Companion animal practice is not immune to the global challenge of antimicrobial resistance. Within the past decade, many companion animal practitioners have been confronted with multidrug-resistant infections for which there are limited effective antimicrobials. Practitioners are not uncommonly presented with pets infected with multidrug-resistant Escherichia coli, Klebsiella spp, and Staphylococcus spp, including methicillin-resistant Staphylococcus pseudintermedius. Fortunately, methicillin-resistant Staphylococcus aureus infections are less common in pets than in humans, but they have become a concern in companion animal practice.
Multidrug-resistant infections are often associated with poor treatment outcomes and longer hospital stays. The antimicrobials most effective for these infections are often more expensive than the most commonly used veterinary antimicrobials and can cause more adverse reactions. Additionally, many of these organisms are found in both humans and companion animals, highlighting the possibility of zoonotic transmission.
Today, many human patients are contracting infections that cannot be treated with currently available antimicrobials.1,2 It is well recognized that with antimicrobial use, there is selective pressure for emergence of resistant bacteria in both human and veterinary medicine. It is estimated that 50% of antimicrobials are unnecessarily or inappropriately prescribed in human medicine,3 and it seems likely that the percentage in companion animal settings is similar. As such, efforts are needed to promote judicious use of antimicrobials or antimicrobial stewardship. This is important to combat the rise in antimicrobial resistance.
The term stewardship has been widely adopted as a way to consider how to optimize the use of antimicrobials. This term considers the “benefit of antibiotic use to the patient while minimizing the development of antibiotic resistance and adverse effects on the patient from unnecessary therapy.”4,5 In addition, the Report to the President on Combating Antibiotic Resistance4 outlines a number of incentives and approaches to encouraging antimicrobial stewardship, including uses in animal agriculture.
Over the past 10 to 15 years, nearly 50% of human health care hospitals have instituted antimicrobial stewardship programs.4 These programs typically involve a variety of strategies, including prescriber education, hospital formulary restrictions, requiring approval before dispensing of certain antimicrobials, streamlining or de-escalating treatment, and implementing computer-assisted programs that track antimicrobial use and provide clinician guidance.5 Many of these programs appear to be successful, and initial reviews of their value demonstrate a reduction in the percentage of antimicrobial-resistant organisms in hospitals, a reduction in the occurrence of Clostridium difficile infections, improvements in patient outcomes, and reductions in costs.6–10
It is possible that some of the antimicrobial stewardship strategies that have been successful in human medicine will also be effective in companion animal practice. Yet, there may be additional strategies that could be used in veterinary medicine. In production animal medicine, a number of practices, such as implementation of quality assurance programs, have been instituted to educate and encourage appropriate antimicrobial use. Recent guidance documents from the US FDA11,12 also provide recommendations and guidelines on antimicrobial use in animal agriculture.
The AVMA recently formed the Task Force for Antimicrobial Stewardship in Companion Animal Practice to provide guidance for implementing antimicrobial stewardship in companion animal practice. The membership consists of an interdisciplinary assemblage of professionals from varied backgrounds representing clinical practice, government, infectious disease, pharmacology, industry, and public health. The task force's goal has been to consider the emerging impact of multidrug-resistant organisms in companion animal practice and design approaches to address this challenge.
Collectively, the task force has developed several strategies to help the veterinary profession combat the serious threat of antimicrobial resistance. Some of these activities include devising assessments to better understand laboratory practices and practitioner prescribing behaviors, developing general do's and don'ts of antimicrobial prescribing, supporting the development of local and regional antibiograms, and creating educational programs and materials for practitioners and clients. The objective is to roll out these efforts to practitioners over the next year and encourage an active discussion promoting antimicrobial stewardship in companion animal practices.
Other organizations are supporting these stewardship efforts. The International Society for Companion Animal Infectious Diseases has sponsored the development of guidelines for common clinical conditions in veterinary medicine, such as urinary tract disease and superficial pyoderma.13,14 These efforts represent an urgently needed collaborative and consensus-building activity to provide clinical guidance to veterinary practitioners.
As a profession, we need to clearly recognize the grand challenges of antimicrobial resistance and encourage initiatives that will slow the progression of resistance. Along with the recent activities of the World Health Organization, the CDC, and the Presidential Task Force, the veterinary profession can reduce the selection pressures that favor the spread of antimicrobial-resistant bacterial pathogens. As individual companion animal practitioners, we need to be aware of antimicrobial stewardship and encourage the practice of antimicrobial stewardship principles. Our efforts will need to be broad, multifactorial, and incorporated at the clinic level. Collectively, we need to take action now.
References
1. CDC. Antibiotic resistance threats in the United States, 2013. Available at: www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Accessed Oct 7, 2014.
2. File TM Jr, Srinivasan A, Bartlett JG. Antimicrobial stewardship: importance for patient and public health. Clin Infect Dis 2014; 59 (suppl 3): S93–S96.
3. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159–177.
4. President's Council of Advisors on Science and Technology. Report to the President on combatting antibiotic resistance. Available at: www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/pcast_carb_report_sept2014.pdf. Accessed Nov 21, 2014.
5. Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol 2012; 33: 322–327.
6. Dortch MJ, Fleming SB, Kauffmann RM, et al. Infection reduction strategies including antibiotic stewardship protocols in surgical and trauma intensive care units are associated with reduced resistant gram-negative healthcare-associated infections. Surg Infect (Larchmt) 2011; 12: 15–25.
7. Fishman N. Antimicrobial stewardship. Am J Infect Control 2006; 34 (suppl 1): S55–S63.
8. Malani AN, Richards PG, Kapila S, et al. Clinical and economic outcomes from a community hospital's antimicrobial stewardship program. Am J Infect Control 2013; 41: 145–148.
9. Schultz L, Lowe TJ, Srinivasan A, et al. Economic impact of redundant antimicrobial therapy in US hospitals. Infect Control Hosp Epidemiol 2014; 35: 1229–1235.
10. Singh N, Rogers P, Atwood CW, et al. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med 2000; 162: 505–511.
11. US FDA Center for Veterinary Medicine. The judicious use of medically important antimicrobial drugs in food producing animals (guidance for industry No. 209). Available at: www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdf. Accessed Oct 1, 2014.
12. US FDA Center for Veterinary Medicine. New animal drugs and new animal drug combination products administered in or on medicated feed or drinking water of food-producing animals: recommendations for drug sponsors for voluntary aligned product use conditions with GFI #209 (guidance for industry No. 213). Available at: www.fda.gov/downloads/AnimalVeterinary/GuidanceComplianceEnforcement/GuidanceforIndustry/UCM299624.pdf. Accessed Oct 1, 2014.
13. Hillier A, Lloyd DH, Weese JS, et al. Guidelines for the diagnosis and antimicrobial therapy of canine superficial bacterial folliculitis (Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases). Vet Dermatol 2014; 25: 163–175.
14. Weese JS, Blondeau JM, Boothe D, et al. Antimicrobial use guidelines for treatment of urinary tract disease in dogs and cats: Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases. Vet Med Int 2011; 2011: 263768.