Introduction
Antimicrobial resistance (AMR) is a growing reality in clinical companion animal practice. Antimicrobial stewardship (AS) is defined by the AVMA as “the actions veterinarians take individually and as a profession to preserve the effectiveness and availability of antimicrobial drugs through conscientious oversight and responsible medical decision-making while safeguarding animal, public, and environmental health.”1 These actions have been outlined by the AVMA in 5 core principles of AS, including the evaluation of antibiotic use (AU) practices.1
Antibiotics, including those used in veterinary medicine, have been categorized by the WHO and European Medicines Agency (EMA) on the basis of risk of contributing to AMR and the importance of preserving them for critical uses in humans.2,3 Such categorization schemes guide veterinarians in their judicious use of the medications, which are essential to both human and animal healthcare. Within these schemes, some antibiotics are classified as “for human use only,” while use of others should be supported by bacterial culture and susceptibility testing. In some countries, antibiotic-use regulations for companion animal practitioners have been established on the basis of these categorizations.4,5 In the US, extralabel use of approved human or animal antibiotics for companion animals is permitted if certain conditions are met and in the context of a valid veterinarian-client-patient relationship.6 European Union member states must report data on the volume of antibiotic sales and by 2030 will require reporting of use of antimicrobial medicinal products in all animal species, including companion animals.7,8 Although measurement and tracking of AU is identified as a critical component of AS, no national or state-level programs are in place in the US to track AU in companion animals, and AU measurement at the practice level is uncommon.9–11 The AVMA encourages veterinarians to collect AU data to assess and improve patient outcomes.1,12 Measurement facilitates description of prescribing practices, identification of drug- and condition-specific targets for prescribing improvement, and tracking of progress and trends over time. One such approach to AU measurement is the single-day point-prevalence survey, which has been used by the CDC to collect standardized AU data from human hospitals and nursing homes and has also been applied to academic veterinary hospitals.13–15
Antibiotic prescribing data were collected from nonacademic primary care and referral companion animal practices in the US for 1 day of practice. The primary objectives were to measure the prevalence of AU in dogs and cats, identify the most common antibiotic drugs prescribed, and determine the most common indications for use.
Methods
Ethics statement and recruitment
Point-prevalence survey methodology was used to collect 1 day of uniform data from multiple study sites. The study was determined to be exempt from review by the University of Minnesota IACUC, and it was categorized as “not human research” by the University of Minnesota Institutional Review Board.
All nonacademic primary care and referral practices treating small animals in the US were invited to participate in the study. Referral practices were defined as veterinary practices that offer specialized services or diagnostic testing. Recruitment occurred during April to July 2021 and was promoted through state veterinary medical associations, veterinary professional email listservs, private practice corporate groups, social media, and veterinary news outlets.16,17 Participating practices received owner or corporate approval.
Data collection
A facility coordinator was identified by each practice and was responsible for obtaining necessary internal approvals, attending an online training session before data collection, adhering to standard operating procedures, utilizing training materials, completing a survey asking about clinical AS efforts, entering medical record data into an electronic database,18 and providing clarification on data entries during the data-validation process. Each facility coordinator selected a single day representing typical operations from a predetermined 2-week range (August 16 to 29, 2021) as the study day.
Medical records were reviewed for all dog and cat inpatients present between midnight and 11:59 PM local time on the study day, as well as all dog and cat outpatients seen by a veterinarian on the study day. Dogs and cats euthanized during the visit were excluded from analyses. The data collection structure is shown in Figure 1. Data collected included signalment, hospitalization status (inpatient or outpatient), up to 3 broad clinical conditions (eg, gastrointestinal, skin) and (if available) a specific diagnosis for select clinical conditions (eg, nonspecific gastroenteritis, superficial focal pyoderma), diagnostic tests conducted on or before the study day and related to the clinical condition(s) (Supplementary Material S1), whether imaging was performed, and the name and route of antibiotics prescribed. Diagnostic and imaging results were used by the facility coordinator to assign a level of evidence of bacterial infection based on criteria from a previous study9 and outlined in Supplementary Table S1.
Data-collection structure in the veterinary hospital point-prevalence survey. This flow chart illustrates the sequence of data collected for each included cat or dog.
Citation: Journal of the American Veterinary Medical Association 2025; 10.2460/javma.24.11.0716
The established (nonproprietary) antibiotic drug name was recorded for antibiotics prescribed on the study day or the calendar day that preceded the study day. Specific ingredients for triple antibiotic topical preparations (eg, neomycin/polymyxin B/bacitracin, neomycin/polymyxin B/gramicidin) were not recorded. If a dog or cat was prescribed an antibiotic by a referring veterinarian and the consulting veterinarian made the decision to continue the antibiotic, that drug was included. If a dog or cat was prescribed multiple antibiotics, details of each were recorded. Antibiotics intended to treat multiple clinical conditions in a single patient were affiliated with each condition in the study database.
The intended reason for AU (treatment of infection, prophylaxis, nonbactericidal effects) or if a determination could not be made was recorded. After reviewing each medical record, facility coordinators used criteria in the study standard operating procedures to assign a level of evidence of bacterial infection (confirmed infection, suspected infection, no evidence of infection) to each condition for which antibiotics were prescribed. Only information available on or before the study day was used to determine evidence of infection. The same antibiotic could be prescribed to a cat or dog for > 1 condition with different levels of evidence of infection.
Data management and analysis
Data were entered and managed in a secure Research Electronic Data Capture database.18 Practice data could only be viewed by the submitting practice and University of Minnesota researchers. No identifiable prescriber, pet, or client data were collected.
Analyses and calculation of 95% CIs were performed with SAS (version 9.4; SAS Institute Inc). Data are summarized as frequencies (n) and percentages (%). Duration of AU was analyzed with median and range because of the small sample size and to account for extreme values. The χ2 test was used to evaluate association between categorical variables, and the t test was used to assess a difference in means. Antibiotics were considered unique on the basis of established name for patient-level analyses. Dogs and cats that were prescribed 2 systemic formulations of the same drug on the study day (eg, IV enrofloxacin with transition to PO enrofloxacin) were considered to have received a single antibiotic drug, and those that were prescribed 2 chemically distinct drugs (eg, transition from IV ampicillin-sulbactam to PO amoxicillin–clavulanic acid) on the study day were considered to have been prescribed 2 antibiotic drugs. Combination drugs (eg, amoxicillin–clavulanic acid, triple antibiotic) were counted as 1 drug. Routes considered to be systemic administration included IM, IV, PO, SC, and local infusion (eg, IA), and routes considered to be topical administration included ophthalmic, otic, or dermatologic. More than 1 clinical condition could be recorded for a dog or cat, so the number of conditions analyzed was greater than the number of animals (Figure 1).
Results
Participating practices and antimicrobial stewardship activities
Fifty-two nonacademic primary care and referral practices agreed to participate and received appropriate practice permissions to consent to the study. Participating referral practices represented > 1 specialty, save for a single practice that identified itself as a referral practice offering complementary and alternative medicine services. Practices were from 23 states and Washington DC, and all US regions19 were represented: 8 (15.4%) in the Northeast, 14 (26.9%) in the South, 17 (32.7%) in the Midwest, and 13 (25.0%) in the West. Of the 52 practices, 32 (61.5%) were primary care clinics, 19 (36.5%) were referral hospitals, and 1 (1.9%) was an animal shelter. Patient caseload varied among participating practices and ranged from 6 to 326 patients, with a median of 32.5. For 33 of 52 practices that responded to a query about the amount of time required for data entry, the range was 0.5 to 80 hours, with a median of 3.5.
Representatives from all 52 practices responded to the prestudy survey: 43 (82.7%) were veterinarians, 3 (5.8%) were practice managers, 2 (3.9%) were veterinary technicians, 2 (3.9%) were veterinary assistants, 1 (1.9%) was a clinical study coordinator, and 1 (1.9%) was a veterinary student extern. Four of 52 practices (7.7%; 2 primary care and 2 referral practices) had an AS committee, and 10 of 48 (20.8%) of those without an AS committee expressed an interest in establishing one. The most cited barrier to establishing such a committee, reported by 38 of 48 practices (79.2%), was lack of staff time dedicated to AS activities. Other identified barriers included lack of commitment or interest from practice leadership (19 of 48 [39.6%]) and staff (18 of 48 [37.5%]), lack of awareness of the importance of AS (19 of 48 [39.6%]), and lack of dedicated resources for AS activities (17 of 48 [35.4%]).
Though most practices lacked an AS committee, many reported activities supporting judicious use of antibiotics. These included use of published treatment guidelines (eg, for conditions including respiratory and urinary tract infections and superficial pyoderma; 32 of 52 [61.5%]), disease-prevention protocols for common clinical conditions (eg, Lyme disease; 31 of 52 [59.6%]), a watchful waiting approach for conditions that usually resolve without antibiotics (29 of 52 [55.8%]), and protocols to guide use of diagnostics (eg, cytology, bacterial culture and susceptibility testing; 26 of 52 [50.0%]).
Evaluation of prescribing practices was not often done, as most practices (40 of 52 [76.9%]) had no mechanism or no known mechanism for doing so. Six practices (11.5%) reported use of an audit and feedback system to inform veterinarians about their prescribing behavior, 4 (7.7%) reported tracking of specific antibiotics, and 3 (5.8%) tracked syndrome-specific prescribing.
Prescribing guidelines for specific common small animal conditions to implement or improve AS activities were identified as a need by 78.9% (41 of 52) of participating practices. The majority also cited continuing education (39 of 52 [75%]), sample AS policies (38 of 52 [73.1%]), client education materials (37 of 52 [71.1%]), materials to guide engagement with practice leadership (29 of 52 [55.8%]), and formal commitment to AS by practice leadership (28 of 52 [53.9%]) as additional support that would help to advance AS in their practices.
Animals
Medical record data were collected from a total of 2,599 animals (Supplementary Table S2), including 612 cats (23.5%) and 1,987 dogs (76.5%), 2,147 outpatients (82.6%), and 452 inpatients (17.4%).
Antibiotic use frequency
The frequency of antibiotic prescribing across all practices was 29.2% (758 of 2,599), with 31.0% (616 of 1,987) of dogs and 23.2% (142 of 612) of cats prescribed an antibiotic (Table 1). The frequency was higher in referral practice (519 of 1,654 [31.4%]) than primary care (230 of 870 [26.4%]) and shelter (9 of 75 [12.0%]) practices. Animals presenting to referral practices were significantly more likely to be prescribed an antibiotic than those presenting to primary care practices (P = .016). Overall, inpatients were more likely to be prescribed an antibiotic than outpatients (52.0% vs 24.4%; P < .001); this was true for both dogs (P < .001) and cats (P < .001). There was no difference in average age of patients that were prescribed (7.11 years) and not prescribed (7.13 years) an antibiotic (P = .949). Most dogs (470 of 616 [76.3%]) and cats (114 of 142 [80.3%]) were prescribed a single antibiotic (Supplementary Table S3). Two or more antibiotic prescriptions were more frequent for inpatients than outpatients for both dogs (73 of 182 [40.1%] vs 73 of 434 [16.8%]) and cats (17 of 53 [32.1%] vs 11 of 89 [12.4%]). Of common clinical conditions for which at least 1 antibiotic was prescribed, 34.7% (35 of 101) of surgical, 22.0% (13 of 59) of respiratory, 20.3% (14 of 69) of ocular, 16.7% (23 of 138) of skin, and 10.1% (13 of 129) of gastrointestinal conditions were prescribed 2 or more antibiotics. The percentage of animals receiving > 1 antibiotic did not differ by practice type (P = .127). Most antibiotics prescribed, regardless of practice setting, species, and inpatient status, were for systemic administration (Table 1).
Number of veterinary patient assessments involving ≥ 1 antibiotic prescription.
| ≥ 1 antibiotic (any route) | ≥ 1 systemic antibiotic | ≥ 1 topical antibiotic | ||||
|---|---|---|---|---|---|---|
| n (%) | 95% CI | n (%) | 95% CI | n (%) | 95% CI | |
| All patient assessments (n = 2,599) | 758 (29.2) | 27.4–30.9 | 640 (24.6) | 23.0–26.3 | 165 (6.3) | 5.4–7.3 |
| Canine (n = 1,987) | 616 (31.0) | 29.0–33.0 | 519 (26.1) | 24.2–28.1 | 139 (7.0) | 5.9–8.1 |
| Inpatient (n = 337) | 182 (54.0) | 48.7–59.3 | 181 (53.7) | 48.4–59.0 | 6 (1.8) | 0.4–3.2 |
| Outpatient (n = 1,650) | 434 (26.3) | 24.2–28.4 | 338 (20.5) | 18.5–22.4 | 133 (8.1) | 6.8–9.4 |
| Feline (n = 612) | 142 (23.2) | 19.9–26.6 | 121 (19.8) | 16.6–22.9 | 26 (4.2) | 2.7–5.9 |
| Inpatient (n = 115) | 53 (46.1) | 37.0–55.2 | 51 (44.3) | 35.3–53.4 | 3 (2.6) | 0–5.5 |
| Outpatient (n = 497) | 89 (17.9) | 14.5–21.3 | 70 (14.1) | 11.0–17.1 | 23 (4.6) | 2.8–6.5 |
Systemic antibiotics prescribed
Among all dogs and cats, aminopenicillins with beta-lactamase inhibitors were the most prescribed antibiotic drug class for systemic use, followed by first-generation cephalosporins and imidazoles (Table 2). Prescriptions for third-generation cephalosporins were more frequent in primary care than referral practices (Table 3). Aminopenicillins with beta-lactamase inhibitors, first-generation cephalosporins, fluoroquinolones, and imidazoles were more frequently prescribed in referral settings. Tetracyclines were the most prescribed antibiotic in shelter settings, comprising 6 of 9 total prescriptions among 75 cats and dogs.
Antibiotic drug classes prescribed for dogs and cats in descending order from most to least prescribed.
| Antibiotic drug class | No. (%) of prescriptions | ||
|---|---|---|---|
| Dogs (n = 788) | Cats (n = 175) | Total (n = 963) | |
| Topical preparation (all)* | 152 | 30 | 182 |
| Aminoglycosides | 65 (42.8) | 11 (36.7) | 76 (41.8) |
| Triple antibiotic† | 33 (21.7) | 1 (3.3) | 34 (18.7) |
| Fluoroquinolones | 27 (17.8) | 5 (16.7) | 32 (17.6) |
| Amphenicols | 10 (6.6) | 1 (3.3) | 11 (6.0) |
| Carboxylic acid | 0 (0) | 1 (3.3) | 1 (0.5) |
| Cephalosporins, first-generation | 1 (0.7) | 0 (0) | 1 (0.5) |
| Polymyxins | 5 (3.3) | 3 (10.0) | 8 (4.4) |
| Macrolides | 4 (2.6) | 3 (10.0) | 7 (3.8) |
| Oxytetracycline/polymyxin combinations | 3 (2.0) | 4 (13.3) | 7 (3.8) |
| Sulfonamides | 2 (1.3) | 0 (0) | 2 (1.1) |
| Lincosamides | 1 (0.7) | 0 (0) | 1 (0.5) |
| Polypeptides | 1 (0.7) | 0 (0) | 1 (0.5) |
| Tetracyclines | 0 (0) | 1 (3.3) | 1 (0.5) |
| Systemic preparation (all)** | n = 636 | n = 145 | n = 781 |
| Aminopenicillins with beta-lactamase inhibitors | 175 (27.5) | 57 (39.3) | 232 (29.7) |
| Imidazoles | 118 (18.6) | 10 (6.9) | 128 (16.4) |
| Cephalosporins, first-generation | 117 (18.4) | 7 (4.8) | 124 (15.9) |
| Cephalosporins, third-generation | 71 (11.2) | 27 (18.6) | 98 (12.5) |
| Fluoroquinolones | 47 (7.4) | 17 (11.7) | 64 (8.2) |
| Lincosamides | 43 (6.8) | 2 (1.4) | 45 (5.8) |
| Tetracyclines | 34 (5.3) | 11 (7.6) | 45 (5.8) |
| Penicillins | 18 (2.8) | 7 (4.8) | 25 (3.2) |
| Macrolides | 4 (0.6) | 7 (4.8) | 11 (1.4) |
| Trimethoprim sulfonamide combinations | 4 (0.6) | 0 (0) | 4 (0.5) |
| Amphenicols | 2 (0.3) | 0 (0) | 2 (0.3) |
| Sulfonamides | 2 (0.3) | 0 (0) | 2 (0.3) |
| Aminoglycosides | 1 (0.2) | 0 (0) | 1 (0.1) |
*Topical antibiotic drugs in each drug class are as follows: Aminoglycosides = Amikacin, gentamicin, neomycin, tobramycin sulfate. Amphenicols = Florfenicol. Carboxylic acid = Mupirocin. Cephalosporins, first generation = Cefazolin. Fluoroquinolones = Enrofloxacin, ofloxacin, and orbifloxacin. Lincosamides = Clindamycin. Macrolides = Erythromycin and lincomycin. Oxytetracycline-polymyxin combinations = Terramycin. Polymyxins = Polymyxin B. Polypeptides = Bacitracin. Sulfonamides = Silver sulfadiazine. Tetracyclines = Oxytetracycline. Triple antibiotic = Triple antibiotic preparations.
†Triple antibiotic topical preparations are combinations of neomycin, polymyxin B, and bacitracin.
**Systemic antibiotic drugs in each drug class are as follows: Aminoglycosides = Amikacin. Aminopenicillins with beta-lactamase inhibitors = Amoxicillin–clavulanic acid and ampicillin-sulbactam. Amphenicols = Chloramphenicol. Cephalosporins, first generation = Cefazolin and cephalexin. Cephalosporins, third generation = Cefovecin, cefpodoxime proxetil, and ceftriaxone. Fluoroquinolones = Ciprofloxacin, enrofloxacin, marbofloxacin, and orbifloxacin. Imidazoles = Metronidazole. Lincosamides = Clindamycin. Macrolides = Azithromycin, erythromycin, and tylosin. Penicillins = Amoxicillin, ampicillin, and penicillin G. Sulfonamides = Sulfadimethoxine. Tetracyclines = Doxycycline. Trimethoprim-sulfonamide combinations = Sulfamethoxazole-trimethoprim.
Six most frequent antibiotic classes prescribed for systemic use in primary care and referral practices, in descending order from most to least prescribed.
| Antibiotic drug class | Primary care practice No. (%) of drugs | Referral practice No. (%) of drugs | P value |
|---|---|---|---|
| Systemic preparation (all)* | n = 282 | n = 590 | |
| Aminopenicillins with beta-lactamase inhibitors | 21 (7.4) | 211 (35.8) | < .001 |
| Imidazoles | 26 (9.2) | 100 (16.9) | .003 |
| Cephalosporins, first generation | 30 (10.6) | 93 (15.8) | .054 |
| Cephalosporins, third generation | 48 (17.0) | 50 (8.5) | < .001 |
| Fluoroquinolones | 7 (2.5) | 57 (9.7) | < .001 |
| Penicillins | 22 (7.8) | 3 (0.5) | < .001 |
*Systemic antibiotic drugs in each drug class are as follows: Aminopenicillins with beta-lactamase inhibitors = Amoxicillin–clavulanic acid and ampicillin-sulbactam. Cephalosporins, first generation = Cefazolin and cephalexin. Cephalosporins, third generation = Cefovecin, cefpodoxime proxetil, and ceftriaxone. Fluoroquinolones = Ciprofloxacin, enrofloxacin, marbofloxacin, and orbifloxacin. Imidazoles = Metronidazole. Penicillins = Amoxicillin, ampicillin, and penicillin G.
Amoxicillin–clavulanic acid constituted 13.7% (132 of 963) of all systemic antibiotic prescriptions and was the most commonly prescribed drug (Supplementary Table S4). Metronidazole (128 of 963 [13.3%]) was the second most frequently prescribed antibiotic. Ampicillin-sulbactam (100 of 963 [10.4%]), cefazolin (84 of 963 [8.7%]), cefpodoxime proxetil (64 of 963 [6.6%]), and enrofloxacin (49 of 963 [5.1%]) followed in frequency.
Topical antibiotics prescribed
Aminoglycosides (76 of 182 [41.8%]) were the most prescribed antibiotic drug class for topical use, followed by triple-antibiotic preparations (34 of 182 [18.7%]) and fluoroquinolones (32 of 182 [17.6%]; Table 3). Fluoroquinolones for topical application were more frequently prescribed in referral practices (20 of 81 [24.7%]) than primary care practices (12 of 100 [12.0%]), while aminoglycosides for topical application were more frequently prescribed in primary care practices (51 of 100 [51.0%]) compared to referral practices (25 of 81 [30.9%]). Specific antibiotics for topical use in dogs and cats are presented in Supplementary Table S3.
Intention of antibiotic use
The same antibiotic could be prescribed to a cat or dog for > 1 clinical condition or indication with different levels of evidence of infection. Treatment of infection was the intended use for 62.4% (603 of 967) of reported indications for antibiotic prescriptions. The most common antibiotics prescribed to treat infection were amoxicillin–clavulanic acid (103 of 603 [17.1%]), ampicillin-sulbactam (67 of 603 [11.1%]), metronidazole (56 of 603 [9.3%]), and enrofloxacin (54 of 603 [9.0%]). For antibiotic prescriptions intended for the treatment of infection, 31.0% (188 of 606) were associated with confirmed infections, 58.1% (352 of 606) for suspected infections, and 10.9% (66 of 606) for conditions with no evidence of infection. When considering hospitalization status, 184 antibiotic prescriptions for inpatients were intended for the treatment of infection, 23.4% (43 of 184) were for confirmed infection, 66.3% (122 of 184) were for suspected infections, and 10.3% (19 of 184) were for conditions with no evidence of infection. Of the 422 antibiotic prescriptions for the treatment of infection in outpatients, 34.4% (145 of 422) were for confirmed infections, 54.5% (230 of 422) for suspected infections, and 11.1% (47 of 422) were for conditions with no evidence of infection.
Prophylactic use was intended for 25.6% (248 of 967) of reported indications and nonbactericidal effects for 5.8% (56 of 967), and an indication could not be determined for 6.2% (60 of 967). Cefazolin (78 of 248 [31.5%]) was the most prescribed antibiotic for prophylactic use, followed by ampicillin-sulbactam (28 of 248 [11.3%]), amoxicillin–clavulanic acid (23 of 248 [9.3%]), and cefpodoxime proxetil (17 of 248 [6.9%]).
Metronidazole (42 of 56 [75.0%]) was the drug prescribed most for its nonbactericidal effects and was the antibiotic most frequently used (18 of 60 [30.0%]) when no indication was noted in the medical record.
Clinical conditions for which antibiotics were prescribed
There were 3,056 clinical conditions reported for the 2,599 dogs and cats in the study. Most (1,900 of 2,599 [73.1%]) cats and dogs had a single clinical condition, and fewer had 2 clinical conditions (349 of 2,599 [13.4%]) or 3 clinical conditions (54 of 2,599 [2.1%]). The remaining dogs and cats (296 of 2,599 [11.4%]) had no clinical condition reported (healthy animals).
Eight-hundred ten clinical conditions were associated with at least 1 antibiotic prescription (810 of 3,056 [26.5%]; Table 4). Skin (138 of 810 [17.0%]), gastrointestinal (129 of 810 [15.9%]), surgical (101 of 810 [12.5%]), otic (70 of 810 [8.6%]), ocular (69 of 810 [8.5%]), urinary (63 of 810 [7.8%]), and respiratory (59 of 810 [7.3%]) conditions accounted for most antibiotic prescriptions.
Summary of clinical conditions and indications for antibiotic prescribing among cats and dogs prescribed at least 1 antibiotic, in descending order from most to least commonly encountered.
| Indication | Canine (661/2,311) n (%) | Feline (49/745) n (%) | Total (810/3,056) n (%) |
|---|---|---|---|
| Gastrointestinal | 115/275 (41.8) | 14/85 (16.5) | 129/360 (35.8) |
| Skin | 124/264 (47.0) | 14/39 (35.9) | 138/303 (45.5) |
| None—no problems identified (healthy) | 0/215 (0) | 1/81 (1.2) | 1/296 (0.3) |
| Neoplasia | 27/189 (14.3) | 7/54 (13.0) | 34/243 (14.0) |
| Surgical | 89/163 (54.6) | 12/49 (24.5) | 101/212 (47.6) |
| Orthopedic—nonsurgical | 15/165 (9.1) | 0/15 (0) | 15/180 (8.3) |
| Urinary | 38/80 (47.5) | 25/90 (27.8) | 63/170 (37.1) |
| Neurological | 8/144 (5.6) | 0/12 (0) | 8/156 (5.1) |
| Dental/oral—including surgery | 24/112 (21.4) | 2/44 (4.5) | 26/156 (16.7) |
| Respiratory | 32/86 (37.2) | 27/59 (45.8) | 59/145 (40.7) |
| Ocular | 53/119 (44.5) | 16/24 (66.7) | 69/143 (48.3) |
| Cardiac | 3/86 (3.5) | 1/33 (3.0) | 4/119 (3.4) |
| Otic | 60/88 (68.2) | 10/13 (76.9) | 70/101 (69.3) |
| Endocrine | 1/35 (2.9) | 2/42 (4.8) | 3/77 (3.9) |
| Open diagnosis | 3/37 (8.1) | 2/21 (9.5) | 5/58 (8.6) |
| Immune mediated | 5/37 (13.5) | 0/1 (0) | 5/38 (13.2) |
| Toxin ingestion | 0/34 (0) | 0/3 (0) | 0/37 (0) |
| Hepatic | 11/33 (33.3) | 3/4 (75.0) | 14/37 (37.8) |
| Trauma | 12/24 (50.0) | 5/10 (50.0) | 17/34 (50.0) |
| Behavioral | 0/22 (0) | 0/6 (0) | 0/28 (0) |
| Anemia (not immune mediated) | 1/8 (12.5) | 2/16 (12.5) | 3/24 (12.5) |
| Obesity | 0/13 (0) | 0/11 (0) | 0/24 (0) |
| Other | 4/18 (22.2) | 0/4 (0) | 4/22 (18.2) |
| Reproductive | 2/12 (16.7) | 1/3 (33.3) | 3/15 (20.0) |
| Chemotherapy/radiation-related side effects | 10/10 (100) | 0/4 (0) | 10/14 (71.4) |
| Fever of unknown origin | 7/10 (70.0) | 2/3 (66.7) | 9/13 (69.2) |
| Pancreatic | 1/5 (20.0) | 0/7 (0) | 1/12 (8.3) |
| Not recorded in medical record | 0/6 (0) | 0/4 (0) | 0/10 (0) |
| Viral—systemic | 3/3 (100) | 2/6 (33.3) | 5/9 (55.6) |
| Parvovirus | 7/8 (87.5) | 0 | 7/8 (87.5) |
| Septic peritonitis | 3/5 (60.0) | 1/2 (50.0) | 4/7 (57.1) |
| Lyme | 1/2 (50.0) | 0 | 1/2 (50.0) |
| Heartworm diseases | 1/2 (50.0) | 0 | 1/2 (50.0) |
| Rickettsial diseases | 1/1 (100) | 0 | 1/1 (100) |
Clinical conditions with the highest rates of antibiotic prescribing (Table 4; Supplementary Table S5), included parvovirus infection (7 of 8 [87.5%]), chemotherapy- and radiation-induced side effects (10 of 14 [71.4%]), otic (70 of 101 [69.3%]), fever of unknown origin (9 of 13 [69.2%]), septic peritonitis (4 of 7 [57.1%]), systemic viral infections (5 of 9 [55.6%]), and trauma (17 of 34 [50.0%]).
Duration of antibiotic prescriptions
The median duration of prescriptions for amoxicillin–clavulanic acid, the most commonly prescribed drug, was 10 days in dogs and 7 days in cats (Supplementary Table S6). Metronidazole prescriptions had a median prescription duration of 7 days in both dogs and cats. Among common clinical conditions, the median duration of antibiotic prescriptions for gastrointestinal disease (n = 96) was 7 days (range, 2 to 30 days). The median duration for skin conditions (n = 110) was 14 days (range, 5 to 30 days), for urinary conditions (35) was 10 days (range, 2 to 28 days), and for respiratory conditions (48) was 10 days (range, 3 to 129 days). For all surgical conditions (n = 47), the median prescription duration was 10 days (range, 1 to 14 days); the reason for antibiotic prescription was determined for 46 of these and included surgical infections (17) with a median duration of 10 days (range, 5 to 14 days) and postsurgical prophylaxis (29) with a median duration of 10 days (range, 1 to 14 days).
Overall, the median duration of prescriptions for prophylactic use was 10 days for dogs and 10.3 days for cats, while the median duration for the treatment of infection was 10 days for both dogs and cats (Table 5).
Duration of oral antibiotic prescriptions for prophylaxis and infection treatment for dogs and cats.
| Duration of antibiotic for oral administration | Prophylaxis canine prescriptions | Prophylaxis feline prescriptions | Infection treatment canine prescriptions | Infection treatment feline prescriptions | ||||
|---|---|---|---|---|---|---|---|---|
| n | Median (range) days | n | Median (range) days | n | Median (range) days | Median n | (range) days | |
| Amoxicillin–clavulanic acid | 17 | 7 (5–14) | 5 | 8 (7–14) | 76 | 10 (5–45) | 23 | 7 (5–56) |
| Cefpodoxime proxetil | 17 | 10 (5–27) | — | — | 39 | 14 (5–30) | 2 | 78.5 (28–129) |
| Metronidazole | 8 | 5 (4–365) | — | — | 43 | 7 (2–30) | 4 | 6 (5–14) |
| Doxycycline | 1 | 14 (14) | — | — | 31 | 14 (3–30) | 7 | 10 (7–28) |
| Cephalexin | 10 | 7 (1–14) | — | — | 25 | 14 (7–21) | — | — |
| Clindamycin | 7 | 10 (7–21) | — | — | 27 | 14 (7–49) | 1 | 21 (21) |
| Enrofloxacin | — | — | — | — | 17 | 10 (2–21) | — | — |
| Amoxicillin | 5 | 10 (7–14) | — | — | 5 | 14 (7–14) | — | — |
| Marbofloxacin | — | — | — | — | 2 | 17.5 (7–28) | 6 | 15 (9–107) |
| Azithromycin | — | — | 1 | 14 (14) | — | — | 3 | 21 (14–65) |
| Sulfamethoxazole-trimethoprim | 3 | 14 (14) | — | — | 1 | 14 (14) | — | — |
| Chloramphenicol | — | — | — | — | 2 | 14 (7–21) | — | — |
| Orbifloxacin | — | — | — | — | 1 | 14 (14) | 1 | 20 (20) |
| Sulfadimethoxine | — | — | — | — | 2 | 5 (5) | — | — |
| Ciprofloxacin | — | — | — | — | 1 | 7 (7) | — | — |
| Tylosin | 1 | 14 (14) | — | — | — | — | — | — |
| All antibiotics | 69 | 10 (1–365) | 6 | 10.3 (7–14) | 272 | 10 (2–49) | 47 | 10 (5–129) |
Diagnostic testing
Overall, 27.7% (719 of 2,599) of patients had diagnostic imaging performed and 52.3% (1,358 of 2,599) had nonimaging diagnostic testing. Of cats and dogs that received an antibiotic prescription, 35.9% (272 of 758) had diagnostic imaging and 61.4% (465 of 758) had nonimaging diagnostics performed.
Of dogs and cats prescribed an antibiotic intended to treat infection, 20.1% (96 of 478) had cytology, 13.4% (64 of 478) had bacterial culture and susceptibility testing, and 11.9% (57 of 478) had a urinalysis performed. Most (58 of 64 [90.6%]) bacterial culture and susceptibility tests were reported by referral hospitals, few (6 of 64 [9.4%]) were reported by primary care practices, and no diagnostic tests were reported by the shelter. Bacterial culture and susceptibility testing was conducted for 32.3% (20 of 62) or 8.2% (8 of 98) of animals administered a systemic fluoroquinolone or third-generation cephalosporin, respectively.
Specific disease focus
Overall, 47.6% (101 of 212) of dogs and cats undergoing surgery were prescribed at least 1 antibiotic. This included 37.9% (58 of 153) of all elective surgeries, 11.0% (9 of 82) of spay and neuter surgeries, and 82.4% (28 of 34) of surgeries involving implants. Antibiotic prescriptions were recorded for 41.8% (66 of 158) of clean, 82.4% (28 of 34) of clean-contaminated, 33.3% (5 of 15) of contaminated, and 50.0% (1 of 2) of infected surgeries as well as 33.3% (1 of 3) of surgeries of unknown classification. Cefazolin (64 of 141 [45.4%]) was the most prescribed injectable antibiotic for surgeries. Commonly prescribed oral antibiotics included amoxicillin–clavulanic acid (21 of 141 [14.9%]), cefpodoxime proxetil (10 of 141 [7.1%]), and cephalexin (8 of 141 [6.7%]).
For all gastrointestinal clinical conditions recorded for dogs and cats in this study, 35.8% (129 of 360) received at least 1 antibiotic prescription. The gastrointestinal conditions with the highest rates of antibiotic prescribing were acute hemorrhagic diarrheal syndrome (18 of 21 [85.7%]), nonspecific gastroenteritis (62 of 148 [41.9%]), and those with an open diagnosis (14 of 46 [30.4%]). Metronidazole was the most prescribed antibiotic among those for gastrointestinal conditions (99 of 145 [68.3%]).
Among the 101 otic conditions, 70 (69.3%) were associated with at least 1 antibiotic prescription. The most prescribed antibiotics were for topical use and included gentamicin (30 of 78 [38.5%]), neomycin (11 of 78 [14.1%]), enrofloxacin (9 of 78 [11.5%]), and florfenicol (9 of 78 [11.5%]). Twelve of 78 (15.4%) otic conditions were associated with an oral antibiotic, including 4 prescriptions each of cephalexin and amoxicillin–clavulanic acid.
Clinical conditions for which antibiotic prescribing guidelines are available include urinary tract and respiratory infections and superficial pyoderma.20–22 Seventy-five percent (18 of 24) of instances of sporadic bacterial cystitis were associated with an antibiotic prescription, including 81.3% (13 of 16) of dogs and 62.5% (5 of 8) of cats with this condition. Among the 18 prescriptions for sporadic bacterial cystitis, 16.7% (3 of 18) was associated with a prescription for amoxicillin, a recommended empiric antibiotic; all amoxicillin prescriptions for this indication were for dogs. None were prescribed trimethoprim-sulfamethoxazole. Eleven of 13 (84.6%) instances of pyelonephritis were associated with 17 antibiotic prescriptions; 47.1% (8 of 17) were fluoroquinolones, 47.1% (8 of 17) ampicillin-sulbactam, and 5.9% (1 of 17) doxycycline. Among the instances of feline upper respiratory tract disease, 76.9% (10 of 13) of those with clinical signs present for < 10 days and 54.5% (6 of 11) with clinical signs present > 10 days received an antibiotic prescription. There were 22 antibiotic prescriptions among all cases of feline upper respiratory tract disease, with 31.8% (7 of 22) representing recommended empirical antibiotics, 18.2% (4 of 22) doxycycline, and 13.6% (3 of 22) amoxicillin–clavulanic acid prescriptions. Of the 78 cases of superficial pyoderma, 46 (59.0%) were prescribed an antibiotic, including prescriptions for 78.8% (41 of 52) for antibiotics for systemic administration and 21.2% (11 of 52) for topical administration. Nineteen (46.3%) of the 41 antibiotics for systemic administration were cefpodoxime proxetil.
Discussion
Overall, 29.2% of cat and dog veterinary assessments were associated with antibiotic prescribing. Prescribing varied by practice type, with referral practices having the highest rate of 31.4%, followed by primary care practices at 26.4% and the single shelter at 12.0%. A higher proportion of dogs than cats and inpatients than outpatients were prescribed an antibiotic. Skin, gastrointestinal, surgical, otic, ocular, urinary, and respiratory conditions accounted for the majority of antibiotic prescriptions.
International antimicrobial prescribing guidelines have been available to companion animal veterinarians in the US for several years. Guidelines for urinary tract infections in dogs and cats were first published in 2011,20,23 for canine pyoderma in 2014,21 and for canine and feline respiratory tract infections in 2017.22 Over 60% of participants in this study indicated that their practices utilize prescribing guidelines, though use of antibiotic drugs recommended for empiric treatment of sporadic bacterial cystitis and feline upper respiratory infections was infrequent, as was guideline-recommended use of topical antibiotics for superficial pyoderma. In a smaller study24 of primary care practices in Minnesota and North Dakota, the frequency with which veterinarians chose guideline-recommended empiric antibiotics was higher when making a selection for hypothetical cases via an online survey than for their actual patients with the same conditions based on medical record review. This suggests that knowledge of available guidelines is not the only input for clinical decision-making. Given the common nature of the conditions (eg, urinary tract infection, pyoderma) for which guidelines have been developed, improved compliance with these best practices would result in considerable reduction in non–first-line AU and tangible progress for individual practice AS programs. Understanding barriers to uptake of published best practices is an important focus for AS efforts in the US, where improved prescribing practices for companion animals will be driven by changing prescriber behaviors, rather than regulation.
At the time of data collection, no peer-reviewed and evidence-based prescribing guidelines were published for other common conditions associated with AU, including for nonspecific acute gastroenteritis and peri- and postsurgical prophylaxis. Ninety percent of dogs with acute hemorrhagic diarrheal syndrome received an antibiotic prescription, though the majority of dogs with this condition do not require antibiotics.25–28 Nearly half of the dogs with nonspecific gastroenteritis in this study were prescribed an antibiotic, most frequently metronidazole. Metronidazole has been shown to disrupt the gastrointestinal microbiome29 and does not reduce the time to clinical resolution compared to placebo,30,31 probiotics,31 or diet.32 A recent systematic review and meta-analysis33 of the use of nutraceuticals and antimicrobials in canine acute diarrhea showed, with high certainty, that antimicrobials did not have a clinical effect on outcome.
In the present study, there was also a high rate of antibiotic prescribing for clean surgeries and duration of postprocedure prophylactic antibiotic prescriptions were as long as prescriptions intended to treat infections. In keeping with the tenets of judicious AU, several veterinary professional organizations discourage use of peri- and postsurgical prophylaxis for most routine clean procedures when adhering to aseptic technique.34,35 A recent review19 highlighted a lack of prospective studies evaluating the use of surgical prophylaxis, especially for procedures other than orthopedic stifle surgeries. This gap in available evidence makes the creation of robust guidelines challenging and underscores the need for outcomes-based studies to determine whether, when, and how long antibiotics are needed for surgical procedures. Though evidence-based guidelines have been recently published for canine acute diarrhea36 and are forthcoming for surgical prophylaxis,37 quality studies are needed to increase the certainty of conclusions and provide veterinarians with confidence when prescribing—and not prescribing—antibiotics.
Several classification systems rank antimicrobials used in animal health to create awareness of the risks of AMR, as well as their importance in human healthcare.2,3 These classification systems are intended to be used in tandem with treatment guidelines to aid in appropriate drug selection and limit the impact on the emergence of AMR in animal and human populations. In this study, the most common drug classes prescribed included aminopenicillins with beta-lactamase inhibitors, imidazoles, and first-generation cephalosporins. These drug classes are considered highly important antibiotics by the WHO. According to the EMA, imidazoles are within the prudent-use category (ie, first-line) of antibiotics for use in animals, and both first-generation cephalosporins and aminopenicillins with beta-lactamase inhibitors are in the cautious-use category, recommended only to be used when no first-line treatments are effective. One in 8 systemically administered antibiotics in the present study were third-generation cephalosporins. The WHO categorizes this drug class as a highest priority critically important antimicrobial, and the EMA places third-generation cephalosporins in the restrict category, emphasizing that they be used only when there are no effective antibiotics in the caution and prudence categories and when their selection is based on culture and susceptibility testing. Fluoroquinolones, which were the fifth most prescribed antibiotic class for systemic administration in this study, are classified along with third-generation cephalosporins in WHO and EMA schemas. Legislation in France and Germany requires that bacterial culture and susceptibility testing accompany prescription of third- and fourth-generation cephalosporins and fluoroquinolones.4,38 In the present study, use of third-generation cephalosporins and fluoroquinolones was associated with bacterial culture and susceptibility testing only 17.5% of the time.
Veterinarians have cited cost of culture and susceptibility testing as a barrier to use.39,40 Given the cost challenge, defining appropriate indications for diagnostic testing (eg, by use of clinical pathways, testing algorithms) and refining client communication about the importance of diagnostics could impact practice-level AS actions. Turnaround time to receive culture and susceptibility results can be another barrier to use. Molecular-based rapid diagnostic tests for the presence of AMR pathogens may be a viable solution, though validation, standardization, and interpretation guidance are needed before robust adoption of such tests.41
There were several limitations in this study. The nature of point-prevalence surveys is that they provide a time-constrained snapshot of measured conditions. Seldomly prescribed antibiotics and rarely seen clinical conditions may not be captured with this methodology. Although no practices indicated an inability to select a representative day for data collection, absence of high- or low-prescribing veterinarians on the study date may also have influenced results. Prescription de-escalation (eg, from broad to narrow spectrum, IV to PO formulation) was not assessed. Despite wide recruitment, practices included in the study were self-selected, and those already informed about AMR and AS may have been more inclined to participate. As a result, prescribing patterns in this population may not be generalizable to all small animal practices. Lastly, the study took place during a period in which the COVID-19 pandemic may have still been impacting veterinary practice in terms of the number of animals and severity of diseases seen.
This investigation highlights areas for targeted AS efforts, including limited use of bacterial culture and susceptibility testing, prescribing of non–first-line antibiotics for empirical use, and use of prophylactic antibiotics for clean surgical procedures. Additional prescribing guidelines and studies that assess adherence to guidelines and the facilitators and barriers to their use are needed. Repeated measurements of AU are critical to determine the effect of prescribing guidelines and AS interventions. Point-prevalence survey methodology allows for the collection of a substantial, consistent dataset of AU from various locations with minimal effort required from each individual practice.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org.
Acknowledgments
The authors sincerely thank the veterinary practices for participating in this research.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.
Funding
This project was supported by the US FDA of the US Department of Health and Human Services (HHS) as part of a financial assistance award (No. 1U01FD007061-01) totaling $999,972 with 100% funded by the FDA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, the FDA/HHS or US Government.
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