Antimicrobial stewardship in small animal veterinary practice: from theory to practice

Despite the increasing recognition of the critical role for antimicrobial stewardship in preventing the spread of multidrug-resistant bacteria, examples of effective antimicrobial stewardship programs are rare in small animal veterinary practice. This article highlights the basic requirements for establishing stewardship programs at the clinic level. The authors provide suggestions and approaches to overcome constraints and to move from theoretic concepts toward implementation of effective antimicrobial stewardship programs in small animal clinics.

Automatic day-2 intervention by a multidisciplinary antimicrobial stewardship-team leads to multiple positive effects

Background: Antimicrobial resistance rates are increasing. This is, among others, caused by incorrect or inappropriate use of antimicrobials. To target this, a multidisciplinary antimicrobial stewardship-team (A-Team) was implemented at the University Medical Center Groningen on a urology ward. Goal of this study is to evaluate the clinical effects of the case-audits done by this team, looking at length of stay (LOS) and antimicrobial use.

Methods: Automatic e-mail alerts were sent after 48 h of consecutive antimicrobial use triggering the case-audits, consisting of an A-Team member visiting the ward, discussing the patient’s therapy with the bed-side physician and together deciding on further treatment based on available diagnostics and guidelines. Clinical effects of the audits were evaluated through an Interrupted Time Series analysis and a retrospective historic cohort.

Results: A significant systemic reduction of antimicrobial consumption for all patients on the ward, both with and without case-audits was observed. Furthermore, LOS for patients with case-audits who were admitted primarily due to infections decreased to 6.20 days (95% CI: 5.59–6.81) compared to the historic cohort (7.57 days; 95% CI: 6.92–8.21; p = 0.012). Antimicrobial consumption decreased for these patients from 8.17 DDD/patient (95% CI: 7.10–9.24) to 5.93 DDD/patient (95% CI: 5.02–6.83; p = 0.008). For patients with severe underlying diseases (e.g., cancer) these outcome measures remained unchanged.

Conclusion: The evaluation showed a considerable positive impact. Antibiotic use of the whole ward was reduced, transcending the intervened patients. Furthermore, LOS and mean antimicrobial consumption for a subgroup was reduced, thereby improving patient care and potentially lowering resistance rates.

Antibiotic resistance: the perfect storm

The worldwide epidemic of antibiotic resistance is in danger of ending the golden age of antibiotic therapy. Resistance impacts on all areas of medicine, and is making successful empirical therapy much more difficult to achieve. Antibiotic choices are often severely restricted, and the pipeline of new antibiotics is almost dry. Resistance cannot be prevented, but its development and spread can be slowed. One of the tools at our disposal is maximising diversity in our prescribing. The advent of tigecycline, the first in a new class of intravenous antibiotics, is important in this context, giving us a further monotherapy option for severe infections. Another strategy is seriously to curtail the large amount of unnecessary antibiotic use in many areas of life, not only medical practice. The various aspects of this strategy are briefly reviewed.

Do we need to put society first? The potential for tragedy in antimicrobial resistance

Antimicrobial use presents a dilemma, say Foster and Grundmann. Appropriate use can benefit individual patients but carries a cost to society by selecting for resistant strains that are difficult to treat.

Antibiotic policies in Central Eastern Europe

To assess the antibiotic policies in Central Eastern European (CEE) countries, a questionnaire on the prevalence of resistance, antibiotic consumption data for ambulatory and hospital care and antibiotic policies, was mailed to national representatives. Data on antibiotic resistance and consumption of antibiotics at national levels are limited and vary considerably among countries. The importance of surveillance data in altering perceptions of the prevalence of resistance is shown by the comparison of surveillance data and interview data. Interview data without surveillance data produced the widest range of estimates of the prevalence of resistance in streptococcus pneumonia -5% in Lithuania and 82% in Belarus. The average consumption of antibiotics in ambulatory care in eight CEE countries in 2001 was 19.35 defined daily doses (DDD)/1000 inhabitants per day, (range 13.1 - 24.8 DDD) and in hospitals in six CEE countries was 2.2 DDD/1000 inhabitants per day (range 1.3-4.5). Over the counter sales of antibiotics are available in some countries. Antibiotic policy interventions do not exist or only apply to specific problems or interventions. Better implementation of antibiotic interventions and education on antibiotic use should be a high priority in this region. An effective strategy requires close co-operation, consultations and partnership at national and international level in particular, via existing international organisations.

Antibiotic policies and control of resistance

PURPOSE OF THE REVIEW

The current worldwide pandemic of antibiotic resistance shows no signs of abating. It is clear that it is driven mainly by heavy and often inappropriate antibiotic use. Although control measures are widely practised, it is important that we assess their efficacy critically in order to concentrate expensive control efforts where they will be most effective. The past year has seen much activity in this area, with evidence-based assessments of the literature according to strict guidelines, as well as progress in basic science studies of mechanisms of resistance, and their causes and relations to pathogenicity and adaptability.

RECENT FINDINGS

The present review summarizes current developments in the causes of antibiotic resistance, the classification of antibiotic stewardship and control measures, the evidence base for their efficacy, current problems in hospital practice, the adaptability of bacteria, the content of antibiotic policies and anticipated activities.

SUMMARY

The conclusions from the published literature are that much of it that pertains to changing prescribing practices does not stand up to modern evidence-based analysis concepts. Nevertheless, we can learn from experience in changing other areas of medical practice. We must be pragmatic and must not expect to change the world, but rather take it step by step, recognizing barriers and measuring outcomes and quality indicators. Studies into the molecular basis of resistance confirm the superb genetic adaptability of micro-organisms. They will always be several steps ahead of us. Nevertheless, we are learning how to modify our prescribing habits to minimize resistance, not only by using antibiotics less frequently but also by altering dosing schedules in various ways.