New study shows poor adherence to antibiotic guidelines in general practice in the UK
13 September 2023
A new study published in the August issue of the Journal of Small Animal Practice (JSAP) has found poor adherence to PROTECT and PROTECT ME antibiotic guidelines and overprescription of antibiotics in general practice in the UK1.
Antibiotics have spearheaded improvements in medical practice by protecting patients from the threat of bacterial infection, however, antimicrobial resistance (AMR) is an increasing problem in both veterinary and human medicine1,2.
To promote responsible antibacterial prescribing practises and reduce unnecessary use, antibiotic stewardship guidelines (PROTECT and PROTECT ME) were developed by the BSAVA and Small Animal Medicine Society (SAMSoc) in 2012. However, the extent to which these are followed and their influence on antibiotic use is unclear.
The new study published in JSAP assessed antibiotic prescription by vets in general practises in the UK before referral to Oncology and Internal Medicine departments, and explored whether prescriptions adhered to the PROTECT and PROTECT ME guidelines.
Medical records of dogs and cats who were referred to the Internal Medicine or Oncology departments of two hospitals between 2016 and 2019 were reviewed. Antibiotic use was assessed using the PROTECT and PROTECT ME Guidelines, and four ways the guidelines were not followed were objectively analysed: (1) evidence of underdosing; (2) cycling antibiotics; (3) inappropriate use of either fluoroquinolones or third and fourth generation cephalosporins; and (4) whether antibiotics were prescribed when not indicated by the guidelines.
Of the 917 animals included in the study (comprising 739 dogs and 178 cats), 53% had been prescribed antibiotics before referral for the condition they were subsequently referred for. For those animals who had received antibiotics, 70.8% of prescriptions did not comply with UK antibiotic stewardship guidelines. In particular, in almost half of cases (47.7%), antibiotics were prescribed for clinical signs for which antibiotics are not recommended by the guidelines.
Additionally, use of diagnostics to guide antibiotic use was infrequently used before referral. A bacterial culture and sensitivity was performed in 8.8% of animals that were prescribed antibiotics before referral, 1.9% of animals underwent cytology testing to guide antibiotic use, and both cytology and culture were performed in 4 cases. A bacterial aetiology was confirmed or suspected in 17.9% of cases that received antibiotics and were referred to the referral centre.
The study was limited in its retrospective design (which resulted in incomplete data for some cases) and a referral population bias, including limitation to Oncology and Internal Medicine disciplines. It’s also possible that veterinarians were following different antibiotic guidelines with alternative or conflicting recommendations to the PROTECT and PROTECT ME guidelines that were assessed.
Overall, the study highlights poor adherence to PROTECT and PROTECT ME antibiotic use guidelines and overprescription of antibiotics in dogs and cats referred to Oncology and Internal Medicine departments. It also found that use of diagnostics, including culture and cytology, to guide antibiotic use was infrequently used before referral, which may have contributed to overprescription of antibiotics.
Previous research on the drivers of antimicrobial resistance has reported a general lack of knowledge of the wider and longer-term effects of over- or mis-use of antibiotics and AMR among vets2. In the same study, vets attributed over-prescribing of antibiotics to several drivers, including perceived client satisfaction, commercial pressures to retain clients, the symbolic value of giving treatment, poor communication and persuasion skills and pet owner’s limited knowledge of appropriate antibiotic use2.
The authors of the latest study recommend that further investment in education on appropriate diagnostics, and antibiotic class and dosage choices, might lead to improved compliance with antibiotic stewardship guidelines and more responsible use of antibiotics.
In November, an Antibiotic Amnesty across veterinary practices and parts of the NHS will be taking place to help protect the effectiveness of antibiotics and reduce environmental pollution. During the amnesty, participating veterinary practices are asked to encourage pet owners to return out-of-date and unused antibiotics to their vet practice for safe disposal.
Keep an eye out for further details in the coming weeks. You can register your interest for 2023 here.
Further information and resources
BSAVA has the following resources on the responsible use of antibacterials:
- A downloadable PDF of the PROTECT and PROTECT ME posters https://www.bsavalibrary.com/content/chapter/10.22233/9781910443644.chap6_1#html_fulltext
- No antibiotic required ‘non- prescription’ form https://www.bsavalibrary.com/content/chapter/10.22233/9781910443644.app15#html_fulltext
- 2022 Veterinary Antibiotic Amnesty: an update (Companion article) https://www.bsavalibrary.com/content/journals/10.22233/20412495.0423.8
- Antibiotic use in cats and dogs (Companion article) https://www.bsavalibrary.com/content/journals/10.22233/20412495.0323.22
- Position Statement on responsible use of antibacterials https://www.bsava.com/position-statement/responsible-use-of-antibacterials/
- Antibiotic Awareness 2023 information https://rumacae.org.uk/vet-antibioticamnesty/
1del Solar Bravo RE, Sharman MJ, Raj J & Scudder C. 2023. Antibiotic therapy in dogs and cats in general practise in the United Kingdom before referral. Journal of Small Animal Practice. https://doi.org/10.1111/jsap.13615