Clinician prescribing practices for managing canine idiopathic acute diarrhea are not evidence based

Widmaier B. Francillon Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH
Comparative Hepatobiliary and Intestinal Research Program, College of Veterinary Medicine, The Ohio State University, Columbus, OH

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Jenessa A. Winston Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH
Comparative Hepatobiliary and Intestinal Research Program, College of Veterinary Medicine, The Ohio State University, Columbus, OH

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Megan E. Schreeg Comparative Hepatobiliary and Intestinal Research Program, College of Veterinary Medicine, The Ohio State University, Columbus, OH
Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH

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M. Leanne Lilly Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH
Comparative Hepatobiliary and Intestinal Research Program, College of Veterinary Medicine, The Ohio State University, Columbus, OH

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Valerie J. Parker Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH
Comparative Hepatobiliary and Intestinal Research Program, College of Veterinary Medicine, The Ohio State University, Columbus, OH

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Adam J. Rudinsky Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH
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Abstract

Objective

To characterize clinician preferences and justification for preferred methods for managing canine idiopathic acute diarrhea (IAD) and compare results to evidence-based literature.

sample

284 surveys from veterinarians in small animal first-opinion practice.

Methods

Veterinarians were asked to complete a survey (61 questions) including background demographic information, practice type and location, duration in practice, and management questions for canine IAD pertaining to nutritional, probiotic, antimicrobial, antidiarrheal, benign neglect, and other therapies. The survey was available between May 5, 2021, and August 30, 2021.

Results

Respondents reported that their preferred first-line therapy for canine IAD included dietary modification (41.3% of respondents), probiotics (20.1%), antimicrobials (21.2%), antidiarrheal medications (13.0%), and benign neglect (4.3%). The percentage of respondents who reported each therapy as either extremely effective or very effective for canine IAD varied by treatment, as follows: antimicrobials (75.2%), dietary modification (59.13%), antidiarrheal medications (42.5%), probiotics (35.5%), and benign neglect (6.52%). Perceptions of effectiveness, efficiency of treatment, and clinician justification for use were variable among treatments. Reported practice styles were occasionally in disagreement with evidence-based methods of canine IAD management.

Clinical Relevance

Current clinical management of IAD is not consistently in agreement with evidence-based recommendations. The results of this study underscore the continued need to evaluate veterinary prescribing practice trends compared to evidence-based recommendations and promote dissemination of new information.

Abstract

Objective

To characterize clinician preferences and justification for preferred methods for managing canine idiopathic acute diarrhea (IAD) and compare results to evidence-based literature.

sample

284 surveys from veterinarians in small animal first-opinion practice.

Methods

Veterinarians were asked to complete a survey (61 questions) including background demographic information, practice type and location, duration in practice, and management questions for canine IAD pertaining to nutritional, probiotic, antimicrobial, antidiarrheal, benign neglect, and other therapies. The survey was available between May 5, 2021, and August 30, 2021.

Results

Respondents reported that their preferred first-line therapy for canine IAD included dietary modification (41.3% of respondents), probiotics (20.1%), antimicrobials (21.2%), antidiarrheal medications (13.0%), and benign neglect (4.3%). The percentage of respondents who reported each therapy as either extremely effective or very effective for canine IAD varied by treatment, as follows: antimicrobials (75.2%), dietary modification (59.13%), antidiarrheal medications (42.5%), probiotics (35.5%), and benign neglect (6.52%). Perceptions of effectiveness, efficiency of treatment, and clinician justification for use were variable among treatments. Reported practice styles were occasionally in disagreement with evidence-based methods of canine IAD management.

Clinical Relevance

Current clinical management of IAD is not consistently in agreement with evidence-based recommendations. The results of this study underscore the continued need to evaluate veterinary prescribing practice trends compared to evidence-based recommendations and promote dissemination of new information.

Introduction

Idiopathic acute diarrhea (IAD) is a common syndrome in dogs.14 Affected dogs often exhibit a self-limiting disease course and lack of an identifying underlying cause (eg, infectious pathogen) and have no history of chronic gastrointestinal or other systemic disease.5 Since an underlying etiology is rarely identified, management of dogs with this syndrome is typically empirical.3,6,7 Recommended options for empirical management of IAD include nutritional modification, probiotics, antimicrobials, fecal microbiota transplant (FMT), and supportive care medications.1,6,814

Treatment of IAD has been a focus of multiple recent clinical trials. These have provided new evidence-based recommendations for the management of canine IAD; however, there is still limited evidence on the relative effectiveness of different empirical treatments.8,10,12,14 In particular, nutritional management and FMT have shown improved outcomes compared to approaches like antimicrobials (eg, metronidazole).8,10 In contrast, other therapies like antimicrobials, probiotics, and gastrointestinal supportive medications continue to be some of the most commonly prescribed treatments by clinicians in first-opinion practice despite minimal supporting evidence.6,15

Previous studies characterizing management preferences of veterinarians for IAD have taken place in Europe and by medical record review and are not translatable to other geographic regions or capture clinician preferences. Clinician preferences and practice style regarding IAD in the US are still unknown, accenting the need to better understand the clinician’s perspective on canine IAD management. This study aimed to characterize clinician preferences for managing IAD, examine reported clinician justification for preferred methods, and compare prescribing practices to what is supported with current evidence-based medicine.

Methods

An online survey was designed for veterinarians in small animal first opinion practice to characterize canine IAD management preferences, prescribing practices, and justification for these practices. Canine IAD was defined in the survey introduction as a dog with acute diarrhea, a negative fecal test, and no suspicion for systemic disease (Supplementary Material S1). The survey only accepted responses from veterinarians. If the “other” or “I am not a veterinarian” option was selected in screening questions, the survey was discontinued and not analyzed. The survey was developed by 1 internist, and independently reviewed by 2 additional internists. The study was reviewed by the IACUC and Institutional Review Board at The Ohio State University and qualified for an exemption. The survey was propagated to veterinarians on social media platforms (Reddit, Twitter, Facebook, Instagram, and Snapchat). The survey was also disseminated directly to veterinarians via emails. All 50 state veterinary medical associations’ general emails were used for contact and distribution. Direct-to-veterinarian emails were sent indirectly by contacting local veterinary medical associations and practitioner listservs. The survey was open between May 5, 2021, and August 30, 2021. In order to participate, respondents were required to actively be practicing in small animal first-opinion practice verified by initial consent form and survey questions. Each veterinarian could only complete the survey once.

Participating clinicians were asked to complete 61 questions including background demographic information, practice type and location, duration in practice, and clinical and prescribing practices questions regarding nutritional, probiotic, antimicrobial, antidiarrheal, benign neglect, and other (with the ability to provide a free-text response) therapies for the management of IAD. Respondents had the ability to select 0 to 6 of the treatment modalities (nutritional, probiotic, antimicrobial, antidiarrheal, benign neglect, and other) in terms of used in practice or not used in practice. For contingency analysis, practice region collected as state or territory was grouped into geographic locations (eg, northeast, southeast, Midwest, south, southwest, and northwest).

General clinical management questions for each approach included perception of efficacy, specific therapeutics (eg, metronidazole), expected response time, decision for use/disuse, effectiveness for different types of diarrhea (small, mixed, or large bowel diarrhea), and how the use of each therapeutic modality has changed temporally with practice experience. The final questions of the survey allowed for free responses to comment on topics not covered by the survey and additional challenges in IAD management. The majority of questions were multiple choice with some short answers to allow clinicians to provide additional details. Short answers were evaluated and grouped on the basis of similarity during data analysis. Respondents also had the option to skip questions. The complete survey can be found elsewhere (Supplementary Material S1).

One survey question asked respondents to rank modalities by effectiveness and in order of preference of use. In these 2 scenarios, respondents were required to rank all options regardless of whether they used them in clinical practice. In addition, if a respondent selected that they did or did not use a certain modality, the survey flow would only present the question banks for those individuals using the modality and those not using the modality, respectively. This survey logic is outlined elsewhere (Supplementary Material S1). The majority (> 90%) of the survey questions must have been answered to be considered complete. If incomplete, it was not included in further analysis.

Statistical analysis

Data were tabulated regarding prescribing practices into the following treatment/therapeutic modality categories: nutritional management, probiotics, antimicrobials, antidiarrheal medications, and benign neglect. Data collected from the survey were collated and stored using survey software (Qualtrics XM; Qualtrics) before downloading to a spreadsheet program (Excel; Microsoft Corp) for analysis. Statistical analyses were completed using statistical software (Prism version 8.0; GraphPad Software). Descriptive statistical analyses were performed on all data, then summarized and reported. Associations between categorical variables were assessed with either the Fisher exact test or χ2 analyses. The Fisher exact test was used when > 20% of cells had frequencies < 5. Frequencies of use or nonuse for each modality were compared to perception of effectiveness, order of use preference, years in practice, geographic region, gender, and practitioner age individually.

Results

A total of 337 surveys were started after dissemination. There were 53 incomplete surveys, which were not included in the analysis. The incomplete surveys varied in the percentage of the survey completed (median, 6.6%; range, 0.0% to 24.6% completion). A total of 284 complete surveys were returned from veterinarians (41 [14.4%] male, 229 [80.6%] female, and 14 [5.0%] undisclosed) in small animal practice (251 [88.4%] majority small animal, and 33 [11.6%] partial small animal). Responses to the 284 surveys were from 33 states (280 [98.6%]) and other US territories (4 [1.4%]). Respondents (n = 284) reported they had been in small animal practice < 1 year (13 [4.6%]), 1 to 5 years (82 [28.9%]), 5 to 10 years (45 [15.8%]), 10 to 20 years (71 [25.0%]), > 20 years (51 [18.0%]), or undisclosed (22 [7.7%]).

Empirical treatment reported for canine IAD included the following: dietary modification (244/284 [85.9%] respondents), probiotics (231/284 [81.3%]), antimicrobials (212/284 [74.6%]), antidiarrheal medications (144/284 [50.7%]), benign neglect (65/284 [22.9%]), and other (12/284 [4.2%]). The percentage of respondents who reported each therapy as either extremely effective or very effective for canine IAD varied by treatment, as follows: antimicrobials (194/258 [75.2%] respondents), dietary modification (152/257 [59.13%]), antidiarrheal medications (103/242 [42.5%]), probiotics (91/256 [35.5%]), and benign neglect (16/245 [6.52%]). Respondents reported their preferred first-line therapy for canine IAD, as follows: dietary modification (78/191 [40.8%] respondents), probiotics (38/191 [19.9%]), antimicrobials (40/191 [21.0%]), antidiarrheal medications (26/191 [13.6%]), and benign neglect (8/191 [4.2%]). There were 8 respondents who reported that they used other methods for management including the following: empirical deworming (3 [1.1%]), NK-1 antagonists (2 [0.7%]), herbal medicine (1 [0.35%]), dexamethasone (1 [0.35%]), and fasting (1 [0.35%]). There were no associations between empirical prescribing practices and other variables (P > .05; eg, antimicrobial management vs gender).

Clinicians utilizing nutritional management (n = 257) reported variable expectations and perceptions in terms of the efficacy, the time to response, and how their use of nutritional management changed over their career (Table 1). The majority of respondents answered that nutritional management was very or moderately effective, had an expected response time of 3 to 4 days, and was being used as frequently as previously used in their career. The type of diarrhea for which respondents reported that each major nutritional management approach was most useful is reported (Figure 1). If using nutritional management for canine IAD, clinicians (n = 238) reported that they prescribed highly digestible diets (220/238 [92.4%]), macronutrient-adjusted diets (46/238 [19.3%]), hydrolyzed diets (38/238 [16.0%]), limited-ingredient diets (26/238 [10.9%]), or other diets (17/238 [7.1%]). The diet reported in the “other” category free response was a bland home-cooked diet (eg, chicken and rice; 16/238 [6.7%]). Additionally, 1 respondent in the other category reported “nothing per os” as their choice approach (1/238 [0.4%]). If using diets with altered macronutrient content for canine IAD, clinicians (n = 36) reported that they preferred to prescribe a diet with altered fiber content (33/36 [91.7%]), fat content (19/36 [52.8%]), protein content (5/36 [13.9%]), or carbohydrate content (2/36 [0.8%]). Altered fiber content was often specifically recommended in large bowel IAD in the survey.

Table 1

Survey responses from participants who do use specific modalities.

Antimicrobials Probiotics Nutritional Antidiarrheals Benign neglect
Respondent perception of effectiveness n = 258 n = 256 n = 257 n = 242 n = 245
 Extremely effective 73 (28.3%) 10 (3.9%) 46 (17.9%) 34 (14.0%) 3 (1.2%)
 Very effective 121 (46.9%) 81 (31.6%) 106 (41.2%) 69 (28.5%) 13 (5.3%)
 Moderately effective 51 (19.8%) 111 (43.4%) 100 (38.9%) 82 (33.9%) 77 (31.4%)
 Slightly effective 9 (3.5%) 49 (19.1%) 5 (1.9%) 45 (18.6%) 108 (44.1%)
 Not effective 4 (1.6%) 5 (2.0%) 0 (0.0%) 12 (5.0%) 44 (17.9%)
Expected response time by respondent n = 182 n = 195 n = 165 n = 79 n = 58
 1–2 d 97 (53.3%) 24 (12.3%) 30 (18.2%) 41 (51.9%) 9 (15.5%)
 3–4 d 73 (40.1%) 101 (51.8%) 103 (62.4%) 27 (34.2%) 22 (37.9%)
 5–6 d 10 (5.5%) 42 (21.5%) 19 (11.5%) 7 (8.9%) 19 (32.8%)
 7–10 d 2 (1.1%) 18 (9.2%) 9 (5.5%) 2 (2.5%) 7 (12.1%)
 11–14 d 0 (0.0%) 5 (2.6%) 2 (1.2%) 0 (0.0%) 0 (0.0%)
 > 14 d 0 (0.0%) 5 (2.6%) 2 (1.2%) 2 (2.5%) 1 (1.7%)
Reason for prescribing therapy n = 209 n = 225 n = 236 n = 130 n = 38
 Veterinary school training 117 (56.0%) 111 (49.3%) 163 (69.1%) 40 (30.8%) 12 (31.6%)
 Continuing education 52 (24.9%) 143 (63.6%) 143 (60.6%) 33 (25.4%) 3 (7.9%)
 Medical literature 22 (10.5%) 55 (24.4%) 60 (25.4%) 13 (10.0%) 1 (2.6%)
 Expert opinion/consultation 42 (20.1%) 62 (27.6%) 88 (37.3%) 18 (13.8%) 3 (7.9%)
 Colleague recommendation 92 (44.0%) 75 (33.3%) 83 (35.2%) 61 (46.9%) 2 (5.3%)
 Practice/hospital protocol 59 (28.2%) 57 (25.3%) 61 (25.8%) 29 (22.3%) 2 (5.3%)
 Personal experience 182 (87.1%) 165 (73.3%) 186 (78.8%) 73 (56.2%) 21 (55.3%)
 Client request 59 (28.2%) 60 (26.7%) 37 (15.7%) 30 (23.1%) 17 (44.7%)
 Other 6 (2.9%) 3 (1.3%) 0 (0.0%) 5 (3.8%) 2 (5.3%)
Perceived useful clinical setting n = 207 n = 225 n = 129 n = 58
 All diarrhea 114 (55.1%) 165 (73.3%) 78 (60.5%) 31 (53.4%)
 Small bowel diarrhea 19 (9.2%) 33 (14.7%) 11 (8.5%) 3 (5.2%)
 Mixed bowel diarrhea 40 (19.1%) 30 (1.3%) 16 (12.4%) 6 (10.3%)
 Large bowel diarrhea 82 (39.6%) 32 (14.2%) 32 (24.8%) 19 (32.8%)
 Other 5 (2.4%) 3 (1.3%) 6 (4.7%) 5 (8.6%)
Frequency of use over time n = 144 n = 147 n = 236 n = 69 n = 39
 More than previously 24 (16.7%) 115 (78.2%) 97 (41.1%) 17 (24.6%) 5 (12.8%)
 Same as previously 66 (45.8%) 25 (17.0%) 128 (54.2%) 28 (40.6%) 20 (51.3%)
 Less than previously 54 (37.5%) 7 (4.8%) 11 (4.7%) 24 (34.8%) 14 (35.9%)

Data collected from respondents regarding their reason for using specific modalities in management of idiopathic acute diarrhea (IAD), perception of efficaciousness, expected response time, evidence-based justification for not using each modality, and how their disuse of these modalities has changed over time. For each box, data are presented as the total numbers of responses (percentage of total responses).

— = Data that were not obtained in the survey. Specifically, data not in the table were due to different questions asking about specific nutritional diet subtypes versus nutritional management as a whole.

Figure 1
Figure 1

Effectiveness of diet types: this figure shows the subtypes of diarrhea that respondents felt were most responsive to different nutritional interventions on the basis of percentage of respondents expecting a clinical response. All data are regarding nutritional management only. The different classifications of diarrhea (all, small, large, mixed, and other) are denoted by graph labels.

Citation: Journal of the American Veterinary Medical Association 261, 12; 10.2460/javma.23.06.0313

The rationale for why clinicians chose to prescribe or not prescribe nutritional management in canine IAD is outlined (Tables 1 and 2). The 3 most common cited evidence-based reasons respondents listed as justification for nutritional management included veterinary school training, continuing education, and personal experience. The top cited evidence-based reasons respondents listed as justification for not using nutritional management included client request for different therapy and personal experience. The top 3 practical reasons for not using nutritional management included owner preference, cost prohibitive, and poor compliance. All respondents avoiding nutritional management reported that they have never used nutritional management for this reason.

Table 2

Survey responses from participants who do not use specific modalities.

Antimicrobials Probiotics Nutritional Antidiarrheals Benign neglect
Reason for not using n = 39 n = 28 n = 11 n = 105 n = 175
 Poor efficacy 6 (15.4%) 17 (60.7%) 1 (9.1%) 23 (21.9%) 85 (48.6%)
 Poor compliance 0 (0.0%) 5 (17.9%) 4 (36.4%) 6 (5.7%) 23 (13.1%)
 Side effects 11 (28.2%) 0 (0.0%) 0 (0.0%) 25 (23.8%) 9 (5.1%)
 Cost prohibitive 0 (0.0%) 5 (17.9%) 4 (36.4%) 1 (1.0%) 1 (0.6%)
 Owner preference 3 (7.7%) 1 (3.6%) 6 (54.5%) 5 (4.8%) 116 (66.3%)
 Prefer other approaches 28 (71.8%) 10 (35.7%) 3 (27.3%) 74 (70.5%) 70 (40.0%)
 Other 16 (41.0%) 2 (7.1%) 1 (9.1%) 18 (17.1%) 15 (8.6%)
Reason for prescribing therapy n = 28 n = 11 n = 3 n = 70 n = 106
 Veterinary school training 13 (46.4%) 1 (9.1%) 0 (0.0%) 29 (41.4%) 24 (22.6%)
 Continuing education 15 (53.6%) 0 (0.0%) 0 (0.0%) 10 (14.3%) 16 (15.1%)
 Medical literature 6 (21.4%) 0 (0.0%) 0 (0.0%) 5 (7.1%) 6 (5.7%)
 Expert opinion/consultation 9 (32.1%) 0 (0.0%) 0 (0.0%) 8 (11.4%) 13 (12.3%)
 Colleague recommendation 2 (7.1%) 0 (0.0%) 0 (0.0%) 10 (14.3%) 24 (22.6%)
 Practice/hospital protocol 3 (10.7%) 0 (0.0%) 0 (0.0%) 5 (7.1%) 23 (21.7%)
 Personal experience 13 (46.4%) 7 (63.6%) 1 (33.3%) 45 (64.3%) 73 (68.9%)
 Client request 1 (3.6%) 0 (0.0%) 2 (66.7%) 4 (5.7%) 59 (55.7%)
 Other 1 (3.6%) 3 (27.3%) 0 (0.0%) 4 (5.7%) 8 (7.5%)
Frequency of use over time n = 14 n = 5 n = 4 n = 47 n = 66
 Less than previously 2 (14.3%) 2 (40.0%) 0 (0.0%) 34 (72.3%) 42 (63.6%)
 Never used 12 (85.7%) 3 (60.0%) 4 (100.0%) 13 (27.7%) 24 (36.4%)

Data collected from respondents regarding their reason for not using specific modalities in management of IAD, evidence-based justification for not using each modality, and how their disuse of these modalities has changed over time. For each box, data are presented as the total numbers of responses (percentage of total responses).

Among clinicians utilizing probiotics (n = 256), they reported variable expectations and perceptions in terms of the efficacy, the time to response, and how their use of probiotics has changed over their career. The majority of respondents reported that probiotic management was very or moderately effective, had an expected response time of 3 to 4 days, and was used more frequently than previously in their career. The type of diarrhea for which clinicians reported that probiotics were most useful is displayed (Table 1). If prescribing probiotics for canine IAD, clinicians (n = 224) reported that they prescribed FortiFlora (Nestle Purina PetCare; single-strain probiotic; 161/224 [71.9%]), Visbiome (ExeGi Pharma; multistrain probiotic; 16/224 [7.1%]), Proviable (Nutramax Laboratories; multistrain probiotic; 120/224 [53.6%]), or other probiotics (34/224 [15.2%]). The probiotics reported in the “other” category free responses included Pro-Pectalin (Vetoquinol; synbiotic; 12/224 [5.4%]), Advita (VetOne; synbiotic; 5/224 [2.2%]), Mycequin (Nutramax Laboratories; yeast-based synbiotic; 4/224 [1.8%]), Vetri Mega Probiotic (VetriScience; synbiotic; 2/224 [0.9%]), Synacore (Van Beek Natural Science; symbiotic; 2/224 [0.9%]), and 1 each of DiaGel (Van Beek Natural Science; prebiotic/mixed compounds), yogurt (probiotic, various), FloraZil+ (Henry Schein Animal Health; multistrain probiotic), Entero Flora Pro (VetriScience; synbiotic), Wysong C-Biotic (probiotic/mixed compounds), Endosorb (PRN Pharmacal; not a probiotic), Probios (specific product not specified), Immediate Response (PBS Animal Health; multistrain probiotic/mixed compounds), and Natura (Natura Petz Organics; specific product not specified; 1/224 [0.4%]).

The rationale for why clinicians prescribed or did not prescribe probiotics is outlined (Tables 1 and 2). The 3 most common cited evidence-based reasons respondents listed as justification for probiotic management included personal experience, continuing education, and veterinary school training. The top cited evidence-based reasons respondents listed as justification for not using probiotic management included personal experience, other reasons, and veterinary school training. The top practical reasons for not using probiotic management included poor efficacy, preference for other approaches, cost prohibitive, and poor compliance. The majority of respondents who avoided using probiotic management reported they have never used probiotics for this reason.

Clinicians who utilize antimicrobials (n = 258) reported variable expectations and perceptions in terms of the efficacy, the time to response, and how their use of antimicrobials has changed over their career. The majority of respondents reported that antibiotic management was extremely or very effective, had an expected response time of 1 to 2 days, and was being used at similar frequency to previously in their career. The type of diarrhea for which clinicians reported antimicrobials were most useful is reported (Table 1). If prescribing antimicrobials for canine IAD, clinicians (n = 209) reported their preferred antimicrobials included metronidazole (208/209 [99.5%]), tylosin (51/209 [24.4%]), or other antimicrobials (7/209 [3.3%]). The antimicrobials reported in the “other” category free responses included amoxicillin (4/209 [1.9%]), enrofloxacin (2/209 [1.0%]), and sulfasalazine (1/209 [0.5%]). Clinicians (n = 39) who reported that they do not prescribe antimicrobials for the management of canine IAD most frequently cited antimicrobial stewardship (8/39 [20.5%]) and antimicrobial impacts on the microbiome (2/39 [5.1%]).

The rationale for why clinicians chose to either prescribe or not prescribe antimicrobials is outlined (Tables 1 and 2). The 3 most common cited evidence-based reasons respondents listed as justification for antibiotic management included personal experience, veterinary school training, and colleague recommendation. The top cited evidence-based reasons respondents listed as justification for not using antibiotic management included continuing education, personal experience, and veterinary school training. The top practical reasons for not using antibiotic management included preference for other approaches, other reasons, and side effects. The majority of respondents who avoided using antibiotic management reported never using antibiotics for this reason.

Clinicians utilizing antidiarrheals (n = 242) reported variable expectations and perceptions in terms of the efficacy, the time to response, and how their use of antidiarrheals has changed over their career. The majority of respondents reported that antidiarrheal management was very or moderately effective, had an expected response time of 1 to 2 days, and was being used at similar frequency or less frequently to previously in their career. The type of diarrhea for which clinicians reported that antidiarrheals were most useful is reported (Table 1). If prescribing antidiarrheals for canine IAD, clinicians (n = 130) reported that they prescribed bismuth subsalicylate (55/130 [42.3%]), opioid agonists (43/130 [33.1%]), serotonin antagonists (18/130 [13.8%]), homeopathic supplements (18/130 [13.8%]), 5-aminosalicylates (16/130 [12.3%]), α-adrenergic antagonists (3/130 [2.3%]), or other antidiarrheals (27/130 [20.8%]). The antidiarrheals reported in the “other” category free responses included Endosorb (7/130 [5.4%]), corticosteroids (3/130 [2.3%]), Diagel (2/130 [1.6%]), carvacrol (1/130 [0.8%]), and diphenoxylate/atropine (1/130 [0.8%]).

The rationale for why clinicians chose to prescribe or not prescribe antidiarrheals is outlined (Tables 1 and 2). The 3 most common cited evidence-based reasons respondents listed as justification for antidiarrheal management included personal experience, colleague recommendation, and veterinary school training. The top cited evidence-based reasons respondents listed as justification for not using antidiarrheal management included personal experience, veterinary school training, continuing education, and colleague recommendation. The top practical reasons for not using antidiarrheal management included preference for other approaches, side effects, and poor efficacy. The majority of respondents who avoided using antidiarrheal management reported they have never used antidiarrheals for this reason.

Among clinicians who utilized benign neglect (n = 245), they reported variable expectations and perceptions in terms of the efficacy, the time to response, and how their use of benign neglect has changed over their career. The majority of respondents reported that benign neglect was moderately or slightly effective, had an expected response time of 3 to 4 or 5 to 6 days, and was being used at similar frequency to previously in their career. The type of diarrhea for which clinicians reported that benign neglect was most useful is reported (Table 1).

The rationale for why clinicians chose or did not choose benign neglect is outlined (Tables 1 and 2). The 3 most common cited evidence-based reasons respondents listed as justification for benign neglect included personal experience, colleague recommendation, and veterinary school training. The top cited evidence-based reasons respondents listed as justification for not using benign neglect included personal experience, client request, veterinary school training, and colleague recommendation. The top practical reasons for not using benign neglect included owner preference, poor efficacy, and preference for other approaches. The majority of respondents who avoided using benign neglect reported they had never used this management approach.

Discussion

Clinicians prescribed a variety of treatment modalities for the management of canine IAD. There were tendencies toward certain prescribing trends when examining all survey responses collectively but no specific associations between demographic variables and prescribing practices. This indicates that responses were likely due to both individual clinician preferences as well as practice trends throughout the profession. Consistent prescribing practices included nutritional management, probiotics, and antimicrobials prescribed most commonly; nutritional management and antimicrobials were considered the most effective, and antimicrobials and antidiarrheal medications were considered to produce the quickest resolution. The most notable discrepancies were seen between clinician-based ranking of preferred treatment options and their self-reported perception of effectiveness and expected clinical response time (eg, clinicians reported that antimicrobials resulted in the quickest resolution, but antimicrobials were not the most effective).

Best practice comes through utilizing the highest grades of evidence.16 The data from this study were in conflict with recently published evidence-based literature for IAD management, most notably the better efficacy of nutritional management and FMT compared to modalities like antimicrobials.8,10,12,14 Ideally, high-grade evidence like systematic reviews and randomized controlled trials would be the basis of the majority of recommendations, as opposed to low-grade evidence such as case reports and expert opinion. This information accentuates the need to compare current prescribing practices to evidence-based recommendations. Factors that influence clinician prescribing practice, management strategies, and the impact of these treatments on clinical outcomes warrants further evaluation.

Nutritional management was the most common first-line therapy for canine IAD and was reported as the second most common modality to be either very or extremely effective. Antimicrobials were the third most common first-line therapy for canine IAD and the most common modality to be either very or extremely effective. The reason for the disconnect between treatment modality efficacy and prescribing practices is unknown. The high frequency of clinician preference for prescribing nutritional and antimicrobial management for canine IAD is consistent with previous retrospective studies on acute diarrhea management.6,15 However, this is not consistent with previous studies demonstrating an inferior response to antimicrobials compared to nutritional management or failing to show an association with positive outcomes.6,8 This disconnect may arise from improved antimicrobial stewardship among veterinarians, despite a perceived benefit in efficacy. Alternatively, there could be a component of social desirability bias in the responses.

Metronidazole for management of acute diarrhea has been recommended on the basis of potential antimicrobial, antiprotozoal, and anti-inflammatory effects, and 99.5% of respondents in this study utilizing antimicrobials reported it as their preferred drug of choice.1719 However, this has historically been based in low-grade evidence (eg, expert opinion) and lacked supporting research until recently.11,18,19 The previous retrospective study6 on prescribing practices failed to find an association between positive outcomes and antimicrobial use. The first study11 supporting the use of metronidazole for canine acute diarrhea demonstrated that metronidazole shortened the duration of diarrhea compared to placebo (randomized controlled trial). Despite the results of this clinical trial, concern over the high frequency of antimicrobial use for acute diarrhea has continued due to concerns with antimicrobial stewardship and the low prevalence of infectious etiologies as well as impact on the microbiome.2022 Recent studies have begun to examine the impact of probiotics, nutraceuticals, fiber, and FMT in combination or in comparison to metronidazole.810,1214 In these studies, nutritional management (randomized controlled trial), a synbiotic nutraceutical (randomized controlled trial), and FMT (case control study) improved clinical outcomes better than metronidazole.810 These clinical trials indicate that prescribing antimicrobials for IAD compared to these other therapeutics is not supported by peer-reviewed literature. Furthermore, even when compared to placebo, metronidazole does not consistently result in a clinical benefit and/or improved outcome.11,12 In the current study, the justification for clinicians regularly prescribing antimicrobials for IAD was veterinary school education (56%), colleague recommendations (44%), and personal experience (87.1%). Alternatively, clinicians not prescribing antimicrobials for IAD cited veterinary school education (46.4%), continuing education (53.3%), and personal experience (46.4%). The current literature does not support the use of antimicrobials for IAD, which is in dissonance with current clinical prescribing practices, thus highlighting the importance of continuing education related to prescribing practices for IAD and antimicrobial use.

Limited data are available on nutritional management of canine IAD in veterinary medicine, and much of the available research on nutritional management of gastrointestinal disease is related to chronic diarrhea and other disorders.23 There are 2 main studies evaluating the impact of nutritional management on acute diarrhea in dogs.8,9 The first study9 documented a benefit of a fiber-enhanced diet in combination with metronidazole for treatment of acute diarrhea when compared to a standard fiber diet in combination with metronidazole (randomized controlled trial). In contrast, the second study8 demonstrated that without the addition of metronidazole, either an easily digestible diet or psyllium fiber–enhanced diet performed better than diet plus metronidazole administration (randomized controlled trial). The most notable finding in the second study was the improved time to normal fecal score and minimized impact on the microbiome when metronidazole was omitted from the therapeutic protocol. Taken together, the results of these robust clinical trials demonstrate that nutritional management alone in canine IAD is superior to metronidazole in combination with nutritional management.8 Positively, on the basis of results of this study, nutritional management is currently prescribed more than previously, which aligns with current evidence-based recommendations for IAD. However, continuing education remains critical to disseminate evidence-based recommendations for nutritional management.

Multiple studies have evaluated probiotics for canine acute diarrhea including for idiopathic IAD, antimicrobial-induced diarrhea, and prevention of stress-mediated diarrhea, with variable results.24 These studies can be challenging to compare given effects of different probiotics and combination products (eg, synbiotics), sometimes resulting in contrasting patient outcomes. Specific to canine IAD, the majority of studies documenting a beneficial effect of the probiotic are in comparison to placebo (randomized controlled trials).2529 However, there are studies that failed to demonstrate a clinical benefit of probiotics compared to placebo (randomized controlled trials).12,30 Some of these studies have confounding treatments, as well as differences in the admitting patient complaint and severity of disease. Other studies have examined the effects of probiotics in combination with other therapies or in comparison to other therapies.12,13 An enhanced clinical response was observed in a clinical trial in which the probiotic was given combined with metronidazole (randomized controlled trial).13 However, another clinical trial comparing dogs with acute diarrhea receiving a probiotic, oral metronidazole, or placebo failed to demonstrate a clinical benefit of the probiotic over metronidazole in terms of clinical outcome.12 Interestingly, there was no difference in response time between metronidazole and placebo in contrast to the Langlois et al study11 described previously (randomized controlled trials).12 Lastly, some studies on the effects of Enterococcus faecium SF68 and other probiotics have not been published in peer-reviewed journals or proceedings, precluding a full evaluation. In summary, based on the currently available veterinary literature, there is some evidence supporting prescription of probiotics in canine IAD compared to benign neglect (placebo). However, based on the results of a single study, probiotics have not yet been shown to be superior to antimicrobials.12 Further research is also required comparing different doses of probiotics as well as single-strain and multistrain probiotics for the management of IAD and safety.

Recommendations for the use of antidiarrheals as well as other gastrointestinal supportive medications (antacids, gastroprotectants, motility modifiers, etc), adsorbents, and other empirical therapies are poorly documented in the veterinary literature beyond retrospective studies characterizing prescription trends among veterinarians.5,6,20 Furthermore, the current recommendations are derived from low levels of evidence including expert opinion found in textbooks, proceedings, and case series.20 Given the self-limiting course of canine IAD, benign neglect is also sometimes utilized in practice.6 Most studies documenting the self-limiting course of canine IAD are those in which a placebo group has been compared to another specified treatment group. On the basis of these clinical trials, there is a benefit of metronidazole and probiotics over benign neglect (randomized controlled trials).11,2529 Finally, in the current study, a small percentage of clinicians reported prescribing nontraditional therapeutic modalities (eg, fasting and herbal remedies). These were not specifically queried and relied on free responses to collect data. Additional modalities could be explored in future targeted studies, but further conclusions regarding nontraditional management and justification for these specific prescribing practices are limited from these data.

Coprescription is common in clinical practice for the management of canine IAD.6 This study asked respondents to rank modalities in terms of order of prescribing preference but did not inquire as to whether these therapies were used concurrently, as it was not designed to specifically address this concept in IAD. However, coprescription represents an important area for future research into clinician-perceived therapeutic efficacy and prescribing practices regarding multimodal canine IAD management. The lack of insight into coprescribing habits remains a limitation of these data.6

The rationale for prescribing or not prescribing different modalities was attributed to a wide array of sources. Veterinary school training, continuing education, and personal experience were consistently reported as common sources of information justifying prescribing practices. These all represent areas for dissemination of evidence-based recommendations as they become available through ongoing veterinary research. Periodic evaluation of current clinician prescribing practices should be utilized to assess effectiveness of continuing education strategies aimed at delivering new evidence, ideally resulting in progression of evidence-based veterinary medical practice. Although not addressed in the current study, another hurdle to clinician prescribing practices for canine IAD is attributed to owner acceptance. Further investigation is required to examine why owner acceptance of therapeutic plans disagrees with evidence-based medical recommendations.

For many modalities, there wasn’t a significant change in use over time for both preferred modalities in use as well as those avoided by practitioners. This begs the question as to whether current methods of disseminating new information to practitioners are truly effective. The study presented here was not designed to evaluate this concept further; however, factors that influence prescribing decisions in human medicine are studied and represent an interesting area for future research.31

There were limitations to this survey study. The largest concern pertains to the potential that clinician-reported prescribing practices may not be in alignment with practice in a real-time clinical setting. Specifically, IAD literature is a rapidly growing area with some evidence published during or shortly after the survey was conducted.8,9,14 As such, it is possible that survey respondents were unaware of recent advances in the IAD research area and their responses may have changed since the survey. It takes time for information to be dispersed through literature, continuing education, and other reference materials, and this may not be reflected in all responses. However, there were also differences in clinician prescribing preferences reported in this study compared to previous retrospective studies on prescribing practices for canine IAD.6,15 The survey logic queried information on why practitioners either use or do not use specific modalities. While mostly similar, the survey did not comprehensively capture the same data for respondents who use a modality and those who do not. As such, it forced responses and did not ask individuals certain questions depending on their responses early in the survey.

Discrepancies in results may also be due to differences in practical application of canine IAD management, differences in geographic practice style, or shifting prescribing trends over time. The online format of this survey study also presented limitations, requiring participating clinicians to have a familiarity with the online platform used, and exposure to study-specific marketing largely distributed in electronic formats potentially biased subsets of participants. The online format also allowed for veterinarians to skip answers, leaving data gaps. All data presented were sorted and subanalyzed to ensure that each analysis was performed on surveys with complete data. Lastly, the survey required a certain level of understanding regarding specifics of each treatment modality investigated or use of colloquial terms (eg, benign neglect). If respondents were unfamiliar with the terminology utilized, it is possible that the questions were misinterpreted or answer choices biased.

In conclusion, the results of this study indicate that a wide array of treatment modalities are currently prescribed by veterinarians for IAD management. These prescribing practices are not always consistent with the evidence-based recommendations in the literature. Recent clinical trials in canine IAD indicate that superior methods of management including nutritional management and FMT independently are more effective than metronidazole, and metronidazole and specific probiotics concurrently and independently are more effective than benign neglect. These conclusions are all obtained from grade-A evidence-based randomized controlled trials. Further studies are needed to continue to interrogate optimized treatment modalities, including combination therapies in the management of canine IAD and combinations as they apply to specific patient populations with IAD (eg, stress-induced IAD). These studies should also include a larger number of dogs, as some studies, although designed well, still report small numbers of dogs in individual groups. Lastly and most notably, the dissonance between current prescribing practices for canine IAD and evidence-based recommendations highlights the importance of disseminating new evidence to clinicians for the betterment of animals receiving care.

Acknowledgments

None reported.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org

Funding

The authors have nothing to disclose.

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