession to help defend our position is to show we take this issue seriously and we use antibiotics in a responsible manner so restrictions are now necessary. This could be done is different ways, but some parts of the profession have taken voluntary steps to restrict e.g. the poultry society took a voluntary step for its members to stop using FQ in young old broilers.

· Reservoir of resistance. Plasmids and other mobile genetic components that can transfer resistance can move between different species. So for examples a plasmid could move from a MRSP to a S aureus that colonises humans. It is also true it could move the other way from an MRSA to SP. The risks are hard to quantify as this is a complex issue, and certainly you could say this is a low risk event. But it happens only once ….

Moidifying our own prescribing.

· e.g. minimising long courses and trying to narrow the spectrum when possible. This is alittle difficult to do in veterinary as a lot of the license products are broad spectrum. However some have narrower spectrums than others. Also minimising policy pharmacy, when possible.

· Developing a practice policy on when antibiotics are indicated and when are not. But also first choice abi ( or empirical) whilst awaiting cultures if taken based on what bacteria is likely to be involved. The PROTECT scheme ( see below) has a poster with suggestions for different conditions to help generate a practice policy. Practice policies have been shown in human settings to reduce unnecessary antibiotics prescribing. I am only aware of one study in the veterinary field from Canada that showed a significant reduction in floroquinolone usage over a 10 year period once a prescribing policy was put in place.

The antibiotics can select for resistant bugs on the patient that may cause an issue or the patient could be colonised and act as a potential reservoir. However the excretion of antibiotics ( a number of orally prescribed antibiotics are exreted in feaces sometimes upto 80% of the dose given ). The half life of antibiotics in the environment can vary but some can exist for years again contributing to selection. If you want to find a microbiologist who is interested in MDR, you will probably find them collecting samples in sewers

My view and the view of others interested in this area is that we all have a role to play in minimising the development in MDR. It is comparable to the role we all play in global warming/protecting our environment etc - “ think globally act locally” . same principle our individual prescribing all contributes to helping address global issue.

Like I said early this is a complex issue with lots of different factors to consider and hard to summarise but there are some great resources on line that are easy to access.

The BSAVA website has the PROTECT section – that is open access

Bella moss Foundation – also has great information again open access.

Finally – my spelling and grammer is not great. so apologise if I have missed a typo etc.

Re: Be an Antibiotic Guardian?

emma_j — Wed, 15 Oct 2014 09:20:51 GMT

I do worry about side effects of TMPS, having seen a few dry eyes, I must be unlucky. Also palatability/compliance - what formulations do you use?

Re: Be an Antibiotic Guardian?

Hannah Wynne Richards — Wed, 15 Oct 2014 09:08:49 GMT

Yes Doctors do seem to dose children by age not weight - and assune all adults are a standard size. They would also probably face less patient pressure if all medication was charged to the patient at full market price (including that for wastes of space)

Wynne

Re: Be an Antibiotic Guardian?

Michael Woodhouse — Wed, 15 Oct 2014 00:05:15 GMT

[quote user="Ian Battersby"]Resistance to antibiotics is a massive issue [/quote]

Is it though? By far the biggest two antibiotic products we use in practice are penicillin & strep and straight amoxycillin. I struggle to remember a true case of resistance in either of the drugs - either clinically or on culture/sensitivity.

They are drugs that need to be used responsibly, especially products like fluoroquinolones and cephalosporins, but the issues they see in human medicine don't seem mirrored in veterinary medicine. The effects we have on the production of antimicrobial resistant bacteria pales into insignificance when you look at what they are using in human medicine.

Personally I'd like the BVA to get behind vets and point some of this out! The problems in human medicine have very little to do with us.

Re: Be an Antibiotic Guardian?

Robin Grimmer — Tue, 14 Oct 2014 23:58:19 GMT

This is a hot topic and rightly so. I have tried to rationalise my use of antibiotics and try not to yield to pressure from owners to prescribe where not needed. eg most gi cases, kennel cough and flutd I don't use whereas once I used to. Unfortunately as GP vets we do see a lot of pyodermas in dogs where sometimes long courses of ABs are required. Also in many countries ABs are given out without proper control eg from pharmacies over the counter. My sister who lives in the US was treated for a splinter under the thumb nail and given a 10 day course of ABs. Was this really necessary?

Re: Be an Antibiotic Guardian?

Laurence Webb — Tue, 14 Oct 2014 22:49:34 GMT

[quote user="Neil Wheadon"] I wanted sulphonamides the other day but the newer graduates were terrified of dry eye, which I never saw, but they did limp after a few days in some cases [/quote] I did cause dry eye in a Springer Spaniel with pot sulph about 6 months ago. The first time in 18 years of using it though. I generally use is because it is cheap, but it is easy to fall into the habit of amoxy/clav as a first line treatment

Re: Be an Antibiotic Guardian?

Andrew Mellor — Tue, 14 Oct 2014 16:14:28 GMT

[quote user="Ian Battersby"]

Resistance to antibiotics is a massive issue ( and a soap box of mine as some of you know) and there is a campaign to raise awareness by encouraging everyone ( weather you prescribe them or given them) to become antibiotic guardians.

[/quote]

Very interesting talk you gave at the AVSTS/ SAM Soc meeting a few weeks ago, I would never have known it was your soap box