Current and future perspectives on the categorization of antimicrobials used in veterinary medicine.

The emergence of antimicrobial resistance in human and veterinary bacterial pathogens has led to concerns regarding the use of antimicrobials in veterinary medicine. Consequently, regulatory agencies have developed procedures for assessing the risk associated with the use of a specific antimicrobial as part of the drug approval process. Due consideration for the importance (priority categorization) of the antimicrobial to human medicine is part of this risk assessment process. Additionally, nongovernmental organizations have developed antimicrobial categorization schemes to protect the use and effectiveness of these medicines. However, the goals and methods of the various categorization schemes vary, resulting in final categorizations that are different. Although harmonizing these schemes would bring clarity to antimicrobial resistance discussions and policy, it has the disadvantage of not accounting for regional antimicrobial resistance and use, potentially removing effective medicines from clinical use in situations where they are wholly appropriate. Antimicrobials should be classified in a One Health manner, where both physician and veterinarian share the responsibility for antimicrobial use. The purpose of this article is to summarize current antimicrobial categorization schemes using illustrative examples to highlight differences and provide perspectives on the impact of the current schemes and future directions.

Differences between predicted outer membrane proteins of genotype 1 and 2 Mannheimia haemolytica.

BACKGROUND: Mannheimia haemolytica strains isolated from North American cattle have been classified into two genotypes (1 and 2). Although members of both genotypes have been isolated from the upper and lower respiratory tracts of cattle with or without bovine respiratory disease (BRD), genotype 2 strains are much more frequently isolated from diseased lungs than genotype 1 strains. The mechanisms behind the increased association of genotype 2 M. haemolytica with BRD are not fully understood. To address that, and to search for interventions against genotype 2 M. haemolytica, complete, closed chromosome assemblies for 35 genotype 1 and 34 genotype 2 strains were generated and compared. Searches were conducted for the pan genome, core genes shared between the genotypes, and for genes specific to either genotype. Additionally, genes encoding outer membrane proteins (OMPs) specific to genotype 2 M. haemolytica were identified, and the diversity of their protein isoforms was characterized with predominantly unassembled, short-read genomic sequences for up to 1075 additional strains. RESULTS: The pan genome of the 69 sequenced M. haemolytica strains consisted of 3111 genes, of which 1880 comprised a shared core between the genotypes. A core of 112 and 179 genes or gene variants were specific to genotype 1 and 2, respectively. Seven genes encoding predicted OMPs; a peptidase S6, a ligand-gated channel, an autotransporter outer membrane beta-barrel domain-containing protein (AOMB-BD-CP), a porin, and three different trimeric autotransporter adhesins were specific to genotype 2 as their genotype 1 homologs were either pseudogenes, or not detected. The AOMB-BD-CP gene, however, appeared to be truncated across all examined genotype 2 strains and to likely encode dysfunctional protein. Homologous gene sequences from additional M. haemolytica strains confirmed the specificity of the remaining six genotype 2 OMP genes and revealed they encoded low isoform diversity at the population level. CONCLUSION: Genotype 2 M. haemolytica possess genes encoding conserved OMPs not found intact in more commensally prone genotype 1 strains. Some of the genotype 2 specific genes identified in this study are likely to have important biological roles in the pathogenicity of genotype 2 M. haemolytica, which is the primary bacterial cause of BRD.

Evaluation of plasma concentration after intravenous and intramuscular penicillin administration over 24 hr in healthy adult horses.

Penicillin is administered intravenously (IV) or intramuscularly (IM) to horses for the prevention and treatment of infections, and both routes have disadvantages. To minimize these shortcomings, a 24-hr hybrid administration protocol (HPP) was developed. Our objective was to determine penicillin plasma concentrations in horses administered via HPP. Venous blood was collected from seven healthy horses administered IV potassium penicillin G at 0 and 6 hr and IM procaine penicillin G at 12 hr. Blood was collected at 2-hr intervals from 0 to 20 hr and at 24 hr. Plasma penicillin concentrations were measured using liquid chromatography and mass spectrometry. Penicillin susceptibility from equine isolates was examined to determine pharmacodynamic targets. The MIC90 of penicillin for 264 isolates of Streptococcus sp. was ≤0.06 µg/ml. For the 24-hr dosing interval, the mean plasma penicillin concentration was >0.07 µg/ml. Five horses (72%) exceeded 0.06 µg/ml for 98% of the dosing interval, and two horses exceeded this value for 52%-65% of the dosing interval. The HPP achieved mean plasma penicillin concentrations in healthy adult horses above 0.07 µg/ml for a 24-hr dosing interval. However, individual variations in plasma concentrations were apparent and deserve future clinical study.

Applying definitions for multidrug resistance, extensive drug resistance and pandrug resistance to clinically significant livestock and companion animal bacterial pathogens.

Standardized definitions for MDR are currently not available in veterinary medicine despite numerous reports indicating that antimicrobial resistance may be increasing among clinically significant bacteria in livestock and companion animals. As such, assessments of MDR presented in veterinary scientific reports are inconsistent. Herein, we apply previously standardized definitions for MDR, XDR and pandrug resistance (PDR) used in human medicine to animal pathogens and veterinary antimicrobial agents in which MDR is defined as an isolate that is not susceptible to at least one agent in at least three antimicrobial classes, XDR is defined as an isolate that is not susceptible to at least one agent in all but one or two available classes and PDR is defined as an isolate that is not susceptible to all agents in all available classes. These definitions may be applied to antimicrobial agents used to treat bovine respiratory disease (BRD) caused by Mannheimia haemolytica, Pasteurella multocida and Histophilus somni and swine respiratory disease (SRD) caused by Actinobacillus pleuropneumoniae, P. multocida and Streptococcus suis, as well as antimicrobial agents used to treat canine skin and soft tissue infections (SSTIs) caused by Staphylococcus and Streptococcus species. Application of these definitions in veterinary medicine should be considered static, whereas the classification of a particular resistance phenotype as MDR, XDR or PDR could change over time as more veterinary-specific clinical breakpoints or antimicrobial classes and/or agents become available in the future.

Genomic signatures of Mannheimia haemolytica that associate with the lungs of cattle with respiratory disease, an integrative conjugative element, and antibiotic resistance genes.

BACKGROUND: Mannheimia haemolytica typically resides in cattle as a commensal member of the upper respiratory tract microbiome. However, some strains can invade their lungs and cause respiratory disease and death, including those with multi-drug resistance. A nucleotide polymorphism typing system was developed for M. haemolytica from the genome sequences of 1133 North American isolates, and used to identify genetic differences between isolates from the lungs and upper respiratory tract of cattle with and without clinical signs of respiratory disease. RESULTS: A total of 26,081 nucleotide polymorphisms were characterized after quality control filtering of 48,403 putative polymorphisms. Phylogenetic analyses of nucleotide polymorphism genotypes split M. haemolytica into two major genotypes (1 and 2) that each were further divided into multiple subtypes. Multiple polymorphisms were identified with alleles that tagged genotypes 1 or 2, and their respective subtypes. Only genotype 2 M. haemolytica associated with the lungs of diseased cattle and the sequence of a particular integrative and conjugative element (ICE). Additionally, isolates belonging to one subtype of genotype 2 (2b), had the majority of antibiotic resistance genes detected in this study, which were assorted into seven combinations that ranged from 1 to 12 resistance genes. CONCLUSIONS: Typing of diverse M. haemolytica by nucleotide polymorphism genotypes successfully identified associations with diseased cattle lungs, ICE sequence, and antibiotic resistance genes. Management of cattle by their carriage of M. haemolytica could be an effective intervention strategy to reduce the prevalence of respiratory disease and supplemental needs for antibiotic treatments in North American herds.

Large genomic differences between Moraxella bovoculi isolates acquired from the eyes of cattle with infectious bovine keratoconjunctivitis versus the deep nasopharynx of asymptomatic cattle.

Moraxella bovoculi is a recently described bacterium that is associated with infectious bovine keratoconjunctivitis (IBK) or "pinkeye" in cattle. In this study, closed circularized genomes were generated for seven M. bovoculi isolates: three that originated from the eyes of clinical IBK bovine cases and four from the deep nasopharynx of asymptomatic cattle. Isolates that originated from the eyes of IBK cases profoundly differed from those that originated from the nasopharynx of asymptomatic cattle in genome structure, gene content and polymorphism diversity and consequently placed into two distinct phylogenetic groups. These results suggest that there are genetically distinct strains of M. bovoculi that may not associate with IBK.

Prevalence of Escherichia coli O-types and Shiga toxin genes in fecal samples from feedlot cattle.

While efforts to control foodborne illness associated with the Shiga toxin-producing Escherichia coli (E. coli) O157 through processes and procedures implemented at harvest facilities have been very successful, there is concern about the burden of illness associated with other Shiga toxin-producing E. coli. The U.S. Department of Agriculture Food Safety and Inspection Service announced plans to classify an additional six non-O157 Shiga toxin-producing E. coli as adulterants. Little is known about the prevalence and distribution of these E. coli in the animal production environment. An investigation of the prevalence of O157 and the six major non-O157 E. coli serogroups was conducted in 21 feedlots over the period July 2011 to October 2011. Individual fecal swabs were collected from cattle approximately 60 days after their arrival in the feedlot and were pooled for evaluation using a polymerase chain reaction assay to identify the presence of seven E. coli O-types (O157, O45, O103, O121, O145, O26, and O111) and four virulence genes (stx1, stx2, eaeA, and ehxA). Overall, 1145 fecal pools were evaluated, with 506 (44.2%) being positive for one or more of the E. coli O-serogroups. The pool prevalences for E. coli O157, O45, O26, O103, O121, O145, and O111 were 19.7%, 13.8%, 9.9%, 9.3%, 5.5%, 1.1%, and 0.5%, respectively. Nearly all pools were positive for ehxA (99.7%) or stx2 (98.6%). The pool level prevalence for stx1 and eae was 65.5% and 69.3%, respectively. Pools that were positive for one or more of the other E. coli O-serogroups were 1.37 times more likely to be positive for E. coli O157. Conversely, pools that were positive for E. coli O157 were 1.43 times more likely to be positive for at least one of the other E. coli O-serogroups evaluated. These data will be useful to understand the expected prevalence of potential Shiga toxin-producing E. coli in cattle feedlots.

Application and Interpretation of Antimicrobial Susceptibility Testing.

Antimicrobial susceptibility testing (AST) is an important component of antimicrobial stewardship. This article discusses how AST methods and breakpoints are developed, describes when AST may or may not be useful in clinical practice, and discusses how to interpret AST results from bacterial isolates from cattle, sheep, and goats. Discussion of when AST is not appropriate or when veterinarians should have low confidence in AST results is also included. Applicability of genomic testing for antimicrobial susceptibility is briefly addressed.

Revision of fluoroquinolone breakpoints used for interpretation of antimicrobial susceptibility testing of canine bacterial isolates.

The fluoroquinolone antimicrobial agents, enrofloxacin and marbofloxacin, were US Food and Drug Administration (FDA) approved in the United States for use in dogs in 1988 and 1999, respectively. There have been many advances since then concerning the pharmacokinetic-pharmacodynamic (PK-PD) evaluation of fluoroquinolones, and there are data available on the susceptibility of targeted pathogens since the original approval. Using this information, the Clinical and Laboratory Standards Institute (CLSI) Veterinary Antimicrobial Susceptibility Testing Subcommittee (VAST) revised its antimicrobial susceptibility testing breakpoints. The previous breakpoints (used in older editions of CLSI standards) for enrofloxacin in dogs were susceptible (S), ≤ 0.5 µg/mL, intermediate (I) 1-2 µg/mL, and resistant (R) ≥ 4 µg/mL. The new breakpoints are S ≤ 0.06 µg/mL for a dose of 5 mg/kg, 0.12 µg/mL for a dose of 10 mg/kg, 0.25 µg/mL for a high dose of 20 mg/kg, and R ≥ 0.5 µg/mL. The breakpoints of 0.12 and 0.25 µg/mL represent a new susceptible-dose dependent (SDD) category. For marbofloxacin, previous breakpoints were S, ≤ 1 µg/mL, I 2 µg/mL, and R ≥ 4 µg/mL. The new breakpoints are S ≤ 0.12 µg/mL for a dose of 2.8 mg/kg, 0.25 µg/mL for a dose of 5.5 mg/kg (SDD), and R ≥ 0.5 µg/mL. The new breakpoints will be published in the next edition of CLSI-Vet01(S) and deviate considerably from the prior breakpoints. Laboratories are encouraged to revise their testing standards. These changes will likely reduce the unnecessary use of these fluoroquinolones in dogs.

Antimicrobial use in 20 U.S. beef feedyards: 2018-2019.

The objective of this study was to report antimicrobial use in a convenience sample of U.S. beef feedyards for the years 2018 and 2019. In addition to antimicrobial use metrics, also reported are the indications for antimicrobial use and outcomes related to these indications. Antimicrobial use is characterized at the study and feedyard levels for a total of 1,141,846 head of cattle in 20 U.S. feedyards. Antimicrobial use is reported as milligrams of active antimicrobial ingredient per kilogram of liveweight sold (mg/kg-LW) and regimens of antimicrobials per animal year (Reg/AY). Regimens are described by antimicrobial class within use category as characterized by mg of active antimicrobial product per regimen (mg/Reg) and calendar days of administration per regimen (CDoA/Reg). A total of 1,128,515 regimens of medically important antimicrobials were captured from records. The number of regimens/100 head-in (Reg/100 head-in) are described in a subset of 10 feedyards with adequate data granularity to directly determine indications for antimicrobial administration. For the indications of bovine respiratory disease (BRD), Lameness (Lame), Liver Abscess Control (LAC), and Other (e.g., central nervous system disease, cellulitis) the Reg/100 head-in study-level values are 37.1, 0.8, 98.4, and 0.7, respectively, for 2018, with similar values for 2019. The regimens for BRD are further categorized in these 10 feedyards by the use categories in-feed, control of BRD, and individual animal therapy, yielding study level values of 4.6, 19.6, and 12.9 Reg/100 head-in, respectively, for 2018, with similar values for 2019. Outcomes of therapy for individual animal treatment of BRD, Lame, and Other are reported as treatment success, retreatment, or mortality by 30 days after the initial therapy of an animal for a disease. Treatment success rates (no treatment or mortality in the next 30 days) for 2018 in the 10 feedyards with sufficient data granularity are 76.5, 86.5, and 83.0% for BRD, Lame, and Other, respectively. The comparison of these results with other reports of antimicrobial use in North American feedyards highlights how differing approaches in calculating metric values may result in substantially different conclusions regarding antimicrobial use, especially in relation to long-duration uses.

Diagnostic and commensal Staphylococcus pseudintermedius genomes reveal niche adaptation through parallel selection of defense mechanisms.

Staphylococcus pseudintermedius is historically understood as a prevalent commensal and pathogen of dogs, though modern clinical diagnostics reveal an expanded host-range that includes humans. It remains unclear whether differentiation across S. pseudintermedius populations is driven primarily by niche-type or host-species. We sequenced 501 diagnostic and commensal isolates from a hospital, veterinary diagnostic laboratory, and within households in the American Midwest, and performed a comparative genomics investigation contrasting human diagnostic, animal diagnostic, human colonizing, pet colonizing, and household-surface S. pseudintermedius isolates. Though indistinguishable by core and accessory gene architecture, diagnostic isolates harbor more encoded and phenotypic resistance, whereas colonizing and surface isolates harbor similar CRISPR defense systems likely reflective of common household phage exposures. Furthermore, household isolates that persist through anti-staphylococcal decolonization report elevated rates of base-changing mutations in - and parallel evolution of - defense genes, as well as reductions in oxacillin and trimethoprim-sulfamethoxazole susceptibility. Together we report parallel niche-specific bolstering of S. pseudintermedius defense mechanisms through gene acquisition or mutation.

Nasopharyngeal Bacterial Prevalence and Microbial Diversity at First Treatment for Bovine Respiratory Disease (BRD) and Its Associations with Health and Mortality Outcomes in Feedyard Cattle.

Bovine respiratory disease (BRD) is an economically important disease in feedyards influencing both animal welfare and antimicrobial utilization. Major pathogens associated with BRD have been identified in previous research, but little information is available on the relationship between nasopharyngeal microbiota and health outcomes. The objective of this study was to identify potential associations between nasopharyngeal microbiota and antimicrobial resistance patterns of clinical cases that lived or died compared to non-diseased controls. Enrolled animals were subdivided based on clinical disease status and case outcome (subsequent mortality). Deep nasopharyngeal swabs were collected on enrolled animals and submitted for bacterial isolation, antimicrobial susceptibility determination, and metagenomics analysis. Enrolled cattle were represented in three groups: animals at first treatment for BRD that subsequently died (BRDM, n = 9), animals at first treatment for BRD that subsequently lived (BRDL, n = 15), and animals that were never treated for BRD during the feeding phase (CONT, n = 11). Antimicrobial resistance patterns for Pasteurella multocida illustrated cattle in each outcome category had isolates that were pan-susceptible or only showed resistance to oxytetracycline. The relative abundance of species and genera illustrated few differences among the three outcomes. Higher alpha diversity was identified in BRDL compared to CONT at the species level, and both BRDL and BRDM showed increased alpha diversity compared to CONT at the general level. Overall, this work illustrated nasopharyngeal microbiota showed relatively few differences among BRD cases that lived or died compared to animals without BRD.

Benefits and challenges of creating veterinary antibiograms for empiric antimicrobial selection in support of antimicrobial stewardship and advancement of one-health goals.

Antibiograms are important tools for antimicrobial stewardship that are often underutilized in veterinary medicine. Antibiograms summarize cumulative antimicrobial susceptibility testing (AST) data for specific pathogens over a defined time period; in veterinary medicine, they are often stratified by host species and site of infection. They can aid practitioners with empiric therapy choices and assessment of antimicrobial resistance trends within a population in support of one-health goals for antimicrobial stewardship. For optimal application, consideration must be given to the number of isolates used, the timeframe of sample collection, laboratory analytical methodology, and the patient population contributing to the data (eg, treatment history, geographic region, and production type). There are several limitations to veterinary antibiograms, including a lack of breakpoint availability for bacterial species, a lack of standardization of laboratory methodology and technology for culture and AST, and a lack of funding to staff veterinary diagnostic laboratories at a level that supports antibiogram development and education. It is vital that veterinarians who use antibiograms understand how to apply them in practice and receive relevant information pertaining to the data to utilize the most appropriate antibiogram for their patients. This paper explores the benefits and challenges of developing and using veterinary antibiograms and proposes strategies to enhance their applicability and accuracy. Further detail regarding the application of veterinary antibiograms by privately practicing clinicians is addressed in the companion Currents in One Health article by Lorenz et al (JAVMA, September 2023).

The association of multiple metrics for evaluating antimicrobial use in U.S. beef feedyards.

In order to accurately portray antimicrobial use in food animals, the need for standardized metrics, and an understanding of the characteristics of different metrics, has long been recognized. Fourteen U.S. feedyards were used to evaluate the effects of using centralized constants such as defined daily dose (DDD) and defined course dose (DCD) applied to the weight of medically important antimicrobials by class (mg) as opposed to using electronic individual animal treatment records and lot level in-feed antimicrobial records obtained from the same population. Three numerators were calculated directly from recorded data for each drug product: the number of antimicrobial regimens associated with indication (Reg), milligrams of drug administered per regimen (mg), and calendar days of administration for each regimen (CDoA). There were four use indications to which numerators were assigned: liver abscess control (LAC), bovine respiratory disease (BRD), lameness (lame), or all other indications combined (other). Three denominators were also calculated directly from the data, these being the number of days animals were present (head days), number of cattle received (head in), and kilograms of live weight sold (kg-LW). Numerators and denominators were calculated at the lot level. The use of DDD or DCD was explored to determine how their use would affect interpretation of comparisons between lots or feedyards. At the lot level across both study years, the lot estimate of nDDD differed from the CDoA value by >25% in 49.2% of the lots. The number of Defined Course Doses (nDCD) was then compared to the number of Regimens (Reg). Comparing nDCD to Reg at the lot level across both study years, the lot estimate of nDCD differed from the Reg value by >25% in 46.4% of lots. Both year and metric were also shown to affect numerical feedyard ranking by antimicrobial use according to seven different metrics. The analysis reported here adds to the body of literature reporting substantial effects of metric choice on the conclusions drawn from comparing antimicrobial use across multiple production sites.

Using telehealth clinical case vignettes to enhance clinical confidence and competence in veterinary students.

Veterinarians contribute substantially to the health of their patients and enhance the communities in which they live. Delivery of veterinary curricula continues to evolve to ensure that veterinary graduates are prepared to meet their professional obligations on Day One of their careers. In this study, veterinary practitioners were recruited to deliver telehealth case rounds to veterinary students at Kansas State University and Texas A&M University. Case discussions were hosted virtually once per month in the 2020-2021 and 2021-2022 academic years for a total of 16 sessions. Each presenting practitioner was instructed to develop a brief presentation for a case routinely seen in their practice, and to discuss important clinical decision points in diagnosis, treatment and management. Cases could also highlight important ethical or communication issues encountered in veterinary medicine. The overall goals of this project were to increase the quantity and diversity of clinical cases to which veterinary students were exposed during their professional training and to evaluate the feasibility and acceptability of telehealth technology as a teaching strategy. Student participants were surveyed to determine the effectiveness of telehealth sessions in increasing overall confidence and competence in case management, and veterinary presenters were surveyed to determine motivations for participating in the project and perceived value of the telehealth sessions. More than 95% of students indicated that participation in telehealth sessions increased their clinical confidence and competence. Presenting practitioners unanimously indicated that they would participate in similar instruction in the future. Recommendations are provided to improve the educational experience for future adopters of telehealth teaching sessions.

Improving farm-level antimicrobial stewardship benchmarks by reporting antimicrobial use within the context of both the magnitude of disease pressure and the outcome of therapy.

This manuscript explores a method of benchmarking antimicrobial use within the context of farm level therapeutic incidence (a proxy for disease incidence), and the outcome of that therapy. This is reported both within the same farm over time (2016-2019), as well as evaluated across participating farms. Reporting antimicrobial use in this format addresses multiple primary questions necessary for evaluating on farm antimicrobial stewardship: How much disease is recorded? How much antimicrobial use is recorded? How often are antimicrobials included in therapy for each disease? What is the outcome of therapy? The three primary metrics reported are: therapeutic events per 100 cow years (TE/100CY), antimicrobial regimens per 100 cow years (REG/100CY), and the percent therapeutic success (% Success). Success was defined as: the cow remained in the herd and had no further TE recorded within 30 days of the end of the TE being evaluated. These measures identify opportunities for change on an individual farm, such as improvement in disease prevention, or a change in choices about when to include an antimicrobial in the treatment protocol. Therapeutic outcomes provide additional context, in some instances demonstrating differences in recording practices and case definitions, while in other cases serving to safeguard animal welfare as efforts are made to decrease antimicrobial use in the future. Although developed for farm level reporting, the metrics may also be more broadly summarized to meet future reporting requirements for marketing chain or national level antimicrobial use reports. The process outlined here serves as a prototype to be considered when developing antimicrobial use reporting systems where farm level antimicrobial stewardship is the primary objective.

Synergistic combinations of clarithromycin with doxycycline or minocycline reduce the emergence of antimicrobial resistance in Rhodococcus equi.

BACKGROUND: The alarming increase in rifampin and macrolide resistance among Rhodococcus equi isolates highlights the need to identify alternative therapeutic options that can effectively control rhodococcosis in foals while limiting the further development of drug resistance. OBJECTIVES: To evaluate bacterial killing, antibiotic synergism and mutant prevention concentrations (MPCs) of clarithromycin alone and in combination with doxycycline, minocycline or rifampin against clinical isolates of R equi. STUDY DESIGN: In vitro experiments. METHODS: Bacterial time-kill, fractional inhibitory concentration (checkerboard) and mutant prevention concentration assays were evaluated in four clarithromycin- and rifampin-susceptible (ClaS /RifS ) and two clarithromycin- and rifampin-resistant (ClaR /RifR ) R equi clinical strains. RESULTS: In this study evaluating a limited number of isolates, combinations of clarithromycin with doxycycline or minocycline, but not with rifampin, were generally synergistic in both ClaS /RifS and ClaR /RifR strains as determined by checkerboard testing. In time-kill assays, all antibiotics, both alone and in combination, reduced viable ClaS /RifS R equi by more than 3 log10 at 24 hours compared with control cultures without antibiotics. Combinations of clarithromycin with doxycycline, minocycline or rifampin induced significantly lower MPC values compared with the individual antimicrobials alone for all ClaS /RifS R equi strains, resulting in a narrower mutant selection window (MSW). However, clarithromycin/rifampin combination did not markedly decrease MPCs of the individual antimicrobials in ClaR /RifR R equi isolates, and the observed decrease in MPCs for doxycycline or minocycline did not generally differ when combined with clarithromycin. MAIN LIMITATIONS: The number of analysed R equi isolates was limited. In vitro outcomes require clinical confirmation. CONCLUSIONS: Dual therapy combinations consisting of clarithromycin with doxycycline or minocycline merit consideration as a treatment protocol against R equi in foals due to in vitro synergy. These combination therapies may also minimise the emergence of antimicrobial resistance in cases of rhodococcosis.