Grow-Your-Own Antimicrobial Stewardship Culture

Veterinary Prescriber presents this practical toolkit for creating a culture of antimicrobial stewardship in the veterinary practice, in five parts: introduction; step 1; step 2; step 3; getting started. The series has also been published as a single module in Veterinary Prescriber’s Virtual Veterinary Medicines Academy. The series (like our modules) includes audio, so you can read while you listen. Continue the series here with step 3. The module was created by Veterinary Prescriber in collaboration with Simon Robinson of Operability.

Antimicrobial stewardship is not simply about following policies and prodedures, because these are unlikely to succeed without a conducive environment. In this Veterinary Prescriber module, we are using the concept of a petri dish to illustrate the three conditions (represented by three ‘microorganisms’) that are needed in the practice to promote an environment in which staff can practice antimicrobial stewardship. Our module will guide you through the process of building a good antimicrobial stewardship culture. The third condition for growing a good AMS culture is to reduce pressure to prescribe.

 3. Reduce pressure to prescribe

Evidence shows that even when practice staff understand the reasons for AMS and good practice, it is not enough to reduce overall AM usage.

In one study, knowledge alone did have an impact on antimicrobial prescribing behaviour. In dogs and cats there was a decrease in the use of off-licence antimicrobials and in cats, there was a decrease in the use of restricted antibiotics (Scarborough et al. 2023). However the prescribing rate for amoxicillin-clavulanic acid (considered first line) increased and so overall there was no reduction in prescribing rates.  So, besides knowledge, what other factors may be acting as pressures on prescribing rates?

When an animal is unwell, vets want to do their best for that animal, by prescribing medication that will cover any uncertainty in diagnosis, and spare owners the expense of revisits and tests to narrow diagnoses.  Evidence shows that many pressures can lead to precautionary prescribing (Scarborough et al., 2023)  Even when staff fully understand, and are committed to, reducing antimicrobial use, prescribing habits can be unintentionally influenced by these factors.  Addressing these factors makes your strategy more likely to succeed. 

Here are some ways you can reduce the pressure on clinicians to prescribe:

• Ensure prescribers feel supported

• Monitor workload and staffing

• Challenge practice initiatives that encourage antimicrobial use

• Educate owners on AMS

• Help owners maximise antimicrobial effectiveness.

Ensure prescribers feel supported

Studies show that vets who feel supported by their leaders and colleagues were more confident about refusing a prescription even when an owner was insistent (Borek et al., 2020). Support includes:

• Knowing that leaders support the AMS programme and will back a decision made by a prescriber

• Knowing that nursing and reception staff will support the AMS line if a client complains to them about not receiving a prescription

• Knowing that the practice leadership will sustain the AMS line in the event of a complaint or negative social media comment.

Monitor workload and staffing

Workload can affect prescribing behaviour.  When there is a shortage of staff, rapid appointment slots or a high case workload there may be additional pressures to prescribe antimicrobials, to bypass diagnostic testing and reduce the chance of revisits. 

• Understand when prescribing staff may be overwhelmed, when more time or resources may be needed. 

• Use the whole team to support the diagnosis, with nursing teams playing an active role in triage, history-taking and monitoring of physiological parameters.

• Locums may also not be familiar with the practice AMS policy, so consider specific locum briefings on policy, and use AMS champions to support the locum. 

• Challenge practice initiatives that encourage antimicrobial use Some practice policies promote the use of anti-infective medicines in a way that is outside the influence of prescribers. For instance, subscription models can lead to parasiticides being supplied without assessment of parasite risk of the individual animal. Similarly a practice policy of peri-surgical antibiotics as a precaution against surgical infection may encourage unnecessary antimicrobial use.

These may be viewed as “just the way the practice conducts business”, but leaders have a particular responsibility to identify and tackle these structural issues. To achieve this, identify policies and initiatives that dictate the standard use of antimicrobial without considering the individual need and risk of the patient. 

Educate owners on the issue

Owners want their pets to start getting well as soon as they step in the practice. It’s not surprising that clients may prefer something they perceive as direct action, that is going to start making a difference immediately and without a lot of time and expense. Consequently there can be pressure to prescribe from clients. 

There are many resources, such as waiting room posters, that practices can use to regularly communicate to clients about AMS, so that they understand the issue and why a vet may choose not to prescribe an antimicrobial.

• “Antibiotic Use Talking Points for Vet Clinics” developed by University of Minnesota (here).

• BSAVA owner information and “No antibiotic prescription required” form (here).

• Show the practice’s commitment to AMS on digital screens, posters in treatment rooms and on social media. Use the BVA’s  “Trust your vet on antibiotics” posters (here).

• Include the practice’s AMS commitment statement in email signatures and documents sent home with owners.

• Participate in Antimicrobial Awareness Week 17 to 24 November.

Help owners maximise antimicrobial effectiveness

Poor owner compliance can result in unnecessary disease progression and additional courses of wider-spectrum drugs. Helping the owner to use a prescribed antimicrobial correctly will reduce the need to escalate the antimicrobial response.

• Ensure the client knows that the prescribed medication is an antimicrobial, using ready-to-hand leaflets for clients. 

• Emphasise the need to complete the course. Reduce the temptation to stop the antimicrobial treatment because the pet seems to get better. 

• Ensure dispensing labels are unambiguous and give clear instructions to complete the course.  Consider specifying hourly dosing intervals on labels; “Give ONE tablet THREE times daily” can be interpreted in various ways, unlike “Give one tablet every 8 hours”.

• Give the exact amount of antimicrobial needed to complete the course to reduce the temptation to use it in the future without the vet’s advice.

• Make sure clients know how to correctly store antibiotic formulations (particularly reconstituted oral liquids) at home.

Now click the fourth image below to get started.

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