Commentary Commentaire Taking care of our professional responsibility to prescribe — for ourselves, our children, and our community Kelly M. Butler OVC 1986
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ecent Sunday morning conversations about antimicrobial resistance (AMR) on CBC reveal that the use of antibiotics on pets is still flying under the public radar. This oversight does not absolve clinicians of our responsibility. How do we veterinarians contribute to the looming menace of what will become ineffective antibiotics moving our Canadian population from about 7% of deaths due to infection to greater than 50% as estimated by the Chief Medical Officer of England? This would be a step back into the Middle Ages. Well, those nations in which antibiotics are available on street corners — India, China, and the continent of Africa will get there first — we will have a preview. Of course many of those antibiotics are counterfeit, but that is a separate discussion. First of all, it might be helpful to admit that we veterinarians are in a clear position of conflict every time we script an antibiotic for a large dog, perhaps $30 or $40 goes into our pockets apart from the prescription fee. This is not the case with physicians. Well, really what harm do antibiotics for pets do? Cefovecin or amoxicillin/clavulanic acid for 2 weeks in a cat for an abscess? Doxycycline for 4 weeks for a dog that has a high Borrelia burgdorferi titer (with no clinical signs)? “Prophylactic” antibiotics for a week for a young healthy dog with a cut on his paw? Oral antibiotics for every hot spot (not pyoderma)? Post spay/neuter injections of “Duplo”? As a locum I have observed many practices following several of these protocols but especially the latter which has perhaps been carried over from the first veterinarian for whom the owner/clinician worked. Not a bad idea maybe for the fellow who in early practice I saw neutering a cat with his bare hands and a cigarette hanging out of his mouth. Over 25 years ago I recall losing a client because she asked whether her cat which had just been neutered would have an antibiotic. “No, I conducted an aseptic surgery on your cat. You may call me anytime Mrs. Smith — here is my home number. If Snowy stops eating or causes you any worry I will see him and not charge any fee including for medications.” The now slightly irate client exclaimed “Well Dr. Jones always gave antibiotics after his surgeries!” I declined to comment further. Formerly on staff as a virologist/field epidemiologist with the WHO in the Western Pacific; previously and currently a practice owner and locum; former avid consumer of antibiotics necessitated by chemo and radiation therapy. Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.
CVJ / VOL 56 / DECEMBER 2015
The Infectious Diseases Society of America recently (2014) updated clinical practice guidelines related to management of skin and soft tissue infections, no doubt in no small part to get ahead of the challenges of antibiotic resistant pathogens and the increasing number of immunocompromised patients requiring antibiotic treatment for a spectrum of ailments. Incision and drainage only is appropriate treatment for abscesses in the absence of clinical illness: fever, tachycardia, or tachypnea. But of course, the clinician is entitled to their clinical judgment. When we veterinarians make that call, we might consider that the list of antimicrobial resistant organisms is longer than generally known, involving virtually all common skin and gut organisms (http://www.cdc.gov/drugresistance/biggest_threats.html) Where does our clinical judgment come in? There are as many considerations in veterinary medicine as in human medicine, but there are a few common uses: feline lower urinary tract disease (FLUTD) cats have essentially no bacteriuria according to sound veterinary research. Maybe we are not “charging” for the long acting penicillin injection but what exactly is that “insurance” on aseptically performed surgery doing? Abscesses are mentioned above, as is the response to elevated Borrelia burgdorferi antibodies in some practices. Scott Weese DVM, DVSc, DipACVIM, gently encouraged us in a recent continuing education (CE) lecture to not keep looking for the bacteria post urinary tract infection (UTI), rather if there are clinical signs then treat. He also recommends and refers to the science for shorter treatment courses when antibiotics are required. Too much information (TMI) as my children say, but last month, the course of antibiotics scripted for me for a UTI was for 5 days. So far so good. The science is shifting in veterinary dentistry from providing antibiotics for dental procedures, where they should be the exception rather than the rule. Typically in our profession, there is not enough research conducted directly on pets but we know that the species we deal with are in close proximity to their owners. They share their microbes directly with their humans whether by kisses or simply years of cohabitation. Our patients routinely share their bacteria/viruses with acquaintances in the dog park or along alley fences and so they also share their little packets of antimicrobial resistance with each other and their humans. Imagine all the sharing with the owner who has kept 3 or 4 pets at a time over a 70-year life span — that’s about the length of time we have had antibiotics in our toolkit. Each time we decide to prescribe antibiotics we might well consider the implications not only for our patients, which will be significant, but also for ourselves, our children, and our community in the long-term. 1293
R
ecent Sunday morning conversations about antimicrobial resistance (AMR) on CBC reveal that the use of antibiotics on pets is still flying under the public radar. This oversight does not absolve clinicians of our responsibility. How do we veterinarians contribute to the looming menace of what will become ineffective antibiotics moving our Canadian population from about 7% of deaths due to infection to greater than 50% as estimated by the Chief Medical Officer of England? This would be a step back into the Middle Ages. Well, those nations in which antibiotics are available on street corners — India, China, and the continent of Africa will get there first — we will have a preview. Of course many of those antibiotics are counterfeit, but that is a separate discussion. First of all, it might be helpful to admit that we veterinarians are in a clear position of conflict every time we script an antibiotic for a large dog, perhaps $30 or $40 goes into our pockets apart from the prescription fee. This is not the case with physicians. Well, really what harm do antibiotics for pets do? Cefovecin or amoxicillin/clavulanic acid for 2 weeks in a cat for an abscess? Doxycycline for 4 weeks for a dog that has a high Borrelia burgdorferi titer (with no clinical signs)? “Prophylactic” antibiotics for a week for a young healthy dog with a cut on his paw? Oral antibiotics for every hot spot (not pyoderma)? Post spay/neuter injections of “Duplo”? As a locum I have observed many practices following several of these protocols but especially the latter which has perhaps been carried over from the first veterinarian for whom the owner/clinician worked. Not a bad idea maybe for the fellow who in early practice I saw neutering a cat with his bare hands and a cigarette hanging out of his mouth. Over 25 years ago I recall losing a client because she asked whether her cat which had just been neutered would have an antibiotic. “No, I conducted an aseptic surgery on your cat. You may call me anytime Mrs. Smith — here is my home number. If Snowy stops eating or causes you any worry I will see him and not charge any fee including for medications.” The now slightly irate client exclaimed “Well Dr. Jones always gave antibiotics after his surgeries!” I declined to comment further. Formerly on staff as a virologist/field epidemiologist with the WHO in the Western Pacific; previously and currently a practice owner and locum; former avid consumer of antibiotics necessitated by chemo and radiation therapy. Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ([email protected]) for additional copies or permission to use this material elsewhere.
CVJ / VOL 56 / DECEMBER 2015
The Infectious Diseases Society of America recently (2014) updated clinical practice guidelines related to management of skin and soft tissue infections, no doubt in no small part to get ahead of the challenges of antibiotic resistant pathogens and the increasing number of immunocompromised patients requiring antibiotic treatment for a spectrum of ailments. Incision and drainage only is appropriate treatment for abscesses in the absence of clinical illness: fever, tachycardia, or tachypnea. But of course, the clinician is entitled to their clinical judgment. When we veterinarians make that call, we might consider that the list of antimicrobial resistant organisms is longer than generally known, involving virtually all common skin and gut organisms (http://www.cdc.gov/drugresistance/biggest_threats.html) Where does our clinical judgment come in? There are as many considerations in veterinary medicine as in human medicine, but there are a few common uses: feline lower urinary tract disease (FLUTD) cats have essentially no bacteriuria according to sound veterinary research. Maybe we are not “charging” for the long acting penicillin injection but what exactly is that “insurance” on aseptically performed surgery doing? Abscesses are mentioned above, as is the response to elevated Borrelia burgdorferi antibodies in some practices. Scott Weese DVM, DVSc, DipACVIM, gently encouraged us in a recent continuing education (CE) lecture to not keep looking for the bacteria post urinary tract infection (UTI), rather if there are clinical signs then treat. He also recommends and refers to the science for shorter treatment courses when antibiotics are required. Too much information (TMI) as my children say, but last month, the course of antibiotics scripted for me for a UTI was for 5 days. So far so good. The science is shifting in veterinary dentistry from providing antibiotics for dental procedures, where they should be the exception rather than the rule. Typically in our profession, there is not enough research conducted directly on pets but we know that the species we deal with are in close proximity to their owners. They share their microbes directly with their humans whether by kisses or simply years of cohabitation. Our patients routinely share their bacteria/viruses with acquaintances in the dog park or along alley fences and so they also share their little packets of antimicrobial resistance with each other and their humans. Imagine all the sharing with the owner who has kept 3 or 4 pets at a time over a 70-year life span — that’s about the length of time we have had antibiotics in our toolkit. Each time we decide to prescribe antibiotics we might well consider the implications not only for our patients, which will be significant, but also for ourselves, our children, and our community in the long-term. 1293
