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ANTIMICROBIAL STEWARDSHIP
ANTIMICROBIAL STEWARDSHIP continued from page 1
in dogs and cats). 5 Upcoming revised Canadian Veterinary Medical Association prudent antimicrobial use guidelines expand on a previous document, adding more depth, broad ASP concerns and expanding the scope to include dogs, cats and small ruminants.
Implementation of an antimicrobial stewardship program
Antimicrobial stewardship is a multi-modal approach to the practice of medicine that goes beyond drug, dose and duration. An ASP obviously has a major emphasis on specific aspects of drug prescription and use. However, a strong ASP has broader approaches to reduce the need for antimicrobials through preventing disease and promptly identifying patients that require antimicrobials and those that do not. It also fosters communication and education of all players in the prescribing cascade( attending clinician, diagnostic laboratory, pharmacy, owner) to facilitate optimal use and remove pressures to use antimicrobials in situations where they are not indicated. Virtually all clinicians practice some form of antimicrobial stewardship on a daily basis, through decisions about when and how to use antimicrobials, and through measures taken to reduce the risk of disease. Therefore, implementation of an ASP should not be approached as a paradigm shift, but rather an evolution of core principles of veterinary medicine.
Antimicrobial stewardship can be employed in any veterinary practice. The approach to an ASP will vary greatly between facilities, based on a range of factors such as the nature of the caseload, the prevalence of resistant pathogens, the current state of antimicrobial use, access to specialists, access to a pharmacist, clinician motivation, management motivation and level of understanding of the issues. Yet, any practice can implement some components of an effective ASP with little effort, time, cost or access to other personnel. Often, starting with some easy measures( low
hanging fruit) is useful to facilitate acceptance of change, with addition of new measures over time as people realize the potential benefits, have increased awareness and understand that an ASP is meant to help, not hamper, patient care.
Why should veterinary medicine embrace antimicrobial stewardship?
There is no doubt that AMR is here to stay. As a result, scrutiny of antimicrobial use in veterinary medicine will continue( and probably increase). The impact of antimicrobial use in animals on AMR in humans is unknown, but it is impossible to deny that a link is present. As public awareness increases, the pressure to‘ do something’ will also increase. Veterinary medicine is at a crossroad in our approach to antimicrobial use and stewardship. One path entails veterinary medicine taking a leading role in antimicrobial stewardship, optimizing antimicrobial use in animals and demonstrating that the issues are being taken seriously and acted upon. The other entails limited voluntary change, something that will almost certainly ultimately result in change being enforced from outside. Our relationship with antimicrobials will change over the next decade. A question veterinary medicine must answer is‘ who will direct that change’? Will it be guided internally, with veterinarians taking the lead( as physicians have done in human ASPs)? Or, will a lack of veterinary response lead to changes being enforced from outside sources, minimizing the role of the veterinarian in deciding how changes will be made to veterinary access and use of antimicrobials? Demonstration of a profession-wide commitment to antimicrobial stewardship will both improve the care of veterinary patients and help reduce the risk of external( and potentially un-informed) pressure. Rather than seeing change exerted from the outside in response to a public or political demand to‘ do something’, veterinarians will be best served by taking charge of the situation, so that informed changes can be made with interests of patients, the public, agriculture and
veterinarians well considered.
Examples of antimicrobial stewardship program resources:
Australian National Centre for Antimicrobial Stewardship https:// www. ncas-australia. org / BSAVA https:// www. bsava. com / Resources / Veterinary-resources / PROTECT Centers for Disease Control and Prevention https:// www. cdc. gov / antibiotic-use / healthcare / implementation / core-elements. html European Centre for Disease Control https:// ecdc. europa. eu / en / publications-data / directoryguidance-prevention-and-control / antimicrobialstewardship Infectious Diseases Society of America http:// www. idsociety. org / Stewardship _ Policy / Public Health Ontario https:// www. publichealthontario. ca / en / BrowseByTopic / InfectiousDiseases / AntimicrobialStewardshipProgram / Pages / Antimicrobial-Stewardship-Program. aspx Society for Healthcare Epidemiology of America https:// www. shea-online. org / index. php / practice-resources / priority-topics / antimicrobialstewardship
REFERENCES 1. Bronzwaer S, Lonnroth A, Haigh R. The European Community strategy against
antimicrobial resistance. Euro Surveill 2004; 9:1-3.
2. McEwen SA, Fedorka-Cray PJ. Antimicrobial use and resistance in animals. Clin Infect Dis 2002; 34 Suppl 3: S93-S106. 3. Page S, Prescott J, Weese S. The 5Rs approach to antimicrobial stewardship. Veterinary Record 2014; 175:207-208.
4. Prescott JF. Antimicrobial use in food and companion animals. Animal health research reviews / Conference of Research Workers in Animal Diseases 2008; 9:127-133.
5. Weese JS, Blondeau J, Boothe D, et al. Antimicrobial use guidelines for treatment
of urinary tract infections in dogs and cats: antimicrobial guidlines working group of the International Society for Companion Animal Infectious Diseases. Vet Med Int 2011; 4:1-9.
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