Tackling antimicrobial resistance across a large veterinary group

According to WHO, antimicrobial resistance (AMR) is one the largest threats to global health and is already causing millions of deaths every year[1]. A significant proportion of all animals visiting a veterinary practice are treated with antibiotics, often unnecessarily or inappropriately. Thus, there is a large incentive to work with Antibiotic Stewardship (ASP) within veterinary medicine to decrease the reported overuse and misuse of antimicrobials[2]. Studies from human and veterinary health care settings show that implementation of ASP programmes leads to a rapid decrease in antibiotic use, fewer relapses, less antibiotic related side effects and a decrease in resistant strains in the local population[3]^,[4],[5],[6]. Worth noting is that implementation of ASP programmes has not been associated with increased mortality rates⁴.  

Measuring antibiotic use

Key tools when striving for prudent use of antibiotics are:

• to measure antibiotic use
• compare it to benchmark data
• identify areas for improvement

The antibiotic use can be measured as the number of antibiotic treatments and prescriptions as a percentage of total number of consultations. As a world leading provider of veterinary care, it is our responsibility to be pioneers and actively work with infection prevention and control. Therefore, IVC Evidensia’s goal is ambitious, striving for less than 5% antibiotic use. The culture and tradition of antibiotic use differs widely between countries with every region experiencing different opportunities and challenges. The biggest advantage of being a multinational veterinary group is the ability to use our collective scale and skillsets to share knowledge and valuable experiences.

Strategies to decrease antibiotic use

Various strategies can be used when working to decrease overuse of antibiotics within an ASP framework.  The strategies can be divided into persuasive, restrictive and structural strategies:

• Restrictive strategies aim to decrease treatment options to guide clinicians to more prudent antibiotic use. These strategies have been shown to be most effective in acute outbreaks of multidrug resistant bacteria, while a combination of different strategies is preferred to achieve long-term goals. One example of a restrictive strategy is to avoid having critically important antibiotics in stock, such as fluoroquinolones and 3^rd generations cephalosporins. If critically important antibiotics are not within reach, practitioners are prone to make other, more prudent choices.
• Persuasive strategies aim to constructively encourage clinicians to reevaluate their treatment regimens through for example antibiotic rounds or regular case discussions. Having prudent antibiotic use as a recurrent subject of discussion, practitioners will be more aware of the problem and reflect upon their antibiotic treatments.
• Structural strategies use technology and improved diagnostic methods to contribute to wiser use of antimicrobials. One of the most important structural strategies in ASP is to measure, analyse and report antibiotic use. This is also essential when evaluating the efficacy of an ASP programme. Benchmarking results to other countries, practices, and individual prescribers have shown to be very effective to decrease antibiotic use.

Local heroes

We have found that appointing a local ASP representative is the key to success when implementing, maintaining, and evaluating ASP programmes at a practice. They are responsible for monitoring antibiotic use, applying guidelines and coaching colleagues in their daily work. Dedicated time and presence are crucial to ensure progress and counteract regression, so local ASP representatives make a difference every day!

Adopting a One Health approach

Antimicrobial resistant bacteria already pose a significant threat to animal as well as human health and will do so even more in the future. We need to recognize that microorganisms that infect animals and humans live in the same eco-systems. Therefore, it is important to adopt a One Health approach. The entire veterinary community must make every effort to counteract further development of antibiotic resistance. ASP, together with impeccable infection prevention and control (IPC) and preventative health care, can and will contribute to prudent use of antimicrobials and a more sustainable future.

Together we can make a difference!

[1] Antimicrobial Resistance Collaborators, Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet, 2022 Feb 12;399(10325):629-655.

[2] Alison H Holmes , Luke S P Moore , Arnfinn Sundsfjord, Martin Steinbakk, Sadie Regmi, Abhilasha Karkey, Philippe J Guerin, Laura J V Piddock. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet, 2016 Jan 9;387(10014):176-87.

[3] Lew K, Ng T, Tan M, Tan S, Lew EL, Ling L, Ang B, Lye D, Teng C, Safety and clinical outcomes of carbapenem de-escalation as part of an antimicrobial stewardship programme in an ESBL-endemic setting. J Antimicrob Chemother. 2015, 4, 1219-25.

[4] Nilholm H, Holmstrand L, Ahl J, Månsson F, Odenholt I, Tham J, Melander E, Resman F. An Audit-Based, Infectious Disease Specialist-Guided Antimicrobial Stewardship Program Profoundly Reduced Antibiotic Use Without Negatively Affecting Patient Outcomes. Open Forum Infect Dis. 2015, 3, 23;2

[5] Hopman NEM, Portengen J, Hulscher MEJL, et al. Implementation and evaluation of an antimicrobial stewardship programme in companion animal clinics: A stepped-wedge design intervention study.

PLoS One. 2019 Nov 18; 14(11):e0225124.

[6] Hopman NEM, Hulscher MEJL, Graveland H, et al. Factors influencing antimicrobial prescribing by Dutch companion animal veterinarians: A qualitative study. Prev Vet Med. 2018 Oct 1;158:106-113.