Antimicrobial stewardship: Time for change

Drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia: a qualitative study

OBJECTIVE

Antibiotic misuse includes using them to treat colds and influenza, obtaining them without a prescription, not finishing the prescribed course and sharing them with others. Although drug providers are well positioned to advise clients on proper stewardship practices, antibiotic misuse continues to rise in Ethiopia. It necessitates an understanding of why drug providers failed to limit such risky behaviours. This study aimed to explore drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia.

SETTING

The study was conducted in rural Haramaya district and Harar town, eastern Ethiopia.

DESIGN AND PARTICIPANTS

An exploratory qualitative study was undertaken between March and June 2023, among the 15 drug providers. In-depth interviews were conducted using pilot-tested, semistructured questions. The interviews were transcribed verbatim, translated into English and analysed thematically. The analyses considered the entire dataset and field notes.

RESULTS

The study identified self-medication pressures, non-prescribed dispensing motives, insufficient regulatory functions and a lack of specific antibiotic use policy as the key contributors to antibiotic misuse. We found previous usage experience, a desire to avoid extra costs and a lack of essential diagnostics and antibiotics in public institutions as the key drivers of non-prescribed antibiotic access from private drug suppliers. Non-prescribed antibiotic dispensing in pharmacies was driven by client satisfaction, financial gain, business survival and market competition from informal sellers. Antibiotic misuse in the setting has also been linked to traditional and ineffective dispensing audits, inadequate regulatory oversights and policy gaps.

CONCLUSION

This study highlights profits and oversimplified access to antibiotics as the main motivations for their misuse. It also identifies the traditional antibiotic dispensing audit as an inefficient regulatory operation. Hence, enforcing specific antibiotic usage policy guidance that entails an automated practice audit, a responsible office and insurance coverage for persons with financial limitations can help optimise antibiotic use while reducing resistance consequences.

Antimicrobial prescribing and antimicrobial resistance surveillance in equine practice

BACKGROUND

Antimicrobial resistance (AMR) is an increasingly serious threat to human and animal health, therefore responsible use of antimicrobials in equine practice is vital. There is a need to have accurate, up to date data on antimicrobial prescribing in equine practice in the UK.

OBJECTIVES

To characterise current antimicrobial prescribing practices by equine veterinarians and to describe surveillance, audit processes and identification of AMR.

STUDY DESIGN

Online cross-sectional, questionnaire-based survey.

METHODS

An online questionnaire targeting veterinarians who treat horses in the UK and Europe was distributed. The questionnaire collected data on participants' country of origin, practice policies, prescribing practices including use of high priority critical antimicrobials. Four common clinical case-based scenarios were included to further explore prescribing practice. Responses were compared using both descriptive statistics and multivariable logistic regression models.

RESULTS

Questionnaires were completed by 264 veterinarians from Europe (n=33/264) and the UK (n=231/264); 87% respondents worked only with horses and 67% worked at premises with hospitalisation facilities. Approximately half of respondents (54.4%) had a written antimicrobial use or stewardship policy within their practice. Over half of respondents did not perform any environmental surveillance (54.2%), audit of clinical infections (53.1%) or audit of infection control (57.1%). Potentiated sulphonamides were cited as the most used antimicrobial, although 44% reported using enrofloxacin in the last year and 66% used 3^rd or 4^th generation cephalosporins. Prophylactic antimicrobials before clean surgery were frequently/always prescribed by 48% respondents and 24% respondents frequently/always prescribed antimicrobials post-operatively in clean surgery.

MAIN LIMITATIONS

Potential selection bias of respondents, given individuals volunteered to take part in the survey.

CONCLUSIONS

Compared to a previous similar study conducted in 2009, overall antimicrobial usage appeared to be declining in clinical scenarios and a greater proportion of practices now have stewardship policies. However, the use of high priority critical antimicrobials is still relatively common in equine practice in the UK and Europe.

Antimicrobial Selection for the Equine Practitioner

Antimicrobial drugs play an important, often central, role in the therapeutic management of mature horses and foals with a variety of illnesses, including those requiring critical care. Antimicrobial use must be based on rational principles involving thorough patient evaluation and sound clinical judgment that indicate a high likelihood that the patient has a bacterial infection and that antimicrobials are indicated to promote recovery. The aim of antimicrobial treatment is to inflict an insult on infecting bacteria sufficient to kill the organism or render it susceptible to inactivation by natural host defenses or the local microenvironment without adversely affecting the patient.

Fate and toxicity of pharmaceuticals in water environment: An insight on their occurrence in South Asia

Pharmaceutically active compounds are newly recognized micropollutants which are ubiquitous in aquatic environment mainly due to direct discharge of treated and untreated wastewater from wastewater treatment plants. These contaminants have attracted mounted attention due to their toxic effects on aquatic life. They disrupt biological processes in non-target lower organisms upon exposure. Biodegradation, photo-degradation, and sorption are key processes which determine their fate in the environment. A variety of conventional and advanced treatment processes had been extensively investigated for the removal of pharmaceuticals from wastewater. However, due to structural complexity and varying operating parameters, complete removal seems ideal. Generally, due to high energy requirement of advanced treatment technology, it is considered cost ineffective. Transport of pharmaceutical compounds occurs via aquatic channels whereas sediments and aquatic colloids play a significant role as sinks for these contaminants. The current review provides a critical understanding of fate and toxicity of pharmaceutical compounds and highlights their vulnerability and occurrence in South Asia. Antibiotics, analgesics, and psychiatric drugs were found predominantly in the water environment of South Asian regions. Despite significant advances in understanding pharmaceuticals fate, toxicity, and associated risks since the 1990s, still substantial data gaps in terms of monitoring, human health risks, and legislation exist which presses the need to develop a more in-depth and interdisciplinary understanding of the subject.

Mapping knowledge and comprehension of antimicrobial stewardship and biosecurity among veterinary students

OBJECTIVES

As an important public health concern, antimicrobial resistance (AMR) is related to lack of knowledge among healthcare professionals. Since the Global Action Plan on AMR highlights the importance of training all healthcare professionals, it is essential to focus our attention on the education related to judicious antimicrobial use. The current study was the first attempt in southeastern Europe to quantify the knowledge about antimicrobial usage and biosecurity measure among veterinary students.

METHODS

This questionnaire-based study was performed between April and May of 2019 on 213 veterinary students of the University of Novi Sad, Serbia and the University of Zagreb, Croatia.

RESULTS

Veterinary students appeared to be little aware of antimicrobial use in veterinary medicine contribution to overall AMR since only 56.8% have chosen strong contribution as the answer. Of the students surveyed, only 22.1%/35.7% of them strongly agreed/agreed that the amount of teaching time for pharmacology was about right. Students who denied having good knowledge of the pharmacology of antimicrobials showed higher knowledge about systemic use of antimicrobials in different clinical scenarios (p = 0.002). High importance of some antimicrobials for human medicine was not recognized by surveyed students. Only 8.5% of them identified gentamicin correctly, as first-line therapy. Students expected to graduate later were more likely to identify the importance of rating antimicrobials correctly than those who thought they would graduate earlier (p = 0.002). More than half of students gave correct answer at scenario regarding a dog with recurrent pyoderma by choosing culture and susceptibility (C & S) testing. Our students who think they will graduate sooner have higher knowledge level on C & S testing sample submission for range of clinical scenarios (p = 0.004). Moreover, appropriate use of PPE (personal protective equipment) procedure and biosecurity measure were reported for two thirds of our students in case of only for two clinical scenarios.

CONCLUSION

This study reveals that among veterinary students from Croatia and Serbia improved undergraduate education is needed on the AMR with emphasis on antimicrobial stewardship (AMS) and appropriate biosecurity.

A multi-centre cohort study investigating the outcome of synovial contamination or sepsis of the calcaneal bursae in horses treated by endoscopic lavage and debridement

Background

Previous studies investigating factors associated with survival following endoscopic treatment of contamination/sepsis of the calcaneal bursa are limited.

Objectives

To investigate the factors associated with survival in horses with contamination/sepsis of the calcaneal bursae treated endoscopically and to describe the bacterial isolates involved in the synovial infections.

Study design

Retrospective analysis of clinical records.

Methods

Medical records from 128 horses with contamination/sepsis of the calcaneal bursae treated by endoscopic lavage at seven equine hospitals were reviewed. A follow‐up questionnaire was used to determine survival and return to athletic performance. Descriptive statistics and Cox proportional hazards survival models were used to determine factors associated with survival.

Results

Horses underwent one (n = 107), two (n = 19), or three (n = 2) surgeries. Survival to hospital discharge was 84.4%. Univariable survival analysis revealed that administration of systemic antimicrobials prior to referral was associated with reduced mortality (hazard ratio, [HR] 0.41, 95% CI 0.18–0.91, P = 0.03). Increased mortality was associated with bone fracture/osteomyelitis (HR 2.43, 95% CI 1.12–5.26, P = 0.03), tendon involvement (≥30% cross sectional area) (HR 3.78 95% CI 1.78–8.04, P = 0.001), duration of general anaesthesia (HR 1.01, 95% CI 1.00–1.02, P = 0.04), post‐operative synoviocentesis (HR 3.18, 95% CI 1.36–7.43, P = 0.006) and post‐operative wound dehiscence (HR 2.5, 95% CI 1.08–5.65, P = 0.04). Multivariable Cox proportional hazards model revealed reduced mortality after systemic antimicrobial administration prior to referral (HR 0.25, 95% CI 0.11–0.60, P = 0.002) and increased mortality with tendinous involvement (≥30% cross‐sectional area) (HR 7.92, 95% CI 3.31–19.92, P<0.001). At follow‐up (median 30 months, range 0.25–13 years, n = 70) 87.1% horses were alive, 7.1% had been euthanised due to the calcaneal injury and 5.7% had been euthanised for unrelated reasons. From 57 horses with athletic performance follow‐up, 91.2% returned to the same/higher level of exercise, 5.3% to a lower level and 3.5% were retired due to persistent lameness of the affected limb.

Main limitations

Retrospective study and incomplete follow‐up.

Conclusion

Endoscopic treatment of contamination/sepsis of the calcaneal bursae has an 84% survival rate to hospital discharge. Tendinous involvement reduced survival whilst systemic antimicrobials administration prior to referral improved survival.

Antimicrobial resistance in bacteria isolated from diseased horses in France

BACKGROUND

Horses are one of the potential reservoirs of antimicrobial resistance (AMR) determinants that could be transferred to human subjects.

OBJECTIVE

To describe the AMR patterns of major bacteria isolated from diseased horses in France.

STUDY DESIGN

Retrospective observational study.

METHODS

Data collected between 2012 and 2016 by RESAPATH, the French national surveillance network for AMR, were analysed. Only antimicrobials relevant in veterinary and human medicine for the isolated bacteria were considered. Mono- and multidrug resistance were calculated. The resistance proportions of major equine diseases were assessed and compared. Where data permitted, resistance trends were investigated using nonlinear analysis (generalised additive models).

RESULTS

A total of 12,695 antibiograms were analysed. The five most frequently isolated bacteria were Streptococcus spp., Escherichia coli, Pseudomonas spp., Staphylococcus aureus, Pantoea spp. and Klebsiella spp. The highest proportions of resistance to gentamicin were found for S. aureus (22.1%) and Pseudomonas spp. (26.9%). Klebsiella spp. and E. coli had the highest proportions of resistance to trimethoprim-sulfamethoxazole (15.5 and 26.2%, respectively). Proportions of resistance to tetracycline were among the highest for all the bacteria considered. Resistance to third-generation cephalosporins was below 10% for all Enterobacteriaceae. The highest proportions of multidrug resistance (22.5%) were found among S. aureus isolates, which is worrying given their zoonotic potential. From 2012 to 2016, resistance proportions decreased in Pseudomonas spp. isolates, but remained the same for S. aureus. For Streptococcus spp. and E. coli, resistance proportions to trimethoprim-sulfamethoxazole increased.

MAIN LIMITATIONS

Since antibiograms are not systematic analyses, any selection bias could impact the results.

CONCLUSIONS

Such studies are essential to estimate the magnitude of the potential threat of AMR to public health, to design efficient control strategies and to measure their effectiveness. These findings may also guide the initial empirical treatment of horse diseases.

Optimization of Antimicrobial Treatment to Minimize Resistance Selection

Optimization of antimicrobial treatment is a cornerstone in the fight against antimicrobial resistance. Various national and international authorities and professional veterinary and farming associations have released generic guidelines on prudent antimicrobial use in animals. However, these generic guidelines need to be translated into a set of animal species- and disease-specific practice recommendations. This article focuses on prevention of antimicrobial resistance and its complex relationship with treatment efficacy, highlighting key situations where the current antimicrobial drug products, treatment recommendations, and practices may be insufficient to minimize antimicrobial selection. The authors address this topic using a multidisciplinary approach involving microbiology, pharmacology, clinical medicine, and animal husbandry. In the first part of the article, we define four key targets for implementing the concept of optimal antimicrobial treatment in veterinary practice: (i) reduction of overall antimicrobial consumption, (ii) improved use of diagnostic testing, (iii) prudent use of second-line, critically important antimicrobials, and (iv) optimization of dosage regimens. In the second part, we provided practice recommendations for achieving these four targets, with reference to specific conditions that account for most antimicrobial use in pigs (intestinal and respiratory disease), cattle (respiratory disease and mastitis), dogs and cats (skin, intestinal, genitourinary, and respiratory disease), and horses (upper respiratory disease, neonatal foal care, and surgical infections). Lastly, we present perspectives on the education and research needs for improving antimicrobial use in the future.

Surgical management of marginal tears/avulsions of the suspensory ligament branches in 29 Thoroughbred racehorses

BACKGROUND

Suspensory ligament branch injuries are common in horses. Most of these injuries are grouped together and considered as a single pathologic entity.

OBJECTIVES

To report a specific injury of the abaxial margin of the suspensory ligament branches and to report its surgical management and outcome.

STUDY DESIGN

Retrospective case series.

METHODS

All horses with suspensory ligament branch injuries over a 9-year period (2007-2015) were identified. Horses with injuries which, on ultrasonographic examination, appeared to have defects in the abaxial margin of the suspensory ligament branch, that were subsequently confirmed during surgery were selected.

RESULTS

Twenty-nine cases fulfilled the inclusion criteria with a specific lesion location on the abaxial margin of the suspensory ligament branch. Nineteen horses raced successfully after surgery, nine returned to training but failed to race and one was lost to follow-up.

MAIN LIMITATIONS

The absence of a comparable population of non-surgically managed horses in this study means that the contribution of removing torn tissue cannot confidently be assessed.

CONCLUSIONS

The location and morphology of injuries described in this study is consistent, which suggests aetiopathogenic commonality. This case series suggests this type of injury has an identity of its own, differs from other types of suspensory ligament branch injuries and represents a previously undescribed subgroup.

Characterization of a newly isolated phage infecting pathogenic Escherichia coli and analysis of its mosaic structural genes

The outbreak of multidrug-resistant pathogenic bacteria made the discovery of novel control strategies necessary. Phages have regained attention for their specific lytic activity against pathogenic bacterium. A newly isolated phage infecting the clinical Escherichia coli isolates, including several multidrug-resistant strains, was isolated, and this phage showed high control effects against the tested pathogenic E. coli strains. Host range analysis revealed that although the phage exhibited broad lytic spectrum against the tested E. coli strains, it could not lyse strains from the other species. Comparative genomic analysis showed that phages had undergone at least three genome recombination events during the evolutionary process at the position of the three phage tail genes, which was reported to be associated with the host range determination of the phage. The recombinant tail proteins contained functional domains that were highly similar with genes of the Salmonella phage and genes of Pseudomonas and Neisseria. The findings of this study not only provide resources for developing phage therapy against E. coli, but also showed the highly variable genome structure of the phage.

Sequential bacterial sampling of the midline incision in horses undergoing exploratory laparotomy

BACKGROUND

There is limited information about bacterial isolates that are present on the equine midline incision during and following exploratory laparotomy.

OBJECTIVES

To investigate the bacterial species cultured from the ventral midline pre-, intra- and post- laparotomy, whether particular bacterial isolates are associated with the development of surgical site infections (SSIs) and to report the antimicrobial resistance phenotypes of these isolates.

STUDY DESIGN

Prospective cohort study.

METHODS

The ventral midline of 31 horses undergoing exploratory laparotomy was sampled for bacterial culture at set time-points pre, intra and post-operatively. Inclusion criteria were that horses must have undergone exploratory laparotomy within 90 min of the initial colic examination upon hospital admission and must not have been placed in a stable prior to surgery. SSI was defined as any purulent or serous discharge from the laparotomy incision of >24 h duration.

RESULTS

Seven horses (22.6%) developed a SSI. None of the variables tested were associated with the altered risk of SSI. The prevalence of a positive bacterial culture from the incision increased progressively over time and a variety of bacteria were isolated. A positive intra-operative culture was not a predictor of SSI; and when a SSI did occur, it was due to a different bacterial isolate. MRSA and ESBL-producers were identified in the post-operative period in one and four different horses respectively, but none of these developed a SSI.

MAIN LIMITATIONS

Sampling was limited to hospitalisation and no culture results were available for horses developing SSI following hospital discharge.

CONCLUSIONS

A variety of bacterial species may be isolated from equine laparotomy incisions peri-operatively without development of SSI. SSI does not appear to be solely related to bacterial contamination of the incision peri-operatively and other mechanisms such as bacteraemia merit further investigation.

Prevalence of antimicrobial resistance from bacterial culture and susceptibility records from horse samples in South Africa

The continuous increase in prevalence of antimicrobial resistant bacteria presents a significant public health problem and is an indicator that antimicrobial prudent usage guidelines are not being followed, especially in developing countries. Despite trends being available from numerous countries, there is little published for South Africa. This study was aimed at estimating the prevalence and trends of antimicrobial resistance from bacterial isolates from equine clinical samples submitted for culture and susceptibility testing to the veterinary bacteriology laboratory of the University of Pretoria. The study covered a period of seven years from 2007. A total of 1505 bacterial isolates were included in this study comprising isolates from 2007 (n=447); 2008 (n=285); 2009 (n=258); 2010 (n=102); 2011 (n=89); 2012 (n=248) and 2013 (n=76). For this study, multiple drug resistance was above 50% for all the isolates. The Cochran-Armitage test showed evidence of a significantly increasing trend in prevalence of resistance to several antimicrobial agents, including amikacin (E. coli, Staphylococcus), AMX/AMP (Corynebacteria, Lactobacillus and Salmonella), chloramphenicol (Enterococcus, E. coli, Pseudomonas, Streptococcus, Staphylococcus and Salmonella), enrofloxacin (E. coli, Staphylococcus, Salmonella and Pseudomonas) and gentamicin (Salmonella, Staphylococcus). The data obtained from this study is relevant to equine practitioners, as it helps enhance the body of veterinary knowledge pertaining to antimicrobial resistance in common equine pathogens in South Africa.

Open standing castration in Thoroughbred racehorses in Hong Kong: Prevalence and severity of complications 30 days post-castration

BACKGROUND

Complications following open standing castration (OSC) in Thoroughbred racehorses are well recognised but variation in their prevalence and severity between populations is not well documented.

OBJECTIVES

To describe the prevalence and severity of complications in the 30 days following OSC.

STUDY DESIGN

A retrospective cohort study of veterinary clinical records relating to horses that underwent OSC between July 2007 and July 2012.

METHODS

Complications were graded on a severity score from N, no complications, to C3, severe complications. Additional data were accessed for each horse including age, import date, racing history, trainer and veterinarian performing the castration. Bacterial culture and antimicrobial sensitivities were performed on a limited number of castration wounds that became infected.

RESULTS

In total, 250 horses were castrated in Hong Kong using the OSC technique over the period of the study. Sixty percent (150/250) of horses experienced some type of post-castration complication, with eight horses experiencing a severe (C3) complication requiring intensive veterinary treatment. Scrotal swelling, funiculitis and seroma formation were present in 70.0%, 36.7% and 24.7% of cases respectively. Most horses experiencing complications required wound reopening (87.3%; 131/150), and/or an extended course of first-line antimicrobials and/or nonsteroidal anti-inflammatory drugs (75/150; 50.0%). Eight horses had cultures submitted for bacterial sensitivity, with 17 bacterial isolates grown. In vitro, the bacteria cultured were sensitive to enrofloxacin (76%; 13/17) and ceftiofur (100%; 17/17). Resistance was detected to penicillin, gentamicin, oxytetracycline, metronidazole and trimethoprim-sulfadiazine.

MAIN LIMITATIONS

Differences in post-castration management cannot be accounted for in this study.

CONCLUSIONS

Complications following OSC in horses in Hong Kong were common. The majority were mild and were successfully treated using antimicrobials and simple wound management. Given the high rate of complications and antimicrobial usage identified in this study, a review of the technique is warranted.

Multidrug resistant Enterobacteriaceae in New Zealand: a current perspective

In this article we review mechanisms and potential transmission pathways of multidrug resistance in Enterobacteriaceae, with an emphasis on extended-spectrum β-lactamase (ESBL)-production. This provides background to better understand challenges presented by this important group of antimicrobial resistant bacteria, and inform measures aimed at prevention and control of antimicrobial resistance in general. Humans and animals interact at various levels; household pets cohabit with humans, and other animals interact with people through direct contact, as well as through the food chain and the environment. These interactions offer opportunity for bacteria such as ESBL-producers to be shared and transmitted between species and, in turn, increase the risk of zoonotic and reverse-zoonotic disease transmission. A key step in curtailing antimicrobial resistance is improved stewardship of antimicrobials, including surveillance of their use, better infection-control and prevention, and a better understanding of prescribing practice in both veterinary and medical professions in New Zealand. This will also require prospective observational studies to examine risk factors for antimicrobial resistance. Due to the interconnectedness of humans, animals and the environment actions to effect the changes required should be undertaken using a One Health approach.

Antimicrobial Susceptibilities of Aerobic Isolates from Respiratory Samples of Young New Zealand Horses

Background

Decreased efficacy of antimicrobials and increased prevalence of multidrug resistance (MDR) is of concern worldwide.

Objectives

To describe and analyze bacterial culture and antimicrobial susceptibilities from respiratory samples submitted from young horses (4 weeks to 3 years old).

Animals

Samples from 289 horses were submitted to a commercial laboratory.

Methods

A retrospective database search of submissions made to a New Zealand veterinary laboratory between April 2004 and July 2014. The results of in vitro susceptibility testing by Kirby‐Bauer disc diffusion were described and tabulated for the major bacterial species isolated. Multiple correspondence analysis (MCA) was used to describe the clustering of MDR isolates and selected demographic variables.

Results

Overall, 774 bacterial isolates were cultured from 237 horses, the majority of these isolates were gram‐positive (67.6%; 95% CI 64.3–70.9%). Streptococcus spp. were the most common genus of bacteria isolated and were 40.1% (95% CI 36.6–43.5%) of the isolates cultured. Susceptibility of Streptococcus spp. to penicillin, gentamicin, and ceftiofur was >85%. Overall, gram‐negative susceptibility to ceftiofur, tetracycline, and TMPS was <75%. MDR was defined as resistance to 3 or more antimicrobials, and was found in 39.2% of horses (93/237; 95% CI 33.0–45.5%).

Conclusions and clinical importance

Culture and susceptibility results have highlighted that MDR is an emerging problem for young horses in New Zealand (NZ), where a bacterial respiratory infection is suspected. This should be considered when prescribing antimicrobials, and emphasizes the need for submission of samples for culture and susceptibility.

Prognosis and impact of equine recurrent uveitis

REASONS FOR PERFORMING STUDY

Equine recurrent uveitis (ERU) is a leading cause of vision loss in horses.

OBJECTIVES

To assess the prognosis and impact of ERU on affected horses and their owners by evaluating the signalment, treatment and outcome (including the loss of use, vision assessment and economic loss).

STUDY DESIGN

Retrospective impact study.

METHODS

Medical records of horses presenting to the North Carolina State University Veterinary Health Complex (NCSU-VHC) with ERU between 1999 and 2014 were reviewed. Signalment, clinical signs, ophthalmic examination findings, treatments and outcomes were evaluated. Owner questionnaires were completed regarding vision, job/role, monetary value, diagnostic and treatment costs, concurrent illness and outcomes.

RESULTS

Records of 224 horses (338 eyes) with ERU were reviewed. There was an overrepresentation of Appaloosas (54; 24.1%), Hanoverians (11; 4.9%) and other Warmbloods (13; 5.8%). Ninety-six eyes (28.4%) were diagnosed as blind and 38 eyes (11.2%) with glaucoma on initial evaluation. Leptospirosis titres of serum and/or aqueous humour were obtained in 88 horses and were positive in 40 horses (45.5%), with L. pomona being the most frequently isolated serovar. Globe loss at the NCSU-VHC occurred in 41 ERU eyes (12.1% of total). Owner questionnaires were evaluated in 194 horses (86.6%) and 91 horses (46.9%) were reported blind in the affected eye(s). Fifty-seven horses (29.4%) did not return to their previous role, while 61 (31.4%) performed at a reduced level. Equine recurrent uveitis decreased the monetary value of 164 horses. Twenty-nine horses (14.9%) were euthanised and 37 (19.1%) underwent change in ownership as a direct result of ERU.

CONCLUSIONS

The impact of ERU is attributed to the high frequency of blindness, globe loss and loss of function. Euthanasia and change of ownership are common sequelae to the progressive nature of ERU. These factors, along with financial costs of the disease, have a significant impact on affected horses and their owners.

Antibiotic resistance-the need for global solutions

The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally. Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensible in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies, and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions are immediately taken. Here, we describe the global situation of antibiotic resistance, its major causes and consequences, and identify key areas in which action is urgently needed.

Equine proliferative enteropathy--a review of recent developments

Equine proliferative enteropathy (EPE) is a disease of foals caused by the obligate intracellular organism Lawsonia intracellularis. This emerging disease affects mainly weanling foals and causes fever, lethargy, peripheral oedema, diarrhoea, colic and weight loss. The diagnosis of EPE may be challenging and relies on the presence of hypoproteinaemia, thickening of segments of the small intestinal wall observed upon abdominal ultrasonography, positive serology and molecular detection of L. intracellularis in faeces. Although the clinical entity, diagnostic approach and treatment of EPE are well established and described, the epidemiology for this disease has remained largely unaddressed. This article focuses on new developments in the field of EPE, including epidemiology, pathophysiology, clinical signs, diagnosis, treatment and prevention.

The Summary is available in Chinese – see Supporting information.