Hi, everyone. Welcome to this lecture. This is a discussion starter for some antimocrobial stewardship topics in equine practice. As I previously mentioned, this presentation just aims to provide some potential discussion topics for antimicrobial stewardship in equine practice. Please use the online discussion boards to begin discussions around the topics raised. Use the information you’ve learned from this course, as well as your own experiences and insights from clinical practise, both first opinion or hospital-based, depending on which background you’ve come from. And we also encourage you to begin similar discussions around these topics amongst your colleagues and practice staff back at your practise, with an aim to spread the knowledge.
Bear in mind that some of these topics might provoke a variety of opinions, some stronger than others. But we do hope that you find the exercise useful. So we’re going to talk through some of the challenges that we might face with antimicrobial stewardship in equine practice. I’m sure a lot of you have already considered a few that you’ve experienced yourselves, but we’re going to talk through them in more of a basic and discussion-starting sense. So client expectation and pressure will probably be the first one that people will think of, including the fear of litigation in the veterinary surgeon.
I would be lying if I said that I had never succumbed to client expectation and pressure when prescribing antimicrobials, particularly as a less experienced vet, as a new graduate.
When you’ve got someone shouting at you, and it’s 10:00 PM, and it’s raining, and it’s cold, I’m afraid to say that it is often easier to succumb to their wishes and provide antimicrobials. However, it will be very interesting to hear your discussion points on this particular topic, and try and figure out ways in which we can perhaps mitigate this. Drug availability is another challenge. And this doesn’t necessarily mean drug availability from the market or the supplier.
This could mean what stock you’ve got in your practise, what stock you happen to have in the car, because “I’m afraid I’ve run out of that” is not really a sensible reason for irresponsible antimicrobial prescription, although, as I said before, I would be lying if I said that that had never happened. Cost is another one. Can the client actually afford your antimicrobial choice? Is this something that’s feasible for them? Or are you going to have to make a different selection based on the availability of finances? Administration route and palatability are really important in equine.
As we know with a lot of our drugs being injectables, this isn’t always feasible for the horse if it’s needle-shy or for the client if they can’t then administer that drug themselves over the next few days. Palatability, important. With our oral antimicrobials, though usually this can be worked around with tricks like apple sauce and molasses, as I’m sure you’re well aware. Drug licencing is a really important one, because I personally believe that it is acceptable to use an unlicensed alternative on the cascade to protect antimicrobial resistance, or to select a more appropriate antimicrobial for the particular area or condition that I’m targeting. I would be very interested to hear your discussion on that. Do you agree?
Do you think that vets can use the cascade for this purpose or do you think that we should be sticking with the licence purpose antimicrobials alone? Again, with licencing, is the data sheet for that particular antimicrobial correct? Is the dosage listed on that datasheet correct? Is there any evidence that you can find in the peer-reviewed literature to show that that is or is not correct? This is very important, because if we’re making appropriate choices, then that also includes correct dosage, correct administration route, and so on. And if our data sheets aren’t necessarily guiding us in the right way, then this could potentially contribute to the problem. Diagnostics, culture & sensitivity.
Yes, in an ideal world we’d use culture and sensitivity for everything that we needed to prescribe antimicrobials for. But in my experience certainly, this isn’t usually feasible with clients. They’re not usually happy with the cost or the timescale or having to wait. And I personally do find culture and sensitivity to be a bit of a hard sell sometimes with some clients. It’s often a lot easier, second line. So if you’ve tried some antimicrobials first, and then they’ve not worked, you have more of an argument. But I find that in the first instance that a lot of my clients are quite resistant to this based on cost.
And I’d be very interested to hear your discussion points and to see what sorts of things you can do in clinical practice to try and improve this. Competition rules, I will mention them because it is relevant in equine. But to my knowledge, and please feel free to correct me if you think I’m wrong, procaine penicillin is the only antimicrobial that has a withhold time. And that’s based on the procaine within it rather than the penicillin itself, so I don’t really think that this is necessarily that much of an issue.
It’s more of an issue in that should we really be competing animals that are obviously unwell and have required antimicrobials and that would be the argument that I have with clients. Knowledge– of course, it all comes down to knowledge both in the veterinary surgeon prescribing and in the client. How do you think that client knowledge could contribute to the challenges we face with antimicrobial stewardship and antimicrobial resistance? How do you think that vet knowledge can contribute to these issues? These are very, very important discussion topics, and I’d really like you all to get involved and have a chat about some of these.
Just as an example, because I know it can be quite intimidating to start a discussion, particularly if you’re first one. I thought I’d put this up as a suggestion for a good place to start. So we mentioned briefly, previously, that the dosage of our antimicrobials is very important, particularly whether this dosage is listed as being correct on the data sheet. Now, we should all be using evidence-based medicine to guide our choices. But I’m aware that this isn’t always the easiest thing to do in clinical practice, particularly when you’ve got 14 calls booked in and you’re busy driving around half the countryside. But I do encourage you to have a look at these particular references.
This is just a list of some papers that discuss the dosage of Trimethoprim/sulphadiazine– TMPS– particularly, in relation to whether it should be dosed once daily as per the data sheet or twice daily. I will encourage you to have a look at those references yourselves and formulate a discussion based on that. And I’d be very interested to hear your responses. In summary, this presentation was just a discussion starter, so please feel free to discuss the things you’ve heard in this presentation and any other challenges to achieving good antimicrobial stewardship that you might have encountered in your own experience. Don’t forget, you can discuss anything you’ve encountered.
It doesn’t necessarily have to have been mentioned in these lectures for you to want to begin a discussion topic around that. Particularly, have a think on how we as equine vets can work towards good antimicrobial stewardship now we’re aware of common challenges. Have a think about how you could work around that in your own practice. Have a think about how we as a profession can aim to improve things for the future. Have a look around and see if there are any resources available for practitioners to use with regards to antimicrobial stewardship. I will point you towards the British Equine Veterinary Association.
Their Protect Me Guidelines, for example, have a look at those and discuss how you think they could be used to improve antimicrobial stewardship, particularly in first opinion practice. As always, if you have any questions, please feel free to contact us.