Antimicrobial stewardship in companion animal practice: an implementation trial in 135 general practice veterinary clinics.

BACKGROUND: Antimicrobial stewardship programmes (ASPs) have been widely implemented in medical practice to improve antimicrobial prescribing and reduce selection for multidrug-resistant pathogens. OBJECTIVES: To implement different antimicrobial stewardship intervention packages in 135 veterinary practices and assess their impact on antimicrobial prescribing. METHODS: In October 2018, general veterinary clinics were assigned to one of three levels of ASP, education only (CON), intermediate (AMS1) or intensive (AMS2). De-identified prescribing data (1 October 2016 to 31 October 2020), sourced from VetCompass Australia, were analysed and a Poisson regression model fitted to identify the effect of the interventions on the incidence rates of antimicrobial prescribing. RESULTS: The overall incidence rate (IR) of antimicrobial prescribing for dogs and cats prior to the intervention was 3.7/100 consultations, which declined by 36% (2.4/100) in the implementation period, and by 50% (1.9/100) during the post-implementation period. Compared with CON, in AMS2 there was a 4% and 6% reduction in the overall IR of antimicrobial prescribing, and a 24% and 24% reduction in IR of high importance antimicrobial prescribing, attributable to the intervention in the implementation and post-implementation periods, respectively. A greater mean difference in the IR of antimicrobial prescribing was seen in high-prescribing clinics. CONCLUSIONS: These AMS interventions had a positive impact in a large group of general veterinary practices, resulting in a decline in overall antimicrobial use and a shift towards use of antimicrobials rated as low importance, with the greatest impact in high-prescribing clinics.

Overcoming challenges in extracting prescribing habits from veterinary clinics using big data and deep learning.

Understanding antimicrobial usage patterns and encouraging appropriate antimicrobial usage is a critical component of antimicrobial stewardship. Studies using VetCompass Australia and Natural Language Processing (NLP) have demonstrated antimicrobial usage patterns in companion animal practices across Australia. Doing so has highlighted the many obstacles and barriers to the task of converting raw clinical notes into a format that can be readily queried and analysed. We developed NLP systems using rules-based algorithms and machine learning to automate the extraction of data describing the key elements to assess appropriate antimicrobial use. These included the clinical indication, antimicrobial agent selection, dose and duration of therapy. Our methods were applied to over 4.4 million companion animal clinical records across Australia on all consultations with antimicrobial use to help us understand what antibiotics are being given and why on a population level. Of these, approximately only 40% recorded the reason why antimicrobials were prescribed, along with the dose and duration of treatment. NLP and deep learning might be able to overcome the difficulties of harvesting free text data from clinical records, but when the essential data are not recorded in the clinical records, then, this becomes an insurmountable obstacle.

Appraisal of the Australian Veterinary Prescribing Guidelines for antimicrobial prophylaxis for surgery in dogs and cats.

The Australian Veterinary Prescribing Guidelines for antimicrobial prophylaxis for surgery on dogs and cats are evidence-based guidelines for veterinary practitioners. Validation of these guidelines is necessary to ensure quality and implementability. Two validated tools, used for medical guideline appraisal, were chosen to assess the guidelines. The terminology from the GuideLine Implementability Appraisal (GLIA) and the Appraisal of Guidelines for Research and Evaluation version 2 (AGREE II) were adapted for use by veterinarians. A two-phase evaluation approach was conducted. In the first phase of the evaluation, the GLIA tool was used by two specialist veterinary surgeons in clinical practice. The results of this phase were then used to modify the guidelines. In the second phase, the AGREE II tool was used by 6 general practitioners and 6 specialists to appraise the guidelines. In phase 1, the specialist surgeons either agreed or strongly agreed that the guidelines were executable, decidable, valid and novel, and that the guidelines would fit within the process of care. The surgeons were neutral on flexibility and measurability. Additional clarity around one common surgical procedure was added to the guidelines, after which the surgeons agreed that the guidelines were sufficiently flexible. In phase 2, 12 veterinarians completed the assessment using the AGREE II tool. In all sections the scaled domain score was greater than 70%. The overall quality of the guidelines was given a global scaled score of 76%. This assessment has demonstrated that the guidelines for antimicrobial prophylaxis for companion animal surgery are valid and appear implementable.

Survey of veterinary prescribing for poultry disease.

BACKGROUND: To enable better antimicrobial stewardship, it is important to know what the patterns of prescribing behaviour are and what diseases or reasons antibiotics are being prescribed. A prescribing guideline (i.e. recommended best practice for writing prescriptions) developed by the Australian poultry veterinarians exists. However, it is not a prescribing guideline detailing treatments for the commonly observed bacterial diseases in commercial poultry. METHODS: An online survey was deployed to all registered veterinarians and members of the Australian Veterinary Poultry Association to identify prescribing behaviours for the most frequently observed bacterial diseases of poultry. RESULTS: A total of 39 survey responses were received. Most surveys were started but not completed; 13 (33%) were completed with 18 (46%) containing some information on prescribing. The most frequent treatment responses were for Escherichia coli in both layers and broilers, chronic respiratory disease (CRD), fowl cholera and spotty liver in layers and necrotic enteritis in broilers. Treatments described were for products registered for poultry use, within the recommended label dose and duration of treatment (Tables 1, 2). Unsurprisingly, tetracyclines and amoxycillin, followed by lincomycin and trimethoprim sulfonamide products were the most frequently reported treatment options. Inappropriate treatments were reported for salmonellosis and one veterinarian recommended the use of enrofloxacin for the treatment of fowl cholera. CONCLUSION: Information provided by respondents will enable the initial development of prescribing guidelines for both commercial and small poultry flocks. Importantly, it identified less than optimal prescribing behaviour for some diseases, a reliance on one class of antibiotic more than others and a failure to utilise all antimicrobial classes potentially available for treatment. Critically, the survey identified a lack of treatment options for bacterial disease in poultry. The most important bacterial diseases of poultry remain the same; effective alternatives for antibiotic treatment are required and old diseases, thought once gone, are reinventing themselves as problems for the future. Surveys of prescribing behaviours are essential for identifying diseases of high priority, changes in treatments and response to treatment and to identify areas for targeted antimicrobial stewardship, and research needs.

Using natural language processing and VetCompass to understand antimicrobial usage patterns in Australia.

BACKGROUND: Currently there is an incomplete understanding of antimicrobial usage patterns in veterinary clinics in Australia, but such knowledge is critical for the successful implementation and monitoring of antimicrobial stewardship programs. METHODS: VetCompass Australia collects medical records from 181 clinics in Australia (as of May 2018). These records contain detailed information from individual consultations regarding the medications dispensed. One unique aspect of VetCompass Australia is its focus on applying natural language processing (NLP) and machine learning techniques to analyse the records, similar to efforts conducted in other medical studies. RESULTS: The free text fields of 4,394,493 veterinary consultation records of dogs and cats between 2013 and 2018 were collated by VetCompass Australia and NLP techniques applied to enable the querying of the antimicrobial usage within these consultations. CONCLUSION: The NLP algorithms developed matched antimicrobial in clinical records with 96.7% accuracy and an F1 Score of 0.85, as evaluated relative to expert annotations. This dataset can be readily queried to demonstrate the antimicrobial usage patterns of companion animal practices throughout Australia.

Antimicrobial dosing for common equine drugs: a content review and practical advice for veterinarians in Australia.

BACKGROUND: Appropriate dosing with antimicrobial agents is critical for effective treatment and to prevent the development of antimicrobial resistance. METHODS: A review was undertaken of equine journal articles (Equine Veterinary Journal, Equine Veterinary Education, Australian Veterinary Journal, Australian Equine Veterinarian, Journal of Veterinary Internal Medicine and Journal of Equine Veterinary Science) between January 2015 and August 2018. Those with dosing regimens for procaine penicillin G, gentamicin or trimethoprim-sulfonamide in adult horses were examined and evaluated. Pharmacokinetics and -dynamics of these drugs were also reviewed. RESULTS & CONCLUSION: The most frequently reported doses for penicillin, gentamicin and trimethoprim-sulfonamide were 20-25,000 IU/kg, 6.6 mg/kg and 30 mg/kg, respectively. Veterinarians treating equine patients in Australia should be aware of the current recommended doses and inter-dosing intervals to ensure efficacy in therapy and to preserve the usefulness of these antimicrobials for the future.

Antimicrobial labelling in Australia: a threat to antimicrobial stewardship?

Antimicrobial resistance is a public health emergency, placing veterinary antimicrobial use under growing scrutiny. Antimicrobial stewardship, through appropriate use of antimicrobials, is a response to this threat. The need for antimicrobial stewardship in Australian veterinary practices has had limited investigation. A 2016 survey undertaken to investigate antimicrobial usage patterns by Australian veterinarians found that antimicrobial dose rates were varied and often inappropriate. Doses of procaine penicillin in horses and cattle were often low, with 68% and 90% of respondents, respectively, reporting doses that were unlikely to result in plasma concentrations above minimum inhibitory concentrations for common equine and bovine pathogens. Frequency of penicillin administration was also often inappropriate. Gentamicin doses in horses were largely appropriate (89% of dose rates appropriate), but 9% of respondents reported twice daily dosing. Amoxycillin and amoxycillin-clavulanate were administered at the appropriate doses, or above, to dogs and cats by 54% and 70% of respondents, respectively. Here, we explore the potential reasons for inappropriate antimicrobial dose regimens and report that antimicrobial labels often recommend incorrect dose rates and thus may be contributing to poor prescribing practices. Changes to legislation are needed to ensure that antimicrobial drug labels are regularly updated to reflect the dose needed to effectively and safely treat common veterinary pathogens. This will be especially true if changes in legislation restrict antimicrobial use by veterinarians to the uses and doses specified on the label, thus hampering the current momentum towards improved antimicrobial stewardship.

Antimicrobial susceptibility testing by Australian veterinary diagnostic laboratories.

BACKGROUND: The national strategy for tackling antimicrobial resistance highlights the need for antimicrobial stewardship in veterinary practice and for surveillance of antimicrobial susceptibility in veterinary pathogens. Diagnostic laboratories have an important role in facilitating both of these processes, but it is unclear whether data from veterinary diagnostic laboratories are similar enough to allow for compilation and if there is consistent promotion of appropriate antimicrobial use embedded in the approaches of different laboratories to susceptibility testing. METHODS: A cross-sectional study of antimicrobial susceptibility testing and reporting procedures by Australian veterinary diagnostic laboratories was conducted in 2017 using an online questionnaire. All 18 veterinary diagnostic laboratories in Australia completed the questionnaire. RESULTS: Kirby-Bauer disc diffusion was the method predominantly used for antimicrobial susceptibility testing and was used to evaluate 86% of all isolates, although two different protocols were used across the 18 laboratories (CLSI 15/18, CDS 3/18). Minimum inhibitory concentrations were never reported by 61% of laboratories. Common isolates were consistently reported on across all species, except for gram-negative isolates in pigs, for which there was some variation in the approach to reporting. There was considerable diversity in the panels of antimicrobials used for susceptibility testing on common isolates and no consistency was apparent between laboratories for any bacterial species. CONCLUSION: We recommend that nationally agreed and consistent antimicrobial panels for routine susceptibility testing should be developed and a uniform set of guidelines should be adopted by veterinary diagnostic laboratories in Australia.

Antimicrobials used for surgical prophylaxis by equine veterinary practitioners in Australia.

BACKGROUND: Antimicrobials are widely used in Australian veterinary practices, but no investigation into the classes of antimicrobials used, or the appropriateness of use in horses, has been conducted. OBJECTIVES: The aim of the study was to describe antimicrobial use for surgical prophylaxis in equine practice in Australia. STUDY DESIGN: Cross-sectional questionnaire survey. METHODS: An online questionnaire was used to document antimicrobial usage patterns. Information solicited in the questionnaire included demographic details of the respondents, the frequency with which antimicrobials were used for specific surgical conditions (including the dose, timing and duration of therapy) and practice antimicrobial use policies and sources of information about antimicrobials and their uses. RESULTS: A total of 337 members of the Australian veterinary profession completed the survey. Generally, the choice of antimicrobial was appropriate for the specified equine surgical condition, but the dose and duration of therapy varied greatly. While there was poor optimal compliance with British Equine Veterinary Association guidelines in all scenarios (range 1-15%), except removal of a nonulcerated dermal mass (42%), suboptimal compliance (compliant antimicrobial drug selection but inappropriate timing, dose or duration of therapy) was moderate for all scenarios (range 48-68%), except for an uninfected contaminated wound over the thorax, where both optimal and suboptimal compliance was very poor (1%). Veterinarians practicing at a university hospital had higher odds of compliance than general practice veterinarians (Odds ratio 3.2, 95% CI, 1.1-8.9, P = 0.03). MAIN LIMITATIONS: Many survey responses were collected at conferences which may introduce selection bias, as veterinarians attending conferences may be more likely to have been exposed to contemporary antimicrobial prescribing recommendations. CONCLUSIONS: Antimicrobial use guidelines need to be developed and promoted to improve the responsible use of antimicrobials in equine practice in Australia. An emphasis should be placed on antimicrobial therapy for wounds and appropriate dosing for procaine penicillin.

Antimicrobial Prescribing in Dogs and Cats in Australia: Results of the Australasian Infectious Disease Advisory Panel Survey.

BACKGROUND: Investigations of antimicrobial use in companion animals are limited. With the growing recognition of the need for improved antimicrobial stewardship, there is urgent need for more detailed understanding of the patterns of antimicrobial use in this sector. OBJECTIVES: To investigate antimicrobial use for medical and surgical conditions in dogs and cats by Australian veterinarians. METHODS: A cross-sectional study was performed over 4 months in 2011. Respondents were asked about their choices of antimicrobials for empirical therapy of diseases in dogs and cats, duration of therapy, and selection based on culture and susceptibility testing, for common conditions framed as case scenarios: 11 medical, 2 surgical, and 8 dermatological. RESULTS: A total of 892 of the 1,029 members of the Australian veterinary profession that completed the survey satisfied the selection criteria. Empirical antimicrobial therapy was more common for acute conditions (76%) than chronic conditions (24%). Overall, the most common antimicrobial classes were potentiated aminopenicillins (36%), fluoroquinolones (15%), first- and second-generation cephalosporins (14%), and tetracyclines (11%). Third-generation cephalosporins were more frequently used in cats (16%) compared to dogs (2%). Agreement with Australasian Infectious Disease Advisory Panel (AIDAP) guidelines (generated subsequently) was variable ranging from 0 to 69% between conditions. CONCLUSIONS AND CLINICAL IMPORTANCE: Choice of antimicrobials by Australian veterinary practitioners was generally appropriate, with relatively low use of drugs of high importance, except for the empirical use of fluoroquinolones in dogs, particularly for otitis externa and 3rd-generation cephalosporins in cats. Future surveys will determine whether introduction of the 2013 AIDAP therapeutic guidelines has influenced prescribing habits.

Hyponatraemic encephalopathy in azotaemic neonatal foals: four cases.

CASE SERIES: Four neonatal foals were presented, over a 2-year period, (2011-2012) with aimlessly walking, head pressing, 'chewing gum' seizures and ataxia. The neurological lesion was consistent with increased intracranial pressure in all cases. All foals had severe hyponatraemia and azotaemia identified on biochemistry. Hyponatraemia was transient in 3/4 cases, with the foal in the final case requiring long-term sodium supplementation. Three foals survived to hospital discharge; one was euthanased because of anuric renal failure and one of the surviving foals was euthanased with septic osteomyelitis 2 weeks after initial discharge. CONCLUSION: Correction of the sodium deficit resulted in resolution of the neurological signs in these foals; however, azotaemia was slow to resolve, suggesting acute renal failure.

Effects of gestational age on physical findings of immaturity, body weight, and survival in neonatal alpacas (2002-2010).

BACKGROUND: Gestational duration is highly variable in camelids (reference range 330-360 days), and a definition for prematurity has not been established. Anecdotally, it is suggested that crias born outside of this have increased incidence of physical findings of immaturity (tendon laxity, floppy ears, and unerupted teeth) and need increased intensive support in the neonatal period. OBJECTIVES: Low gestational age (<330 days) is associated with physical findings of immaturity, low birth weight, more intensive and expensive care, but not decreased short-term survival. ANIMALS: A total of 130 alpacas presented to the University of Wisconsin. METHODS: Retrospective study of all neonatal crias <1 month of age. RESULTS: Of 130 neonatal alpacas presented, 86 (66%) had gestational age recorded (range 312-393 days). There were 16 (18.6%) crias with gestational age below 330 days. Crias born before 330 days were lighter at birth (mean 6.4 kg, SD 1.3 kg) than those born after 330 days (mean 7.4 kg, SD 1.7 kg, P = .002). Clinically immature crias had lower birth weights (mean 6.5 kg, SD 1.5 kg) than physically mature crias (mean 8.8 kg, SD 3.2 kg, P = .05). Survival rates were similar in all groups (premature 77%, mature 88%, P = .12). However, treatment costs were higher in crias born prior to 330 days with physical findings at birth consistent with immaturity compared with gestationally mature crias and those born prior to 330 days but with a physically mature appearance. CONCLUSIONS: Crias born before 330 days and those with physical findings of immaturity have a good prognosis, but require more intensive care, resulting in higher treatment costs.

Renal agenesis in an alpaca cria.

A 4-day-old alpaca cria presented for inappetence that responded to symptomatic treatment. The cria re-presented with acute signs of inappetence and azotaemia. The azotaemia persisted despite intravenous fluid therapy. There was no right kidney on ultrasound and there appeared to be perirenal oedema around the left kidney. A diagnosis of right renal agenesis and acute renal failure of the left kidney was made. The cria failed to improve and was euthanased. Necropsy examination confirmed right renal agenesis and agenesis of the right ureter and right renal artery. A section of left kidney submitted for histological examination revealed diffuse, acute, marked tubular degeneration and nephrosis. The cause of the renal failure in the left kidney was not determined.