Call for antimicrobial stewardship policy

The recent publication of a study¹ that mentions the inappropriate administration of fluoroquinolones for management of otitis media in cattle highlights the importance of legal and ethical use of antimicrobials in all species. The subsequent editorial² calling for judicious use of these products in all species is a timely reminder in light of growing pressures on veterinary antimicrobial use as a result of concerns related to antimicrobial resistance. In 2005, the American College of Veterinary Internal Medicine published its consensus statement on the use of antimicrobials in veterinary species.³ These recommendations remain valid today, and we believe that standardized protocols for the empirical use of antimicrobials in common case scenarios play an essential role in good antimicrobial stewardship. Such protocols are widely used in human health care,⁴ but few veterinary organizations have adopted them, although they may have prevented the inappropriate use of enrofloxacin in the reported study.¹ An important feature of such protocols include the categorization of antimicrobials as primary, secondary, or tertiary, such that drugs classified as critically important for human health are used only in exceptional circumstances. The World Health Organization currently classifies third- and fourth-generation cephalosporins, fluoroquinolones, and macrolides as critically important agents for human health.⁵

In 2013, the Equine Veterinary Journal became, to our knowledge, the first journal worldwide to include an antimicrobial stewardship policy in its author guidelines.⁶ This policy does not limit the publication of innovative research involving antimicrobials but requires any study that uses or evaluates agents classified as critically important to include a discussion of the importance of these antimicrobials to human health. The policy is similar to the policy that research be conducted in an appropriate, ethical manner and should lead to the development of research studies that consider the importance of antimicrobial resistance during the study design process. We encourage the JAVMA to adopt a similar policy regarding antimicrobial stewardship to ensure that published studies are not used as evidence of inappropriate use of antimicrobials by the veterinary profession.

Mark Bowen, bvetmed, phd, dacvim

Senior Vice President, British Equine

Veterinary Association

University of Nottingham

Nottingham, England

Keith J Chandler, bvms

Senior Vice President, British Equine

Veterinary Association

Fordham, Cambridgeshire, England

Methods in a study of cranial cruciate ligament disease in dogs

In a recently published study¹ of outcomes 1 year after tibial plateau leveling osteotomy (TPLO) or lateral fabellar suture stabilization (LFS) in dogs with cranial cruciate ligament (CCL) disease, the authors concluded that “kinematic and owner satisfaction results indicated dogs that underwent TPLO had better outcomes than those that underwent LFS.” We acknowledge the contribution this study makes, but we are concerned about some methodological issues.

First, the study did not include a control group of dogs that did not undergo surgical treatment. A previous study² of dogs with experimentally transected CCLs found that peak vertical force (PVF) at a trot improved over a period of 12 months without surgical stabilization of the knee joint, plateauing at approximately 60% of body weight. Thus, we believe monitoring of dogs treated without surgery is mandatory for sound interpretation of the results of surgical stabilization.

Second, we believe that statistical approaches for evaluating some of the data may have been inappropriate. The PVF data were correctly identified as a repeated-measures variable, but incorrectly tested with an ANOVA method that assumes normally distributed data with no autocorrelation and requires identical group sizes and homogeneous variances among groups and across times.³ Examination of Figures 1 and 2 in the report suggests that the groups were unbalanced and that the PVF data were not normally distributed, were autocorrelated, and were heteroscedastic. The discrete owner satisfaction scores (rated on a scale from 1 to 10) were not analyzed with a repeated-measures model, even when dichotomized (< 9 vs ≥ 9), which would have allowed the use of a generalized linear model with a logistic link function and a generalized estimating equation to account for autocorrelation. The goniometry, thigh circumference, and Canine Brief Pain Inventory data were not analyzed with repeated-measures, generalized, linear mixed models. Instead, the authors performed multiple paired t tests without controlling the overall type I error rate and, in the case of the Canine Brief Pain Inventory data, neglecting the requirement that the t test be used for continuous data. In addition, none of these tests included covariates such as body weight or velocity, and the rationale for recoding satisfaction rates and the criteria for pairing animals were not discussed by the authors.

Third, and of particular concern to us, dogs still demonstrated clear functional impairment after surgical correction, with mean PVF < 50% of body weight at a trot and < 38% of body weight at a walk for both groups 12 months after surgery. Such low PVFs are a hallmark of osteoarthritic lameness in dogs.^4,5

With these concerns in mind, the benefits of surgical correction for dogs with CCL disease remain unclear. Given the study design, it cannot be determined what effect surgical stabilization, regardless of whether TPLO or LFS was performed, had on the outcome. The clinical importance of the claimed difference between the two methods of surgical correction is doubtful, and we cannot determine whether either had any significant beneficial effect.

Maxim Moreau, msc

Bertrand Lussier, dvm, msc, dacvs

Jérôme R.E. del Castillo, dvm, phd

Eric Troncy, dv, phd

Department of Veterinary

Biomedical Sciences

Faculty of Veterinary Medicine

Université de Montréal

Saint-Hyacinthe, QC, Canada

The authors respond:

The authors appreciate the comments from Dr. Moreau et al. However, the specific research question addressed in our study was which surgical procedure—tibial plateau leveling osteotomy or lateral fabellar suture stabilization—would be better in dogs with cranial cruciate ligament disease, and the materials and methods were designed to answer that question. No other questions were addressed, and we did not specifically undertake to determine whether these procedures are better than nonsurgical treatment or whether either procedure would allow a return to normal function or decrease the progression of osteoarthritis.

We stand by our statistical methods, which were provided by our statistician and conformed to standard practice.

Although it would have been nice if our study solved all of the questions regarding cranial cruciate ligament disease in dogs, we only provided evidence toward one.

Wanda Gordon-Evans, dvm, phd, dacvs

Wisconsin Veterinary Referral Center

Waukesha, Wis

AVMA governance changes

I agree with the opinion from Goldman et al¹ that the present federated structure of the AVMA House of Delegates (HOD) provides satisfactory professional representation and does not need radical overhaul. However, I do not agree with the assertion that “much more would be lost in terms of cohesiveness, the shared wisdom of our collective experience, and intraprofessional unity” than would be gained through the new governance structure. The veterinary profession urgently needs improved mutual understanding and support among its various sectors, each of which has some unique characteristics that are often poorly understood by others.

Effectively serving society in the future will depend on educational reforms that require a dynamic partnership between the academic community and the rest of the veterinary profession. We are unlikely to solve the profession's knotty problems unless we are moving together. A few years ago, Dr. Ole Nielsen, Dr. James Bellamy, and I urged the creation of a coalition² that would include representatives from the AVMA, the Canadian Veterinary Medical Association, state and provincial licensing authorities, and the Association of American Veterinary Medical Colleges, and I suggest that it is time to revive this idea. The number of representatives from each organization should be strictly limited so as to facilitate efficiency and control costs, and the coalition should be given the necessary freedom to use fair compromise in finding solutions to the profession's most pressing complex problems. In such a small close-knit group, members would be obliged to lower their voices and refrain from finger-pointing. I believe this idea merits consideration.

Peter Eyre, dvm&s, bvms, bsc, phd

Blacksburg, Va

I appreciate the efforts of the Task Force on Governance and Member Participation in examining the governance structure of the AVMA but find myself in basic agreement with the delegates who recently submitted a letter¹ in opposition to the proposed changes.

I served in the AVMA House of Delegates as both an alternate and a delegate representing a state association, and I agree that there are flaws, inequities, and inconsistencies in the present AVMA system of governance. Over the course of time, however, it has served the profession well. I worry that the changes proposed in the report of the Task Force on Governance and Member Participation would essentially eliminate the important role that state and other allied organizations play in AVMA affairs and that the proposed Veterinary Resources Committee would have too much power to shape the future of our profession. In addition, considering the number of advisory committees and task forces envisioned and the complex voting procedures required under the proposed plan, it seems doubtful that substantial cost savings would result.

In past years, changes to the AVMA bylaws have been made to accommodate societal and professional changes. Perhaps, the current AVMA governance structure could be improved with relatively minor changes to the bylaws, such as granting the Executive Board explicit fiduciary power and increased management responsibility and policy authority.

As the political philosopher Russell Kirk once wrote, “Sudden departing from tradition, however abstractly rational, may sweep away much that is good together with a little that is bad.”²

John E. Willson, dvm

Essex, Conn

Urethral obstruction and age of cats

I read the recent retrospective study¹ on factors associated with recurrent obstruction in cats treated medically for urethral obstruction and wondered whether the authors knew how old the cats were when they were neutered. Others have suggested that certain medical problems may be prevented in dogs and cats by neutering them after physical maturity (ie, > 1 year of age).

Robert M. Jackson, dvm

Animal Medical Clinic Inc

Lakeland, Fla

Veterinary education and the profession's future

The recent commentary¹ concerning workforce dynamics by the Association of American Veterinary Medical Colleges (AAVMC) is timely, considering ongoing concerns about veterinarian supply versus demand. However, I ultimately found the commentary disappointing and thought that it did not contain any new ideas or recommendations for strategic changes. It has been shown that 70% of organizations fail to implement necessary changes despite overwhelming evidence of need,² and I worry that the veterinary education community is in that group. I believe that to enable the veterinary profession to adapt to new economic conditions, including the emphasis on one health, the colleges of veterinary medicine will have to train veterinarians with extensive socioeconomic and environmental science skills, in addition to clinical skills.

For many years, I have been urging more system-wide thinking within the profession,³ and I believe that these discussions should be about veterinary education as a whole. The fact that the colleges of veterinary medicine are autonomous institutions makes such discussions a challenge, but I believe that the veterinary profession will improve if the colleges work closely together under AAVMC leadership.

The veterinary profession needs to change its conservative culture. If it cannot do so promptly, it will risk becoming a minor player in environmental and health sciences (one health), which would be tragic given its unique strengths in comparative medicine. Shall we, in good conscience, sidestep our societal obligations once again?

Peter Eyre, dvm&s, bvms, bsc, phd

Blacksburg, Va

Equality of opportunity in veterinary medicine

Dr. Andrew T. Maccabe's recent letter to the editor¹ raises some interesting questions regarding the issue of diversity in veterinary medicine. I am encouraged by efforts to present veterinary medicine as an interesting career option to high school and undergraduate college students, especially in communities where it would seem to be an infrequently chosen profession. As well, efforts to discuss diversity at the level of the profession are helpful, so long as these discussions are not limited to veterinary educators and are inclusive of practitioners.

That said, ongoing research into the effects of diversity, or the lack thereof, on the veterinary profession needs to be continued, as it seems to me that the positive and negative effects of efforts to enhance diversity are still unclear. Of course, no one with an interest in veterinary medicine should be dissuaded from pursuing such a career; quite to the contrary, such interest should be encouraged. However, we should not be pursuing diversity simply for the sake of diversity itself, and educators need to constantly guard against the temptation to use quotas as a tool to achieve diversity.

We want the brightest and the best, regardless of personal background or interests outside of veterinary medicine, and the criteria used to determine whether a particular individual would make a good veterinary school candidate should not be adjusted to favor applicants of an underrepresented group solely on the basis of their being a part of such a group.

I applaud efforts not only to “gather data that helps us better understand where we are and where we could be,”¹ but also to better understand where we should be. Just as in practicing veterinary medicine, simply because we can do something doesn't mean we should.

John S. Parker, dvm

Briarpointe Veterinary Clinic

Novi, Mich

Broadening our veterinary clientele

The plan by the Partners for Healthy Pets, of which the AVMA is a major partner, to run advertisements promoting preventive healthcare visits for dogs and cats¹ is certainly a worthwhile one. My concern as a practice owner, however, is that the focus is too narrow. The targeted demographic (women 30 to 40 years of age with yearly household incomes exceeding $75,000 who have a veterinary relationship, yet are not seeking regular preventive visits for their pets) describes many of my clients, and I would certainly like to see them and their pets more often, at least annually. But, I'm hopeful that this campaign can be expanded to reach those socioeconomic groups that do not ever seek veterinary care. As a profession, we seek a more diverse workforce and there is no surer way to accomplish this than by broadening our veterinary clientele. For most veterinarians, being a pet owner and client was likely the most common introduction to the profession, and without this relationship, veterinary medicine would have been an unlikely career choice. Also, greater inclusiveness fosters the goals of both economic improvement for veterinarians and improved health and welfare for all pets. The long-term health of the veterinary medical community is stronger if there is a more broadly based relationship between veterinarians and clients and their pets.

Michael Karg, dvm

Frederick Cat Vet

Frederick, Md