Antimicrobial stewardship in companion animal practice: an implementation trial in 135 general practice veterinary clinics.

BACKGROUND: Antimicrobial stewardship programmes (ASPs) have been widely implemented in medical practice to improve antimicrobial prescribing and reduce selection for multidrug-resistant pathogens. OBJECTIVES: To implement different antimicrobial stewardship intervention packages in 135 veterinary practices and assess their impact on antimicrobial prescribing. METHODS: In October 2018, general veterinary clinics were assigned to one of three levels of ASP, education only (CON), intermediate (AMS1) or intensive (AMS2). De-identified prescribing data (1 October 2016 to 31 October 2020), sourced from VetCompass Australia, were analysed and a Poisson regression model fitted to identify the effect of the interventions on the incidence rates of antimicrobial prescribing. RESULTS: The overall incidence rate (IR) of antimicrobial prescribing for dogs and cats prior to the intervention was 3.7/100 consultations, which declined by 36% (2.4/100) in the implementation period, and by 50% (1.9/100) during the post-implementation period. Compared with CON, in AMS2 there was a 4% and 6% reduction in the overall IR of antimicrobial prescribing, and a 24% and 24% reduction in IR of high importance antimicrobial prescribing, attributable to the intervention in the implementation and post-implementation periods, respectively. A greater mean difference in the IR of antimicrobial prescribing was seen in high-prescribing clinics. CONCLUSIONS: These AMS interventions had a positive impact in a large group of general veterinary practices, resulting in a decline in overall antimicrobial use and a shift towards use of antimicrobials rated as low importance, with the greatest impact in high-prescribing clinics.

Survey of veterinary prescribing for poultry disease.

BACKGROUND: To enable better antimicrobial stewardship, it is important to know what the patterns of prescribing behaviour are and what diseases or reasons antibiotics are being prescribed. A prescribing guideline (i.e. recommended best practice for writing prescriptions) developed by the Australian poultry veterinarians exists. However, it is not a prescribing guideline detailing treatments for the commonly observed bacterial diseases in commercial poultry. METHODS: An online survey was deployed to all registered veterinarians and members of the Australian Veterinary Poultry Association to identify prescribing behaviours for the most frequently observed bacterial diseases of poultry. RESULTS: A total of 39 survey responses were received. Most surveys were started but not completed; 13 (33%) were completed with 18 (46%) containing some information on prescribing. The most frequent treatment responses were for Escherichia coli in both layers and broilers, chronic respiratory disease (CRD), fowl cholera and spotty liver in layers and necrotic enteritis in broilers. Treatments described were for products registered for poultry use, within the recommended label dose and duration of treatment (Tables 1, 2). Unsurprisingly, tetracyclines and amoxycillin, followed by lincomycin and trimethoprim sulfonamide products were the most frequently reported treatment options. Inappropriate treatments were reported for salmonellosis and one veterinarian recommended the use of enrofloxacin for the treatment of fowl cholera. CONCLUSION: Information provided by respondents will enable the initial development of prescribing guidelines for both commercial and small poultry flocks. Importantly, it identified less than optimal prescribing behaviour for some diseases, a reliance on one class of antibiotic more than others and a failure to utilise all antimicrobial classes potentially available for treatment. Critically, the survey identified a lack of treatment options for bacterial disease in poultry. The most important bacterial diseases of poultry remain the same; effective alternatives for antibiotic treatment are required and old diseases, thought once gone, are reinventing themselves as problems for the future. Surveys of prescribing behaviours are essential for identifying diseases of high priority, changes in treatments and response to treatment and to identify areas for targeted antimicrobial stewardship, and research needs.

Appraisal of the Australian Veterinary Prescribing Guidelines for antimicrobial prophylaxis for surgery in dogs and cats.

The Australian Veterinary Prescribing Guidelines for antimicrobial prophylaxis for surgery on dogs and cats are evidence-based guidelines for veterinary practitioners. Validation of these guidelines is necessary to ensure quality and implementability. Two validated tools, used for medical guideline appraisal, were chosen to assess the guidelines. The terminology from the GuideLine Implementability Appraisal (GLIA) and the Appraisal of Guidelines for Research and Evaluation version 2 (AGREE II) were adapted for use by veterinarians. A two-phase evaluation approach was conducted. In the first phase of the evaluation, the GLIA tool was used by two specialist veterinary surgeons in clinical practice. The results of this phase were then used to modify the guidelines. In the second phase, the AGREE II tool was used by 6 general practitioners and 6 specialists to appraise the guidelines. In phase 1, the specialist surgeons either agreed or strongly agreed that the guidelines were executable, decidable, valid and novel, and that the guidelines would fit within the process of care. The surgeons were neutral on flexibility and measurability. Additional clarity around one common surgical procedure was added to the guidelines, after which the surgeons agreed that the guidelines were sufficiently flexible. In phase 2, 12 veterinarians completed the assessment using the AGREE II tool. In all sections the scaled domain score was greater than 70%. The overall quality of the guidelines was given a global scaled score of 76%. This assessment has demonstrated that the guidelines for antimicrobial prophylaxis for companion animal surgery are valid and appear implementable.

Antimicrobial dosing for common equine drugs: a content review and practical advice for veterinarians in Australia.

BACKGROUND: Appropriate dosing with antimicrobial agents is critical for effective treatment and to prevent the development of antimicrobial resistance. METHODS: A review was undertaken of equine journal articles (Equine Veterinary Journal, Equine Veterinary Education, Australian Veterinary Journal, Australian Equine Veterinarian, Journal of Veterinary Internal Medicine and Journal of Equine Veterinary Science) between January 2015 and August 2018. Those with dosing regimens for procaine penicillin G, gentamicin or trimethoprim-sulfonamide in adult horses were examined and evaluated. Pharmacokinetics and -dynamics of these drugs were also reviewed. RESULTS & CONCLUSION: The most frequently reported doses for penicillin, gentamicin and trimethoprim-sulfonamide were 20-25,000 IU/kg, 6.6 mg/kg and 30 mg/kg, respectively. Veterinarians treating equine patients in Australia should be aware of the current recommended doses and inter-dosing intervals to ensure efficacy in therapy and to preserve the usefulness of these antimicrobials for the future.

First detection of bovine noroviruses and detection of bovine coronavirus in Australian dairy cattle.

BACKGROUND AND OBJECTIVE: Noroviruses have been recognised as a significant cause of neonatal enteritis in calves in many countries, but there has been no investigation of their occurrence in Australian cattle. This study aimed to establish whether bovine noroviruses could be detected in faecal samples from Australian dairy cattle. It also sought to determine whether bovine coronaviruses, also associated with neonatal enteritis in calves, could be detected in the same faecal samples. METHODS: A selection of faecal samples that were negative for rotaviruses from dairy farms located in three geographically distinct regions of Victoria were pooled and tested by reverse transcription-PCR for the presence of noroviruses (genogroup III), neboviruses and bovine coronaviruses. RESULTS AND CONCLUSION: Genetically distinct genogroup III noroviruses were detected in two sample pools from different geographic regions and bovine coronavirus was detected in a third pool of samples. This is the first report of bovine norovirus infection in Australian cattle and suggests that future work is required to determine the significance of these agents as a cause of bovine enteric disease in Australia.

Antimicrobial labelling in Australia: a threat to antimicrobial stewardship?

Antimicrobial resistance is a public health emergency, placing veterinary antimicrobial use under growing scrutiny. Antimicrobial stewardship, through appropriate use of antimicrobials, is a response to this threat. The need for antimicrobial stewardship in Australian veterinary practices has had limited investigation. A 2016 survey undertaken to investigate antimicrobial usage patterns by Australian veterinarians found that antimicrobial dose rates were varied and often inappropriate. Doses of procaine penicillin in horses and cattle were often low, with 68% and 90% of respondents, respectively, reporting doses that were unlikely to result in plasma concentrations above minimum inhibitory concentrations for common equine and bovine pathogens. Frequency of penicillin administration was also often inappropriate. Gentamicin doses in horses were largely appropriate (89% of dose rates appropriate), but 9% of respondents reported twice daily dosing. Amoxycillin and amoxycillin-clavulanate were administered at the appropriate doses, or above, to dogs and cats by 54% and 70% of respondents, respectively. Here, we explore the potential reasons for inappropriate antimicrobial dose regimens and report that antimicrobial labels often recommend incorrect dose rates and thus may be contributing to poor prescribing practices. Changes to legislation are needed to ensure that antimicrobial drug labels are regularly updated to reflect the dose needed to effectively and safely treat common veterinary pathogens. This will be especially true if changes in legislation restrict antimicrobial use by veterinarians to the uses and doses specified on the label, thus hampering the current momentum towards improved antimicrobial stewardship.

Barriers to and enablers of implementing antimicrobial stewardship programs in veterinary practices.

BACKGROUND: Antimicrobial stewardship (AMS) programs are yet to be widely implemented in veterinary practice and medical programs are unlikely to be directly applicable to veterinary settings. OBJECTIVE: To gain an in-depth understanding of the factors that influence effective AMS in veterinary practices in Australia. METHODS: A concurrent explanatory mixed methods design was used. The quantitative phase of the study consisted of an online questionnaire to assess veterinarians' attitudes to antimicrobial resistance (AMR) and antimicrobial use in animals, and the extent to which AMS currently is implemented (knowingly or unknowingly). The qualitative phase used semi-structured interviews to gain an understanding of the barriers to and enablers of AMS in veterinary practices. Data were collected and entered into NVivo v.11, openly coded and analyzed according to mixed methods data analysis principles. RESULTS: Companion animal, equine, and bovine veterinarians participated in the study. Veterinary practices rarely had antimicrobial prescribing policies. The key barriers were a lack of AMS governance structures, client expectations and competition between practices, cost of microbiological testing, and lack of access to education, training and AMS resources. The enablers were concern for the role of veterinary antimicrobial use in development of AMR in humans, a sense of pride in the service provided, and preparedness to change prescribing practices. CONCLUSION AND CLINICAL IMPORTANCE: Our study can guide development and establishment of AMS programs in veterinary practices by defining the major issues that influence the prescribing behavior of veterinarians.

Antimicrobials used for surgical prophylaxis by equine veterinary practitioners in Australia.

BACKGROUND: Antimicrobials are widely used in Australian veterinary practices, but no investigation into the classes of antimicrobials used, or the appropriateness of use in horses, has been conducted. OBJECTIVES: The aim of the study was to describe antimicrobial use for surgical prophylaxis in equine practice in Australia. STUDY DESIGN: Cross-sectional questionnaire survey. METHODS: An online questionnaire was used to document antimicrobial usage patterns. Information solicited in the questionnaire included demographic details of the respondents, the frequency with which antimicrobials were used for specific surgical conditions (including the dose, timing and duration of therapy) and practice antimicrobial use policies and sources of information about antimicrobials and their uses. RESULTS: A total of 337 members of the Australian veterinary profession completed the survey. Generally, the choice of antimicrobial was appropriate for the specified equine surgical condition, but the dose and duration of therapy varied greatly. While there was poor optimal compliance with British Equine Veterinary Association guidelines in all scenarios (range 1-15%), except removal of a nonulcerated dermal mass (42%), suboptimal compliance (compliant antimicrobial drug selection but inappropriate timing, dose or duration of therapy) was moderate for all scenarios (range 48-68%), except for an uninfected contaminated wound over the thorax, where both optimal and suboptimal compliance was very poor (1%). Veterinarians practicing at a university hospital had higher odds of compliance than general practice veterinarians (Odds ratio 3.2, 95% CI, 1.1-8.9, P = 0.03). MAIN LIMITATIONS: Many survey responses were collected at conferences which may introduce selection bias, as veterinarians attending conferences may be more likely to have been exposed to contemporary antimicrobial prescribing recommendations. CONCLUSIONS: Antimicrobial use guidelines need to be developed and promoted to improve the responsible use of antimicrobials in equine practice in Australia. An emphasis should be placed on antimicrobial therapy for wounds and appropriate dosing for procaine penicillin.

Management of dizziness in primary care.

BACKGROUND: We sought to determine the types of dizziness problems that are commonly seen in primary care practices, and to bring to light clinical and demographic factors that predict management decisions. METHODS: We undertook a prospective cohort study with a 6-month follow-up using data gathered in nine primary care practices in two North Carolina counties. Subjects were 144 dizziness patients examined by primary care physicians. Data collected included demographic characteristics, a standardized dizziness history, physician estimation of symptom severity and diagnostic certainty, and physician "worry" about arrhythmia, transient ischemic attack, and brain tumor. Physicians reported their management decisions and diagnosis (or differential diagnosis) by responding to a questionnaire after completing the patient encounter. A 6-month follow-up chart review and physician interview were completed on 140 patients (97.2 percent); information obtained included changes in diagnosis and patient mortality. RESULTS: The most common diagnoses were labyrinthitis, otitis media, benign positional vertigo, unspecified presyncope, sinusitis, and transient ischemic attack. The initial diagnosis changed during the 6-month follow-up period in 34 (24.3 percent) of patients. The overall course of these patients was benign, however, with only one death occurring during the 6-month follow-up period. Patients' dizziness tended to be managed using a combination of strategies, including office laboratory testing (33.6 percent), advanced testing (11.4 percent), referral to a specialist (9.3 percent), medication (61.3 percent), observation (71.8 percent), reassurance (41.6 percent), and behavioral recommendations (15.0 percent). Office laboratory testing was associated with younger patient age, a suspected metabolic or endocrine disorder, and physician worry about a cardiac arrhythmia; advanced laboratory testing was associated with suspected cardiovascular or neurologic disorders. Medication tended to be prescribed for vertigo and severe symptoms and avoided when physicians were worried about a cardiac arrhythmia. Referral to a specialist was associated with suspected neurologic disease. Observation, behavior change, and reassurance were avoided in patients with poorly defined dizziness and tended to be used in older patients. The management approaches employed by the 4 physicians who referred the most subjects to the study varied considerably. CONCLUSIONS: Dizziness in primary care represents an extremely broad spectrum of diagnoses. The generally conservative management approach of primary care physicians in this study is consistent with basic clinical and epidemiologic principles, and patient mortality with this approach is low.

Collaborating with nonphysician professionals in practice-based research. Dizziness Research Group.

Although much has been written about the importance of collaboration among physicians in practice-based research, the relationship between the clinical investigator and nonphysician professionals in this setting has received less attention. Nurses, physician assistants, and other office support staff can provide valuable insights pertinent to research design and project implementation. Because nonphysician professionals frequently play a large part in implementing a research project, how well the investigator collaborates with them often determines the success or failure of the project. We suggest the following guidelines: 1. Consider the research interests of the nonphysician collaborators. 2. Adapt the project to office routine. 3. Limit the demands on staff. 4. Use detailed protocols. 5. Orient all collaborators. 6. Be available and visible. 7. Provide feedback and reward to all collaborators.

Which primary care patients with dizziness will develop persistent impairment?

OBJECTIVE: To determine which factors identifiable during an office visit for dizziness predict chronic impairment from dizziness 3 months later. DESIGN: A prospective cohort study with 3-month telephone follow-up. SETTING: Nine primary care office practices in North Carolina. SUBJECTS: 117 adults who presented to primary care practices because of dizziness. OUTCOME MEASURES: Our outcome of interest, restriction of daily activities due to dizziness 3 months after the enrollment visit, was characterized using three different but correlated self-reported measures. Independent analytic models tested the relationship between demographic variables, health status, psychological state, and dizziness characteristics at baseline and our three measures of activity restriction due to dizziness. RESULTS: A two-stage logistic regression analysis identified the following baseline characteristics to be independent predictors in one or more models of activity-limiting dizziness at 3 months: dependency in instrumental activities of daily living (odds ratio [OR] = 11.1, P = .002); a high anxiety score (OR = 5.7, P = .003); self-rating of health as fair or poor (OR = 3.2, P = .042); the presence of three or more chronic conditions (OR = 1.9, P = .022); interference from chronic conditions (OR = 1.7, P = .012); dizziness duration of greater than 1 year (OR = 20.9, P < .001); frequent dizziness (OR = 4.3, P = .016); subjective imbalance (OR = 4.7, P = .012); and activity limitation due to dizziness (OR = 11.7, P < .001). CONCLUSION: To estimate the prognosis and clinical significance of dizziness complaints, primary care physicians should take into account not only the characteristics of the patient's dizziness but also the patient's baseline health status and psychological state.