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Practical approaches to AMS in companion animal practice

Dr Tim Nuttall introduces ways of implementing good AMS in companion animal practice.
In this module, I’m going to briefly introduce some of the steps that could be taken within practices to include antimicrobial stewardship. And one of the really important things here is to realise that this involves engagement of the whole veterinary team. So that’s the vets, as well as the nurses. And the clients as well because this is a true one health problem. The two sides to the coin are the prescribing of the antimicrobials, as well as the administration and completement of courses. And by engaging everybody, we can make a difference. Now, this is some data that was commissioned by the Bella Moss Foundation and conducted by a team at the Royal Veterinary College.
And this is one of the questions amongst many. Now, this is a little bit old. The data comes from 2014. But I did repeat this a little over a year ago, now, amongst a smaller group of vets. And interestingly, the figures were almost the same. So roughly speaking, about a third of practices were using written antimicrobial guidelines. But still, a majority of practices weren’t or the vets weren’t sure with that. And that’s something we do need to get better about. And there are plenty of guidelines available, now, for all sorts of different types of practice, for different species, and so on.
And the important thing to realise is that these guidelines are not designed by people like me in an ivory tower, in a university, trying to dictate what people do in first opinion practice. It’s a set of tools to help people make rational decisions about the most appropriate therapy for the case that they have with them. And the guidelines are there to provide assistance. The ultimate responsibility for the treatment choices and care of the patient is still lying with the primary care vet. These are absolutely not about trying to dictate fixed treatment patterns. Now, I have to declare a conflict of interest, here, because I’m one of the authors of these guidelines.
And they were produced by CIVA, who are a pharmaceutical company. But the final draft of these was very carefully observed by the International Society for Feline Medicine, CAVA, the Bella Moss Foundation, and others, to ensure that the authors had complete editorial freedom, here, and that there was no undue pressure being exercised by CIVA. And I and the other authors are very happy that these are independent. And the author panel consisted of a very wide range of clinicians, both from the medicine side of things, the surgical side of things, alongside pharmacologists, epidemiologists, microbiologists, and so on, to ensure that the information was as accurate and as up-to-date as possible. And the main body of this book are the disease fact sheets.
And these are generally two-to-three-page very quick guidelines covering just about every disease presentation you could think about in dogs, dogs and cats. And then there are the recommendation sides, which go through things in a little bit more detail in terms of the background over sampling for cytology and culture, interpreting results, selecting drugs appropriately, what to do when treatment fails, how to manage multidrug-resistant infections, prophylactic use around surgical cases, and so on. And then there are the more in-depth background topics right at the end. And the beauty of these guidelines is that you’ve got everything you need for small animal practice in one place. Where sometimes, the disadvantage with other guidelines is you’re having to collect them from different sources.
And now they operate very much at a sort of traffic-light system, in terms of first, second and third-line choices. So I’ve just pulled out a couple of examples, here, that I was involved with for the surface and superficial bacterial skin infections and then the deeper bacterial skin infections. And they go through how to approach the diagnosis of these by looking at the lesions, by looking at the cytology. When to consider culture, and so on. And you can see, certainly, that for the superficial infections, here, the first-line choice is to use topical therapies, topical antiseptic therapies. And then it goes into more details about which ones have evidence to support their use, and so on.
And then with the deep pyodermas, so similar things. So, cytology for diagnosis. When to consider empirical therapy. When to consider culture and antimicrobial susceptibility testing. And then, like the other treatments, you do have the first-line, second-line, and third-line antimicrobials, there. And certainly, using guidelines like this can get the whole practice team on board. Means everybody’s working from the same set of instructions. And if you do have a client who questions things, it gives you a backup to say, this is what the practice does. And here are the authoritative reasons why that is. And certainly, adoption of these guidelines in large institutions, my own university amongst these, has been proven to reduce overall antimicrobial, systemic antimicrobial use.
And to see a switch from the second or third-line drugs to a greater proportion of first-line drugs being used. And this can have an impact on infection rates. So for example, in my own university, we’ve been monitoring our overall infection rates and our antimicrobial resistance infection rates. And we got alarmed in the mid– from about 2013, as we started to see an increase in those. And one of the measures that we took was to adopt antimicrobial use guidelines. And in the last couple of years, we have seen our rate of infections level off. And if early indications are correct, this year, 2019, we’ll see an actual reduction in the rate of infection, particularly antimicrobial-resistant infection.
And this is despite a quite considerable increase in caseload. Now, the other side of things, of working in a big referral institution, is our big caseload. But also, our heavy caseload of animals that are particularly at risk of infection. For example, those that are immunocompromised, those that are having long stays in our intensive care unit with catheters and other implants, and our complex surgery cases, and so on. So we place a very high emphasis on infection control. And all practices really should have infection control guidelines that are rolled out and monitored by an infection control team that is responsible for their design, training of staff, and then auditing to ensure that they’re adhered to.
And they should cover things like hand washing, hand disinfection techniques, which is the single biggest thing you can do in practice to reduce the spread of organisms to vulnerable patients. But it should cover clothing, gloving, aseptic surgery, how to handle patients, and so on. Now, I mentioned clinical audit a little bit, there. And clinical audits, again, are an incredibly valuable tool because they enable you to define current practice, but also enable you to identify problems that require an intervention. And it can seem a little bit daunting to begin with. But with modern practice management software, then it’s relatively straightforward to abstract the records and have these reviewed by the clinical audit team. And I’ve just put some examples there.
Now, this is something that what practices really want to be doing is focusing in on a few key problems. Because if you try and address everything at the start, then the whole thing just grinds to a halt under uncertain inertia it’s almost impossible to do. But once the clinical audit group and the practice begin to work together, then the whole thing can become much simpler, much more responsive to change. One thing that, from an antimicrobial resistance point of view I would strongly advise practices signing up for, is the SAVSNET programme. And I’m sure Vet Compass do something similar, although I’m less familiar with that. And basically what this does is insert–
effectively a virus, I suppose, on your practice management software. And this allows it to abstract data. Now, this can be data on anything. So for example, a lot of the data that’s abstracted for research purposes might look at the rate of prescribing various drugs. It might look at the rate of post-operative infections. It can look at the number of animals presented with itch or urinary tract infections. What was the diagnosis of animals presenting with vomiting? And so on and so on. But if you look at the My SAVSNET AMR programme, this is all geared around antimicrobial resistance.
And basically, what it can do is start providing you with benchmarking data about the amount of antibiotics being used, the sorts of cases it’s used in, and resistance rates. And this can enable a clinical audit group to look at, for example, cephalexin use, and say, right, are we about median for practices in our area and practice of a similar size and type? Or are we considerably higher? And if the data is out of kilter with what the average is, then that can be a prompt to have a look at what’s happening within the practice. And it might be that that use can be justified. But it might be that, by simple changes, that use can be reduced.
And these approaches have been very successful in both the National Health Service in the UK, but also in veterinary practice.
There are websites around. Now, this is one that I’ve been involved with. So I’m part of the Controlling Antimicrobial Resistance in Scotland group. And as part of that, I sit on the Scottish Veterinary Antimicrobial Prescribing group. And one of our aims has been to produce this Scotland’s Healthy Animals website. Now, you can actually get onto this from anywhere. We don’t limit it to people in Scotland. But it’s a one-health, one-stop shop, for anybody involved in animal care. So this is for vets, nurses, farmers, zookeepers, people who run rescue and wildlife rehabilitation units, and for owners of horses, pets, and so on. Anybody working with animals. It provides a basic level of advice.
But what we’ve tried to do is also act as a signpost. So where that advice is available elsewhere, we have signposted to that, rather than trying to reinvent the wheel. But it’s an incredibly useful one-health resource. Other things people can get involved with. Certainly, within the European Union there is the Antibiotic Awareness Week, which is usually around the third week in November. There is a lot of information on their website, both aimed at health care practitioners– this would be the vets and nurses in practice– but also educational stuff that you can run for your clients to engage them in antimicrobial stewardship as well. Antibiotic Action Champions– this is mainly geared at scientists and clinicians who are involved in the field.
But again, if you wanted to be an Antibiotic Action Champion and promote antimicrobial stewardship within your practice, that’s something to consider and apply to. And then the Antibiotic Guardian Campaign is something that anybody can join up to. And it’s very, very simple. You go onto the website, and you make a pledge. So it’s a bit like Antibiotics Anonymous. And you can pledge to not ask for antibiotics if you’re a patient or an animal owner. And as a clinician, you can pledge to use fewer antibiotics. Always make a diagnosis, or something like that. And it’s been a great tool for engaging everybody involved in antimicrobial use, be you a clinician or not.
And getting people to think about how we need to preserve these drugs for the future. And thank you for listening.

Dr Tim Nuttall introduces some practical approaches to establishing antimicrobial stewardship in companion animal practice.

AMS in practice involves the client as well as the vet (the prescriber), the nurses and the administration team. However, it is not uncommon to find a vet practice that does not use written antimicrobial guidelines, or where the practice team are not clear on their implementation. It’s important to remember that these guidelines are not trying to dictate how first-opinion practice works, but rather they are a set of tools to help practitioners make rational decisions about appropriate antimicrobial use. More information on antibacterials and associated guidelines can be found from the BSAVA in the link in the see also section.

One of the main aims of implementing antimicrobial stewardship in practice is to move from second and third-line treatments to more first-line treatments; in the video, Tim Nuttall discusses many ways to do this.

A link to the website mentioned in a video can be found in the see also section; there are also many other ways you can get involved in AMS:

Use the comments section to discuss which of these ideas you are already involved in, and what you learnt that was new in this step which you could introduce to your practice.

Now we have looked at a more general approach to implementing AMS in companion animal practice, in the next two steps Rosanne Jepson will discuss methods of implementing good antimicrobial guidelines and good hand hygiene in order to achieve antimicrobial stewardship.

Please find a downloadable copy of the PowerPoint slides used in the video in the downloads section below.

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Antimicrobial Stewardship in Veterinary Practice

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