A presentation given by Dr Sara Cowan of SASH (Small Animal Specialist Hospital) from Sydney Australia at their February Food For Thought education evening.

1. INFECTION CONTROL 2015 –
ANTIMICROBIAL USE AND RESISTANCE
UPDATE STRATEGIES FOR MANAGING
INFECTIONS IN HOSPITAL
Sara M. Cowan, DVM (hons), DACVIM (Internal Medicine)
Small Animal Specialist Hospital

2. www.sashvets.com
Overview
• The Issues
• The Claims
• The Evidence
• Some evidence-based strategies
– Empirical Antibiotic Therapy
– Hand Hygiene and personal protection
– Equipment and Hospital Disinfection

3. www.sashvets.com
The Issues
• Antimicrobial Prescription/Use
• Antimicrobial Resistance
– DNA
– GIT
– C&S
• Patient Management
– Non-infectious
– Potentially infectious
• Hospital Cleaning
Boothe 2009, Dellit 2007

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The Claims
• Resistant infections can increase cost, morbidity and
mortality to veterinary patients
• Resistant organisms can pose a zoonotic threat to
hospital staff, clients and the community
• There is a finite resource of antimicrobial classes
Lloyd, WSAVA 2010; Black, JVECC 2009; Baptiste, Emerg Infec Disease 2005

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The Claims
• “Pre-antibiotic era”
• “Quinolones and cephalosporins should be banned
from veterinary use” – Annual Report of the BMA
Chief Medical Officer 2008
• “No Action Today, No Cure Tomorrow” – World
Health Organisation Campaign 2009

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The Responses
• Working Group on Hygiene and the Use of Antimicrobials in
Veterinary Practice (Lloyd et al 2009)
• International Society for Companion Animal Infectious
Diseases (ISCAID) 2011
• World Veterinary Day Theme: Antimicrobial Resistance
2012
• Textbook Veterinary Infection Prevention and Control
(Caveney and Jones, Wiley-Blackwell 2013)
• ACVIM Consensus Statement 2014: Antimicrobial Use and
Resistance
• AVMA Task Force
• AVA President The Veterinarian, May 2012)
• AVA Updated guidelines for Veterinary Personal Biosecurity

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The Evidence
• Resistant Infections in Humans
(Phillips review J Antimicrob Chemother 2004)
• Human-Animal ‘bonds’
– Animals may be reservoirs to human pathogens and vice
versa
• Same strains
• Shedding
(JAVMA 2009; J Antimicrob Chemother 2012; Haenni Vet Micro 2014, Huber Vet
Micro 2013)
• Environment
– 100 vet clinics swabs
• E. coli, C. dificile, MRSA, MRSP
– Rats harbour resistant bacteria
(J Appl Micro 2011, J Antimicrob Chemo 2010)

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The Evidence
Veterinary antibiotic use
• MRSP in dogs
(Beck Vet Dermatol 2012, Bemis J Vet Diagn Invest 2009, Perreten J Antimicrob
Chemother 2010, Weese JAVMA 2012)
• Dogs treated with commonly used AB have E.coli resistant
fecal strains
(Damborg Vet Micro 2011, Lawrence Vet J 2013)
(Gibson Epidemiol Infect 2011)
Conclusion?
• Policies and surveillance programs
– Food animal
– Human
– Companion animal

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The Evidence
Proven Benefits of Prudent Antimicrobial Use:
• Reduce resistant organisms in hospital
• Reduce nosocomial infections
• Improve patient outcomes
• Reduce hospital costs
(Dortch 2011; Fishman 2006; Malani 2013; Schultz 2014; Singh 2000)

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Antimicrobial Therapy
• Antimicrobial
– Antiviral
– Antibiotic
– Antifungal
– Antiparasitic
• Antibiotic
– Prophylactic
– Definitive
– Empirical*

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Strategies for Empirical Therapy
Prudent EMPIRICAL use
Primum non nocere
• From:
– ‘just in case’
– ‘can’t hurt’
• To:
– avoiding excessive or unnecessary use
– Client education
– Diagnostic tests
Papich et al JAVMA 2013, Papich pers communication, Gebru Vet
Micrbiol 2012, ISCAID 2011

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Strategies for Empirical Therapy
• Best drug
– More difficult
– Compounding
– ‘1st line’: ampicillin, cephalexin, tetracyclines, TMS
– Avoid empirical use of 2nd and 3rd line
• Fluoroquinolones, Convenia, Clindamycin, Timentin
• Best dose
– On-label?
– Mutants
– Go higher
• Best duration
– Data emerging
– Go shorter
Papich et al JAVMA 2013, Papich pers communication, Irom OSU 2010, Gebru Vet Micrbiol 2012,
Boothe, Auburn Uni 2011, Osborne 1995, Sequin JVIM 2003, ISCAID 2011

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Strategies for Empirical Therapy
Example: Acute Diarrhoea +/- blood
• Self resolving
• If not, diagnostic tests
– Indications:
• Breach of intestinal barrier
– TPR: metronidazole or ampicillin
– Sepsis: full coverage
• Pathogenic infection strongly suspected
– Puppies
– Boxers
Unterer JVIM 2011; Marks JVIM 2011

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Strategies for Empirical Therapy
Urinary Infection
• Indications:
– Bacteriuria and pyuria
– Co-morbidity, debilitated patient pending results:
• h/o UTI, CKD, DM, hyperA, PUO, immunosuppression
• renomegaly, renal pain, urolithiasis, cystitis, incomplete voiding
• Colonisation vs infection
• Amoxicillin or clavulox 22 mg/kg po bid
Seguin et al JVIM 2003; International Society for Companion Animal Infectious
Diseases 2011; Osborne, personal comm. 2012

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Strategies for Empirical Therapy
Infectious bronchitis or pneumonia
• Indications
– TPR or high index of suspicion (LMN, h/o regurgitation)
PLUS one or more:
– Ventral alveolar infiltrates, bronchointerstitial pattern; cats variable
– Hypoxaemia SPO2 <90%
• Diagnostic tests
– AW wash, culture tip of tube
• Don’t ‘Treat the Client’ using antibiotics
• Empirical Options
– Cats: Doxycycline (second line: marbofloxacin)
– Dogs: Doxycycline or Amoxicillin-clavulanate (second line: clindamycin +/-
enrofloxacin if life threatening)
– Intubated tick paralysis prophylaxis??: Amoxicillin-clavulanate
Epstein JVECC 2010; Textbook of Respiratory Disease in Dogs and Cats

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Strategies for Empirical Therapy
Pyoderma Linda Vogelnest, personal communication
• Question/Confirm:
– Client education on cytology
– Prominent pustules, papules, epidermal collarettes
– Debilitating pruritis
– SIRS
– Cytology: Neutrophils and intracellular cocci
• Rx Cephalexin 22mg/kg TID x 21 days
– Cytology: Rods (or cellulitis)
• Rx amoxicillin-clavulanate or cephalexin + metronidazole
• Do No Harm
– Topical 2-3% chlorhexidine solution on lesions bid
Otitis
• Topical
– Surolan for yeast
– Canaural if cocci
– Otomax or Topigen if rods
• If otitis media, need deep C&S

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Strategies for Empirical Therapy
Full coverage
• Variable pathogens (septic peritonitis)
• Life-threatening consequences
• NOT necessarily indicated when not improving
Ampicillin + metronidazole + enrofloxacin
Cefazolin + metronidazole + enrofloxacin
Cefazolin + metronidazole + gentamicin
Ampicillin + enrofloxacin
Enrofloxacin + metronidazole

18. Hand Hygiene and Personal Protection

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Hand Hygiene and Personal Protection
Hand Hygiene
• The single most important
measure to prevent the spread
of infectious agents
• Hand wash versus alcohol
hand rub?
CDC 2007, 2010; HICPAC 2003

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Hand Hygiene and Personal Protection
Hand Hygiene Indications:
• Before and after
– each episode of direct patient contact
• From dirty to clean
– areas on the same patient
• Arms and fronts
– Increase awareness of arms and scrub fronts

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Hand Hygiene and Personal Protection
Indications for gloves:
• Animals with infections
• Wounds
• Secretions
• Desire for clean or aseptic procedures
• NOT a substitute for hand washing
Other Personal Protective Equipment (PPE)
• Scrub top, gloves, masks, eye/face shield, gown
Nuttall, BSAVA 2011

22. Equipment and Hospital Disinfection

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Equipment and Hospital Disinfection
• CLEAN
– Routinely
– Everything
• DISINFECT
– Routinely
– Contact with:
• Any mucous membranes
• Any broken skin
• Potential infection…
– Q, A, B, C
– (Accelerated hydrogen peroxide?)

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Equipment and Hospital Disinfection
• Potential infection…
Advanced Precautions
Wright JAVMA 2008, CDC, WHO

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Equipment and Hospital Disinfection
• Advanced Precautions – URINARY
– Strict hand hygiene.
– Wear gloves when handling if the patient tends to soil
itself in cage.
– Wear gloves when handling urine, changing bed.
– Disinfect any surfaces that come in contact with urine or
perineum (e.g. if the patient sits on a trolley then
disinfection is required).
– Disinfect any equipment that contacts potentially
contaminated surfaces (e.g. lab bench after UA, BP cuff on
tail base).
Portner 2010, CDC, WHO, et al

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Advanced Precautions - Gastrointestinal
• Strict hand hygiene
• Wear gloves when handling caudal half or hair
• Wear gloves when obtaining rectal temperature
• Wear gloves when changing soiled bedding
• Disinfect cage q24h
• Disinfect any surfaces that come in contact with
gastrointestinal excretions
• Disinfect any equipment that contacts the patient

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Advanced Precautions - Respiratory
• Strict hand hygiene
• Keep 1 metre away from other animals
• Disinfect cage q24 h
• Disinfect any surface that comes in contact with
respiratory droplets or aerosols (e.g. if coughs on a
trolley).
• Disinfect any equipment that contacts oral or
respiratory mucous membranes (e.g. SPO2 probe)

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Advanced Precautions
• Dermatological and Wounds
• Strict hand hygiene
• Wear gloves when handling
• Disinfect cage q24 h
• Disinfect all contact surfaces (floor, table)
• Disinfect all equipment that contacts diseased skin

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Advanced Precautions
• Critically ill or immunocompromised
• Strict hand hygiene
• Strict catheter and/or drain asepsis
• Strict aseptic handling of intravenous injections
• Newly prepared saline flushes?
• Multi-dose vials?
• Strict disinfection of all cages, surfaces, and
equipment before coming into contact with the
patient

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For the Veterinary Profession
CLINICIANS
• Improve prescribing behaviour
– Avoid prescribing restrictions
• Adhere to general do’s and don’t’s
• Educate clients
CLINICIANS and PATHOLOGISTS
• Develop local antibiograms
Mealy ACVIM 2011, CDC, WHO

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For the Veterinary Profession
PATHOLOGISTS and RESEARCHERS
• Improve diagnostic tests
– MIC v MPC
– PCR, LA, PFGE for strains
RESEACHERS
• Create new treatments for infections
– Genetic susceptibilities
– Immunostimulatnts
– Molecular therapy e.g. drug efflux pump inhibitors
– Remove biofilm
• Chlorhexidine, Tris EDTA
Mealy ACVIM 2011, CDC, WHO

32. Thank You

33. www.sashvets.com.au twitter: @SASHvets
Phone - (02) 9889 0289 Fax - (02) 9889 0431
Level 1, 1 Richardson Place, North Ryde 2113, Sydney, NSW