Dr. Jeff Bender - Companion Animal Antimicrobial Stewardship
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The document discusses antibiotic stewardship in companion animal practice, emphasizing the significance of managing antimicrobial resistance in pets, particularly dogs and cats. It outlines various strategies for effective stewardship, including clinician education and guidelines to limit inappropriate antibiotic use, while also highlighting survey findings on veterinary prescribing habits. The overarching goal is to optimize clinical outcomes while mitigating the unintended consequences of antimicrobial usage.
Dr. Jeff Bender - Companion Animal Antimicrobial Stewardship
- 1. Antibiotic Stewardship for Companion Animal Practice Jeff Bender DVM, MS DACVPM Hospital Epidemiologist University of Minnesota College of Veterinary Medicine
- 2. Outline • Overview of antimicrobial resistance in companion animals • Stewardship programs • AVMA Task Force activities • Educational and outreach
- 3. Drug Resistant Infections in Companion Animals • Methicillin-resistant Staphylococcus pseudintermedius and Schlieferi • Methicillin-resistant Staphylococcus aureus • MDR E. coli and Klebsiella
- 4. Companion Animals and Antimicrobial Resistance • Pets, especially cats and dogs are potential sources of spread of antimicrobial resistance due to common use of antimicrobials and their close contact with humans. Guardabassi et. al. J Antimic Chemo 2004;54:321-32
- 5. Companion Animals and Antimicrobial Use • In 2002, companion or non-food animals accounted for 37% of the pharmaceutical products sales in the EU • Lack of bacterial identification and antimicrobial susceptibility • Pets often receive medically important antimicrobials (i.e. cephalosporins or fluoroquinolones) Guardabassi et. al. J Antimic Chemo 2004;54:321-32
- 6. Clinically related Staphylococcus sp. identified through the Dermatology Service University of Minnesota VMC, 2008-2013 50 45 40 35 30 25 20 15 10 0 5 MRSP MRSS MRSA 2008 2009 2010 2011 2012 2013 Number
- 7. Dog Park Study Minneapolis/St. Paul (n=22) 50 (27%) of 186 samples were E. coli positive – 46 (25%) of E. coli positive samples were AmpC positive – 4 (2%) of E. coli positive samples were extended spectrum beta-lactamase (ESBL) producers – Many of these isolates were multidrug resistant
- 8. Veterinary Medical Center ICU Survey Source # of E. coli Isolates Pansensitive1 n (%) MDR2 n (%) Community Practice 102 70 (69%) 4 (4%) ICU 113 42 (37%) 42 (37%) 1 Sensitive to all antimicrobials on the panel 2 Multi-drug resistant Chi-square = 37.9; p<0.0001
- 9. Selective Pressures (The Why) • Regardless of use (appropriate or inappropriate), the selective pressure of antibiotics underscores the importance of prudent use to slow the development of resistance Fishman N. AJIC 2006
- 10. Inappropriately Prescribed, Why? • Absence of bacterial infection or an indication for prophylaxis • Violation of one of the following “D’s” – The right Dose – The right Drug – The best route of Delivery – Attention to De-escalation – The appropriate Duration of administration
- 11. Stewardship • “The primary purpose of stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms, and the emergence of resistance.” Fine TM et. al. 2014 Clinic Infect Disease
- 12. Commonly Used Tactics • Clinician education • Formulary optimization • Antibiotic use restrictions • Prospective audit with intervention and feedback • Optimization of dose administration • Streamlining: de-escalation and elimination of redundant therapy • Early switch from IV to oral • Appropriate duration of antibiotic therapy • Clinical guidelines with site specific treatment pathways Stan Deresinski MD, Antimicrobial Stewardship: Optimization of Antibiotic Practices
- 13. General Recommendations • Treat infection not colonization • Ideally, culture before Abx treatment , but provide Abx as soon as possible • Evaluate patient daily, especially within 48-72 hours (take routine antibiotic “time out”)
- 14. Antibiotic “time out” • Re-evaluate Abx therapy: • Clinical response • Microbiologic data – Organism – Local antibiogram – Isolate susceptibility Host Bug Drug
- 15. AVMA Task Force for Antimicrobial Stewardship in Companion Animal Practice • Understand practitioner prescribing behaviors • Understand laboratory practices – Support regional/hospital antibiograms • Encourage development of practice guidelines • Promote educational programs – Do’s and Don’ts recommendations
- 16. Survey of Practitioner Prescribing Practices • Need to understand the knowledge, attitudes and beliefs of veterinarians • In a 2011 University of Minnesota survey of companion animal veterinarians – 85% did not perceive antimicrobial resistance as a problem in their daily clinical practice
- 17. Survey of Influences of Choosing an Antibiotic • The most influential reasons for choosing a specific antimicrobial were: – owner finances (68%) – antimicrobial resistance concerns (64%) – side effects (52%) – client expectations (51%). Voss and Bender Unpublished
- 18. Veterinarian Practices • 30% of practitioners reported routinely using antimicrobials for clean surgical procedures, such as ovariohysterectomies, castrations, or uncomplicated mass removal • Upcoming AVMA survey Voss and Bender Unpublished
- 19. Influences of Laboratory Standards • Does the laboratory you use follow quality assurance standards – Clinical and Laboratory Standards Institute (CLSI)? • AVMA sponsored survey of laboratory practices and how they report back to practitioners
- 23. Educational Programs • “Get Smart” • State sponsored – Health Departments • Web-based training modules • Client focused
- 24. “Get Smart” Program Centers for Disease Control and Prevention
- 27. Clinical Modules
- 28. Antimicrobial Therapy – “On Target” General Considerations for Judicious Antimicrobial Use • Consider and “rule-out” non-bacterial causes • Consider other therapeutic options • Utilize culture and sensitivity results • Refer to published treatment guidelines • Monitor treatment response and client compliance • Take a “time out” before adding, switching, or changing antibiotic treatments
- 29. GASTROINTESTINAL DISEASE • Avoid antimicrobials in healthy pets with diarrhea • Provide supportive therapy • Make a diagnosis before prescribing antimicrobials • Fecal smears are not reliable for diagnosing enteropathogenic infections
- 30. RESPIRATORY DISEASE • Avoid antimicrobials for acute, uncomplicated URT disease • Perform additional diagnostics for complicated disease or chronic respiratory disease
- 31. URINARY TRACT DISEASE • Avoid diagnosis based on free-catch urine samples • Do not routinely prescribe antimicrobials for a cat <10 years of age with lower urinary tract signs • Confirm infections with quantitative cultures
- 32. DENTAL DISEASE • Avoid antimicrobial use for routine dental procedures in healthy patients • Choose antimicrobials with activity against known oral pathogens • Antimicrobials are not a substitute for appropriate dental management
- 33. DERMATOLOGIC DISEASE • Perform cytology of lesions in all cases of suspect pyoderma • Perform microbial culture and sensitivity as well as additional diagnostics to investigate recurrent or refractory pyoderma • Use topical shampoos or antimicrobials when possible
- 34. PERI-OPERATIVE USE • Adhere to best practices for infection control in the operating room • Avoid prophylactic antimicrobials for routine surgeries • If prophylactic antimicrobials are used, administer them IV 30 – 60 minutes before surgery and do not administer them beyond the perioperative period
- 35. VECTOR-BORNE DISEASE • Avoid antimicrobial therapy in animals that are seropositive for vector-borne pathogens; seropositivity does not imply active infection • Recommend preventive treatments for ectoparasite control to prevent infection and spread of vector-borne pathogens
- 36. Others • Canadian Veterinary Medical Association CVMA Antimicrobial SmartVet – http://www.canadianvete rinarians.net/practice-economics/ antimicrobial-smartvet • Clinic antibiogram App
- 37. VMC Antimicrobial Stewardship Team • Hospital epidemiologist • Clinical pharmacist • Microbiologist • Infection control practitioner • Clinicians (Small animal, Large Animal)
- 38. Summary • Antimicrobial resistance is a “Grand Challenge” • Clinicians need to be aware and encourage good antimicrobial stewardship practices
- 39. Acknowledgements Task Force Members Tamar F. Barlam MD, MSc., IDSA Reilly P. Glore DVM, AAHA Nigel Gumley DVM, Canadian Veterinary Medical Association, Sharon E. Grayzel DVM, MPH Columbia Veterinary Center Christine Hoang, DVM, MPH, AVMA Mike J. Murphy DVM, PhD, Food and Drug Administration Mark G. Papich DVM, MS . North Carolina State University Jane E. Sykes BVSc(Hons), PhD, DACVIM (SAIM). University of California, Davis Jeffrey L. Watts PhD. Animal Health Institute. Zoetis, Anti-Infectives Research Jean M. Whichard DVM, PhD. Centers for Disease Control and Prevention
- 40. Questions?
Editor's Notes
- #8: 58 (53%) of 109 samples Campylobacter positive. 1 (0.5%) of 186 samples Salmonella positive