This document discusses antibiotic stewardship in veterinary medicine. It emphasizes that stewardship includes judicious use of antibiotics according to treatment protocols, case definitions, dosing regimens, and monitoring treatment success and failure. It stresses preventing infectious disease through other means before using antibiotics. The document also argues that antimicrobial use monitoring should track actual use tied to reasons for use rather than just total kilograms. Overall it promotes prudent antibiotic use in veterinary medicine to minimize selection for antibiotic resistance.

1. Antibiotic Stewardship and
Veterinary Medicine

2. Alternate Title
Regimen Rage from a
Clinical Pharmacologist
The carconnection.com

3. The Basics of Clinical Pharmacology
(in one slide)
•Can I do some good?
•Can I do any harm?
•Can I get it in the animal(s)?
•What is the cost?

4. Stewardship includes...
• Judicious use
• Treatment protocols
• Case definitions
• Regimen
• Drug
• Dose
• Route
• Duration
• Frequency
• Success/failure definitions
• Post-treatment intervals
• Post-mortems
• Treatment failures
• Treatment records

5. Stewardship includes...
• Judicious use
• Treatment protocols
• Case definitions
• Regimen
• Drug
• Dose
• Route
• Duration
• Frequency
• Success/failure definitions
• Post-treatment intervals
• Post-mortems
• Treatment failures
• Treatment records
Withdrawal time

6. Stewardship includes...
• Judicious use
• Treatment protocols
• Case definitions
• Regimen
• Drug
• Dose
• Route
•Duration
• Frequency
• Success/failure definitions
• Post-treatment intervals
• Post-mortems
• Treatment failures
• Treatment records
Withdrawal time

7. Stewardship includes...
• Judicious use
• Treatment protocols
• Case definitions
• Regimen
• Drug
• Dose
• Route
•Duration
• Frequency
• Success/failure definitions
• Post-treatment intervals
• Post-mortems
• Treatment failures
• Treatment records
Withdrawal time

8. But stewardship starts with…
• Prevention of infectious disease
• Have I taken every step possible to eliminate the need
for prevention, control, or therapy?
• Is it really needed?
• Is there a disease present or imminent which requires
an antibiotic for prevention, control, or therapy?
• Is this a disease that will respond to antibiotics?

9. But stewardship starts with…
• Does the antibiotic I am considering have a
chance?
• Spectrum
• System and industry-wide monitoring of antibiotic
susceptibility for key pathogens
• This assumes we have breakpoints which apply to the
pathogen/disease/animal/regimen in question…
• Are other’s doing the same thing? More? Less?
• Metrics

10. Speaking of metrics
• In my opinion, antimicrobial use monitoring
should be actual use, tied to reason for use
• Total kg as a metric only serves as a stick to drive “cut
the use” as a goal
• Animal Daily Doses (ADD) and Animal Regimens (AR)
provide a look into drug exposure as well as number of
animals receiving the regimen.
• There may be different regimens for the same drug in a
species.

11. Antimicrobial Use Monitoring
• Sales data do not drive accurate estimates of
indications for use, or even actual use

12. Antimicrobial Use Monitoring
• The only way to drive the needed granularity in
the data is to …
• Give agriculture the steering wheel for data collection
• Government audit of the sampling strategy and data
handling
• Absolute guarantee of anonymity for participants
• Sampling structure must balance a view of the industry
with utility for individual participants

13. Fundamentals
• Denominators really, really matter
• Numerators are relatively easy
• And this has driven an interactive environment for this
issue in which some engage based only on numerators

14. Antimicrobial Use Monitoring
• Only actual use tied to reason for use will allow us
to drive antimicrobial stewardship in food animals
• Participants must be able to anonymously compare
themselves to peers in a private venue, and…
• investigate reasons for differences from peers

15. Is it as simple as…
•Label use?
• See previous slides
• Could I have avoided the disease challenge?
• Is an antibiotic actually needed?
• is the disease challenge actually present or
imminent?
• Is there a chance for efficacy?
• And, label use has nothing to do with
magnitude of selection for resistance

16. Labeled use doesn’t necessarily
mean…
• Judicious use, or
• Compatible with stewardship, or
• The regimen most likely to minimize selection for
resistant organisms

17. Is it as simple as…
• 100 mg in one animal = one resistance factory….
1 mg in each of 100 animals = 100 resistance
factories
• Who decided that the exposure dynamics for growth
promotion (low and long) are the most likely to select
for resistant organisms?
• Don’t confuse a policy decision to reduce total kg of
drug with proof that this exposure is the worst
exposure to select for resistant organisms

18. Time to wake up…
• The PK/PD parameters for efficacy don’t
necessarily match with optimal exposure for
minimizing the selection for resistant organisms.
• Maybe the marketing guys aren’t the ones who
understand what the best PK exposure is?
• We have focused on dose comparisons for the
same duration in veterinary and human medicine
• Take your antibiotic for as long as your doctor
prescribes so that you don’t get a relapse with a
resistant infection

19. Time to wake up…
•Narrow spectrum…what is “narrow
spectrum”
• Does a definition based on therapeutic effect
apply to avoiding selection for resistant
organisms?

20. What is “Stewardship”?
Is there a non-antibiotic alternative
which will appropriately prevent,
control, or treat this disease challenge?
Selection of an antibiotic which
has been demonstrated to be safe
and effective for this purpose
Assuring use of the
antibiotic as shown to
be safe and effective
While…

21. Education without systems
change will not work

23.  Unthinkable
 Radical
 Acceptable
 Sensible
 Popular
 Policy Prohibition of growth
promotion uses of medically
important antimicrobials
Prohibition of prevention
and control uses of medically
important antimicrobials
Prohibition of therapeutic
uses of medically important
antimicrobials

24. Rushworth Kidder told us…
• Right vs. wrong is easy, it’s right vs. right that is
hard
• He outlines 4 basic components of ethical
dilemmas
• Short term vs. Long Term
• Individual vs. Community
• Truth vs. Loyalty
• Justice vs. Mercy
This is Stewardship

25. The veterinary profession is
not only going to be
responsible for all medically-
important antimicrobial uses in
food animals…
we are going to be
accountable

26. …from here
• The days of verbal treatment protocols are
gone
• The days of unacceptable treatment records
are gone
• The days of nontransparent use of
antimicrobials in food animals are coming
to an end
• Neither veterinarians or producers can be
passive in these efforts.