Comparison of antimicrobial prescription patterns in calves in Switzerland before and after the launch of online guidelines for prudent antimicrobial use

BACKGROUND

The increasing threat of bacterial resistance promotes the need for antibiotic stewardship programs to foster responsible antimicrobial use. Therefore, guidelines for prudent use supported by an online stewardship tool (AntibioticScout.ch) were introduced in Switzerland in December 2016. They recommend (with decreasing preference) a first, second or third line antimicrobial for treatment. The objective of this study was to evaluate antimicrobial prescriptions for Swiss calves before (2016) and after (2018) the launch of these guidelines. Cases of calves with pneumonia, diarrhea and otitis from a university hospital and eight private practices in Switzerland were included. Data on anamnesis, clinical findings, diagnostic work-up and treatment were collected. Type and percentages [95% confidence interval] of antimicrobial prescriptions were compared between 2016 and 2018.

RESULTS

Of the total number of calves, 88.2% [85.4-90.6] in 2016 (n = 625) and 88.4% [85.7-90.7] in 2018 (n = 655) were treated with antibiotics. The use of highest priority critically important antimicrobials (HPCIAs) decreased from 52.7% [48.6-56.9] in 2016 to 38.0% [34.2-41.9] in 2018; this decrease was found at the university hospital and in private practice and in cases with pneumonia and diarrhea. Particularly the use of fluoroquinolones decreased (2016: 43.1% [39.2-47.2]; 2018: 31.1% [27.6-34.8]). Overall, the number of first line treatments increased from 12.8% [10.4-15.6] in 2016 to 20.2% [17.3-23.4] in 2018. In cases of pneumonia, first line treatments increased (2016: 15.3% [11.6-19.9]; 2018: 26.5% [21.8-31.9]) and third line treatments decreased (2016: 43.5% [38.0-49.3]; 2018: 27.9% [23.1-33.3]); this was seen at the university hospital, whereas in private practice only a decrease of third line treatments was observed. In cases of diarrhea, more second line at the expense of unlisted antimicrobials were prescribed at the university hospital in 2018. Antimicrobial treatment of calves with otitis did not change from 2016 to 2018.

CONCLUSIONS

After the introduction of AntibioticScout.ch, more prudent use was observed in the treatment of calves with pneumonia and diarrhea as less HPCIAs, particularly fluoroquinolones, and more first line antimicrobials were prescribed. However, the overall frequency of antimicrobial treatment did not change and the use of HPCIAs was still common in 2018, especially in private practices. Therefore, further antimicrobial stewardship activities are necessary.

Antimicrobial prescriptions in cats in Switzerland before and after the introduction of an online antimicrobial stewardship tool

BACKGROUND

Antimicrobial stewardship activities are essential to improve prudent antimicrobial use. The aim of the present study was to evaluate changes in antimicrobial prescriptions in cats after the introduction of prudent use guidelines promoted by an online antimicrobial stewardship tool (AntibioticScout.ch) in Switzerland. Data from 792 cats presented to two university hospitals and 14 private practices in 2018 were included and compared to 776 cases from 2016. Cats were diagnosed with acute upper respiratory tract disease (aURTD), feline lower urinary tract disease (FLUTD) and abscesses. Clinical history, diagnostic work-up and antimicrobial prescriptions (class, dosage, duration) were assessed. Type and proportions [95% confidence intervals] of antimicrobial prescriptions were compared between the two evaluation periods and a mixed effects logistic regression model was applied to evaluate compliance with Swiss prudent use guidelines.

RESULTS

From 2016 to 2018, the proportion of antimicrobial prescription in all included cases decreased from 75.0% [71.8-78.0] to 66.7% [63.3-69.9]; this decrease was most pronounced for treatments at university hospitals (67.1% [59.5-74.0] to 49.3% [40.9-57.8]) and for cats with FLUTD (60.1% [54.6-65.4] to 48.8% [43.2-54.4]). Use of 3rd generation cephalosporins in private practices declined from 30.7% [26.5-35.1] to 22.1% [18.4-26.2], while overall use of non-potentiated aminopenicillins increased from 19.6% [16.4-23.0] to 27.8% [24.1-31.9]. In cases where antimicrobial therapy was indicated, compliance with guidelines did not increase (33.3% [26.6-40.6] to 33.5% [27.2-40.2]), neither at universities nor in private practices. On the other hand, antimicrobial treatment was more often withheld in cases with no indication for antimicrobial therapy (35.6% [30.1-41.4] to 54.0% [47.6-60.4]); this was found for private practices (26.7% [20.8-33.4] to 46.0% [38.4-53.7]) and for aURTD cases (35.0% [26.5-44.2] to 55.4% [44.7-65.8]).

CONCLUSIONS

Overall proportions of antimicrobial prescription, unjustified antimicrobial therapy and, in private practices, use of 3rd generation cephalosporins decreased from 2016 to 2018 for the investigated feline diseases. However, overall compliance with Swiss prudent use guidelines was still low, implying that further efforts are required to foster prudent antimicrobial use in cats.

Impact of the Suissano Health Programme on antimicrobial usage on 291 pig farms in Switzerland

BACKGROUND

In 2015, in Switzerland the Suissano Health Programme was implemented in pig production to improve transparency for antimicrobial usage (AMU) and to reduce the usage of fluoroquinolones (FQ), macrolides and cephalosporins, representing highest priority critically important antimicrobials.

METHODS

In the presented cohort study, the impact of the Suissano programme on the AMU of 291 pig farms between 2016 and 2017 was investigated. AMU was calculated in total numbers of defined course doses (nDCDch) for all farms in the programme. For each single farm the nDCDch/animal/year was determined for four different age categories (suckling piglets, weaned piglets, fattening pigs, sows) as well as each antimicrobial substance separately. Trends between 2016 and 2017 were investigated for all farms as well as the 25 per cent with the highest usage of antimicrobials (high users) separately.

RESULTS

Total AMU measured in nDCDch declined by 23 per cent between 2016 and 2017, but statistically significant differences could not be observed when comparing the data sets of the individual farms. A significantly reduced usage of FQ could be demonstrated in suckling piglets (P=0.003), weaned piglets (P=0.006) and sows (P=0.008) in 2017 compared with 2016. For high users, a significant reduction of total AMU could be shown in suckling piglets (P=0.02), weaned piglets (P=0.0004) and fattening pigs (P=0.01).

CONCLUSION

This study demonstrated a significant reduction in the usage of FQs in suckling piglets, weaned piglets and sows as well as total AMU in suckling piglets, weaned piglets and fattening pigs on high-usage farms.

Antimicrobial prescriptions and adherence to prudent use guidelines for selected canine diseases in Switzerland in 2016

Background

Antimicrobial resistance is an increasing problem in human and veterinary medicine and is closely linked to the use of antimicrobials. The objective of this study was to describe antimicrobial prescriptions for selected canine diseases in Switzerland during 2016.

Methods

Dogs presented to two university hospitals and 14 private practices for acute diarrhoea (AD; n=371), suspected or confirmed urinary tract infections (UTIs; n=245), respiratory tract infections (RTIs; n=274) or wound infections (WIs; n=175) were included. Clinical history, diagnostic work-up and antimicrobial prescription (class, dosage and duration) were retrospectively assessed. A justification score was applied to evaluate appropriateness of antimicrobial therapy based on available national and international consensus guidelines.

Results

Antimicrobials were prescribed in 65 per cent of dogs with AD, 88 per cent with UTI, 62 per cent with RTI and 90 per cent with WI. The most prescribed antimicrobial classes (monotherapy and combination therapy) were potentiated aminopenicillins (59 per cent), nitroimidazoles (22 per cent), non-potentiated aminopenicillins (16 per cent) and fluoroquinolones (13 per cent). Overall, 38 per cent (95 per cent CI 0.35 to 0.41) of the prescriptions were in accordance with consensus guidelines. In dogs with AD, antimicrobial therapy was associated with the presence of haemorrhagic diarrhoea (P<0.05) and complied in 32 per cent with consensus guidelines, which recommend antimicrobial treatment only when sepsis is suspected. A bacterial aetiology was confirmed via culture and/or sediment examination in 36 per cent of dogs with suspected UTI.

Conclusions

Overall, adherence to consensus guidelines was poor both, at university hospitals and private practices. Antimicrobial stewardship measures are therefore needed to improve prudent use.

[Use of antibiotics in Swiss piglet production and fattening farms]

INTRODUCTION

In 164 randomly selected Swiss piglet production farms and 101 fattening farms, the indication for antibiotic use in 2012/2013 was recorded and an animal treatment index (TBI) was calculated for each age group. Sows were treated on average 0.9 days per year mainly due to mastitis-metritis-agalactia (MMA). Suckling piglets were treated on average 0.5 days per production cycle, mainly due to diarrhea and polyarthritis. Weaned piglets were treated during 4.4 days, especially due to diarrhea, polyarthritis and wasting. In fattening pigs, treatments were mainly due to diarrhea and HPS-suspicion, and lasted on average 4.8 days. In sows, antibiotics were used prophylactically on 22.6% of the treatment days, in suckling piglets on 50.5%, in weaners on 86.1% and in fattening pigs on 79.0% of the treatment days. A prophylactic oral antibiotic group therapy did not have a significant positive effect on daily weight gain of fattening pigs, nor was it able to reduce the number of individual or group therapies. In farms with prophylactic oral group therapy, the mortality rate during the first two fattening weeks even tended to be higher (p=0.06) than in farms without oral group therapy. Highest priority critically important antibiotics were used in 22.6% of all treatment days in sows, in 37.5% in suckling piglets, in 17.2% in weaned piglets and in 27.3% in fattening pigs. In many farms, antibiotics were not prescribed and used according to the rules of "prudent use".

[Vigilance for veterinary medicinal products: Reports of adverse reactions in the year 2017]

INTRODUCTION

A total of 306 reports of adverse reactions to veterinary medicinal products were received during the year 2017 representing an increase of 21% compared to the previous year. The majority of these reports described reactions concerning companion animals (180 dogs and 59 cats) as well as cattle (38 reports) and horses (14 reports). Most of the reported reactions were linked to the use of antiparasitics (158 reports), hormone products (30 reports) and anti-inflammatory products (25 reports). 40 reports were generated from consultations with Tox Info Suisse in Zürich and mainly involved the excessive intake of flavoured tablets and, in some cases, the use of products under the cascade regulation (applied to another species than that authorized). Nine signals were identified from the reports, resulting in revisions of the product information in the sections addressing contra-indications or adverse reactions.

Expert opinion on livestock antimicrobial usage indications and patterns in Denmark, Portugal and Switzerland

We aimed at describing antimicrobial usage patterns throughout livestock production cycles, and comparing them across three countries from Northern, Central and Southern Europe. Given the difficulties to collect such detailed usage data, an expert opinion was deemed the most appropriate study design. This study provides new insights into the time periods and indications for which specific antimicrobial substances are used in different livestock sectors. Veterinary experts (n=67) from different livestock sectors (broilers, pigs, dairy cattle and veal/fattening calves) and countries (Denmark, Portugal and Switzerland) replied to a questionnaire focusing on the time periods in the production cycle when antimicrobial substances were administered, and the respective indications for treatment. Our results showed that for several antimicrobials, between-country and within-country variations exist regarding the temporal distributions of treatments and indications for use. These differences were also true for several critically important antimicrobials, which is a matter of concern. Furthermore, differences between countries were also evident regarding the antimicrobial substances licensed. Based on our results, it is recommended to establish and promote treatment guidelines, invest in the prevention of diseases during critical moments of the production cycle and target undifferentiated use of antimicrobials. Moreover, discrepancies between countries should be further investigated to better understand the factors underlying the identified patterns and to distinguish prudent from non-prudent use. The results can inform decision-making with the aim to foster antimicrobial prudent use in the veterinary setting and, therefore, protect public health from the threat of antimicrobial resistance.

[AntibioticScout.ch: Decision support for the prudent use of antimicrobials: Application in cattle]

INTRODUCTION

The administration of antibiotics in livestock has been criticized for many years, in particular because of an inappropriate use and the appearance of antibiotic residues in the environment, which can promote the emergence and spread of resistant bacteria. However, antibiotics are essential for the successful and sustainable control of bacterial pathogens. With the aim of optimizing the use of antibiotics in food animals and minimizing the prevalence of resistant bacteria, AntibioticScout. ch provides a decision aid for the prudent use of antimicrobial drugs. This approach emphasizes the importance of supportive therapy and the hallmarks of preventive concepts. Procedures to improve animal health and animal welfare in accordance with the principles of good veterinary practice are primary and effective tools to reduce the use of antimicrobial drugs. The necessary reduction in the use of antibiotics must, therefore, be accompanied by appropriate management strategies in animal husbandry. In particular, hygiene, animal welfare and biosecurity measures are crucial to ensure an optimal health status in farm animals.

Risk Ranking of Antimicrobial-Resistant Hazards Found in Meat in Switzerland

Human exposure to bacteria resistant to antimicrobials and transfer of related genes is a complex issue and occurs, among other pathways, via meat consumption. In a context of limited resources, the prioritization of risk management activities is essential. Since the antimicrobial resistance (AMR) situation differs substantially between countries, prioritization should be country specific. The objective of this study was to develop a systematic and transparent framework to rank combinations of bacteria species resistant to selected antimicrobial classes found in meat, based on the risk they represent for public health in Switzerland. A risk assessment model from slaughter to consumption was developed following the Codex Alimentarius guidelines for risk analysis of foodborne AMR. Using data from the Swiss AMR monitoring program, 208 combinations of animal species/bacteria/antimicrobial classes were identified as relevant hazards. Exposure assessment and hazard characterization scores were developed and combined using multicriteria decision analysis. The effect of changing weights of scores was explored with sensitivity analysis. Attributing equal weights to each score, poultry-associated combinations represented the highest risk. In particular, contamination with extended-spectrum β-lactamase/plasmidic AmpC-producing Escherichia coli in poultry meat ranked high for both exposure and hazard characterization. Tetracycline- or macrolide-resistant Enterococcus spp., as well as fluoroquinolone- or macrolide-resistant Campylobacter jejuni, ranked among combinations with the highest risk. This study provides a basis for prioritizing future activities to mitigate the risk associated with foodborne AMR in Switzerland. A user-friendly version of the model was provided to risk managers; it can easily be adjusted to the constantly evolving knowledge on AMR.

[AntibioticScout.ch: A decision supporting tool for antimicrobial stewardship: application to companion animal medicine]

INTRODUCTION

Bacterial resistances to antimicrobial drugs pose serious public health challenges. The observed increase of resistances is attributed to the uncontrolled, massive and often unnecessary administration of antibiotics both in human and veterinary medicine. To support the responsible use of antimicrobials in animals and help veterinarians selecting the most suitable antimicrobial drugs, we developed the AntibioticScout.ch as a comprehensive decision supporting tool providing online access to the current knowledge of rational antibiotic prescription practices. User-friendly search functions allow for the fast and efficient retrieval of information that is structured in this database by animal species, organ systems and therapeutic indications. In addition, an online form allows to report treatment failures in order to identify problematic cases as well as ensuing risks and take appropriate mitigation measures. The present report describes the workflow of this decision support system applied to the prudent use of antimicrobials in companion animal medicine.

[Vigilance for veterinary medicinal products: Reports of adverse reactions in the year 2016]

INTRODUCTION

A total of 253 reports of adverse reactions to veterinary medicinal products were received during the year 2016 representing a decrease of 13% compared to the previous year (292 reports). The majority of the reports described reactions affecting companion animals (178 dogs and 32 cats) as well as cattle (17 reports) and horses (10 reports). Most of the reactions reported were linked to the use of antiparasitics (145 reports), hormone products (26 reports) and antiinfectives (10 reports). 32 reports were generated from consultations with Tox Info Suisse in Zürich and involved mainly the excessive intake of flavoured tablets and, in some cases, the use of reconverted products (applied to another species than that authorized). Five signals were identified from the reports, which resulted in revisions of the product information in the sections addressing contraindications or adverse reactions.

[Calculation of therapeutic intensity for pigs treated using medicated feed]

INTRODUCTION

The correct oral treatment of pigs in groups is a demanding procedure. Prescriptions of medicated feed for groups larger than 20 pigs have to be made on official forms submitted to veterinary authorities. In this work, we evaluated 1'126 such forms for the years 2010-2011 to calculate the therapeutic intensity for piglets and fatteners at farm level in the canton of Lucerne. This analysis shows that essential data were often difficult to obtain and that the provided information did not always allow for plausible intensity calculations. In total, 654 and 424 kg of antimicrobials were prescribed during the 2 years under investigation. For the years 2010 and 2011, the calculated median intensities were 43.5 and 32.5 treated animals per 1'000 individuals per day (PIDvet) for piglets and 75.9 and 64.8 for fatteners. PIDvet for the whole populations of piglets and fatteners treated with medicated feed delivered from feed mills were 37.51 resp. 84.44 in the year 2011.

Approaches for quantifying antimicrobial consumption per animal species based on national sales data: a Swiss example, 2006 to 2013

Antimicrobial use in animals is known to contribute to the global burden of antimicrobial resistance. Therefore, it is critical to monitor antimicrobial sales for livestock and pets. Despite the availability of veterinary antimicrobial sales data in most European countries, surveillance currently lacks consumption monitoring at the animal species level. In this study, alternative methods were investigated for stratifying antimicrobial sales per species using Swiss data (2006−2013). Three approaches were considered: (i) Equal Distribution (ED) allocated antimicrobial sales evenly across all species each product was licensed for; (ii) Biomass Distribution (BMD) stratified antimicrobial consumption, weighting the representativeness of each species' total biomass; and (iii) Longitudinal Study Extrapolation (LSE) assigned antimicrobial sales per species based on a field study describing prescription patterns in Switzerland. LSE is expected to provide the best estimates because it relies on field data. Given the Swiss example, BMD appears to be a reliable method when prescription data are not available, whereas ED seems to underestimate consumption in species with larger populations and higher treatment intensity. These methods represent a valuable tool for improving the monitoring systems of veterinary antimicrobial consumption across Europe.

[AntibioticScout: Online tool for antimicrobial stewardship in veterinary medicine]

INTRODUCTION

Resistances to antimicrobials pose serious public health challenges. This issue concerns both human and veterinary medicine and can only be solved by a multidisciplinary approach. A comprehensive concept is, therefore, being worked out within the StAR (strategy antibiotic resistance) program in order to preserve the effectiveness of antibiotics for humans as well as animals. In this context, the AntibioticScout (www.AntibioticScout. ch) offers a new online tool for the prudent use of antibiotics in veterinary medicine. By involving all stakeholders, the guidelines included in the AntibioticScout will result in a nationwide accepted standard for the treatment of bacterial infections in animals. An additional system for the rapid reporting of cases of suspected lack of efficacy of antimicrobials is integrated to allow early detection of emerging resistance and the immediate launch of risk mitigation measures. A first version of the AntibioticScout for the treatment of dogs, cats and horses is available by the end of 2016. All stakeholders are now invited to contribute to the development of the AntibioticScout decision support.

[Vigilance for veterinary medicinal products: Reports of adverse reactions in the year 2015]

INTRODUCTION

A total of 292 adverse reactions to veterinary medicinal products were reported during the year 2015. This represents an increase of 9% compared to the previous year (268 reports). Similar to previous years, most of the reactions reported were linked to the use of antiparasitics (55.1%), non-steroidal anti-inflammatory products (8.9%) or antiinfectives (9.3%). The affected animal species were primarily dogs (198 reports) and cats (42 reports), followed by cattle (31 reports) and horses (8 reports). Additional 42 reports were provided within the frame of consultations with Tox Info Suisse in Zürich and involved mainly the excessive intake of flavored tablets. Eight signals were identified from the reports received or the periodic safety update reports. They resulted in revisions of the product information in sections addressing contraindications, adverse reactions or withdrawal times.

[Vigilance for veterinary medicinal products: declarations of adverse reactions in the year 2008]

With 106 reports of suspected adverse reactions to veterinary medicinal products (VMPs) there was a slight decrease in the year 2008 compared to 2007. However, the distribution according to species and drug classes remained grossly the same: dogs were involved in 45 % of the cases followed in frequency by cats (26 %) and cows or calves (21 %). Most often the reports described reactions following the use of either an antiparasitic drug (46 %) or an antibiotic (22 %). One particular case of off-label use and serious skin reactions are presented. For the vaccinovigilance a total of 310 reports were received, with 250 of them related to adverse events following vaccination against blue tongue disease. In most cases, aborts and elevated cell count in the milk were reported. A detailed evaluation of these cases is presented. Finally, 305 enquiries were received by the Swiss Toxicological Information Center in Zürich (concerning mostly dogs or cats). Most of the cases concerned either preparations for the nervous system or anti-inflammatory drugs (human medicinal products) or antiparasitics (VMPs).

[Swiss veterinary drug compendium as a tool for reconversions]

The new Swiss ordinance on veterinary drugs poses a new challenge to the veterinarians, specially those working with farm animals. A complete overview about the registered veterinary drugs and immunobiologicals is absolutely necessary to cope with these new tasks: the internet version of the Swiss Veterinary Drug Compendium is a versatile tool to satisfy this needs (http://www.tierarzneimittel.ch). Due to the frequent updates and powerful search possibilities, this database is a reliable and comprehensive information system regarding Swiss veterinary drugs. We will demonstrate how this system can be used as a valuable help in the case of reconversions of drugs (e.g. use of small animal drugs in farm animals).