1
|
Fins IS, Singleton DA, Radford AD, Sánchez-Vizcaíno F, Pinchbeck GL. A mixed-methods approach utilising electronic health records to examine antimicrobial prescription surrounding gastrointestinal clinical presentations in dogs and cats. Front Vet Sci 2023; 10:1166114. [PMID: 38149298 PMCID: PMC10749927 DOI: 10.3389/fvets.2023.1166114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 11/16/2023] [Indexed: 12/28/2023] Open
Abstract
Introduction Systemically-administered antimicrobials are often prescribed in canine and feline gastrointestinal clinical presentations. Responsible use of antimicrobials, particularly those considered Highest Priority Critically Important Antimicrobials (HPCIAs) is vital to tackle antimicrobial resistance. Although practice-level prescription guidance is available, further strategies based on a greater understanding of antimicrobial prescription at the population-level are needed. Here, we used a mixed-methods approach, harnessing veterinary electronic health records (EHRs) to characterise the use of antimicrobials in canine and feline gastrointestinal presentations, and to explore justification and reasoning around antimicrobial prescribing, particularly of HPCIAs. Methods This observational study used 23,337 EHRs complemented with veterinary practitioner-completed questionnaires, from canine and feline gastrointestinal consultations from 225 volunteer UK veterinary practices between April 2014 and September 2018. Results A total of 83.4% (95% confidence interval (CI) 82.6-84.3) gastrointestinal presentations were reported as mild, with non-haemorrhagic diarrhoea and vomiting the most frequently reported clinical signs. Systemically-administered antimicrobials occurred in 28.6% of canine (95% CI 26.9-30.3) and 22.4% of feline (95% CI 20.4-24.4) gastrointestinal consultations, with HPCIA prescription occurring more frequently in cats. Results of multivariable analysis showed the presence of non-haemorrhagic diarrhoea (canine Odds Ratio (OR) 2.1, 95% CI 1.9-2.3; feline OR 1.8, 95% CI 1.5-2.1), haemorrhagic diarrhoea (canine OR 4.2, 95% CI 3.8-4.7; feline OR 3.1, 95% CI 2.4-3.8), and moderate/severe presentations (canine OR 1.9, 95% CI 1.7-2.8; feline OR 2.0, 95% CI 1.7-2.5) were positively associated with receiving a systemically-administered antimicrobial. Thematic analysis of clinical narrative content of 516 gastrointestinal consultations where HPCIAs were prescribed allowed the identification of ten factors underpinning reasoning or decision-making for HPCIA prescription: perceived animal/owner compliance; owner's expectations; perceived risk of infection; clinical signs; recent clinical history; perceived positive previous response to antimicrobial therapy; geriatric patients and euthanasia; concomitant conditions; diagnostic testing and the behavioral trend to trial antimicrobial therapy empirically in gastrointestinal cases. No explicit justification for HPCIA prescription was recorded in 77% of cases. Discussion Improving recorded justification represents a clear target for stewardship programmes. By utilising a complementary mixed-methods approach to EHRs, this study unlocks previously untapped data recorded within EHRs. These results can help inform targeted interventions, contributing towards enhanced antimicrobial stewardship.
Collapse
Affiliation(s)
- Ivo S. Fins
- Institute of Infection, Veterinary and Ecological Sciences, Department of Livestock and One Health, University of Liverpool, Neston, United Kingdom
| | - David A. Singleton
- Institute of Infection, Veterinary and Ecological Sciences, Department of Livestock and One Health, University of Liverpool, Neston, United Kingdom
| | - Alan D. Radford
- Institute of Infection, Veterinary and Ecological Sciences, Department of Infection Biology and Microbiomes, University of Liverpool, Neston, United Kingdom
| | | | - Gina L. Pinchbeck
- Institute of Infection, Veterinary and Ecological Sciences, Department of Livestock and One Health, University of Liverpool, Neston, United Kingdom
| |
Collapse
|
2
|
Tompson AC, Mateus ALP, Brodbelt DC, Chandler CIR. Understanding Antibiotic Use in Companion Animals: A Literature Review Identifying Avenues for Future Efforts. Front Vet Sci 2021; 8:719547. [PMID: 34692805 PMCID: PMC8531418 DOI: 10.3389/fvets.2021.719547] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/02/2021] [Indexed: 12/25/2022] Open
Abstract
Addressing antibiotic use is essential to tackle antimicrobial resistance, a major human and animal health challenge. This review seeks to inform stewardship efforts in companion animals by collating research insights regarding antibiotic use in this group and identifying overlooked avenues for future research and stewardship efforts. The development of population-based methods has established that antibiotics are frequently used in companion animal care. Research insights are also contributing toward an in-depth comprehension of the contexts to antibiotic use. Qualitative approaches, for example, have enabled a nuanced understanding in four key areas: interactions with owners, clinical and financial risk management, time pressures, and clinic dynamics. This review identifies that much of the existing research frames antibiotic use as the result of choices made by the individuals at the interface of their use. Future research and policy endeavours could look beyond the moment of prescribing to consider the societal structures and networks in which companion animal antibiotic use is entangled. A diversification in research approaches and frameworks through which antibiotic use is understood will facilitate the identification of additional targets for stewardship initiatives beyond providing information and awareness campaigns.
Collapse
Affiliation(s)
- Alice C Tompson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ana L P Mateus
- VEEPH Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, London, United Kingdom
| | - Dave C Brodbelt
- VEEPH Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, London, United Kingdom
| | | |
Collapse
|
3
|
Smith SL, Afonso MM, Roberts L, Noble PJM, Pinchbeck GL, Radford AD. A virtual biobank for companion animals: A parvovirus pilot study. Vet Rec 2021; 189:e556. [PMID: 34101190 DOI: 10.1002/vetr.556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/19/2021] [Accepted: 05/13/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is a lack of national population data concerning infectious disease in companion animals. Here, we piloted the feasibility of linking diagnostic laboratories, population surveillance and modern sequencing approaches to extract targeted diagnostic samples from laboratories before they were discarded, as a novel route to better understand national epidemiology of major small animal pathogens. METHODS Samples tested for canine or feline parvovirus were requested from a national veterinary diagnostic laboratory and analysed by Sanger or next generation sequencing. Samples were linked to electronic health data held in the SAVSNET database. RESULTS Sequences obtained from positive samples, together with associated metadata, provided new insights into the recent geographical distribution of parvovirus strains in circulation in the United Kingdom (UK). CONCLUSIONS This collaboration with industry represents a 'National Virtual Biobank' that can rapidly be called on, to efficiently add new layers of epidemiological information of relevance to animal, and potentially human, population health.
Collapse
Affiliation(s)
- Shirley L Smith
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Neston, Wirral, UK
| | - Maria M Afonso
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Neston, Wirral, UK
| | | | - Peter-John M Noble
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Neston, Wirral, UK
| | - Gina L Pinchbeck
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Neston, Wirral, UK
| | - Alan D Radford
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Neston, Wirral, UK
| |
Collapse
|
4
|
Werner M, Unterer S. [Use of antimicrobials in acute canine diarrhea - overview of potential risks, indications and alternatives]. TIERAERZTLICHE PRAXIS AUSGABE KLEINTIERE HEIMTIERE 2021; 49:110-120. [PMID: 33902119 DOI: 10.1055/a-1395-2001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In Germany, antibiotics are frequently used in dogs with gastrointestinal disorders such as acute diarrhea. In line with global efforts to limit antibiotic use, this literature review aims to provide a guideline for the rational and judicious use of antibiotics in acute canine diarrhea. Antibiotics can lead to gastrointestinal side effects and may exert a negative influence on the intestinal microbiota in addition to increasing the occurrence of resistant bacteria. There is also evidence that chronic immunological diseases may be triggered by the administration of antibiotics. Therefore, these should not be administered in uncomplicated acute diarrhea without signs of sepsis or systemic inflammatory reaction. In addition, enteropathogenic bacteria usually do not play a role in the etiology of acute diarrhea. For select clinical entities such as acute hemorrhagic diarrhea syndrome, antibiotic therapy should only be recommended in cases displaying signs of bacterial translocation with subsequent sepsis. In the case of parvovirosis, on the other hand, the administration of antibiotics is unavoidable due to the immunological incompetence of the dog caused by the accompanying severe neutropenia.
Collapse
Affiliation(s)
- Melanie Werner
- Medizinische Kleintierklinik, Zentrum für Klinische Tiermedizin, Ludwig-Maximilians-Universität München
| | - Stefan Unterer
- Medizinische Kleintierklinik, Zentrum für Klinische Tiermedizin, Ludwig-Maximilians-Universität München
| |
Collapse
|
5
|
Singleton DA, Rayner A, Brant B, Smyth S, Noble PJM, Radford AD, Pinchbeck GL. A randomised controlled trial to reduce highest priority critically important antimicrobial prescription in companion animals. Nat Commun 2021; 12:1593. [PMID: 33707426 PMCID: PMC7952375 DOI: 10.1038/s41467-021-21864-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 02/12/2021] [Indexed: 01/31/2023] Open
Abstract
Robust evidence supporting strategies for companion animal antimicrobial stewardship is limited, despite frequent prescription of highest priority critically important antimicrobials (HPCIA). Here we describe a randomised controlled trial where electronic prescription data were utilised (August 2018-January 2019) to identify above average HPCIA-prescribing practices (n = 60), which were randomly assigned into a control group (CG) and two intervention groups. In March 2019, the light intervention group (LIG) and heavy intervention group (HIG) were notified of their above average status, and were provided with educational material (LIG, HIG), in-depth benchmarking (HIG), and follow-up meetings (HIG). Following notification, follow-up monitoring lasted for eight months (April-November 2019; post-intervention period) for all intervention groups, though HIG practices were able to access further support (i.e., follow-up meetings) for the first six of these months if requested. Post-intervention, in the HIG a 23.5% and 39.0% reduction in canine (0.5% of total consultations, 95% confidence interval, 0.4-0.6, P = 0.04) and feline (4.4%, 3.4-5.3, P < 0.001) HPCIA-prescribing consultations was observed, compared to the CG (dogs: 0.6%, 0.5-0.8; cats: 7.4%, 6.0-8.7). The LIG was associated with a 16.7% reduction in feline HPCIA prescription (6.1% of total consultations, 5.3-7.0, P = 0.03). Therefore, in this trial we have demonstrated effective strategies for reducing veterinary HPCIA prescription.
Collapse
Affiliation(s)
- David A Singleton
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Chester High Road, Neston, UK.
| | | | - Bethaney Brant
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Chester High Road, Neston, UK
| | - Steven Smyth
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Chester High Road, Neston, UK
| | - Peter-John M Noble
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Chester High Road, Neston, UK
| | - Alan D Radford
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Chester High Road, Neston, UK
| | - Gina L Pinchbeck
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Chester High Road, Neston, UK
| |
Collapse
|
6
|
Singleton DA, Noble PJ, Radford AD, Brant B, Pinchbeck GL, Greenberg D, Appleton C, Jewell C, Newton R, Cuartero CT, Sánchez-Vizcaíno F. Prolific vomiting in dogs. Vet Rec 2020; 186:191. [PMID: 32054807 DOI: 10.1136/vr.m553] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- David A Singleton
- University of Liverpool, Institutes of Infection and Global Health and Veterinary Science, Leahurst Campus, Chester High Road, Neston, Wirral CH64 7TE
| | - P J Noble
- University of Liverpool, Institutes of Infection and Global Health and Veterinary Science, Leahurst Campus, Chester High Road, Neston, Wirral CH64 7TE
| | - Alan D Radford
- University of Liverpool, Institutes of Infection and Global Health and Veterinary Science, Leahurst Campus, Chester High Road, Neston, Wirral CH64 7TE
| | - Beth Brant
- University of Liverpool, Institutes of Infection and Global Health and Veterinary Science, Leahurst Campus, Chester High Road, Neston, Wirral CH64 7TE
| | - Gina L Pinchbeck
- University of Liverpool, Institutes of Infection and Global Health and Veterinary Science, Leahurst Campus, Chester High Road, Neston, Wirral CH64 7TE
| | | | | | - Chris Jewell
- The Liverpool Vets, 11 Cleveland Square, Liverpool L1 5BE
| | - Richard Newton
- CHICAS, Furness College, Lancaster University, Lancaster LA1 4YG
| | | | | |
Collapse
|
7
|
Singleton DA, Noble PJM, Sánchez-Vizcaíno F, Dawson S, Pinchbeck GL, Williams NJ, Radford AD, Jones PH. Pharmaceutical Prescription in Canine Acute Diarrhoea: A Longitudinal Electronic Health Record Analysis of First Opinion Veterinary Practices. Front Vet Sci 2019; 6:218. [PMID: 31334254 PMCID: PMC6615257 DOI: 10.3389/fvets.2019.00218] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/18/2019] [Indexed: 12/17/2022] Open
Abstract
Canine acute diarrhoea is frequently observed in first opinion practice, though little is known about commonly used diagnostic or therapeutic management plans, including use of antimicrobials. This retrospective observational study utilised electronic health records augmented with practitioner-completed questionnaires from 3,189 cases (3,159 dogs) collected from 179 volunteer veterinary practices between April 2014 and January 2017. We used multivariable analysis to explore factors potentially associated with pharmaceutical agent prescription, and resolution of clinical signs by 10 days post-initial presentation. Use of bacteriological and/or parasitological diagnostic tests were uncommon (3.2% of cases, 95% confidence interval, CI, 2.4–4.0), though systemic antimicrobials were the most commonly prescribed pharmaceutical agents (49.7% of cases, 95% CI 46.1–53.2). Such prescription was associated with haemorrhagic diarrhoea (odds ratio, OR, 4.1; 95% CI 3.4–5.0), body temperature in excess of 39.0°C, or moderate/severe cases (OR 1.3, 95% CI 1.1–1.7). Gastrointestinal agents (e.g., antacids) were prescribed to 37.7% of cases (95% CI 35.4–39.9), and were most frequently prescribed to vomiting dogs regardless of presence (OR 46.4, 95% CI 19.4–110.8) or absence of blood (OR 17.1, 95% CI 13.4–21.9). Endoparasiticides/endectocides were prescribed to 7.8% of cases (95% CI 6.8–9.0), such prescription being less frequent for moderate/severe cases (OR 0.5, 95% CI 0.4–0.7), though more frequent when weight loss was recorded (OR 3.4, 95% CI 1.3–9.0). Gastrointestinal nutraceuticals (e.g., probiotics) were dispensed to 60.8% of cases (95% CI 57.1–64.6), these cases less frequently presenting with moderate/severe clinical signs (OR 0.6, 95% CI 0.5–0.8). Nearly a quarter of cases were judged lost to follow-up (n=754). Insured (OR 0.7, 95% CI 0.5–0.9); neutered (OR 0.4, 95% CI 0.3–0.5), or vaccinated dogs (OR 0.3, 95% CI 0.3–0.4) were less commonly lost to follow-up. Of remaining dogs, clinical signs were deemed resolved in 95.4% of cases (95% CI 94.6–96.2). Provision of dietary modification advice and gastrointestinal nutraceuticals alone were positively associated with resolution (OR 2.8, 95% CI 1.3–6.1); no such associations were found for pharmaceutical agents, including antimicrobials. Hence, this study supports the view that antimicrobials are largely unnecessary for acute diarrhoea cases; this being of particular importance when considering the global threat posed by antimicrobial resistance.
Collapse
Affiliation(s)
- David A Singleton
- Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Neston, United Kingdom
| | - P J M Noble
- Institute of Veterinary Science, University of Liverpool, Neston, United Kingdom
| | | | - Susan Dawson
- Institute of Veterinary Science, University of Liverpool, Neston, United Kingdom
| | - Gina L Pinchbeck
- Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Neston, United Kingdom
| | - Nicola J Williams
- Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Neston, United Kingdom
| | - Alan D Radford
- Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Neston, United Kingdom
| | - Philip H Jones
- Epidemiology and Population Health, Institute of Infection and Global Health, University of Liverpool, Neston, United Kingdom
| |
Collapse
|