Antimicrobial Stewardship Guidelines
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The primary goal of antimicrobial stewardship is to optimise clinical outcomes while minimising unintended consequences of antimicrobial use, including the emergence of resistance.
Given the association between antimicrobial use and the selection of resistant pathogens, the frequency of inappropriate antimicrobial use is often used as a surrogate marker for the avoidable impact on antimicrobial resistance. The combination of effective antimicrobial stewardship with a comprehensive infection control program has been shown to limit the emergence and transmission of antimicrobial-resistant bacteria.
These guidelines are based on our experience in implementing antimicrobial stewardship in veterinary practices in Australia – you can read our papers on this topic (Hardefeldt et al, Richards et al).
There are 6 main components to consider for a veterinary antimicrobial stewardship program. The top 4 we consider to be core components with the other 2 additional and recommended:
- Having a champion
- Utilisation of guidelines & judicious antimicrobial use
- Implement a traffic light system
- Diagnostic testing
- Delayed prescribing
- Local guidelines
Champions
The antimicrobial stewardship champion is a vet or senior nurse within the practice who takes ownership of the program. Their role includes implementing the traffic light system (see below), promoting the guidelines and responsible use policies to all clinic staff (including nurses and reception staff) and promoting educational opportunities.
Education
Veterinary education
In medical practice, there have been numerous studies that assessed either prescriber or patient education and assessed antimicrobial prescribing rates. Generally education interventions are multi-faceted and include discussion of the current guidelines, feedback, communications skills training and information about diagnostic testing.
You’ve found the guidelines so that’s step 1! Check out the resources page for the posters and flip books.
We’ve created a series of short videos about antimicrobial stewardship.
- Introduction – Glenn Browning introduces the topic
- Part 1: The when and why of antimicrobial use; making a diagnosis
- Part 2: Pharmacokinetics and pharmacodynamics of antimicrobial drugs
- Part 3: Pharmacodynamic factors affecting dose and therapeutic response
- Part 4: Antimicrobial stewardship: what is it and how will it effect veterinary medicine?
- Part 5: Antimicrobial resistance: where does it come from and how does it spread?
- Part 6: Antimicrobial resistance: how can we control it?
You can also watch a video about the results of some of our work:
- Antimicrobial use for surgical prophylaxis in companion animal practice – Dr. Laura Hardefeldt
- Antimicrobial use for surgical prophylaxis in equine practice – Dr. Laura Hardefeldt
The veterinary schools, along with the Commonwealth government, have developed an online veterinary antimicrobial stewardship course.
Agriculture Victoria, in collaboration with our research group, have developed a webpage with lots of information about antimicrobial resistance.
Want more educational opportunities?
- Speak to your local AVA representative about holding a talk in your region
- Check out this MOOC, it’s free and, targeted at the veterinary community, I found it useful
- The World Health Organisation has developed an online course “Antimicrobial Stewardship: A competency-based approach.” It’s also free but targeted at medical clinicians.
Client education
Pressure from clients to prescribe antibiotics is a problem in all sectors of veterinary practice; large and small practices, equine, bovine and companion animal practice. Clients see us as a valuable source of information, so it’s our job to educate them on appropriate use of antimicrobials and, importantly, when antimicrobials are not indicated. It can be difficult to do this, especially on Friday evening after 8 hours of consults!
Having a policy in place helps you defend your position; it’s not me, it’s the policy!
Utilisation of guidelines and judicious antimicrobial use
Antimicrobial guidelines have been shown to improve prescribing and reduce antimicrobial use in medical primary care practice. The guidelines on this website are, where possible, evidence based and are designed to be evolving and transparent. We encourage you to participate in the process by sending us any evidence that we may have missed and suggesting syndromes or diseases for guideline development.
The appropriate use of antimicrobials is critical in both effective care of our patients and in the reduction in antimicrobial resistance. Antimicrobial resistance will develop in the face of ANY antimicrobial use so when we use these drugs we need to use them correctly to reduce the likelihood of treatment failure. Use the MIND ME acronym to remember the following important factors:
M Microbiology should guide therapy where possible
I Indications should be evidence based and include a bacterial cause in most instances
N Narrowest spectrum possible
D Dosage appropriate to species, site and type of infection (label not always accurate)
M Minimise duration of therapy
E Ensure mono therapy wherever possible (one drug rather than combinations of drugs)
Traffic light system
This involves colour-coding antimicrobials in the clinic pharmacy by their importance rating. This can be done by either:
- Placing a coloured sticker on each box or bottle; and/or
- Colour coding the shelves where antimicrobials are stored
The importance ratings of antimicrobials can be found on the traffic light cards in the resources section of this website.
Delayed prescriptions
Delayed prescribing typically gives patients a 2-day delay on a prescription, so if symptoms persist or worsen antimicrobials can be obtained. There has been mixed results in medical practice but this could be easily implemented in veterinary practice whereby a note is made on a clinical record to allow antimicrobials to be dispensed 2 days later if deemed necessary by the client.
Diagnostic testing guidelines
Antimicrobials that are high-importance rating in human medicine should only be used after culture and susceptibility testing in veterinary medicine. This doesn’t mean you can’t use these drugs, just that if you think they are necessary you obtain a sample for culture and susceptibility testing prior to initiating therapy and adjust therapy accordingly once susceptibility results are available. This is referred to as de-escalation in the medical field and involves switching from drugs with a high-importance rating to those with a low or medium-importance rating if susceptibility testing indicates their effectiveness, or shifting from broad-spectrum to narrow spectrum therapy once a causative agent has been identified.
Increased diagnostic testing allows for discernment between cases with a bacterial origin and those that do not. Cases that do not have a bacterial cause do not need antibiotic therapy. Culture and susceptibility testing is very useful but the time delay in obtaining results, and the cost, reduce the implementation of this test. Other cheap and fast tests are available such as cytology and patient side tests (Rainbow 6 for calf diarrhoea etc) that can refine a differential diagnoses list and give you confidence in not prescribing antimicrobials.
Biosecurity is also really important
There are a wide variety of pathogens can be transferred from animals to humans, and vice versa. Interactions between animals and humans may occasionally result in infection in our patients but can also result in disease is us. Veterinarians carry antimicrobial resistant pathogens at a higher rate than the general public, both in Australia and around the world, but we also share those bacteria with our family and pets, putting people in close contact with us at risk. In addition, recent cases of illness and death among veterinarians and animal handlers have highlighted the grave danger of emerging and established zoonoses.
The AVA has produced guidelines to provide a practical understanding of zoonotic diseases, and empower veterinarians to significantly reduce the risk of zoonotic infection to themselves, their staff or clients. It is not practical or possible to eliminate all risks associated with zoonotic infections. However, reasonable measures can, and should, be taken to minimise risks of exposure to known, and unknown, pathogens.
The AVA guidelines are practical and provide a good source of information for veterinary practices establishing biosecurity procedures for their clinic.
The cattle veterinarians special interest group has also developed a very useful resource for advising farmers on biosecurity – Biocheck. You have to be a member of the cattle veterinarians to get access. Equine Veterinarians Australia is also working in this area and resources may become available – we’ll keep you updated.