Article

Introduction

Veterinary antibiotic use can lead to the development of antimicrobial resistance (AMR) in animal and human populations, and there is also a growing body of evidence that small animal drugs may be impacting the wider environment. This final article in our three-part series suggests future steps to safeguard drug efficacy and environmental protection. 

The international outlook 

There are two main approaches to effective drug stewardship: 

a) enablement methods and b) legislative action. 

Enablement approaches are based on prescriber education. The role of guidelines to promote rational antimicrobial use has been discussed in the previous article in this series, but (as with all fallible beings) veterinarians may not adhere to the recommendations in these guidelines as often as they should (1,2). Furthermore, veterinarians typically report better prescribing protocols (i.e., in line with guidelines) than they exercise in practice (3,4). In the UK, the use of benchmarking (to detail how a practice’s antimicrobial use compared to other similar practices) was effective in bringing down prescription rates of highest-priority critically important antimicrobials, suggesting that comparison with peers may motivate altered prescribing patterns (5). Currently, most countries rely on the voluntary engagement with stewardship initiatives, and in theory at least, this approach preserves prescriber autonomy and protects animal welfare while maintaining access to essential treatments and promoting prudent use to safeguard future efficacy.

Legislative approaches, such as the European Union Regulation (2019/6), restrict access to certain antimicrobials; indeed, some European countries have already banned the use of a subset of EMA (European Medicine Agency) category A antimicrobials altogether (e.g., vancomycin and the carbapenems) and require bacterial culture and appropriate susceptibility test results before prescribing EMA category B drugs. There are some exclusions to this, such as cases where sampling could endanger the pet’s health, if the pathogen cannot be cultured, or where there is no suitable method for determining pathogen susceptibility. The objective of these laws is to reduce resistance rates to these antimicrobials in humans through eliminating their exposure to the animal reservoir. Future extension of the list of banned antimicrobials – to include fluoroquinolones or potentiated aminopenicillins – could limit therapeutic options for serious bacterial infections in pets, compromising their health and well-being.  

This type of legislation has prompted a significant increase in antimicrobial susceptibility testing (AST) submissions to veterinary diagnostic laboratories in both France and Germany (6,7). It has also been associated with a reduced use of fluoroquinolones and cefovecin (8). In contrast, an older study of UK veterinarians working without legal restriction found that AST was only performed in five (0.4%) of 1,148 instances of cefovecin use in cats (9). 

Certain parasiticides, including fipronil and imidacloprid, are currently available for general sale in some countries, meaning that they can be purchased without a prescription or consultation with a suitably qualified professional. There have been calls to review access to parasiticides and bring their supply under tighter control to reduce environmental contamination (10), and some countries (e.g., Switzerland) are taking action to limit access by making some of these products prescription-only (11).

Antimicrobial use metrics

Measuring antimicrobial use (or sales) is crucial for evaluating stewardship strategies. By 2030, all EU states must report standardized antimicrobial use data for all species, including pets. Efforts to meet this requirement have met with varying success so far – veterinarians in Spain went on strike following the introduction of a new national data recording system due to the very high financial penalties for non-compliance (up to 1.2 million euros). Data collection poses multiple other challenges, including the calculation of the amount of antimicrobial used and the mass of the total population into which it is administered. Data collated by the UK Veterinary Medicines Directorate has allowed monitoring of national trends since 2014 (Figure 1) and greater granularity may soon reveal the impact of national stewardship measures. 

Veterinary practices and corporate groups can also collate usage data. Linking antimicrobials to specific indications would help tailor future educational initiatives, and could highlight where there is inappropriate overuse. Assessing appropriateness of antimicrobial use requires case details that may be missing from records, but nonetheless, with improved understanding of the clinical drivers of antimicrobial prescription, it may be possible to adapt guidelines so that they reflect the realities of veterinary practice and encourage targeted reductions where possible. 

Antimicrobial and environmental surveillance 

The companion animal sphere is lagging other sectors in AMR surveillance. The European Antimicrobial Resistance Surveillance Network for Veterinary Medicine (EARS-Vet) collects surveillance data from EU countries (12), and a UK project led by the University of Liverpool is underway to collate similar information. These programs aim to deliver a clearer picture of resistance trends, enabling more informed decision-making and improving overall stewardship efforts. However, both programs require testing and reporting methodologies to be harmonized. 

Environmental monitoring of parasiticides, including fipronil and imidacloprid, is essential to evaluate contamination levels and intervention effectiveness. Expanding research on alternative sinks and sources of parasiticide emissions, such as soil pollution, is essential to prevent “regrettable substitution,” where the widespread use of one harmful chemical is replaced by another with similar or worse impacts. Additionally, monitoring resistance to pet parasiticides is crucial for ensuring their long-term efficacy. 

Future objectives for guideline development

More guidelines are under development to incorporate systematic analyses of the existing evidence base, including more detailed guidance on responsible small animal parasiticide use. The European Network for the Optimisation of Veterinary Antimicrobial Therapy (ENOVAT) has published recommendations for managing acute diarrhea in dogs, and guidelines for surgical antimicrobial prophylaxis are imminent. These resources are the product of an international collaboration that fosters shared learnings and the exchange of experience, and are created using a standardized methodology (the AGREE – Appraisal of Guidelines for Research and Evaluation – framework). This ensures transparency and stakeholder engagement, including using pet owners to validate the proposed outcomes (e.g., what change in the duration of diarrhea is meaningful to a pet owner?). Future guidelines must remain adaptable, incorporating new findings via online or app-based updates; the Firstline app from Ontario Veterinary College* is an early example of this approach.

*https://firstline.org/#:~:text=Firstline%20is%20a%20health%20technology,With%20you%2C%20we%20win! 

The role of education 

Education of both pet owners and veterinary professionals has a vital part to play in overcoming obstacles that hinder optimal prescribing. Promotion of judicious antimicrobial use requires multiple strategies, and the most important of these is owner education. Managing a client’s expectations when they visit the clinic is essential (Figure 2); if pet owners are informed about the risks of pharmaceutical overuse (such as AMR and environmental contamination) then hopefully their expectations can be aligned with best practice. These discussions can however take time, so extended consultations (particularly at the primary puppy or kitten consultation stage, or when starting a pet healthcare plan) may be needed to facilitate shared decision-making and reduce unnecessary prescriptions of many drugs. Owners often expect immediate interventions, and may presume antimicrobials are needed for many common ailments. The assumption is that a prescription equates with proactive care, and the veterinarian may feel pressure to dispense antimicrobials and other drugs unnecessarily. However, several studies have shown that veterinary advice is respected, and many clients are now aware of AMR (13). 

In addition, support tools such as a non-prescription form (Figure 3) can help the clinician to engage with pet owners and conclude a consultation without prescribing antimicrobials. There is also an owner education animation which has been shown to increase awareness of the impact of AMR, and pet owners that view the video prior to consultation are more likely to support measures in line with antimicrobial stewardship* (Figure 4) (14). These freely available resources can be accessed online**. 

*https://www.youtube.com/watch?v=4ApEAfN4dWU

** www.bsavalibrary.com/content/book/10.22233/9781913859312 

It is also important to provide resources to assist owners in administering medications correctly; this can reduce reliance on long-acting antimicrobials that may be chosen for convenience. When asked, many owners report that they believe that they are able to give tablets and liquid medications, despite veterinarians’ views on this (13). If owners are shown how to give a tablet to a cat (Figure 5) then it should be routine to check in with them after initiating antimicrobial therapy, so that any difficulties with administration can be dealt with promptly. This training of owners also requires ongoing professional development and supportive peer networks within the veterinary team, as discussed below.

Campaigns such as the UK’s Veterinary Antibiotic Amnesty* prompt awareness by encouraging clients to return any unused or out of date antibiotics (15). This allows the correct and safe disposal of medications, which will avoid environmental contamination and help prevent antimicrobial resistance due to inappropriate disposal. The organizers provide a campaign toolkit with a wide range of resources that practices can access; these include posters, client hand-outs, guidelines on how to run the campaign, and pre-written content for practice newsletters and social media channels. The amnesty provides an annual platform to start conversations with pet owners about the issues of antimicrobial stewardship. 

*www.rumacae.org.uk 

Educating veterinarians

From undergraduate curriculum setting to continuing professional development of experienced practitioners, the education of veterinarians in antimicrobial stewardship is also vital. Such stewardship requires an understanding of microbiology, pharmacology, epidemiology and a good grounding in client management. Simple aids such as mnemonics (e.g., SODAPOP = Source and Organism, Decide to treat, Antimicrobials, Patient, Options, and Plan) make good learning tools for many students (16). For veterinarians in primary care or specialist practice, it is known that just providing guidelines has little effect on the frequency of AMR (1,2); however, practical interventions have been shown to have a positive outcome (17), and for academic clinicians, future directions of clinical research have recently been defined (18). There are now many educational resources available to help, with a few examples provided in Table 1.

Table 1. Some examples of educational resources; the list is far from complete and there are many other good resources available online.

Other factors that may affect how a clinician prescribes medication, and may need to be addressed, include the following:

i. Time constraints: Limited consultation times may prevent thorough diagnostic investigations or risk assessments, leading to empirical prescribing of many drugs without appropriate clinical justification. 

ii. Fear of negative outcomes: Concerns about misdiagnosing or under-treating diseases, and the potential for client dissatisfaction or complaints, may drive more conservative (i.e., broader or more aggressive) use of drugs that are perceived (often incorrectly) to have few side effects (such as antimicrobials/ parasiticides).

iii. Established prescribing habits: Long-standing prescribing patterns and peer influences, especially on newer graduates, can perpetuate suboptimal practices in many areas of clinical practice. Entrenched prescribing behaviors need a lot of support to allow a shift towards more appropriate practices.

The role of leadership 

Effective leadership in the veterinary profession is essential to combat AMR, environmental contamination and the overuse of parasiticides, and requires a concerted effort to promote responsible pharmaceutical use. By promoting education, implementing policies, and advocating for responsible antimicrobial use, veterinary leaders can significantly reduce the impact of over prescribing while safeguarding both animal and public health. 

In the clinic, good leadership plays a crucial role in driving change, implementing drug stewardship programs (as part of a larger sustainability initiative) and fostering a culture of accountability and education. Practice leaders can act through establishing clear prescribing guidelines based on evidence-based recommendations, providing training and promoting a stewardship culture. Practice-wide policies will ensure that drugs are used judiciously, only when necessary, and with contextualized diagnostic investigations. A culture of accountability and reflection should include routine clinical audits, case discussions, and monitoring prescribing patterns to identify areas for improvement. Encouraging an open dialogue, where veterinarians feel supported in making responsible prescribing decisions without client pressure, is vital. Continuous professional development is essential for reducing inappropriate prescribing, and leaders should facilitate training programs for both clinicians and support staff, ensuring that all team members understand the risks associated with unsuitable prescribing and the importance of alternative management strategies. These may include infection prevention through vaccination and improved husbandry, or early detection through routine monitoring.

Leadership must also promote adherence to national and international stewardship frameworks, such as those provided by relevant professional bodies, and veterinary leaders can be advocates for effective stewardship on the larger political stage, in collaboration with others, and play a major role in influencing industry standards and policy. By engaging with professional bodies, regulatory agencies and research institutions, this will contribute to national sustainability strategies and ensure veterinary clinics align with best practices in pharmaceutical stewardship. 

Subscription pet healthcare plans

Pet owners often now expect routine provision of broad spectrum parasiticides, frequently provided through “health care plans” promoted by many veterinary practices (19). Sometimes owners sign up to these plans before they have had an opportunity to discuss an appropriate parasite risk assessment with their veterinarian, or without obtaining information on responsible parasiticide use. Incentives are sometimes provided to employee veterinarians by practice owners, based on the number of clients that enroll on a plan, and clinicians may feel pressurized to dispense these medications as clients have already paid for and are expecting them (20). Once prescribed, repeat medications are often posted out as a convenience for both the practice and the owner, but compliance is not monitored. This undermines the provision of balanced, evidence-based information to pet owners to support informed decision-making, and limits the clinical freedom of veterinary surgeons. There is an urgent need to reform this culture, and ways must be found to balance preventive care with evidence-based risk assessment to avoid overuse of pharmaceuticals.

Conclusion

Veterinary professionals have numerous tools to support rational antimicrobial stewardship, but engagement with these resources must increase to curb AMR and environmental damage. The ongoing development of guidance must incorporate current evidence as it becomes available, and policymakers are working to quantify antimicrobial use and AMR prevalence. If voluntary schemes promoting rational use fail to meaningfully improve outcomes, restrictive measures may follow. Urgent action is needed – as with climate change, every effort matters. In the words of Greta Thunberg, “no one is too small to make a difference”. Veterinarians and pet owners must work together to protect the environment and safeguard animal and human health for the future. By proactively optimizing antimicrobial and parasiticide use now, veterinarians can help prevent the need for restrictive legislation that could limit access to essential treatments.

References 

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