What can we agree on?
Over the past almost 4 decades that I have been involved with the veterinary profession, there have been numerous major studies1 examining the state of the profession. Most have largely agreed on the challenges, but the continued existence of these challenges proves our efforts to address them have fallen short. Do we need another study, or do we need a different approach?
To galvanize broad-based action, the first step is to agree on the problems. But igniting true motivation for change will require understanding the potential impacts of those problems to prioritize them and recognize that we are all personally at risk and should all personally engage.
I believe there are 5 major issues we as a profession must face:
• Student debt: The continuing increase in student debt creates stress for students and new graduates, adds to the mental health and well-being problems facing the profession, and possibly pushes economic considerations above compassion.
• One health: With increasing globalization, risks to animal agriculture continue to rise, and if the veterinary profession is not able to address these issues, other professions will.
• Corporatization: Whether a good development or bad, corporatization brings substantial changes to veterinary practice. Has the profession learned from other professionals (eg, opticians and pharmacists) how to adapt to these changes?
• Mental health and well-being: Personal debt, practice stress, low self-esteem, and a host of other factors play a part. Which are most amenable to change?
• Economic uncertainty: Clinical practice is dependent, at least in part, on client discretionary spending. When the next economic downturn comes, how will practices respond? How will veterinary college applicants respond?
Perhaps if we can agree not only on what is wrong but also that not acting is worse than acting, we, working through national organizations such as the AVMA and Association of American Veterinary Medical Colleges, can turn from endless introspection to urgent action.
Frank Pearsall, DVM
Blacksburg, Va
1. Dicks MC. A short history of veterinary workforce analyses. J Am Vet Med Assoc 2013;242:1051–1060.
The therapeutic challenge of ESBL-producing pathogens in veterinary intensive care units
Extended-spectrum, β-lactamase-producing (ESBL-producing) Enterobacteriaceae have become endemic in human hospitals and community settings in numerous countries, and these pathogens have now emerged as a new challenge for small animal critical care medicine.1 Human and small animal patients with infections caused by ESBL-producing organisms frequently require hospital admission because many of these pathogens are resistant to nearly all orally administered antimicrobials. Unfortunately, this means that veterinarians face this resistance problem with limited available treatment options.2
Patients in intensive care units (ICUs) frequently have life-threatening infections, and many common ICU interventions, such as urinary catheterization, artificial ventilation, and prolonged hospitalization, are risk factors for hospital-acquired infections in veterinary patients.1,3 Although not yet documented, infection with ESBL-producing pathogens likely increases the mortality rate of veterinary ICU patients.
With the exception of emergency situations, antimicrobial selection should be guided by results of bacterial culture and susceptibility testing. Even if antimicrobial treatment needs to be undertaken empirically, concurrent bacterial culture and susceptibility testing can be used to predict best treatment options. One stewardship approach when empirical treatment with critically important antimicrobials is used is to de-escalate to less important antimicrobials once susceptibility data are available. The Clinical Laboratory Standards Institute's Veterinary Antimicrobial Susceptibility Testing subcommittee and the European Committee on Antimicrobial Susceptibility Testing's Veterinary Subcommittee on Antimicrobial Susceptibility Testing are engaged in developing clinically relevant veterinary criteria for standardization of methods, establishment of minimum inhibitory concentration breakpoints, and interpretation of susceptibility testing results.4 Although a common global standard is needed, the current and future activities of these important groups will support veterinarians in selecting the most appropriate antimicrobials.
Another important issue relates to extralabel use of carbapenem antimicrobials for treatment of infections caused by ESBL-producing pathogens in animals. In human medicine, carbapenems are considered the treatment of choice for infections caused by ESBL-producing organisms, but no carbapenems have been approved for this use in animals. In the absence of other treatment options, carbapenems have been used empirically to treat life-threatening infections caused by multidrug-resistant or ESBL-producing pathogens in companion animals.2 However, such empirical use may contribute to the dissemination of carbapenemase-producing pathogens, which is currently a critical issue in human medicine.5 Thus, the use of carbapenems in animals should be severely discouraged, unless there are no other treatment options.6 Developing criteria for the use of these “third-line” antimicrobials has been described as an important part of veterinary antimicrobial stewardship.6
In summary, the appearance of ESBL-producing bacteria in veterinary ICUs constitutes a serious one-health challenge for veterinary medicine. Because there is increasing concern about dissemination of antimicrobial-resistant pathogens in human and veterinary medicine, clinicians working in veterinary emergency and critical care medicine should take steps to address this hazard. As a matter of urgency, we call on all relevant national and international veterinary organizations to work toward a common global standard to address antimicrobial resistance in ICUs.
Luciano C.B.A. da Silva, DVM, MSc
Department of Surgery Santos Metropolitan University São Paulo, Brazil
Nilton Lincopan, PhD
Department of Microbiology Institute of Biomedical Sciences University of São Paulo São Paulo, Brazil
John F. Prescott, VetMB, PhD
Department of Pathobiology Ontario Veterinary College University of Guelph Guelph, ON, Canada
Fábio P. Sellera, DVM, PhD
Department of Internal Medicine School of Veterinary Medicine and Animal Science University of São Paulo São Paulo, Brazil
1. Hartmann FA, Fox L, Fox B, et al. Diagnostic and therapeutic challenges for dogs with urinary tract infections caused by extended-spectrum β-lactamase-producing Escherichia coli. J Am Vet Med Assoc 2018;253:850–856.
2. Phillips H, Occhipinti LL, Aronson LR. Septicemia and infection due to ESBL-producing K pneumoniae following feline renal allograft transplantation. J Am Anim Hosp Assoc 2015;51:119–129.
3. Ogeer-Gyles J, Mathews KA, Sears W, et al. Development of antimicrobial drug resistance in rectal Escherichia coli isolates from dogs hospitalized in an intensive care unit. J Am Vet Med Assoc 2006;229:694–699.
4. Sellera FP, Madec JY, Lincopan N. Comment on: applying definitions for multidrug resistance, extensive drug resistance and pandrug resistance to clinically significant livestock and companion animal bacterial pathogens. J Antimicrob Chemother 2019;74:535–536.
5. Sellera FP, Fernandes MR, Ruiz R, et al. Identification of KPC-2-producing Escherichia coli in a companion animal: a new challenge for veterinary clinicians. J Antimicrob Chemother 2018;73:2259–2261.
6. Weese JS, Page SW, Prescott JF. Antimicrobial stewardship in animals. In: Giguère S, Prescott JF, Dowling PM, eds. Antimicrobial therapy in veterinary medicine. 5th ed. Ames, Iowa: John Wiley and Sons, 2013;117–132.
