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Antibiotics - Developing a prescription for change

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01 August 2017, at 12:00am

RICHARD GARD reports on a recent meeting which considered the issues of critically important antibiotics and the development of a toolkit which aims to transform medicine use on-farm

A DOZEN VETERINARY SURGEONS from various locations in England and Wales gathered at the headquarters of the British Cattle Veterinary Association. The task was to experience and discuss a toolkit for transforming medicine use on the farm. The technical understanding that underpins the toolkit was reviewed in depth. There were many questions and the science of resistance was of interest, but this topic will have to be addressed at another time. However, the over-riding conclusion was that because we don’t have all the answers in practice doesn’t mean that we can’t do anything to improve medicine use. A quotation from Edmund Burke (1729-1797) guided the day: “Nobody made a greater mistake than he who did nothing because he could only do a little.” Professor David Barrett has issued a challenge for the UK dairy sector to stop using all 3rd and 4th generation cephalosporins and flouroquinolones by 2020. The prescribing of danofloxacin, enrofloxacin and marbofloxacin can be stopped immediately as they are not needed clinically. There is an issue of established use to be overcome with the cephalosporins that have a zero milk withholding time. The experience of individual veterinary practices is that, within two  years, critically important antibiotics can be removed from the practice pharmacy. The discussion is not “can it be done?” but “what is the most successful approach?” The group understood that antimicrobial resistance in livestock can influence human flora by food chain contamination, farm run-off into water courses, direct interaction with farm animals and manure  contamination of pasture. In assessing the risk to humans, from animal infections that are drug-resistant, there may have been an underestimation of environmental interactions. Cattle production is now tasked with employing husbandry and disease prevention methods that are not reliant on antimicrobials. The changes that are introduced need to be long-lasting and reflect responsible use of medicines together with farm production efficiency. In practice, there is a mix of veterinary prescription and farmers asking for therapies that have been historically used. One of the key observations is that many farmers are unaware of what are critically important products and once aware accept the concept of responsible use. Taking the time and trouble to explain the practice attitude to critically important antibiotics to farmers and achieving the support of  all clinicians within the practice has been shown to be achievable with targeted application. Success is unlikely if the topic is left to drift in the hope of a worthwhile conclusion. There are various definitions of the responsible use of medicines, but the group settled on “achieve a cure without contributing to resistance”. The aim is to reduce overall medicine use while improving animal health. This approach has been declared at national level, but now the target applies to individual  veterinary practices and individual farms. Although it is accepted that the main driver of antimicrobial resistance in people remains the use of antimicrobials in human medicine, there is increasing concern about the transfer of resistant infections from animals to people. It was at this point that the veterinary understanding of resistance gene transfer was found to be in need of updating, but had to be left for another time. However, it was established that because of co-selection for resistance between antibiotics, it is necessary to target red section of all antibiotic use, not just critically important antibiotics.

Who is responsible?

A major point of clarification was “who is responsible for responsible medicines use?” It is clear that veterinary surgeons are the gatekeepers for antibiotic use on-farm, but that farmers are often the main users. Selecting the right antimicrobial and treating the right cases is the way to optimise treatment outcomes. Practices that are now auditing and benchmarking each client’s herd are showing a broad range of clinical cases and product use. This information is proving of direct value in influencing clients to consider improvements in their antimicrobial use. Monitoring allows the farmer and the practice to make sure that disease control is moving forward. It was highlighted that this process was easier with dairy herds and difficult with many beef herds. However, the volume use of antibiotics is often with the dairy enterprises. Withdrawing the critically important products from the practice pharmacy has shown a fall in the profit from antibiotic sales, but an increase in vaccine sales and consultancy for buildings and management. The
farmer requires a farm- and vetspecific promotion to drop their use of critically important products. General, well-intentioned statements of national or international benefits are not enough to cause immediate change. 

Red, bad and naughty

It is anticipated that veterinary surgeons will be adopting the idea of “red drugs”, “bad drugs” and “the naughty drug shelf ”. Physically placing products of resistance risk in a red category, with their own shelf, has highlighted the topic to everyone within the practice and onwards to clients. This approach also overcomes the education issue of unawareness of the critically important products. If the farmer is using a red product then a review is highlighted. Farmers who are not using red products, but with a good disease control record, are then highlighted within the benchmarking. A chart showing the purchases by the practice of red drugs with a clear rapid downward trend is a clear indication of success. This whole approach also raises the need to question attitudes to diagnosis and clinical awareness. Treating with antibiotics indicates bacterial involvement, but basic questions
arise whether antimicrobial therapy improves the prognosis. Much more can be anticipated about challenges to accepted use, particularly for pneumonia  in young healthy adults and immunocompromised animals. The group exhibited various attitudes to diagnosis and treatment, but it became clear that in targeting responsible antibiotic use there are challenges to existing approaches to treatment. Defensive prescribing, where antimicrobials are administered “just in case”, were discussed and considered questionable although the pressure to “do something” is real. The application of non-steroidals, with a review after 24 hours and then antimicrobials if necessary, has value. Early assessment of cases and the means to achieve this was seen as important. Sharing knowledge with colleagues and proceeding in an
evidence-based way is a successful approach. establishing genuine treatment failures will become more important because apparent poor response is a driver for the use of critically important antimicrobials. Two sources of information related to prescribing are bestbetsforvets.org and ebvmlearning.
org. An important part of the change process is motivation. The group considered that change is not easy. Three hot topics were teased out: 1.
“But we’ve always done it this way”, “but that won’t work on my farm”, “but that doesn’t make sense for my system”; 2. “I don’t have a problem”, “I’m not interested in changing”, “I don’t want to do this now”; and 3. “This cow got worse”, “she’s died and it’s your fault”, “if only you had treated her properly”. This area has been extensively researched and for some vets the whole area of applying different approaches is an unfamiliar aspect.  fundamentally, people like to be listened to and many difficult situations arise because of misunderstandings about aims. Listening to the client rather than advising does not sit easily with many vets, but where there is mutual understanding between the vet and the farmer about aims, solutions are forthcoming. “Active empathy” may be a veterinary term to understand.
The toolkit was presented by Professor David Barrett and Dr Kristen Reyher (University of Bristol), David Tisdall (University of Surrey) and Jenny Bellini (Friars Moor Veterinary Group). Observations from the pilot group will be considered in finalising the course, which will then be rolled out for the
benefit of veterinary practices and their clients. Some of the topics discussed are due to be part of BCVA Congress in October. Comments from practices
with experience of introducing prescription changes are very welcome (David.Barrett@bristol.ac.uk).