Antimicrobial stewardship in equine medicine

Since graduating in 1993, I've seen enormous changes in attitudes to antimicrobial use, and it's good to reflect on what's brought about those changes. As a recent graduate and intern in an equine hospital, I can clearly remember when enrofloxacin first became recognised as an antimicrobial for horses. We were excited to have a new, relatively palatable, once-daily, oral antibiotic for horses, and we adopted its use both quickly and widely. Of course, we were concerned about its potential to cause colitis or damage juvenile cartilage, but antibiotic resistance seemed like something that only happened in human hospitals—the health of the patients standing in front of us felt like our number one priority. Now, I work in a practice where antimicrobial stewardship is firmly engrained in the culture of how we work. So, what has made a difference to our mindset?

Although antimicrobial resistance (AMR) has been recognised for almost as long as we have used antibiotics, it took until the early twenty-first century before AMR policy started to impact equine veterinary practice significantly. By 2010 we knew it was necessary, we knew we should do something, but the issue lacked focus.

For me, a lot of credit should go to BSAVA and BEVA for developing the "Protect Me" campaign, which was introduced around 2013 and gained wide acceptance in equine practice. Whilst it gave explicit information around protected antibiotics, it also provided a "toolkit" for practices to develop their own in-house policy. Importantly, it was an interactive resource that demanded engagement from practices, but there was enough supporting material to make it achievable. For the first time, we had something which we, as a practice team, could recognise as our own antimicrobial policy. The "Protect Me" resources have stood the test of time well and are just as relevant in equine practice today as when they were first developed. It needs strong leadership from trusted organisations to make widely accepted changes across the profession.

On reflection, I think that was a significant turning point because if we had not fully embraced antimicrobial stewardship as a profession, then it may well have happened through legislation. I believe that was also felt to be one of the drivers to change, so perhaps the threat of legislation had its place? I sincerely believe that the veterinary profession is best placed to use professional judgement about antimicrobial use, but we need to continue to demonstrate leadership and behavioural change.

Another fundamental change has been the many vet students and recent graduates coming into practice who are passionate about the issue. That's a strong driver when you've been in practice for over twenty years and are determined not to be left behind in embracing new thinking. I clearly remember a clinical meeting when a locum vet asked tough questions about my choice to use a fourth-generation cephalosporin for lymphangitis. I think that's the last time I used cephalosporins in an adult horse without culture and sensitivity. It's important that we create practice cultures where everyone has an equal voice in key issues, and all team members feel they can influence change. Everyone has an equal role when it comes to AMR.

Ultimately, I think antimicrobial stewardship is really about the culture we create in our practices. If we believe in using antibiotics appropriately and are proud of that, it happens naturally. Despite posters stuck to the drug room door, if vets don't believe in its value, it won't happen.

I believe our profession can be proud of the widespread changes in antimicrobial policy, but how can we do better still? I think one of the main challenges is reducing the pressure from clients to prescribe antibiotics. In private practice, where we feel strong loyalty to our clients, it can be one of the main factors in deciding to prescribe. BVA’s Voice of the profession survey this year showed 46% of equine vets often faced a client expectation for antibiotics. I believe many horse owners do now recognise the value of saving antibiotics for when they're really needed and usually respond well to discussions about unnecessary drugs and not wanting to disturb the gut flora, even if their underlying expectation was for antibiotics. They can be challenging conversations to have.

The threat of climate change has helped wider society acknowledge that we must embrace behavioural change to tackle tough issues. I sincerely hope that antimicrobial stewardship becomes even more recognised throughout horse owners and society in the next decade, further reducing the pressures on vets to use antibiotics and helping us to champion antimicrobial stewardship. I think that's best achieved at all levels, including us as individual vets, practices and veterinary organisations. I believe we can be trusted to make that difference without legislation.