T - Types of drug and bacteria
Select appropriate drugs based on empirical use guidelines
Use cytology where possible
Consider the dose and pharmacokinetics of the drugs selected
Avoid empirical use of the highest priority critically important antimicrobials
E - Employ narrow spectrum drugs wherever possible
e.g. penicillin, rather than drug combinations.
C - Culture and sensitivity
Use bacterial culture promptly, especially when clinical response to empirical
use is less than expected or when long term therapy is likely to be required
T - Treat effectively
Using enough drug for long enough then stop
Standardize dosing frequency and dose rates across the practice,
acknowledging that sometimes dosing intervals licenced in the marketing
authorisation differ from current clinical evidence. As such it is important to
review the veterinary literature to determine optimal dosing here.
M - Monitor antimicrobial use, compliance and resistance
Undertake a clinical audit of antimicrobial use within your practice
Formulate a policy to record the use of ‘protected’ antimicrobials in your
practice
Formulate a policy to review antimicrobial susceptibility from any cultures
obtained within the practice
Audit emerging antimicrobial resistance and consider adapting guidelines for
empirical use.
E - Educate
Inform your team and your clients
Ensure that protocols and changes to protocols are cascaded through the
entire team
Educate your clients to reduce pressure for antimicrobial prescribing
The important underlying principle of this protocol was that it should be established at
a local practice level (or even within practices). Even the categorisation of antibiotics
as ‘PROTECTED or ‘AVOIDED should be established locally, although the WHO
highest priority antimicrobials were recommended as being classed as protected,
while those in category 3 of the EMA guidance as ‘AVOIDED’.
Experiences of PROTECT ME
The release of these protocols has been widely adopted by practices in the UK, with
over 66% of UK practices having adopted protocols based on the principles of this
policy (BEVA membership survey 2013). An audit of use in one clinical setting
demonstrated that use of quinolones fell by 97% after the adoption of persuasive
policies for antimicrobial use using the PROTECT ME documents (unpublished data).
A recent international survey of antibiotic use in equine practice (n=164) showed that,
of those who had adopted antibiotics use protocols, 78% had adopted the PROTECT
ME templates. These documents are available freely through a Creative Commons
Licence at beva.org.uk/protectme.
Of the category 3 (EMA) or AVOIDED (BEVA) antibiotics, the carbepenems are
currently the most relevant to equine practice. The importance of the carbepenems to
human health relates to their use in the treatment of Enterobacteriaceae. While the
pharmacokinetics of imepenem has been established in the horse18, the use in
equine practice is currently uncommon. The survey of antibiotic usage described
above identified that imepenem has been used in 9.4% of responding clinics, with
15-‐18
February
2016
East
London
Convention
Centre,
East
London,
South
Africa
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