Vets can feel pressured to prescribe antibiotics for horses, researchers report

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An Australian study has found that veterinarians often feel pressured by owners to prescribe antibiotics for horses or cattle without seeing the animals.

Antimicrobial dispensing to bona fide clients without formal consultation was not reported in companion animal practice, but was commonly reported in horse and cattle practice, the researchers said.

“It was deduced that antimicrobials were given without a formal consultation for three reasons,” Laura Hardefeldt and her colleagues reported in the Journal of Veterinary Internal Medicine.

“Firstly, veterinarians feel pressured to ‘keep clients happy’ because of competition among practices and fear that clients would consult a new practice if they were not pleased with the service they received.

“This concern was equally common in equine and cattle practice, where clients often have many animals and can contribute proportionately more to the practice’s profitability than an individual companion animal client with only one animal.”

One veterinarian told the researchers: “Because you have to provide a business and you have to keep the clients happy. That’s that difference between us and the medical profession. They still get paid at the end of the day. But if we don’t have clients, we don’t get paid or have a job. So at some point you do have to keep them happy.”

The second reason identified by the study team was that some clients felt they were capable of diagnosing common diseases and were not willing to pay for a veterinary consultation for routine disease management, and that veterinarians felt that they were unable to examine every animal requiring antimicrobial treatment.

“However, participants often conceded that the treatment they advise was different from the client’s first preference and that, in many cases, the antimicrobials were not used in accordance with the advice given, or with the label, and that consultation with clients usually led to more appropriate treatment.

“Finally, veterinarians often reported that, because of long work days and lack of time, it was easier to dispense antimicrobials than to spend time convincing clients that the antimicrobials were not necessary or that a veterinary consultation was required.”

The study team had set out in their research to examine factors that helped or hindered the establishment of antimicrobial stewardship programs in veterinary practices.

They described antimicrobial resistance as a global health emergency.

Antimicrobial stewardship programs are widely implemented in human hospitals worldwide and have been shown to improve clinical outcomes, they said, but no formal reports have described the outcomes of such programs in veterinary practices.

However, medical strategies for antimicrobial stewardship were unlikely to be directly applicable to veterinary medicine, they added.

Most veterinary practices in Australia employed fewer than five vets and the average profit margin was 16%, including the profits from dispensing drugs.

The study involved an online 36-question questionnaire to assess veterinarians’ attitudes to antimicrobial resistance and antimicrobial use in animals, and the extent to which any kind of antibiotic stewardship is implemented. A total of 168 vets answered the 10-minute questionnaire.

It was then followed by semi‐structured interviews to gain an understanding of the barriers and enablers around antimicrobial stewardship.

Those who took part comprised a mix of companion animal, equine, and bovine veterinarians.

“Veterinary practices rarely had antimicrobial prescribing policies,” the study team reported.

“The key barriers were a lack of antimicrobial stewardship governance structures, client expectations and competition between practices, cost of microbiological testing, and lack of access to education, training and stewardship resources.”

Enablers were concern for the role of veterinary antimicrobial use in development of antimicrobial resistance in humans, a sense of pride in the service provided, and preparedness to change prescribing practices.

The researchers found that 89% of the veterinarians who responded to the questionnaire said they would support antimicrobial stewardship programs in their practices and that limiting factors commonly involved pressure from clients to dispense antimicrobials.

“This finding is in contrast to a survey of factors influencing prescribing in European veterinarians, where owner demands were among the least important factors.

“However, the interviews indicated that pressure from clients is just one of the factors driving prescribing, and that the situation is complex, with a multitude of contributing influences reflecting the competitive nature of veterinary practice and underlying client‐related socioeconomic and situational factors.”

Participants showed motivation in favour of antimicrobial stewardship. Most felt that the profession had a responsibility to address inappropriate antimicrobial use.

“Most veterinarians were cognizant of the potential role that veterinary antimicrobial prescribing could play in the development of antimicrobial resistance and most also felt that overuse of antimicrobials was common in veterinary medicine.”

Most veterinarians who took part said the expectations of some clients who demanded antimicrobials, sometimes without a formal consultation, had an impact on their prescribing practice, although some felt that it did not influence their therapeutic choices.

The researchers said the veterinary profession would need to develop strategies for antimicrobial stewardship that were innovative and appropriate to the size, variability, and resource availability of the majority of veterinary practices.

“Our study can guide development and establishment of antimicrobial stewardship programs in veterinary practices by defining the major issues that influence the prescribing behavior of veterinarians.”

The University of Melbourne study was funded by the National Health and Medical Research Council, through the Centres of Research Excellence programme, and an Australian postgraduate award scholarship to Hardefeldt.

Barriers to and enablers of implementing antimicrobial stewardship programs in veterinary practices
Laura Y. Hardefeldt, J.R. Gilkerson, H. Billman‐Jacobe, M.A. Stevenson, K. Thursky K.E. Bailey, G.F. Browning. https://doi.org/10.1111/jvim.15083

The study, published under a Creative Commons License, can be read here

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