2. Category 2: Antibiotics with higher risk to public health (including
fluoroquinolones and 3rd/4th generation cephalosporins)
3. Category 3: Antibiotics not marketed for use in veterinary medicine (including
the carbepenems)
The EMA have called for responsible use of all classes of antimicrobials, and
consider that specific restrictions be placed on those in category 2 to be used only
when no alternatives exist. The current recommendation is that antibiotics in category
3 should be used only in exceptional circumstances and only in companion animals
and the horse. This classification system offers a more appropriate risk-based
approach compared to that proposed by the WHO.
Antimicrobial stewardship
Antimicrobial stewardship does not imply stopping the use of antibiotics, but
encourages effective use. Such programmes seek to optimise antimicrobial use to
maintain clinical outcomes while reducing antimicrobial therapy. Their development is
based on the philosophy of the use of the right antibiotic in the right clinical setting,
using ‘as little as possible but as much as needed’. In many clinical settings it is
inappropriate or impractical to await bacterial isolation and sensitivity testing,
therefore standard practice in human medicine is to develop strategies for first line
therapy of common clinical conditions. The ACVIM consensus statement1 calls for
vets to develop common case scenarios and develop standardize drug use
combinations ‘tailored for use in their practices’. The concepts of antimicrobial
stewardship are part of the AAEP prudent drug usage guidelines (2006)14.
The development of standardized antibiotic use guidelines are commonplace in
human healthcare settings and, through systematic reviews, have been shown to
reduce antibiotic resistance and hospital acquired infections while improving clinical
outcomes15. There are two methods of promoting antimicrobial stewardship; either
persuasive, providing guidance to prescribers or restrictive, limiting the use of certain
antibiotics and in some cases only allowing their use with approval by infection
control specialists. While the latter method results in more rapid responses both
methods result in the same result after 6 months. There is limited historical evidence
of the use of such protocols in equine practice. One study identified only 1% of
equine practices that had employed standard use guidelines, in line with the ACVIM
consensus statement16. In 2012, a template for the development of responsible use
of antimicrobials was deployed by The British Equine Veterinary Association under
the acronym PROTECT ME17. It was developed based upon the ACVIM consensus
statement and identified the following steps for the creation of local antibiotic use
protocols.
P – Practice Policy
Develop protocols for antimicrobial usage based on common clinical
scenarios
Classify key antibiotics as PROTECTED or AVOIDED.
R – Reduce Prophylaxis
Develop rational protocols for prophylaxis
Define
prophylaxis
for
surgical
procedures
whether
CLEAN,
CONTAMINATED or HIGH RISK
Rationalise disease control for common conditions
O - Other options
Reduce or replace antimicrobials with other methods for bacterial reduction
• Utilise wound debridement / lavage
• Consider topical preparations or local intravenous administration
15-‐