P Practice Policy
Develop protocols for antimicrobial usage based on common clinical scenarios
Develop a practice policy by:
- Identifying common clinical scenarios
- Formulating protocols for first line and alternative antimicrobial therapy for these conditions
- Consider appropriate antimicrobial dosing using an evidence based approach
- Classify key antibiotics as protected and avoided
Useful resources to help you develop your practice policy:
Download the PROTECT ME policy template
Download the PROTECT ME example practice protocol for use of the protected antimicrobials
Please note the policy template available to download is by no means the ideal antimicrobial policy. It is offered as an example that you can amend as appropriate.
R reduce prophylaxis
Develop rational protocols for prophylaxis
Define prophylaxis for surgical procedures whether clean, contaminated or high risk. Practice protocols can be included as part of the general clinic protocols.
O oTHER OPTIONS
Reduce or replace antimicrobials with other methods for bacterial reduction
Utilise wound debridement / lavage
Consider topical preparations or local intravenous administration
T Types of drugs and bacteria
Select appropriate drugs based on empirical use guidelines
Use cytology where possible
Consider the dose and pharmacokinetics of the drugs selected
E eMPLOY APPROPRIATE DRUGS BASED ON EMPIRICAL USE GUIDELINES
Predict likely bacteria based on type of infection
Staphylococcus sp are common skin commensals and will often colonise wounds and commonly sensitive to penicillins and/or gentamicin
Streptococcus sp are common respiratory pathogens and often sensitive to pencillins
Wounds with environmental contamination are likely to be colonised by Coliform bacteria or Pseudomonas sp and are frequently sensitive to aminoglycosides
C Culture and sensitivity
Use bacterial culture and sensitivity, even initiating empirical therapy pending results where needed especially where:
clinical response is less than expected
when long term therapy is suspected
critically important antibiotics (PROTECTED) are being used
Formulate practice policies for when culture and sensitivity is used as part of your PROTECT ME policy.
T Treat effectively
As little as possible, as much as needed
Standardise dosing frequency and does rates across the practice
Sometimes dosing intervals licenced in the marketing authorisation differ from current clinical evidence.
Review the veterinary literature to determine optimal dosing
Audit antibiotic use and resistance
MONITORING ANTIMICROBIAL USE
1. Monitoring impact of your practice policy - CLICK HERE FOR CLINICAL AUDIT TOOLS
The is considerable evidence in human health that auditing antimicrobial use can be a powerful tool to changing prescribing practices. If the highest priority critically important antibiotics are used sparingly then we can preserve their effectiveness for the future.
BEVA has created a flexible framework allowing veterinary surgeons to undertake effective clinical audit without significantly impacting on working practices. This will help members comply with their obligations under the RCVS practice standards scheme
2. Monitoring the impact of your policy on emergence of antimicrobial resistance
Regular review of emerging antimicrobial resistance is as important as the establishment of your initial practice policy. It will enable you to monitor the effectiveness of your practice protocol in reducing the emergence of resistance, while making it respond to changes in bacterial sensitivity in your practice.
The practice should establish a protocol for monitoring of emerging resistance. The guide below is designed to give a simple mechanism, but can be adapted as needed to your individual needs. Ideally bacterial culture and sensitivity will be undertaken prior to any change in antimicrobials, in a prospective manner, however the analysis of any culture and sensitivity can be used in an opportunistic manner.
The purpose of this process is to record the development of resistance that should impact on your prescribing policy. An example template document for recording and reviewing the emergence of antimicrobials is shown below
3. Monitor use of critically important antimicrobials in your practice
Decisions regarding antimicrobial selection are often based upon previous experience of a disease. In order to promote change of behaviour BEVA suggest that practices require staff to record the reasons why critically important antimicrobials are used. These antibiotics include
- The macrolides (eg erythromycin)
- The fluoroquinolones (eg enrofloxacin)
- The 3rd and 4th generation cephalosporins (ceftiofur and cefquinome)
Experience from practices that have developed this policy have seen a 90% reduction in the use of these agents.
Educate your team and your clients
Education is a vital part of changing practice and promoting responsible use. When constructing and reviewing local policies it is vital to develop buy in from all members of the practice. A range of resrouces have been curated to enable staff to develop an evidence based approach to antimicrobial use in the horse. The abstracts of these can be viewed here
BEVA members have free access to the full text from all EVJ and EVE articles. Simply click here to login first
A Virtual issue of Equine Veterinary Journal on the subject can be accessed here
This will open a new window / tab so that you can continue browsing in this window. If you have a pop-up blocker this can usually be overridden by holding the alt key while clicking on this link
A brochure promoting responsible antimicrobial use can be downloaded below
1. Promote responsible use of prescribed antibiotics
BEVA has produced client information leaflets that can be provided to clients in paper form, as well as shortened URLs and QR codes that can be attached to medicine packaging.
These leaflets are designed to promote a better understanding of antimicrobial resistance and how to use these medicines responsibly. Recent research from the WHO showed that 74% of the global population do not understand what the term antimicrobial resistance means.
Labels can be printed (21 per page) and attached prior to prescribing. CLICK HERE TO ACCESS
2. Reduce pressure to prescribe antibiotics
A poster and fact sheet have been developed for use by practices to help explain the importance of responsible antimicrobial use. Click on the images below to download these.