Introduction
Antimicrobials are essential medications in both human and veterinary medicine.1–3 Many of the antimicrobials essential for human medicine have widespread use in veterinary patients.3 As a result, the development of antimicrobial resistance (AMR) in veterinary patients risks spreading AMR among veterinary species and from animals to humans. The WHO has classified antimicrobials important to human medicine on the basis of the number of patients they are used to treat, availability of alternatives, and risks of developing resistance.2
The third-generation cephalosporins are listed as “highest priority critically important” by the WHO.2 This group includes cefovecin, currently marketed in the US as Convenia, a long-acting injectable antimicrobial for use in dogs and cats.4 World Organisation for Animal Health guidelines on the use of third-generation cephalosporins in veterinary patients discourage their use as a first-line antimicrobial agent and encourage their use in conjunction with culture and sensitivity testing.3 Despite this, cefovecin makes up roughly one-third of all antimicrobials administered to cats.5–8 Third-generation cephalosporin use selects for AMR in Salmonella and Escherichia coli, both of which are transmissible to humans and have limited alternative treatments,2,9 making cefovecin overuse a threat to both human and veterinary medicine.
Cefovecin is often given to cats when a narrower spectrum, oral antimicrobial would suffice for several reasons.10 First, owners may struggle to administer oral medications to their cats.11–13 Cefovecin is currently the only long-acting injectable antimicrobial available in the US, and all the preferred alternatives are administered orally. Veterinarians may opt for cefovecin when an owner is unable to medicate their cat to ensure the cat receives sufficient antimicrobial treatment.14–16 Owners may also request cefovecin because they prefer the convenience of not having to medicate their cat themselves.17,18 Second, cefovecin is a cost-competitive choice in cats.14,16 Third, best antimicrobial stewardship practice is to use culture and sensitivity testing to guide antimicrobial choice,3,19 but pet owners may not be willing to pay the cost of bacteriologic testing, making the selection of the most appropriate antimicrobial difficult.13,14,20,21 Veterinarians may also be reluctant to pursue bacteriologic testing due to lack of sufficient appointment time or perception that the client will not consent to diagnostics.15,16,21 When bacteriologic tests are not done, a veterinarian may select a broader-spectrum antimicrobial such as cefovecin to increase the chances of effective treatment.14 In addition, many veterinary practices carry a limited number of antimicrobials to reduce the financial burden of inventory.21 Since veterinarians tend to dispense medications that are stocked by their practices, they may use a less desirable antimicrobial because a better option is not immediately available.21
Cefovecin is also used in situations where antimicrobial treatment is not indicated.22 While most pet owners understand that antimicrobials are used to treat infections and some may understand the risks of AMR, few understand or are concerned about the contribution of antimicrobial use (AMU) in pets to AMR, or the risks that AMR in pets pose to human health.13,17,23–25 Owners with sick animals often expect antimicrobials and may push for them, especially in ambiguous cases where the need for an antimicrobial is unclear (ie, “just in case”).13–15,18,23–25 Veterinarians may respond to pressure or perceived pressure from owners by prescribing antimicrobials when they are not indicated.14,21,24 Studies show veterinarians are highly trusted sources of information to owners and that many owners are willing to learn more about antimicrobial stewardship.18,24,25 However, veterinarians may lack sufficient time to educate owners on judicious AMU or perform other antimicrobial stewardship tasks.16 Financial considerations may also encourage unnecessary AMU, as veterinarians may fear losing clients if they do not prescribe antimicrobials.15,21,24 Finally, not all veterinarians are aware of the current AMU guidelines,14,20 with younger veterinarians generally being more aware of antimicrobial stewardship principles and therefore less likely to prescribe antimicrobials.14,16,24
The objective of this study was to identify the factors that drive veterinarians to prescribe cefovecin to cats, particularly when it is not necessary, and the barriers to using oral antimicrobials among veterinarians and cat owners. This information will help to build interventions to reduce inappropriate AMU in cats.
Methods
This research was granted exemption from review by the Cornell University Institutional Review Board (No. IRB0143833).
Cat owner surveys
Surveys (Supplementary Materials S1 and S2) were developed and piloted on 9 cat owners who were not animal health professionals. Two parts comprised the final survey: a brief screening survey for recruitment and a main survey. The screening survey was administered to identify cat owners who had previous experience giving cats oral medication and to collect demographic information. Participants who owned cats and had given them oral medications were invited to take the main survey after providing consent. They shared experiences medicating cats, preferences for medication administration, use of medication administration aids, trusted sources of information, medication decision-making processes, and awareness of AMR (modeled after the survey by Taylor et al12 of cats worldwide). Cat owners’ shared views on oral antimicrobial administration and learning about the antimicrobial and medication decision-making process via free-text responses.
The surveys were implemented in Qualtrics and distributed by CloudResearch via their Amazon Mechanical Turk (MTurk) toolkit, an internet-based crowdsourcing platform. The screening survey was open to all MTurk workers in CloudResearch’s Approved Participants group,26 residing in the US, with at least a 95% Human Intelligence Task approval rating, and who had completed < 5,000 Human Intelligence Tasks. Recruitment notices and surveys were available in English and Spanish (transcribed by native Spanish speaker, author LG).
Participants were paid $0.25 for completing the screening survey. Invitations to the main survey were sent to qualifying screening survey participants, who were paid $2.00 for the main survey plus a $2.00 bonus for high-quality short answers. The screening survey was open from July 1, 2022, until July 12, 2022, and, after discarding incomplete and duplicate responses, there were 2,096 unique responses collected. Of these, 801 were invited to complete the main survey from July 1, 2022, until July 15, 2022, and 632 responses were received. Survey responses were imported to Stata (standard edition, version 17; StataCorp LLC) for data cleaning, merging screening and main survey responses by MTurk worker ID, and analysis. After discarding the incomplete (n = 11), duplicate (2), ineligible (3 reported not giving oral medications to cats), and unmatched (11 had poor-quality screening surveys, and 5 had no matching screening survey) responses, there were 600 unique, complete responses collected (Supplementary Figure S1).
Descriptive statistics for each survey question were generated using Stata. Gender-variable responses other than male or female were recoded into 1 “nonbinary/trans/prefer not to say” category. Cat owner age was grouped by decade. Ordinal responses were converted into a numeric scale (1, not at all, to 4, very/extremely) for summary statistic calculations. Cat owner confidence and preferences for medication formulation (1, strongly prefer not to use, to 5, strongly prefer to use) were compared with Wilcoxon rank sum when comparing 2 groups or Kruskal-Wallis test when comparing > 2 groups.
Cat owner short answer responses were analyzed using content codes developed through an iterative process involving all authors. The short answer responses were coded in Excel (Microsoft Corp) by 2 authors (JL and AF) before being imported back into Stata. Responses coded as low quality were dropped, and the frequency of occurrence for the remaining codes was tabulated.
Veterinarian interviews
The semistructured interview guide (Supplementary Material S3) was divided into 3 major sections: AMU in cats, benefits and drawbacks of cefovecin, and perspectives on AMR. In the interviews, cefovecin was referred to by the brand name Convenia. The interview guide was evaluated and edited through 5 pilot interviews in July and August 2022, 4 with veterinarians recruited through Cornell University veterinary alumni email listservs and 1 with one of the researchers (AF), who is a veterinary technician.
Recruitment of veterinarians primarily occurred through the New York State Veterinary Medical Society newsletter (10/21 veterinarians), but they were also recruited through Cornell University College of Veterinary Medicine alumni email listservs (3/21 veterinarians; classes of 2012 to 2017 were solicited), the 2022 Fred Scott Feline Symposium (0/21), snowball sampling (2/21 veterinarians), posts in veterinary Facebook groups (1/21 veterinarians), and random selection of veterinary clinics in New York state (5/21 veterinarians). Veterinarians were asked to invite others to participate in the study (snowball sampling). After the initial interviews, veterinary clinics were contacted in 38 randomly selected New York State zip codes, weighted by population, and invited veterinarians to participate. After 17 interviews, the geographic location and experience (ie, years since graduation) of interviewees were examined to target less represented geographic areas and graduation years for the remaining interviews.
Participants were informed that the goal of the study was to learn more about veterinarians’ decision-making processes for selecting medications for cats (but were not told it was specifically about antimicrobials prior to the interview) and provided consent to participate, be recorded, and be anonymously quoted in resulting publications and conference presentations. Participating veterinarians completed a preinterview survey (Supplementary Material S4) via Qualtrics to gather demographic and veterinary practice data.
Semistructured interviews27 (approx 45 minutes) were conducted and recorded via Zoom by 2 researchers (JL and LG), both present during all interviews. Follow-up questions occurred as needed to allow for a more complete understanding of veterinarians’ responses. A total of 21 interviews were conducted between August 6, 2022, and October 6, 2022. Veterinarians received a $100 Amazon gift card for participating in the interview.
The interviews were transcribed through automated transcribing (Rev.com), and 1 researcher (LG) compared the transcriptions to the original audio and corrected any errors before they were uploaded to ATLAS.ti (version 23.1.1.0; ATLAS.ti Scientific Software Development GmbH) for analysis. A qualitative, thematic analysis approach was utilized that allowed us to both pursue original questions of interest and allow for emergent (new) topics and themes.28 This occurred in multiple steps: reading the transcripts multiple times so the team could be familiar with the data, developing a codebook, refining the codebook, applying codes, and identifying themes and patterns from the codes. Each of the 5 researchers read through 5 transcripts for initial impressions and discussed observations with the team, specifically the range of responses to interview questions. These observations were the start of the codebook (Supplementary Material S5), which was refined multiple times by the entire team over 6 weeks with a focus on what would be impactful for veterinary practice. The transcripts were divided into sections and qualitative coding in ATLAS.ti was conducted by authors JL, LG, CC, AF, and AGS. The themes were developed through thematic analysis, as follows: each researcher looked at assigned codes, found patterns, and collectively discussed the themes that arose. In presenting qualitative results below, quotes were left as close to verbatim as possible. Pauses and fillers were removed when they made text confusing; ellipses were placed to indicate removal of text that was not relevant to the point. The authors clarified interviewees’ use of “it” and “this” by putting the referent in brackets when necessary.
Results
Demographics of cat owners and veterinarians
Cat owners in the survey were predominantly female (70%), with a median age of 30 to 39 years old, a median annual household income of $50,000 to $74,999, most had either a high school diploma or a bachelor’s degree, and 26% had 3 or more cats. The survey sample (Supplementary Table S1) was slightly wealthier, more educated, and had more cats than the overall US cat owner population as estimated in 2016, which had a median household income of $35,000 to $54,999, 19% had a bachelor’s degree, and only 17% had 3 or more cats.29 The interviewed veterinarians worked primarily in small animal primary care in a variety of practice structures (eg, varying numbers of patients per day and full-time veterinarians; Supplementary Table S2). The interviewees were a mix of practice owners, associates, and relief veterinarians, with a median of 15 years’ (range, 2 to 36 years) experience since receiving their DVM. They saw a median of 20 (range, 8 to 35) patients per day, with a median of 30 minutes for sick appointments (range, 20 to 60 minutes). The median practice size was 3 full-time–equivalent veterinarians (range, 1 to 9 veterinarians), and half of the practices hospitalized patients overnight.
Why veterinarians prescribe antimicrobials in general and, sometimes, inappropriately
Interviewed veterinarians reported that physical exam findings, clinical signs, the use of diagnostics, pressure from clients, clinical uncertainty, and prior experience influence their decisions to prescribe antimicrobials (Supplementary Table S3). Notably, many mentioned feeling pressure to prescribe antimicrobials from clients, colleagues, and/or other sources. Finally, 95% of veterinarians mentioned some reason other than clinical presentation or pressure for prescribing antimicrobials. For many, this included “just-in-case” prescribing (81% of interviewees mentioned this) or erring on the side of administering antimicrobials in clinical situations where the diagnosis was unclear, but this was far from the only reason. The thematic analysis identified (1) scenarios in which interviewees revealed inappropriate use of antimicrobials (Table 1), (2) the reasons that the interviewees prescribed antimicrobials injudiciously in these scenarios (Supplementary Table S4), and (3) how the interviewees responded to pressure to prescribe antimicrobials (Table 2).
Examples of inappropriate antimicrobial use from veterinarian interviews, revealing either the veterinarian’s own inappropriate antimicrobial use or inappropriate use by another veterinarian. Although specific clinical situations may merit the antimicrobial use described below, antimicrobial use guidelines typically either (1) do not recommend antimicrobial use in these situations or (2) recommend a different antimicrobial than the one described. The number following the quotation refers to the individual veterinarian interviewed. Quotes have been edited for clarity.
| Scenario | Quote |
|---|---|
| Interviewee’s own inappropriate antimicrobial use, though they were not necessarily aware of misuse | “I’ve got a cat who probably has recurrent herpes and [the owner] just called the [front desk] and asked if she could get a refill of Zeniquin because that usually calms her cat’s signs down … This case I did give it to her”(Veterinarian #6). |
| “I am still in the camp of using antimicrobials for stress cystitis … if I cultured it, I’d often get a negative culture, which many would argue, ‘well, you shouldn’t treat them with an antibiotic.’ But the fact that blood in the bladder is going to create a more favorable environment and change the pH of the urine and then create an environment in which bacteria will grow. So I find that if I treat my stress cystitis with antimicrobials, they do a lot better in the long run” (Veterinarian #8). | |
| Other veterinarians’ inappropriate antimicrobial use | “I think in the shelter it’s more pressure from other veterinarians, for example, with upper respiratory infections. Even if something is mild like just a little bit of ocular nasal discharge that’s serous, with no mucopurulent discharge, some vets will want to start antibiotics right away, to be proactive and prevent breakouts within the shelter” (Veterinarian #3). |
| “We have a few colleagues that do prescribe antibiotics for cats post-surgery for routine surgeries like spays and neuters” (Veterinarian #12). | |
| Interviewee’s inappropriate cefovecin use, though they were not necessarily aware of misuse | “especially when you have a patient with feline lower urinary tract disease and they constantly have an issue. I feel like I love giving it [cefovecin], then 14 days later boosting it; that’s basically a month of antibiotics consistently given with only 2 injections. They normally do surprisingly well” (Veterinarian #7). |
| “We see a lot of urinary tract [issues]. We use it [cefovecin] with our dentals all the time because it’s just really easy to administer. Especially if you’re extracting teeth, you don’t really want to then be poking around in the mouth afterwards … So I would say for cats, it’s probably our number one antibiotic chosen” (Veterinarian #7). | |
| “I’m a culprit for the dentals because I want those meds in the cat … as opposed to trying to get clindamycin into them. [It] might be a better choice, but it’s a nasty-tasting liquid that they have to give by mouth and they just had oral surgery” (Veterinarian #12). | |
| “For dentals or oral procedure, I would say almost 100% [of the time I use Convenia]” (Veterinarian #16). | |
| Inappropriate cefovecin use by other veterinarians | ”As I mentioned before, some cats with upper respiratory infections get Convenia injections [from my colleagues], even though that’s not the spectrum that it needs” (Veterinarian #3). |
Examples of refusing a client’s request for antimicrobials or redirecting the client with communication strategies. The number following the quotation refers to the individual veterinarian interviewed. Quotes have been edited for clarity.
| Refusal approach | Quote |
|---|---|
| Refusing client request as clinically appropriate | “As far as clients go, the more years in practice I am, the less I am influenced by what they really, really want. I used to … think, ‘Oh my god, they came in, they paid for an exam, and I’m not sending them home without any treatment at all … they’re gonna be very upset by that,’ but I don’t cave to that anymore” (Veterinarian #15). |
| “I’m pretty strict with [giving antibiotics without seeing the cat] despite the fact that clients get really upset about it, but I don’t care … They have to bring them in” (Veterinarian #17). | |
| “Sometimes I will get owner pushback of, ‘ well, the last time Dr. So-and-so prescribed this antibiotic and it seemed to help. So I wanna do that again’… I don’t know that I’ve ever let an owner talk me into using an antibiotic when I didn’t want to. So the pressure exists, but it’s not changing the way that I’m practicing” (Veterinarian #19). | |
| Offering antibiotic alternatives | “I try to give them something else, like, not noxious to do … like FortiFlora or a supplement, like lysine, that gives the owner something to do, whether or not I think it will actually make a huge difference in the animals’ outcome. I’m kind of treating the people more than the cat sometimes” (Veterinarian #3). |
| Focus on antimicrobial resistance | “People will bring in their pet because they had an accident in the house … they think she has a urinary tract infection. So, we always say, ‘Okay, well we need to do diagnostics first before you can potentially have your antibiotics.’ Some people are a little resistant to that. And usually, my next kind of talking point is, ‘well, we need to check, because if we just give antibiotics for every accident in the house, we could be contributing to antimicrobial resistance’” (Veterinarian #11). |
There were 9 common scenarios in which veterinarians prescribe antimicrobials when it may not be their preference to do so and/or prescribing is not advised by best practice (Supplementary Table S4). The data arose in response to questions about what the participants do in terms of prescribing in times of clinical uncertainty, how they use diagnostics, scenarios in which they prescribed antimicrobials when they may not have wanted to (including responses to pressure from clients), and responses to other questions—not specific to diagnostics, uncertainty, or reluctance—that revealed antimicrobial prescribing when it may not be the most appropriate treatment choice. Multiple sample quotes for each scenario show both the recurrence and range of concerns (Supplementary Table S4). Some of these situations are amenable to intervention to make stewardship more feasible30; some interventions would be education focused, and others would need to be more structural. The common situations or influences from the interviews that were associated with inappropriate antimicrobial prescribing were as follows:
Some veterinarians mentioned that they are more likely to consider antimicrobials if the cat belongs to an older client, indicating an assumption about age and ability.
Veterinarians noted that the older a cat is and the more comorbidities it has, the more likely they are to prescribe antimicrobials. Sometimes this tendency is related to the likelihood or risk of infection in older cats or sick cats or palliative care, and sometimes it is not.
Veterinarians noted that the context of a client’s request for antimicrobials—in terms of owner care and capability, temperament of the cat, and frequency of previous AMU—impacts prescribing practices.
Veterinarians frequently mentioned that they may end up prescribing an antimicrobial if clients cannot afford or refuse diagnostic tests.
Clinical uncertainty and fear about worsening clinical outcomes can motivate veterinarians to prescribe antimicrobials when they may not be needed.
While in the minority, some veterinarians noted that they believe there is no downside to prescribing a course of antimicrobials to see if it works.
When veterinarians do not have good alternatives to antimicrobials to alleviate cat clinical signs, they will sometimes pursue antimicrobials when such interventions are not required.
Some veterinarians noted that they believe that cat owners will go elsewhere for the treatment (ie, antimicrobials) they want, so the veterinarian will prescribe antimicrobials.
Veterinarians reported a variety of factors that affect their willingness to “give in” to client requests for antimicrobials, including the client’s degree of pushiness, the vet’s concern about pushing back, the vet’s burnout, or intense workdays.
Response to pressure—Pressure from clients to prescribe antimicrobials was a frequent issue among the interviewees (Supplementary Table S4). Their experience aligned with responses from cat owners: 41% of the cat owners in the survey had requested an antimicrobial from their vet, most commonly for urinary (26% of the requests) or skin problems (22% of the requests). In addition, 14% of the cat owners’ requests for an antimicrobial illustrated that the owner had misunderstood what an antimicrobial is and why it is given. For example, cat owners confused antiparasitics with antimicrobials or described a problem with their cat that likely was not caused by a bacterial infection. Among surveyed cat owners who recalled specific scenarios when they requested antimicrobials from their veterinarians, almost three-quarters reported that their veterinarians prescribed antimicrobials when the cat owner requested them. In only 4% of the scenarios did cat owners recall their veterinarian explaining why antimicrobials would not work for treating their cat’s problem.
Veterinarians gave several potential informative responses about how to address client pressure, other than prescribing an antimicrobial when they would prefer not to. Interviewee responses to the question, “Are there ever situations when pet owners ask for antimicrobials and you end up prescribing them even though originally you weren’t going to?” fell into 4 categories (Table 2): (1) refusing the request in line with clinical best practice, (2) offering alternatives to address clinical signs, (3) focusing on AMR, and (4) prescribing antimicrobials.
What veterinarians think about cefovecin and their reasons for prescribing it
It is important to understand general antimicrobial prescribing practices for stewardship, although different types of antimicrobials present different levels of concern for AMR. Thus, the interview guide included questions about veterinarians’ perceptions of cefovecin, including perceived drawbacks, and why they prescribe it. The scenarios in which veterinarians recommend cefovecin offer insight into possible areas for stewardship interventions for less-than-ideal cefovecin use.
Assessment of cefovecin—Many interviewed veterinarians referred to the ease, convenience, and likelihood of improving compliance with prescribing cefovecin over alternative antimicrobials. When asked about drawbacks, multiple veterinarians mentioned that cefovecin does not have any risks and/or they have never seen any negative consequences with using cefovecin. For example:
I don’t really explain any risks [to my clients]. I haven’t come across any risks, besides the chance of the pet not responding to [cefovecin] (Veterinarian #9).
I feel like the only risk with Convenia, other than its overuse and risk of possibly creating antimicrobial resistance, is the risk of possible neurological side effects or other side effects that can occur. I’ve probably given Convenia well over a thousand times in my time practicing. I’ve never seen it. I’ve never once got a phone call from a client who has been freaked out over the side effects of Convenia (Veterinarian #16).
The veterinarians were asked about the factors they consider when they decide to prescribe cefovecin, including any characteristics of the cat owner that they perceive. In the interviews, 5 reasons arose for prescribing cefovecin, 2 of which (#2 and #4) conflicted with data from cat owners (Supplementary Table S5):
Cefovecin is easy for cat owners and guarantees cat owner/cat compliance.
For specific groups of cat owners, such as elderly cat owners, those with physical ability limitations, and those who live alone, veterinarians are more likely to prescribe cefovecin.
Cats with fractious temperaments and stray or feral cats are more likely to receive cefovecin.
Some veterinarians assume that cat owners cannot give oral medications by default, leading to the use of cefovecin.
Cefovecin is clinically effective.
Many of the veterinarian participants expressed concerns and named specific consequences they had seen with cefovecin, which stands in contrast to those who have never seen consequences. These concerns about cefovecin fell into 5 categories (Table 3): (1) potential for side effects, (2) potential for AMR, (3) it is the only option for an injectable antimicrobial, (4) it might not work for certain bacteria and infection sites, and (5) issues with pharmacokinetics and bioavailability.
Veterinarians’ perceptions of drawbacks, negative consequences, and limitations of using cefovecin in cats. The number following the quotation refers to the individual veterinarian interviewed.
| Drawback category | Quotes |
|---|---|
| Potential for adverse reactions or side effects | “I have seen what we suspect is GI-related signs, so vomiting and diarrhea that started in a cat that was given Convenia. I’ve also seen, abscess and necrosis of the skin at the injection site” (Veterinarian #19). |
| “We can’t take it back, so if it causes any GI upset, if there are any reactions to it, then there’s not a whole lot that we can do” (Veterinarian #3). | |
| “I’m old enough unfortunately to have seen a lot of cats with fibrosarcomas, so anything that we inject certainly makes me concerned from that standpoint as well” (Veterinarian #2). | |
| Potential for resistance to develop | “I think it’s an antibiotic that is used very frequently, and so I do, I guess, wonder whether, at some point, we will create resistance to it” (Veterinarian #1). |
| “I do worry about antibiotic resistance with that. So, if we’re giving a single injection, if the duration of action is not necessarily as long as we would like it to be, are we going to develop resistance?” (Veterinarian #2). | |
| It is a more “big gun” antimicrobial than required, but it’s the only option for a long-acting injectable antimicrobial | “and it’s a third-generation cephalosporin, it’s a bigger gun than necessary for a lot of bacterial infections” (Veterinarian #3). |
| “It makes me a little uncomfortable that it may be a more advanced antibiotic than is necessary. I just reach for it because it’s the only one that’s available in that format … I know we’re encouraged as veterinarians to try to use whatever will work that’s a first-generation or second-generation [cephalosporin] if that would work. If I want an injectable that’s a long acting injectable, [cefovecin] is just what I’ve got” (Veterinarian #10). | |
| “There are times where I would really like to use something else, but it’s the only one I can get into the cat. I’ll try it. I wish that there were other injections of antibiotics that I could use that way” (Veterinarian #15). | |
| It might not penetrate the tissue at the infection site or work for some types of bacteria or conditions | “Convenia is a specific antibiotic that works great for a gram-positive and some anaerobes, but it may not be the greatest for agram-negative infection” (Veterinarian #4). |
| “I think sometimes there can be infections that it’s not going to really treat, based on the types of bacteria or the tissue penetration” (Veterinarian #5). | |
| Suboptimal pharmacokinetics | “The other piece of some of the long-acting things is I don’t actually believe that every individual is going to metabolize in the same way” (Veterinarian #8). |
| “I know I’ve read the articles where they’re worried that it’s availability, it’s not a straight line. There’s more of a peak and a trough is my understanding” (Veterinarian #6). |
Comparing veterinarian perceptions and cat owner self-assessment of abilities and preferences
Veterinarians were asked how cat owner characteristics influenced their decision to prescribe antimicrobials in general, and to prescribe cefovecin specifically, and they noted that they consider owner age, physical ability, and time availability, among other factors (Supplementary Tables S4 and S5). Veterinarians were also asked to estimate the percentage of cat owners who find it very difficult or impossible to give their cats oral medication, and the percent of cat owners who are confident in giving their cats oral medication. For comparative purposes, in the survey, cat owners were asked how many of their cats were impossible or very difficult to orally medicate, and they rated their confidence in giving different types of oral medications. Veterinarians’ perceptions were compared to cat owner self-assessments.
Overall, it appears that veterinarians overestimate how many cat owners struggle to give oral medication to their cats (Figure 1). The interviewed veterinarians estimated that 60% of cat owners found it difficult to medicate their cats and 20% found it impossible. However, significantly fewer cat owners reported having at least 1 cat that was very difficult or impossible to give pills (31% of had 1 very difficult cat and 9% impossible) or liquids (20% very difficult and 5% impossible). Considering individual cats, 21% of cats owned by survey participants were reported to be very difficult to pill and 13% were very difficult for administering liquid medications. Only 6% of cats were reported as impossible to pill by their owners, and only 3% were impossible to give liquid medications.
Comparison of veterinarians’ perceptions and cat owner self-reported challenges and confidence in giving oral medication to cats. A—Veterinarians were asked what percent of their clients find it difficult or impossible to give oral medication. Median veterinarian response is reported. Cat owners were asked about the difficulty level of individual cats. The percent of cat owners with at least 1 difficult or impossible cat is reported. B—Veterinarians were asked what percent of their clients are confident in giving oral medication to cats; median response is reported. The percent of cat owners who self-reported as “somewhat” or “very” confident in giving liquids or pills to their cats is reported.
Citation: Journal of the American Veterinary Medical Association 261, 12; 10.2460/javma.23.08.0487
Interviewed veterinarians thought that 30% of their clients, in general, are confident in giving oral medications to their cats, but 82% of cat owners feel somewhat (52%) or very confident (30%) in giving pills or tablets and 91% feel somewhat (44%) or very confident (47%) in giving liquids (Figure 1). There were no statistically significant differences in cat owner confidence using liquids or pills by owner age groups or gender (Kruskal-Wallis P > .05). The cat owners in the survey were experienced in giving oral medications. Most of them self-rated their experience as “occasionally” (47%) or “often” (23%) giving oral medication to their cats; 31% of owners had medicated their cats in the last month, 45% in the last year, 22% in the last 1 to 5 years, and 2% > 5 years ago. Considering all cat owners identified in the screening survey, 68% (846/1,237 responses) had given oral medication to their cats at some point in the past.
Formulation preferences—Sixty-four percent of cat owners always or sometimes request a specific medication formulation; liquid was the most frequently requested. Cat owners in the surveys had about equal experience giving liquids and tablets but overwhelmingly preferred using liquid medications over tablets (Wilcoxon rank sum P < .001; Table 4). They reported that their formulation preferences are driven by their ability to give the medication or inability to give other forms.
Cat owner experience with, preferences for, difficulty administering, and confidence administering different oral medication formulations.
| Formulation | Owners that have given* | Use preferences | ||||
|---|---|---|---|---|---|---|
| Strongly prefer† | Prefer† | No preference† | Prefer not to, but will if needed† | Strongly prefer not to, or cannot use† | ||
| Tablets | 349 (58) | 33 (10) | 71 (20) | 23 (7) | 173 (50) | 44 (13) |
| Capsules | 133 (22) | 13 (9) | 22 (17) | 9 (7) | 72 (54) | 12 (9) |
| Sprinkles, powders, or granules | 109 (18) | 33 (30) | 42 (39) | 4 (4) | 23 (21) | 5 (5) |
| Pastes | 107 (18) | 26 (24) | 39 (36) | 5 (5) | 29 (27) | 6 (6) |
| Liquids | 377 (63) | 146 (39) | 117 (31) | 15 (4) | 76 (20) | 15 (4) |
| Other | 7 (1) | 2 (29) | 2 (29) | — | 3 (43) | — |
*n (%), Percent of all responses (n = 600 cat owners).
†n (%), Percent of respondents who indicated they had used that medication formulation.
Asking for and receiving advice from veterinarians—The most common challenges reported by cat owners were obtaining and restraining the cat (n = 436 cat owners [73%]), ensuring the medication was swallowed by the cat (473 cat owners [79%]), and being injured or almost injured by the cat (340 cat owners [57%]). Forty-one percent of cat owners said that these challenges prevented them from giving their cats oral medication as prescribed by their veterinarian. However, only 65% of these owners talked to their veterinarian about their challenges. Cat owners recalled getting primarily verbal advice (74% of cat owners) from veterinarians; 46% reported getting a demonstration on oral medication administration at some point in the past. The most common advice cat owners received from veterinary staff was to give the medication with food (eg, mix with food or use pill pocket treats) and improve cat restraint (eg, towels, harness, or a second person to help). Cat owners reported that the most successful technique for giving oral medication was mixing crushed tablets, capsule contents, or liquid with food. Putting the medication directly in the cat’s mouth was also a successful technique for cat owners when they had a liquid formulation but was less successful with pill formulations.
Discussion
These findings on cat owner experience and preferences are similar to cat owners across several countries.12 Notably, Taylor et al12 compared cat owners with significant animal handling experience (eg, veterinary staff, shelter staff, and cat breeders) to cat owners without this experience. They found that cat owners with more experience were more confident in restraining their cat, an essential step for administering oral medication. This suggests that cat owner confidence in restraining and administering oral medication can be improved through training and practice and supports a recommendation in the related Currents in One Health article by Cazer et al, JAVMA, December 2023, for veterinary staff to spend more time guiding cat owners through the medication process. If veterinarians teach cat owners to successfully give their cats oral medication, cefovecin use can be reduced.
The drivers of inappropriate AMU in general in this study have been found in other quantitative and qualitative studies of veterinary AMU around the world.15 “Just-in-case” antimicrobial prescribing is a common phenomenon in veterinary medicine15,25; veterinarians fear possible complications or poor outcomes if they fail to prescribe antimicrobials in situations where there is a possibility of a bacterial infection but clear evidence of an infection is lacking. Experts rank “just-in-case” antimicrobial prescribing in companion animals as one of the top factors contributing to AMR.31 There are complex interactions between the veterinarian, client, and pet underlying “just-in-case” prescribing.25 Structural, educational, and technological interventions are recommended to tackle the different causes of “just-in-case” AMU as described in the Currents in One Health by Cazer et al, JAVMA, December 2023.
There was a disconnect between what veterinarians think cat owners are capable of and how cat owners rate their own capabilities and confidence in terms of giving their cats oral medication. Although the veterinary-client relationship and veterinarian familiarity with client preferences was discussed by many of the interviewees, it is not known whether the veterinarians’ assessment was an accurate reflection of owner ability and/or preferences for antimicrobial formulation. This misalignment in veterinarian and cat owner perceptions of oral medication capabilities likely contributes to excess cefovecin prescribing by veterinarians to increase the likelihood of owner and cat compliance. A systematic review of factors contributing to veterinary antimicrobial prescribing found a similar rationale in several studies; veterinarians reported that owner ability, or lack thereof, to give oral antimicrobials influenced their antimicrobial prescribing decisions.15 However, cat owners’ ability to medicate their cat results from a complex interaction of cat, owner, and medication factors. A cat that cannot be pilled may accept a liquid medication, an owner with one cat that is impossible to medicate may have other cats that take medications easily, and a bitter medication may be detectable in a pill pocket, but a more palatable medication may be readily consumed by the cat. The systematic review also found that veterinarians make presumptions about their clients’ expectations for antimicrobials; because veterinarians think that their clients expect an antimicrobial prescription, they prescribe them.15 Veterinarians should consider the assumptions they may make about cat owners and the influence their assumptions may have on their antimicrobial prescribing and formulation choices.
The limitations of this study were primarily related to generalizability to the broader US cat owner and veterinarian population. Although the cat owners participating in the survey were similar to national cat owner demographics,29 because the sample was internet based, populations with reduced access or use of the internet were likely excluded, including pet owners who are older, people of color, lower income, rural, and/or have a primary language other than English. The cat owner and veterinarian populations in this study arose from different geographic areas, and this may have introduced differences between cat owner perceptions and veterinarian perceptions. The veterinarian sample was limited to New York State to minimize geographic differences in infectious disease prevalence that may contribute to different approaches for antimicrobial prescribing. The in-depth interview approach, with long transcripts and a large amount of content generated per interview, limited the interview sample size; the sample could not sufficiently capture the impact of these geographic differences across the US. Given the size of the qualitative dataset, an exhaustive list of quotes is not possible. The quotes presented represent key concepts, but the number of quotes does not relate to frequency of the concept occurring in the interviews. It is noted when a quote represents an outlier topic. The small sample size also limits comparisons of themes and topics between groups of veterinarians, such as recent graduates versus experienced veterinarians. This is an area for future research, particularly since veterinarian confidence, communication skills, and habits are expected to change with increased years in practice.
Through the interviews, several areas were identified that would be amenable to interventions to encourage the use of antimicrobials, especially cefovecin, more sustainably. The analysis also identified clinically challenging situations that are less likely to benefit from intervention. As addressed in the Currents in One Health by Cazer et al, JAVMA, December 2023, areas where it is possible to see progress toward sustainable AMU through educational or structural change include the following: veterinarians recognizing situations in which antimicrobials may be prescribed when not necessary; veterinarians’ perceptions of client age, ability, and/or willingness to orally administer antimicrobials to their cats; willingness/ability of the veterinary team to demonstrate how to medicate cats, talk about AMR, and/or ask whether cat owners need guidance; cost of diagnostics; and veterinarians’ response to pressure from clients. For many of these areas, interventions that model how such conversations could unfold hold promise for improving stewardship. Veterinarians also requested or revealed the need for the following training to address sustainable antimicrobial and cefovecin use (Table 1; Supplementary Table S4): (1) clarifying ailments for which antimicrobials in general, and cefovecin specifically, should not be used; (2) the potential harms of antimicrobials (ie, they are not benign); and (3) the drawbacks of cefovecin, including but not limited to its impact on AMR.
Targeted, theory-informed, strategic campaigns that address both barriers and motivations specific to the 2 audiences—veterinarians and cat owners—are required to increase the likelihood of behavior change.32,33 Veterinarians and cat owners could benefit from greater understanding through conversations, demonstrations, and materials about alternatives to antimicrobials; what AMR means for them and their cats’ health; how to pill a cat; and other, nonbacterial factors that are harming a cat. Sustainable AMR campaigns, though not specific to cat owners, have been successful elsewhere when designed well.34,35 Multiple communication guidance documents exist for how to wed this research with best practice for communication interventions.36,37 These findings create a solid base from which to suggest more structural interventions and also to develop and test education interventions with both cat owners and veterinarians.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org
Acknowledgments
The authors would like to thank the cat owners and veterinarians who participated in the research into the use of cefovecin and oral antimicrobials in cats.
Authors contributed the following: CC: conceptualization, methodology, formal analysis, resources, writing (original draft and review), supervision, project administration, and funding acquisition. JL: methodology, software, investigation, formal analysis, data curation, and writing (review). AF: validation, formal analysis, data curation, writing (original draft and review), and visualization. LG: investigation, formal analysis, data curation, and writing (original draft and review). AGS: conceptualization, methodology, formal analysis, resources, writing (original draft and review), supervision, project administration, and funding acquisition.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.
De-identified data and code to reproduce the analysis are available upon request.
Funding
This research was funded by a Cornell University Department of Public and Ecosystem Health Impact Award.
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