Veterinary Antimicrobial Stewardship programs are critical to not only improve patient outcomes, but support global action against antimicrobial resistance.
Emerging antimicrobial resistance (AMR) impacts treatment outcomes in human and veterinary medicine by compromising the ability to treat bacterial infections. This is further complicated by the proliferation of multi-drug resistant pathogens and the dwindling pipelines of new antimicrobial agents to treat them.
Under the WHO’s One Health paradigm, veterinary Antimicrobial Stewardship (AS) programs play a critical, strategic role in the AMR crisis. Strictly judicious, evidence-based use of antimicrobial agents in companion animal medicine slow the development and spread of resistant pathogens, while preserving the effectiveness of antimicrobials for clinical use. Establishing AS programs and practices in your clinics will not only improve client outcomes, but support global action against AMR.
Need for Antimicrobial Stewardship in Companion Animal Medicine
The injudicious use of critically important antimicrobials in companion animals, some authorized for human use only, creates selective pressure towards AMR and high risk of zoonotic transmission to owners and veterinary care providers. While most practitioners are aware of the underlying risks, failure to translate this into actionable AS programs is having troublesome consequences.
Surveys show that while AMR concerns most veterinarians and they believe that antibiotic usage in companion animals impacts AMR, significant knowledge and behavior gaps exist in adhering to judicious antimicrobial use. For example, despite the availability of published guidelines on judicious antimicrobial use, an overwhelming majority of responding practitioners were unaware of the existence of such guidelines.
Similarly, recent veterinary graduates are less likely to be concerned about AMR compared with more experienced counterparts, indicating an inadequate emphasis on judicious use of antimicrobials in the veterinary curriculum. In many practice settings, veterinarians are ill-equipped with adequate resources and support to take actions to address their concerns on the AMR issue.
Reported increases in multi-drug resistant pathogen infections in companion animal practices, such as multidrug-resistant Enterobacteriaceae including Carbapenem-resistant strains and Methicillin-resistant Staphylococcus pseudintermedius, are arguably a result of not deploying programs and technologies to support concrete action in the clinic.
AMR pathogens are also associated with poor treatment outcomes and drug-mediated adverse reactions from the use of less commonly used drugs with side effects. To the client, they pose an extra financial burden because of the need for expensive drugs, diagnostics tests, extra hospital visits, and prolonged hospital stays.
Establishing Antimicrobial Stewardship Program in Companion Animal Clinics
The American Veterinary Medical Association (AVMA) defines Antimicrobial Stewardship (AS) as “the actions veterinarians take individually and as a profession to preserve the effectiveness and availability of antimicrobial drugs through conscientious oversight and responsible medical decision-making while safeguarding animal, public, and environmental health”. AS includes a multifaceted and dynamic approach to reducing the need for antimicrobials through preventative medicine, evidence-based prescription and monitoring, and evaluating treatment outcomes involving antimicrobials.
Due to the wide disparity in type and size, a one-size-fits-all approach might not be effective for developing and implementing an AS program for companion animal practices. Rather, individual practices should focus on developing a program that works in their particular setting. With this in mind, the AVMA has developed the “Core Elements” of a companion animal stewardship program (Figure 1).
The AS Core elements are heavily focused on maintaining animal health and welfare through the judicious use of antimicrobials. Additionally, they are focused on the strategies and approaches to achieve, sustain, and advance this goal. This includes approaches to:
- Reduce use of antimicrobials, focusing on preventive and management approaches to disease, or the use of non-antimicrobial alternatives.
- Support evidence-based decision making for antimicrobial treatments, based on diagnostic tests, local antibiograms, and clinical guidance.
- Use antimicrobials judiciously. Use only when needed, never unless indicated, and only with the appropriate dose, duration, and oversight.
- Ensure client compliance on drug administration.
Resources for Developing Veterinary Antimicrobial Stewardship Program
General antimicrobial use guidelines developed by key stakeholders in the veterinary medicine field, such as AVMA, AAFP/AAHA, CVMA, FECAVA, are excellent sources of information on recommendations for judicious use of antimicrobials.
ISCAID (International Society of Companion Animal Infectious Diseases) antimicrobial use guidelines for the treatment of specific disease conditions in companion animals provide benchmark references to evaluate current antimicrobial prescription and use practices. They also help to develop approaches to identify and correct deficiencies and formulate effective, clinic-specific AS strategies.
Individual clinics can also model their own AS program after other well-established AS initiatives in the veterinary setting, such as those of the University of Minnesota and the Ohio State University.
Barriers to Antimicrobial Stewardship Program Adoption
Successful implementation of an effective AS program in a companion animal clinic heavily depends on identifying the barriers to adoption and devising strategies to overcome such barriers. These barriers could be at the clinic level in developing, implementing, and sustaining the program, or at the client’s level in adopting the responsibilities in ensuring compliance with AS.
Overcoming Barriers in the Clinic
Successfully implementing an AS program requires leadership, commitment, communication, and informed decision-making based on accepted clinical practices and guidelines. These require commitment of resources, time, expertise, and additional funding, which may be scarce in many practice settings.
Other constraints include lack of available antimicrobial use guidelines, access to diagnostics, antibiograms, and AMR data and training programs.
While Culture and Sensitivity Testing (C&ST) remains the gold standard diagnostic method for bacterial infections, diagnostic evidence-based treatment decisions are hard in many cases. C&ST is infrequently performed because of the additional cost considerations and delay in getting results to drive an informed treatment decision.
Availability of sensitive and specific patient side diagnostic testing that can detect pathogens and associated markers that are predictive of AMR phenotype will empower veterinarians to make evidence-based treatment decisions without undue delay.
Client-Side Compliance Education
From the client’s side, barriers include compliance education, cost-associated constraints, and difficulty in ensuring proper storage and administration of medication.
While resource constraints are difficult to address, client education on AMR and the importance of proper antimicrobial use can greatly increase compliance with treatment regimes. This can reduce opportunities for the development and propagation of resistance traits.
Veterinary Medicine Can Lead the Way on Antimicrobial Stewardship
Veterinarians should lead the decision-making process for antimicrobial use in animals and take a proactive step in embracing AS. This will aid in keeping the veterinarian’s armory in fighting infectious diseases in companion animals intact.