A roadmap for antimicrobial stewardship in veterinary practice

Too much of a good thing can be disastrous. The Centers for Disease Control and Prevention estimates that at least 2.8 million people get antibiotic-resistant infections each year in the United States, resulting in more than 35,000 deaths.¹ And with widespread antibiotic use—both appropriate and inappropriate—as the main culprit in this growing resistance, attention in human medicine (as well as in agriculture) has rightly shifted in recent decades to pursue more responsible antimicrobial practices.

And yet, a crucial gap persists in this One Health issue. According to a team from the University of Minnesota College of Veterinary Medicine (CVM), a truly comprehensive approach would need to consider the millions of household pets that are prescribed antimicrobial medications from the same drug classes as their owners.

In fact, the American Veterinary Medical Association (AVMA) estimates that the frequency of inappropriate antimicrobial use in human medicine and companion animal veterinary medicine is comparable, and a veterinary teaching hospital study found that 40% of canine antibiotics were prescribed for patients with no evidence of infection.² The AVMA also recently released a report that details the critical role veterinary professionals play in preserving the effectiveness of antimicrobials and includes species-specific report cards summarizing pathogens of concern.³

The CVM team launched the Antimicrobial Resistance and Stewardship Initiative (ARSI) last fall. According to its website, ARSI exists to “[provide] high-quality and evidence-based resources for antimicrobial resistance and stewardship and [conduct] research to advance knowledge of companion animal diseases (dogs, cats, horses) and treatment.”

Less than a year after its formation, the initiative has released a free, downloadable guide to implementing the AVMA’s 5 core principles of antimicrobial stewardship in companion animal veterinary clinics.⁴ The Handbook of Antimicrobial Stewardship in Companion Animal Settings provides a self-paced, stepwise approach to improving antimicrobial use, complete with concrete actions, tools, and examples.⁵

Do I really have time for this?

If the thought of implementing new antimicrobial standards sounds overwhelming, Jennifer Granick, DVM, MS, PhD, DACVIM, associate professor in the Department of Veterinary Clinical Sciences at the University of Minnesota CVM, wants to reassure you. She and her team haven’t designed the handbook for an idealized world. It was crafted with your daily obstacles in mind.

“For many veterinarians, the biggest hurdle in implementing an antimicrobial stewardship (AS) program is just knowing where to start,” says Dr. Granick. “In human health care, hospitals have AS teams with dedicated effort and resources. We just don’t have that in vet med, so we need to adapt AS implementation to our reality—limited time!” That’s why, she says, the handbook aims to provide a roadmap of small actions that can be used to build a robust AS program.

How to get started

Here’s a quick snapshot of what it would look like for your clinic to take the first step in implementing the standards outlined by the handbook.

The guide is divided into 3 categories—basic, intermediate, and advanced—each with a clear set of tasks dedicated to addressing the AVMA’s core principles of AS. The activities completed in the basic category position you for beginning the intermediate one, and so on.

The first core principle to tackle in the basic category is to commit to AS, which is broken into 4 tasks:

1. Form your AS committee. Identify relevant and representative stakeholders, meet regularly to assess priorities and evaluate progress, and educate all staff on the problem of antimicrobial resistance and the importance of AS.
2. Identify an AS champion. Choose a veterinarian to lead the committee and serve as the AS point of contact, draft a written statement that identifies and defines the role of the AS champion, and display a commitment poster for both clients and staff that identifies the champion and states the clinic’s commitment to AS.
3. Make a public commitment to your clients. Send a letter or email to clients about your clinic’s AS policies, use talking points to discuss appropriate antimicrobial use with clients, display your clinic’s commitment to AS in exam and waiting rooms, and include a clinic AS commitment statement in email bylines and in documents sent home with clients.
4. Define (and redefine) your hospital AS priorities. Set AS priorities for initial intervention and then revise them as progress is made, identify protocols to support these priorities, and educate staff on AS priorities and protocols.

Perhaps the handiest part of the handbook is that it is full of links to free tools, templates, and resources that are ready to go and easy to use, says Dr. Granick. For example, she notes that it provides a link to a sample commitment poster (part of making a public commitment to your clients) that you can download, customize for your practice, and print and post in your lobby. “This is the same idea as telling your friend that you made a commitment to exercise daily,” she explains. “It provides easy accountability, making it more likely you will stick with a plan.”

Small steps matter

The fight against antimicrobial resistance needs veterinary professionals. While your clinic may not be able to implement each and every strategy the handbook recommends, the CVM team says it’s possible for all clinics to make important incremental changes. As Dr. Granick puts it: “One small step at a time.”

Sarah Mouton Dowdy is a freelance writer and editor in Kansas City, Missouri.

References

1. Antibiotic/antimicrobial resistance (AR/AMR). Centers for Disease Control and Prevention. Accessed September 8, 2020. https://www.cdc.gov/drugresistance/index.html​

2. Wayne A, McCarthy R, Lindenmayer J. Therapeutic antibiotic use patterns in dogs: observations from a veterinary teaching hospital. J Small Anim Pract. 2011:52;310-318. doi:10.1111/j.1748-5827.2011.01072.x

3. AVMA/Committee on Antimicrobials. Antimicrobial resistant pathogens affecting animal health in the United States. American Veterinary Medical Association; 2020. Available at https://www.avma.org/sites/default/files/2020-08/AntimicrobialResistanceFullReport.pdf​

4. Antimicrobial stewardship definition and core principles. American Veterinary Medical Association. Accessed September 8, 2020. https://www.avma.org/resources-tools/avma-policies/antimicrobial-stewardship-definition-and-core-principles​

5. University of Minnesota. Handbook of Antimicrobial Stewardship in Companion Animal Veterinary Settings. University of Minnesota; 2020. Available at https://arsi.umn.edu/handbook.