Small and Large Animal Veterinarian Perceptions of Antimicrobial Use Metrics for Hospital-Based Stewardship in the United States

Bernard S, Blackie K, Gronlund U, Battersby I. Evaluation of antimicrobial purchasing by companion animal veterinary facilities in Canada, the United Kingdom, and the United States of America (2019-2021)

BACKGROUND

Measuring antimicrobial use is a core component of antimicrobial stewardship. Purchasing data may be easier to obtain than prescription data in some situations, but differences in clinic size, caseload and collection timeframes must be considered.

OBJECTIVE

Our objective was to evaluate purchases of systemic antibacterial agents by small animal veterinary facilities in 5 networks across 3 countries, using a mg/veterinarian full time equivalent (FTE)/week as the metric.

METHODS

Data were obtained from purchasing records of 2194 veterinary facilities from networks from the United States (US, n = 3: US-A, 1036 facilities; US-B, 101 facilities; US-C, 886 facilities), Canada (n = 1: 117 facilities) and the United Kingdom (UK, n = 1: 54 facilities) during 2019-2021.

RESULTS

In total, 20 020 269 767 mg (20.02 t) of antimicrobials were purchased. Overall differences between the UK and North America were driven by significantly higher purchases of amoxicillin-clavulanic acid in the UK (P < .001), with substantially less purchasing of third generation cephalosporins in the UK (P < .0001). A significant association was found between FTE and purchasing, with decreased purchasing (mg/FTE/week) as facility FTE increased. Significant differences also were found among US regions. Facilities in the top 10% of total purchasing accounted for 23%-30% of purchases, compared to only 1.6%-3.8% for the bottom 10%.

CONCLUSIONS AND CLINICAL IMPORTANCE

These data provide useful information about general purchasing trends, inter- and intraregional differences and differences among facility types and identify high purchasing outliers for further investigation.

Standardization and evaluation of indicators for quantifying antimicrobial use on U.S. dairy farms

Antimicrobial resistance (AMR) is a global One Health threat. A portion of AMR development can be attributed to antimicrobial use (AMU) in animals, including dairy cattle. Quantifying AMU on U.S. dairy farms is necessary to inform antimicrobial stewardship strategies and help evaluate the relationship between AMU and AMR. Many AMU indicators have been proposed for quantifying AMU in dairy cattle. However, these indicators are difficult to interpret and compare because they differ in the type of data used, the calculation approach, and the definitions of variables and parameters used in the calculation. Therefore, we selected 16 indicators (count-based, mass-based, and dose-based) applicable for quantifying AMU on U.S. dairy farms. We systematized the indicators by standardizing their variables and parameters to improve their interchangeability, interpretation, and comparability. We scored indicators against six data-driven criteria (assessing their accuracy, data and effort needs, and level of privacy concern) and five stewardship-driven criteria (assessing their ability to capture trends and inform antimicrobial stewardship). The derived standardized indicators will aid farmers and veterinarians in selecting suitable indicators based on data availability and stewardship needs on a farm. The comparison of indicators revealed a trade-off requiring farmers to balance the granularity of data necessary for an accurate indicator and effort to collect the data, and a trade-off relevant to farmers interested in data sharing to inform stewardship because more accurate indicators are typically based on more sensitive information. Indicators with better accuracy tended to score better in stewardship criteria. Overall, two dose-based indicators, estimating the number of treatments and administered doses, scored best in accuracy and stewardship. Conversely, two count-based indicators, estimating the length of AMU, and a mass-based indicator, estimating the mass of administered antimicrobials, performed best in the effort and privacy criteria. These findings are expected to benefit One Health by aiding the uptake of farm-level AMU indicators by U.S. dairy farms.

Knowledge and Attitudes of Small Animal Veterinarians on Antimicrobial Use Practices Impacting the Selection of Antimicrobial Resistance in Dogs and Cats in Illinois, United States: A Spatial Epidemiological Approach

Inappropriate antimicrobial use in animals and humans has been associated with the emergence of antimicrobial resistance, which has become a global public health concern. Veterinarians’ practice locations and their knowledge and opinions on antimicrobial resistance may influence their antimicrobial prescription practices, which could impact the emergence of antimicrobial-resistant bacteria. This study used a spatial modeling approach to identify areas where veterinarians are knowledgeable about factors that impact the selection of antimicrobial resistance. In addition, we sought to identify regions with higher- and lower-than-expected response rates to our survey to aid future antimicrobial stewardship efforts. A total of 83 veterinarians who treated dogs and/or cats across 34 different Illinois counties responded to our online survey. Most of the responders (90.9%) considered that insufficient doses or duration of antibiotic treatments contribute the most to the selection of antimicrobial resistance. A high proportion of veterinarians (78.7%) attended educational programs on antimicrobial use and resistance; however, only 46.2% were knowledgeable about the current antimicrobial resistance profiles of prevalent bacteria in their area. A mean knowledge score for each county was calculated based on the responses of veterinarians to the survey questions. Local Moran’s I statistic was used to identify counties with high and low knowledge scores. A high knowledge score area in the northeast region and a low knowledge score area in the southeast of Illinois were identified. Using scan statistics with a Poisson model that accounted for the estimated number of veterinarians in a county, a higher-than-expected response rate area was identified in central-east Illinois and a lower-than-expected area in the northeast. This study showed the effectiveness of using geographic analysis and spatial statistics to identify locations where future antimicrobial stewardship programs should focus.

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.

Veterinary Practitioners' Standpoints and Comprehension towards Antimicrobial Use-Are There Opportunities for Antimicrobial Stewardship Improvement?

The main subject of the research is the assessment of the knowledge, attitudes and behaviors of veterinarians regarding the use of antibiotics (AMU) and antimicrobial resistance (AMR) through a questionnaire conducted among veterinarians in the northern region of Serbia. A total of 62 respondents completed the questionnaire, which represents a response rate of 44.3%. Male veterinarians are less likely to be in the group of veterinarians with insufficient knowledge (p < 0.05). Veterinarians engaged in mixed practice (small and large animals) (p < 0.001) and veterinarians who have over 100 patients per month (p < 0.005) are also less likely to be in the group with insufficient knowledge of antimicrobial resistance. The proportion of those with insufficient knowledge is growing among veterinarians whose source is the Internet (p < 0.01), while the proportion of those with insufficient knowledge about antimicrobial resistance is declining among veterinarians whose source of information is continuous education (p < 0.05). The majority of the respondents (n = 59, 95.2%) completely agreed that AMR is a very big issue in the global health sector right now. Unfortunately, there are crucial gaps in the knowledge and attitudes of the surveyed participants. They do not appear to be aware of the importance of AMU in veterinary medicine and its influence on overall AMR, or the crucial part that non-prescribed antibiotics have in all of it. Positively, many veterinarians use good practice AMU guidelines in their everyday practice and in line with the global trend of AMU reduction, respondents have also decreased their AMU compared to the previous year.

Assessment of Antibiotic Stewardship Components of Certification Programs in US Animal Agriculture Using the Antibiotic Stewardship Assessment Tool

Antibiotic stewardship programs (ASPs) are meant to promote appropriate use of antibiotics and to help maintain the effectiveness of antibiotics. For the United States (US) animal agriculture industry, multiple resources exist to guide antibiotic stewardship practices. Animal management certification programs can promote on-farm compliance with antibiotic stewardship through the incentive of achieving certification. The goal of this project was to determine whether the stewardship-related requirements of US-based certification programs align with identified core components of antibiotic stewardship in food animal agriculture using the Antibiotic Stewardship Assessment Tool (ASAT). We applied the ASAT to publicly available information from four different US animal agriculture certification programs that incorporate some level of antibiotic stewardship. In part due to varying scopes, the programs demonstrated a great deal of variability in meeting the metrics of the ASAT, with one program meeting all the required metrics and the other three only meeting the metrics to varying degrees (ranging from 3 to 67%). We identified several areas as opportunities for enhancing and promoting ASP implementation on farms. The area with the most opportunity for improvement is evaluation. Evaluation can help ensure effective outcomes of stewardship practices and ensure accountability for following recommended antibiotic stewardship guidelines. While evaluation currently may fall outside the scope of some certification programs, the incorporation of more specific antibiotic stewardship evaluation details within certification program content could serve as an important mechanism for promoting voluntary on-farm compliance with antibiotic stewardship guidelines.

Development and Pilot of an Interactive Online Course on Antimicrobial Stewardship in Companion Animals

A holistic approach to antimicrobial use (AMU) and prescribing is needed to combat the problem of antimicrobial resistance (AMR). Previously, an antimicrobial stewardship programme (ASP) was developed, introduced, and evaluated in 44 Dutch companion animal clinics, which resulted in an optimization of AMU. As a follow-up to this, an online course was developed to promote awareness of AMU, AMR, and responsible antimicrobial prescribing. The aim of this paper is to describe the development and pilot, including evaluation, of this course, which will be disseminated more widely among Dutch companion animal veterinarians. The interactive programme consists of a major e-learning component and two online, face-to-face meetings. The course comprises five different parts corresponding with five consecutive weeks. Theory on several topics is offered, for example on AMU and AMR in general, Dutch regulations and guidelines on veterinary AMU, behavioural change, and possible methods to quantify AMU. Additionally, several assignments are offered, for example to reflect upon one’s own current antimicrobial prescribing behaviour. Interactive discussion and peer-to-peer learning are promoted. Since September 2020, the course has been offered in a pilot phase, and the feedback is promising. Evaluation of the pilot phase will result in recommendations for further optimization and dissemination.

Evaluation of an OPEN Stewardship generated feedback intervention to improve antibiotic prescribing among primary care veterinarians in Ontario, Canada and Israel: protocol for evaluating usability and an interrupted time-series analysis

INTRODUCTION

Antimicrobial resistance (AMR) impacts the health and well-being of animals, affects animal owners both socially and economically, and contributes to AMR at the human and environmental interface. The overuse and/or inappropriate use of antibiotics in animals has been identified as one of the most important drivers of the development of AMR in animals. Effective antibiotic stewardship interventions such as feedback can be adopted in veterinary practices to improve antibiotic prescribing. However, the provision of dedicated financial and technical resources to implement such systems are challenging. The newly developed web-based Online Platform for Expanding Antibiotic Stewardship (OPEN Stewardship) platform aims to automate the generation of feedback reports and facilitate wider adoption of antibiotic stewardship. This paper describes a protocol to evaluate the usability and usefulness of a feedback intervention among veterinarians and assess its impact on individual antibiotic prescribing.

METHODS AND ANALYSIS

Approximately 80 veterinarians from Ontario, Canada and 60 veterinarians from Israel will be voluntarily enrolled in a controlled interrupted time-series study and their monthly antibiotic prescribing data accessed. The study intervention consists of targeted feedback reports generated using the OPEN Stewardship platform. After a 3-month preintervention period, a cohort of veterinarians (treatment cohort, n=120) will receive three feedback reports over the course of 6 months while the remainder of the veterinarians (n=20) will be the control cohort. A survey will be administered among the treatment cohort after each feedback cycle to assess the usability and usefulness of various elements of the feedback report. A multilevel negative-binomial regression analysis of the preintervention and postintervention antibiotic prescribing of the treatment cohort will be performed to evaluate the impact of the intervention.

ETHICS AND DISSEMINATION

Research ethics board approval was obtained at each participating site prior to the recruitment of the veterinarians. The study findings will be disseminated through open-access scientific publications, stakeholder networks and national/international meetings.