Introduction

Antimicrobials revolutionized human and veterinary medicine; however, the parallel emergence and dissemination of antimicrobial resistance continues to compromise these gains. Antimicrobial resistance (AMR) has been called the global health crisis of our time. Effective antimicrobials are required for the health and safety humans and animals, and AMR puts modern healthcare at risk, with challenges ranging from complications treating common and simple conditions such as urinary tract infections or resistance that threatens the use of complex conditions such as cancer care and surgery. Antimicrobials are also important for the health and welfare of food producing animals, facilitating humane, safe and economically viable food production and helping assure food security. The dire economic consequences of AMR cannot be overstated. The World Bank estimates that, by 2050, AMR will result in global economic damage at least equivalent to the financial collapse of 2008 if left unchallenged, and no country will be spared.

What Is Antimicrobial Stewardship?

Antimicrobial stewardship is a coordinated approach to optimizing the use of antimicrobials, maximizing patient care and while minimizing the risk of resistance, toxicity or other adverse events. This involves a multifaceted approach to determine when to prescribe antimicrobials, what drug, dose and duration, how they are administered and whether other approaches are needed in addition to or in lieu of antimicrobials (e.g., surgery, wound care, management of underlying disease). While the concept of antimicrobial stewardship is now attracting much attention, there is sometimes the perception that an antimicrobial stewardship program (ASP) is meant to be restrictive and will therefore negatively impact the practice of veterinary medicine. While some aspects of an ASP may implement controls, an ASP is not meant to complicate patient care, remove access to needed antimicrobials or decrease practice efficiency. Rather, a well-structured and functioning ASP can improve patient care and facilitate timely and effective treatment.

Despite the increasing attention being patient towards antimicrobial stewardship, there has been limited specific implementation of ASPs in veterinary clinics and limited practice—or patient-level guidance.

While general statements about the need for ‘prudent’ use of antimicrobials have existed in veterinary medicine for some time,^1-4 practical clinical guidance has been limited. However, in recent years, there has been an increase in available information, including broad national treatment guidelines, as well as detailed guidelines for specific diseases (e.g., urinary tract infections in dogs and cats)⁵.

In human medicine, the field of antimicrobial stewardship has evolved into comprehensive program run by people specializing in the field, using a multifaceted approach to address a range of issues related to antimicrobial use. While some aspects of human stewardship programs do not apply to veterinary medicine, or are most relevant for large referral facilities, a large percentage of the core human strategies can be effectively and practically implemented in veterinary medicine. The state of antimicrobial stewardship in veterinary medicine is perhaps similar to the situation in community medicine in humans, an area where stewardship activities have lagged far behind hospitals. Many of the issues faced by community healthcare are similar to those faced by veterinary practices, and as the ASP field advances in human community care, there should be increasing potential for cross-application of new ideas and approaches. Regardless, there are initiatives that virtually any veterinary clinic can undertake now. Further, as there is increased scrutiny on antimicrobial resistance and antimicrobial use in veterinary medicine, development and implementation of practical ASPs will be necessary to optimize patient care and as a method of due diligence, to help ensure that veterinarians have access to antimicrobials.

Components of Antimicrobial Stewardship

Antimicrobial stewardship is a multi-modal approach to the practice of medicine that goes beyond specific aspects of antimicrobial use. An ASP obviously has a major emphasis on specific aspects of drug prescription and use. However, a strong ASP has broader aspects to reduce the need for antimicrobials through preventing disease and promptly identifying patients that require antimicrobials and those that do not. It also fosters been communication and education of all players in the prescribing cascade (attending clinician, diagnostic laboratory, pharmacy, owner) to facilitate optimal use and remove pressures to use antimicrobials in situations where they are not indicated.

Virtually all clinicians practice some form of antimicrobial stewardship on a daily basis, through decisions about when and how to use antimicrobials, and through measures taken the reduce the risk of disease. Therefore, implementation of an ASP should not be approached as a paradigm shift, but rather an evolution of core principles of medicine.

There is a wide range of potential components of an anti-microbial stewardship program (Table 1). The feasibility and potential benefits of these vary, with some representing rather easy-to-implement and potentially high yield measures, and others that can be categorized as useful to more complex and lower priority.

Table 1

Implementation of an Antimicrobial Stewardship Program

The approach to an ASP will vary greatly between facilities, based on a range of factors such as the nature of the caseload, the prevalence of resistant pathogens, the current state of antimicrobial use, access to specialists, access to a pharmacist, clinician motivation, management motivation and level of understanding of the issues. Yet, any practice can implement some components of an effective ASP with little effort, time, cost or access to other personnel. Often, starting with some easy measures (low hanging fruit) is useful to facilitate acceptance of change, with addition of new measures over time as people realize the potential benefits, have increased awareness and understand that an ASP is meant to help, not hamper, patient care.

Resources

While clinical antimicrobial stewardship is still in its infancy in veterinary medicine, a variety of resources are available. These include general position statements,^4,6-8 disease-specific diagnosis and treatment guidelines,^5,9-12 human healthcare ASP resources and ASP program websites (Table 2). There are also national broad treatment guidelines, such as those from the Australian Infectious Disease Advisory Panel (http://www.ava.com.au/sites/default/files/AVA_website/pdfs/AIDAP%20prescribing%20guidelines.pdf) and Danish Small Animal Veterinary Association (http://www.fecava.org/sites/default/files/files/DSAVA_AntibioticGuidelines%20-%20v1-1_3(1).pdf). These can provide the foundation for a facility-specific ASP in any veterinary practice, although more specific and practical guidance for veterinary facilities will hopefully be increasingly available in the near future.

Table 2. Examples of antimicrobial stewardship program resources

References

1.  Bronzwaer S, Lonnroth A, Haigh R. The European community strategy against antimicrobial resistance. Euro Surveill. 2004;9(1):1–3.

2.  McEwen SA, Fedorka-Cray PJ. Antimicrobial use and resistance in animals. Clin Infect Dis. 2002;34(Suppl 3):S93–S106.

3.  Prescott JF. Antimicrobial use in food and companion animals. Animal Health Research Reviews/Conference of Research Workers in Animal Diseases. 2008;9(2):127–133.

4.  Page S, Prescott J, Weese S. The 5Rs approach to antimicrobial stewardship. Vet Rec. 2014;175(8):207–208.

5.  Weese JS, Blondeau J, Boothe D, et al. Antimicrobial use guidelines for treatment of urinary tract infections in dogs and cats: antimicrobial guidelines working group of the International Society for Companion Animal Infectious Diseases. Vet Med Int. 2011;4:1–9.

6.  Weese J, Giguère S, Guardabassi L, et al. ACVIM consensus statement on therapeutic antimicrobial use in animals and antimicrobial resistance. J Vet Int Med. 2015;29:487–498.

7.  American Veterinary Medical Association. Judicious therapeutic use of antimicrobials. http://www.avma.org/scienact/jtua/jtua98.asp. 2004. Accessed April 11, 2005.

8.  Morley PS, Apley MD, Besser TE, et al. Antimicrobial drug use in veterinary medicine. J Vet Intern Med. 2005;19:617–629.

9.  Hillier A, Lloyd DH, Weese JS, et al. Guidelines for the diagnosis and antimicrobial therapy of canine superficial bacterial folliculitis. Vet Dermato. 2014;25:163–e43.

10.  Lappin MR, Blondeau J, Booth D, et al. Antimicrobial use guidelines for treatment of respiratory tract disease in dogs and cats: Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases. J Vet Intern Med. 2017;31:279–294.

11.  Beco L, Guaguere E, Lorente Méndez C, et al. Suggested guidelines for using systemic antimicrobials in bacterial skin infections: part 1. Vet Rec. 2013:1–11.

12.  Beco L, Guaguere E, Lorente Méndez C, Noli C, Nuttall T, Vroom M. Suggested guidelines for using systemic antimicrobials in bacterial skin infections: part 2. Vet Rec. 2013;172(6):156–160.