Feb. 12, 2026

155: Antibiotic Prescribing Habits Vets Need To Ditch Now. With Dr Riati Scarborough and Dr Laura Hardefeldt

155: Antibiotic Prescribing Habits Vets Need To Ditch Now. With Dr Riati Scarborough and Dr Laura Hardefeldt
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Season 1

Four years after our original antibiotic myth-busting episode (Ep 60), we’re back with Dr Riati Scarborough to talk antibiotic prescribing habits. This time we’re joined by fellow stewardship expert Dr Laura Hardefeldt, and this time we’re asking the harder question:

Have we actually changed?

The good news? Some prescribing habits are shifting. We’re seeing shorter courses and less ‘just in case antibiotic usage. 

But let’s not pat ourselves on the back too quickly. Because some of our most entrenched habits are still alive and well, like how we treat skin disease, and our ongoing love affair with amoxiclav.

This episode is a practical, clinically grounded update on what the evidence says in 2026 - and how to make realistic changes without compromising patient care.

We cover:

  • Why skin disease remains the single biggest driver of antimicrobial resistance in small animal practice, and what to do about it
  • Amoxicillin vs amoxiclav: when de-escalation is not just safe, but smarter
  • Why convenience (you know the brand we’re talking about right…) is not a clinical indication
  • Trimethoprim-sulphonamide and the real story on KCS risk
  • Dentals, heart murmurs, and what prophylaxis actually looks like in 2026
  • Simple in-clinic stewardship strategies that genuinely shift prescribing behaviour

This isn’t about perfection. It’s about progress.

If you’d like effective antibiotics to still exist in five to ten years…

This episode is essential listening.

 

Find out how we can support you in your vet career at ⁠⁠⁠⁠⁠⁠⁠thevetvault.com⁠⁠⁠⁠⁠⁠⁠.

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Tips and Timestamps

  • 3:03 Progress in prescribing habits including UTI durations and surgical prophylaxis
  • 4:55 Skin disease as the biggest problem area in small animal practice
  • 7:01 Topical therapy versus systemic antibiotics for skin conditions
  • 9:28 Deep pyoderma and the new consensus statement
  • 11:00 Gut bacteria as a source of resistant infections
  • 12:41 Rise of MRSP, methicillin-resistant Staphylococcus pseudintermedius
  • 14:00 Amoxicillin-clavulanate overuse
  • 16:47 Vets on Tour conferences advertisement
  • 18:08 Pharmacology refresher on amoxicillin, amoxicillin-clavulanate, and cefovecin
  • 19:45 Why cefovecin is classified as high importance, vs the convenience argument for cefovecin in cats
  • 22:56 Long-acting amoxicillin injections as an alternative
  • 24:00 Getting amoxicillin back on the shelf
  • 24:53 Communicating antibiotic choices to clients
  • 29:32 Dental antibiotics and debunking the heart murmur myth
  • 34:07 Subclinical bacteriuria and stopping cultures in asymptomatic patients
  • 38:30 Reassessing the dry eye risk of trimethoprim-sulfonamide
  • 41:43 Antimicrobial stewardship trial using colour-coded pharmacy shelves

 

 

 

Revisiting Antibiotic Prescribing Habits with Experts
Back in 2022, when this podcast was still a little baby podcast, Doctor Rihati Scarborough rocked my world with an episode on antibiotic myth busting that changed the way I work in one of the biggest paradigm shifts of my career.
And I know I wasn't alone in this.
A lot of listeners told me that they had the same Road to Damascus moment after listening to that one.
That was episode 60.
If you haven't listened to it, by the way, you really should.
That episode was the one that started a four year process for me, completely overhauling the way I prescribe and also set me on a four year long exploration of more and more learning and more and more content on our clinical podcast about responsible antibiotic usage.
If you are already on that journey with me, of doing your bit to ensure that we still have antibiotics that work 5 to 10 years from now and minimizing the invisible but significant effects that we have on our patients when we are antibiotic Cowboys, then you will love this episode.
And if you're not on that bus with us yet, why the hell not?
This one is definitely for you.
In this follow up conversation, Doctor Rhee is joined by her colleague Doctor Laura Hardefeld, another antibiotic stewardship expert, and together we pick up where we left off 4 years ago.
We revisit the state of antibiotic prescribing in Australia and around the world, looking at where meaningful progress has been made, but also what are the bad prescribing habits that we struggle to shake as a profession.
We double click on what the science says about how to prescribe for urinary tract infections, very operative antibiotic use, including some eye opening evidence around antibiotic use in dentals, Spoiler in it Don't do it and skin disease, the biggest driver of antimicrobial resistance in vet science.
We also look at practical decision making around amoxicillin versus everybody's favorite amoxiclav, and why convenience should be stored right at the back of a locked fridge in your practice.
Plus some evidence to convince you to fall back in love with trimethoprim sulfas.
This episode focuses on practical, achievable changes, small steps that improve prescribing habits without compromising patient care.
Please enjoy Dr. E and Doctor Laura.
Welcome back to the Red Vault after three years and welcome Laura to talk more adorhotic stuff.
I feel like it's my soapbox and it's your fault tree or I don't know if it's your fault or thanks to you, but you were the the seed that made me think about this.
Speaker 2
It's a great soapbox and I think it's becoming a really popular topic with vets in Australia.
Speaker 1
Popular, controversial is too strong a word, but I, I think does sometimes divisive.
We, it's one of those things that we, and I speak for myself as well, kind of know we have to do better.
But then the practicalities on the clinic floor sometimes makes it harder.
So that's what I've got got you back on.
So should we start 3 with what's changed since we talked?
Like is everything fixed?
We've did our episode and everybody's listened to it and everybody's like oh shit, we should be much better.
And now Australian vets are sorted.
Speaker 2
I wish that with the case, but the good news is actually there is a lot more awareness than there was three years ago and definitely more than when Laura started working on this ten years ago.
When we go to conferences, people want to come to talks about stewardship, which I think in in the past wasn't really the case.
People want to do better.
I think we totally understand that there are, it's difficult sometimes to change things.
You have challenging clients, you have challenging colleagues.
Sometimes you've got structural things that stop you doing the things you want to do.
But the fact that people really want to do better is the most important part.
And I think any improvement is good news really in this space.
So every prescription that we can do better makes a difference.
Speaker 1
So how are we 'cause you researched that you guys are looking into it?
Have you still been looking at prescription habits?
Improvements in UTI Durations and Surgical Prophylaxis
Yeah.
So we have been looking how prescriptions are changing over the time.
So we just one recent example, we looked at how the prescribing for urinary tract infections and a decade ago people were prescribing kind of 10 to 14 days and that's now come down to seven days.
So people are definitely getting the message that we need shorter course durations.
We know another example with surgical prophylaxis.
When I started and we did some surveys, about half of people were still using antibiotics around space and now that's less than 10%.
So there has been big changes over the last decade.
And as Ray said, I think it's this not trying to let perfection get in the way of progress.
So little, little steps really.
The way that stewardship works, it's not trying to make big change.
That can be a bit scary for people in practice.
Speaker 1
OK, cool.
We're heading in the right direction where I was still most lacking.
Like from your research, what concerns you most and where should we be focusing on?
Skin Disease: Biggest Driver of Antimicrobial Resistance
Well, I think we all agree that skin disease is probably the big problem that we need to tackle in small animal practice.
It is responsible for about 1/3 of all the antimicrobial prescriptions in Australia in small E practice and the courses tend to be very long in that space and they tend to be broad.
You know, Keflex is the number one drug used in skin disease and we're seeing courses three to six weeks is fairly common.
So that's that's a lot of pressure for antimicrobial resistance.
And in a lot of cases, those animals that are going on systemic antimicrobials for weeks with all the issues that that brings for the animal could have been treated with TOP.
And that is set the trend that is starting.
A lot of vets are onto this already treating hotspots with Chlorhexidine with shampoos rather than putting the animal on systemic antimicrobials.
But we've got a long way to go.
There are still a lot of people reaching for those tablets and that causes dysbiosis for the animal.
And we know that dogs often feel quite well, they get vomiting with keflexin quite a lot.
But then of course, there's the problems that we can't see all of the pressure on the, on the enterobacteria AC in their system that that it could cause future problems.
So really where we can use topical therapy, that is a big win over using systemic antimicrobial.
So coming into summer, we'd love people to start thinking about how are we managing hotspots in this practice?
Can we switch more to topical therapy?
Speaker 3
And one of the things the, the problems that we see with that vet's report is that they feel like clients are unwilling to, you know, shampoo their dog every day or treat the skin topically every day.
But Ray's done some great research that has shown that actually pet owners are happy to do that work.
They're happy to do the topical therapies if they know that there's a benefit for their pet.
You know, talking about global AMR is that's too big picture.
But when they know that there's a benefit for their pet and they're going to say less gastroenteropathy, then they're willing to do it.
And so I think we just need to make that offer for them.
Speaker 2
Yeah, I think there's always going to be clients who are resistant, but the vast majority of people want, they want the best result for their animal and they are actually willing to do more than we possibly expected for that pet.
And one of the things that I got from speaking to pet owners was this sense of future regret was really powerful.
So if we tell an owner that if we use this antibiotic now, maybe they had a hotspot in the past and they received Keflex tablets and that cleared things up and they want that again.
If we explain to them that if we use that drug all the time, it might not work when the animal need really needs it in the future.
So we want to avoid using that when we don't have to.
And therefore I would like you to do this washing every day.
That really, that sense of, well, I don't want to do the wrong thing for my pet is really, really powerful as a motivator for owners.
Speaker 1
Yeah, I find, and maybe it's where I live, I work near Noosa, which is a little bit, that's a Wellness influence as you live in the area.
But people are aware of the Biome in general.
The general public know about the gut Biome.
So I say that as well.
I, I say to people, but five years ago I would have treated this with a systemic antibiotic, but I'm way more aware of the bio and all the good stuff it does and of the chaos I'm going to cause by putting a dog on an oral antibiotic.
The other thing is cost it.
The reality is in, in private practice, the course of antibiotics is $6080 in Australia.
And I said to people, I have $5 bottle of chloroxidine or an $80.00.
I said I'm also, I'll explain all the reasons.
And I'll say also it's going to save you about 80 bucks.
I'll be on board.
And that's the last thing to get there.
Like, Oh yeah, that's the thing.
Speaker 2
On the cake.
Is this cheaper?
Speaker 1
You guys will be very happy that we did a very nice comprehensive episode with a dermatologist Doctor, David Robson at Science Week where we talked about all this and it was very antibiotic heavy, the conversation about how to manage skin diseases.
And we did touch on the the new consensus statement that came in earlier this year about how to treat bacterial skin disease, specifically Bioderma, deep Bioderma, hotspots, all those things.
And he gave a beautiful breakdown of the three types of hotspot that are very clinically relevant, superficial, the folliculitis and then the deep Bioderma.
And on the deep one, you're going to have to go systemic, but the others, and it's interesting, out shifted.
I remember as a student, our dermatology lecture was like hotspots and these they're need antibiotic.
They were trying us to use less bread because we were all just, everything was just bread.
And they're like, give it antibiotics.
They're just wagging with breads.
And now it's the opposite.
Now people are saying no, they really need bread.
They don't actually bread in a topical and you're going to sort them.
Speaker 3
Like when I went to uni in the early 2000s, they told us three weeks of antibiotics, everything with skin got 3 weeks and now you know, the guidelines that you spoke with Dave about are like 7 days.
So I think that's the big change in antibiotic U synderm as well, so.
Speaker 1
Even the deep item this the consensus that because I I went through uniris deep item six weeks done and now it's and correct me if I'm wrong, is it 3 weeks reassess smear.
If there's still bacteria extended for two weeks, reassess again.
But as soon as you see no more bacteria on some cytology, you've done, Yeah.
Speaker 3
Two to three weeks and reassess, I think, yeah.
Speaker 1
Big changes my recent conversation on antibiotics as well.
Just to recap again, the the why, because that's the big thing to say because yeah, we understand the long term repercussions, but I didn't quite understand why it's relevant for that animal, for the rest of that animal.
Just that when you keep hitting those gut bugs with your cephalexin or Amoxiclav, which we'll get to which people like using that do organoselect specifically, is it specifically the E Coli's and the gut?
Speaker 2
It's a scatter gun approach and it hits all of the gut bacteria.
So all that big family of enterobacteriasy.
One of the things that we worry about with drugs like Keflex and drugs like Amoxiclav and with Kefavacin as well, which is very popular in cats still, despite the fact that we've been banging on and about not using.
Speaker 1
If a reason is, that's convenient.
Speaker 2
Convenient, although it's gone generic which makes us nervous and I can I totally understand the temptation to use it, but it is a real problem for selecting for extended spectrum beta lactamase producing bugs.
And when we've got extended spectrum beta lactamase flying around those genes in that pool of bacteria and if we get a surgical site infection or if we get an another infection a sepsis.
So that's going to be very, very difficult to treat if if it's at all treatable because that once you've got that extended spectrum beta lactamase that rules out almost all of the drugs that we have available to us in small is practice.
Speaker 1
The thing that sort of suck in for me was that it's the gut bacteria that's probably going to be the source of whatever bug ends up in the urinary tract on the skin in the surgical site infection, which is why, because again, I'm aware of gut Biome and all of that, but the gut is the source, right?
It's the it's the fountain of infection almost for a lot of things that.
Speaker 3
It is.
And I think the other thing with skin though is that we're seeing more and more MRSP as well.
And some of these MRSP that we're seeing are extensively drug resistant.
They're not just multi drug resistant anymore to the point where you know, some of the dermatologists are resorting to treating these with bleach as the topical therapy because they're so resistant.
And so, you know, we need to try and stem that tide as well because MRSP is becoming a big problem.
You know, a decade ago when I started, nobody was saying drug resistance in practice.
We asked vets and nobody was reporting it as a problem.
And now in skin infections and particularly in emergency and critical care, it's a problem that's impacting patient outcomes on a daily, if not daily, definitely weekly basis.
And so it is becoming much more of a problem in practice.
Speaker 1
Yeah.
David was saying in that interview exactly what you said 10 years ago, zero.
And now in their practice and again, they only see skin.
So it's obviously very concentrated case selection.
But he says about 10% of his patients will have significant MSRP resistance.
Yeah, that I said, right, Always get denied with the solar resistant.
Yeah, you know what I mean, Mrs. OK, so let's talk about Amoxiclav.
Addressing the Over-Prescription of Amoxicillin-Clavulanate
If we can, we set off Amoxiclav is probably antibiotic #1 to the when I was a student, if, if in doubt, that's the drug that's probably going to work for most infection.
Good penetration, good spectrum of cover, great drug.
So we use it because we want our patients to get better, Should we not?
Speaker 2
I, I'm not, I wouldn't say we should not use amoxyclav.
It is definitely indicated in some circumstances.
But I would say the current level of usage, which is for dogs about 70% of antibiotic prescriptions are amoxyclav.
For cats it's about 50%.
That is more than is required for the bugs that we are currently treating in Australian practice.
I can't speak for what's happening overseas, but when we look at the bugs that come in our UTI's in dogs and cats, for example, most of them can be treated with amoxicillin.
Those that can't be treated with amoxicillin, almost all of them can be treated with TMS.
So adding the amoxiclav is really not required.
But we do it because we're comfortable with the drug.
We use it all the time.
It's always on the shelf.
So we need to make if we want to get away from putting clavulanic in everything, which just selects for clavulanic resistance, right?
Like it tells these bugs to develop a, a beta lactamase resistance.
And if we want to do that, we need to consciously make an effort to back off the Amoxiclav and where possible use amoxicillin.
So you're in a tract infections for sure, but also in things like when you've got cat fight Abscess and you need to give antibiotics, which we can talk about that because most of the time you don't.
But if you do need to give antibiotics because they're systemically unwell, then amoxicillin is actually the drug you need, not Amoxiclav and definitely not Convenia, which is unfortunately the one that most of them get.
We know this.
We did a big study on cat fight Abscess management.
Obviously cat fight abscesses are a surgical problem mainly, and we really need to be clear about that with our clients as well, that this is about managing the the wound and keeping that clean.
It's not about throwing systemic antibiotics at a pocket of pus that they can't really penetrate.
But yeah, we can go off on many tangents here, but maybe I should stop.
Speaker 1
Well, we talked about that in that Seminole episode that you and I did way back.
That was one of the things we talked about.
And I have personally, and I know lots of vets have since stopped giving antibiotics to can't fight abscesses.
And guess what?
The world didn't end and they do get better.
I've had no client complaints about it as long as I communicate clearly about it.
So listen, this conversation is super important, but maybe it's making you feel a bit stressed.
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Understanding Amoxicillin, Cefovecin, and Alternatives
Can we do a very quick pharmacology refresher?
Because all these concepts are there in my head, but I'm not 100% clear on all of them.
So let's differentiate the, I'm curious to why you say definitely not convenient.
So amoxicillin.
So it's a straight penicillin and the reason we add clavulanic acid to it put it in nice clear English for me, I vaguely remember.
But just so we understand why we want to extend it with clavulanic acid, what it does and why we can, which instances we can get away without it, and which ones we should.
Speaker 3
Actually, so amoxicillin is predominantly A narrow spectrum antimicrobial.
So it gets gram positives and a couple of gram negatives and anaerobes really well.
We add the clavulanate to extend the spectrum.
So amoxicillin alone is a low importance rated antimicrobial.
We add the clavial anate, it gets a whole bunch more of the gram negatives.
That becomes a broad spectrum antimicrobial and then is a medium importance.
And then cephavacin is a third generation Cephalosporin.
So it's a high importance antimicrobial.
The spectrum is not too much different to amoxiclav except it has less anaerobic coverage.
So it's probably, well, it's definitely not as good as amoxicillin or amoxicillin for things like fat fight abscesses, which are predominantly anaerobes.
Speaker 1
So it's actually worse at doing the job beyond being convenient.
It's really not the drug 100.
Speaker 3
Percent for almost all of the clinical infections.
In practice it is less logical as a choice, apart from the fact that it's very convenient.
Speaker 1
Why is it high important?
How do they rate the the red light orange?
Speaker 3
And yes, that is set by a group of experts who reports the Australian government and they assess the different antimicrobials according to how devastating it would be if resistance developed in human medicine.
So if it's a low rated antimicrobial, that means if resistance developed, there's lots of alternates for treating infections in people.
If it's medium, there might be a few, but there's some alternates.
And if it's high, there's very few or no alternative therapies available if resistance develops.
So.
Speaker 1
OK, so Cepheid like what is special about its spectrum that makes it so unique that we can't just use a multi CLEV or something else to Yeah, so the.
Speaker 3
3rd generation cephalosporins.
So the cephalosporins, the generation has got to do with the spectrum that they cover.
So the third generation cephalosporins have more activity against some of those hard to get pathogens like the Klebsiella's and the pseudomonases and that kind of thing.
Speaker 1
OK, OK.
All right.
Question or a counter argument that I have heard in defence of civil reason is that for a cat that's really hard to peel that the lesser of two evils is giving a drug that you really don't want in, but it's at least it's going to be there consistently and do the job versus maybe every second dose is missed and you, you know, your antibody coverage spikes and comes if the cat spits the tablet out.
Is there a sense to that argument?
Like if if the owners say I really can't promise you that I'm going to get them.
No, no, no.
That's why I'm asking because that I have heard people say that, but I'd rather treat it properly because that's less like resistance can.
Speaker 3
Yeah.
And I think if sepivacin was had a 2 day duration of action, then that argument might fly a bit.
I mean, most of the time sepivacin is being used for infections that actually probably don't need antibiotics or don't need very much antibiotics.
And so like if we take our cat fight Abscess for example, probably two or three days of antibiotics would be enough in a cat that actually needed antibiotics for a cat fight Abscess.
We're just trying to tip the balance in favor of the cat's immune system.
So, you know, there might be circumstances, like if a cat had felon aids, for example, that they might need a longer course.
You know, immune system is not great.
But in most situations, we just need to tip the balance so that the Cellulitis can be overcome.
And so you don't need 14 days of antibiotics to do that.
And so, you know, if we are prescribing a shorter course of oral antibiotics that makes it more achievable for the owners get two or three days in.
Or if they really can't, then we can use things like long acting amoxicillin injections which every second day.
And if we need to get them back for one extra dose, then that can be administered by a nurse or something like that.
So.
Speaker 1
Which is the, I think what was classically the large animal.
Yeah, injectable or do you get is there a small animal?
Again for the non Australian listeners, I'm sorry, but what have we got?
Because you do have those long acting penicillins.
Speaker 3
Oxyland LA, Beta mocks LA are the I think the most the two most commonly in found in practice.
And yeah, they're labeled for small and large animals together.
So.
Speaker 1
OK, they feel like they're kind of old.
True, but they should be back on the shelf.
It sounds like amoxicillin.
Speaker 3
I think amoxicillin has drifted off the shelf.
People, when you talk to them, they're like, oh, I don't actually even remember when we stopped stocking it because, you know, amoxiclav just became so popular that people kind of just forgot about amoxicillin.
But you know, I think we need to remember.
Speaker 2
It yeah, it's still a very effective drug and people should be using it, but there is this kind of self perpetuating issue.
If vet clinics are not ordering amoxicillin preparations, pure amoxicillin, then the wholesalers don't want to stock it.
We get more problems because people are not using it, but we want people to use amoxicillin before they go to Amoxiclav.
You can escalate to Amoxiclav if you need to.
And I have had some friends say, you know, they've started using amoxicillin for most of their Utis in cats.
And then if that doesn't work, they tell the owner this might not work.
Most of the time it's going to to work, but you might be the unlucky one in 10 doesn't work for or one in 20.
And if that's true, come back in in a couple of days, we'll change the drug to something else.
People are pretty on board with that as far as I can tell.
Yeah.
Speaker 1
I I agree.
I I had this conversation with somebody from America, a practitioner, not a specialist, and they went, Oh no, American clients are not open to it.
Speaker 3
Information is a lot different in the US too, like I've got some mates who work in the US and a third of their staff from just community staff, methicillin resistant and so we don't want to get into that situation.
Communicating Antibiotic Choices and Debunking Dental Myths
That's kind of the writing on the wall for us.
You know, looking at some of these other countries who have been a little, let's say, less careful with the antibiotic use, you can see where it's heading.
So it's really important that while we have the opportunity to put those brakes on, that we take action.
Speaker 1
Almost good to hear that because it I said it in the other interviews, but it kind of feels like a distant problem that yeah, I'm aware of it, but I don't see an issue.
So I'm just going to keep doing what I'm doing because I get good results.
So it's hard to change, especially what you said there that it may not work.
Most of us it's hassle to get it back and you're worried that the client is going to be annoyed.
You just want to fix the problem now.
But it's short sighted.
And again, I what you said, I can vouch for that.
If I say to clients, look, I'm using this antibiotic and I like give a brief explanation why I say there's a small chance it's we have a Plan B.
So here's what you're going to see if it's not working.
And then you don't even have to bring your animal in.
Just call me.
Speaker 2
Yeah, and I think just knowing for them to know the reason why you're, I'm starting with AI guess you could say I'm starting with a less intense antibiotic because I want to protect your animals like microbiome as much as I can.
Or, you know, make sure that we don't use a drug that we might really need in the future.
Now if we don't need it today, we shouldn't be using this other drug, but if we will, we can.
If we do need to, we can escalate.
So I think making sure that they're on board, I mean, of course there will be some clients that.
Speaker 1
And I leave that door open.
I will say to people, I I'll just tell the white lie.
I'll say a safer antibiotic.
I'm going to start with a safer antibiotic, but it's got a narrow spectrum.
So it might not be as efficient, it might not do the job.
So we might have to escalate to different antibiotic.
Or when I have the conversation about not using an antibiotic, so let's say the catfight Abscess or I wouldn't that I think going to get better anyway.
At the end I will always say if you're not comfortable with that, I'm not going to argue with you.
But this is my thinking behind it.
If you want antibiotics, fine.
So it's not an argument, it's their decision.
I've never had anybody say, yeah, actually rather give me the antibiotics.
Speaker 2
That's awesome.
Speaker 1
Back to the amoxiclav versus amoxicillin, I asked before when clinically would we consider you said Ugis are often amoxiclav will do the job.
What about skin?
Are there other conditions where without culture, we should still think Amoxiclav is probably the most sensible idea right off the.
Speaker 3
Bat yeah, I think for for pyoderma like deep pyodermas where the the penicillin susceptibility of the amoxicillin susceptibility in most Staffs which you know, even if they're susceptible Staffs, the penicillin susceptibility is pretty average these days.
And so I don't think amoxicillin would be a good first choice for for deep pyodermas, for example, but certainly for abscesses in general, great anaerobic spectrum of amoxicillin.
Amoxicillin doesn't give you anything in that realm.
And so abscesses and Utis for sure.
I mean, amoxicillin concentrates so highly in the urine that we just get these super high levels that overcome most resistance, which is great.
Speaker 1
OK, so even if it's resistant on paper, like if you send it for culture it'll come back amoxicillin resistant, it could still work because you it can.
Speaker 3
Be tricky with culture of the urine because it really depends on the cut off that the lab is using.
So they should be using a urine cut off, which there are urine cut offs for dogs and cats now and so the urine cut off is much higher than the plasma cut off.
And so you might need to give your lab a call and see.
Make sure they're using the appropriate cut off.
Speaker 2
So if they are using a urine cut off, what you see on paper should reflect what you see in vivo.
But there are some labs where aware of who were using a plasma cut off level which did not reflect what would happen in real life.
It was sort of a low level of amoxicillin that they were saying was resistant and actually you could have treated a urinary tract infection with amoxicillin.
Speaker 1
So just to be clear, I understand this, that that's because there's going to be way more antibiotic in the urine than there is any plasma.
Yeah, yeah.
Is that just amoxicillin or other drugs as well?
Are the antibiotics?
Speaker 3
No, lots of antibiotics are excreted through the urine, through the kidneys.
So, yeah, yeah.
Speaker 1
What else are we not covering guys?
What can we do in everyday practice to get better still at this everybody who's on board, which is everybody listening.
Speaker 2
Well, I had a whole list here.
I said dentals.
We are still I think clinging to the idea that if an animal has any kind of heart murmur and they have a dental, then they have to have antibiotics and that is out of date.
And the other thing that people do, I think a lot, and I understand this, is they see a really manky mouth or a manky, anything manky Abscess, and they have a kind of discussed reflex.
The vet has a disgust reflex.
And if it's disgusting, I need to give it antibiotics to clean it up.
That's something we really need to get away from and think more about.
When can I not use antibiotics?
And dentals and animals with heart murmurs, if you're not doing extractions, there's no, there's no indication for using antimicrobials.
And if you're doing extractions, then you do prophylactic antimicrobials for immunosuppressed patients, patients with severe heart disease, not just a murmur.
I think we need more than just a murmur.
We need actual clinical issues with the heart, with the murmur.
And if they've got systemic illness, then you would give them prophylactic antimicrobials at the time perioperatively and that's your IV amoxicillin.
Speaker 1
So not after, so they're not.
So if you said prophylactic not as in the week before the dental, I'm going to put you on.
Speaker 2
Well, I'm glad you mentioned.
Speaker 1
We used to do that.
I don't well I haven't done many dentals for a long time in emergency.
Speaker 2
Yeah, it is definitely out.
And if if one person listening today is doing that still and changes their practice because of that, I will be a very happy, very happy person.
Speaker 3
So we know that these patients only get bacteremic for about 20 minutes after you pull out the tooth.
And so as long as we've got antibiotics on board at the time of the surgery that can cover off that 20 minutes, then we're good.
And in fact, these patients get bacteremic when they're eating, so they're being exposed to bacteria in their blood.
Speaker 1
What?
What is it?
A dog with rotten teeth, every time they eat, they actually eject the bacteria into the blood.
The immune system just goes, Yep, got this.
Yeah.
Wow.
So to be clear, so no antibiotics before I look at my teeth on day of dental and go, it's going to be a scale of Polish with no extractions, no antibiotics.
It's 13 year old dog.
It has potentially a heart disease or cushion rate or something.
And I know obviously there's going to be extractions.
They always do.
So then antibiotics as if I would when I'm doing orthopedic surgery As in pre op IV dose of what?
Cephalon or something like that.
Speaker 3
Just broad spectrum antimicrobials pre op 30 to 60 minutes before surgery and then no more doses.
As long as surgery doesn't go for more than 90 minutes, which I'm sure it won't.
When?
Speaker 1
Was the last time we did a dental in the Greyhound, it can go away more than 90 minutes.
So if it is one of those extended dentals with 90 minutes, again, if you're still in there, you're going to and then you're done.
Then I'll go home on antibiotics, even the ones with Cushings and heart disease, and I'll believe.
Speaker 2
You give it a try, but.
Speaker 3
This brings up a really important point that I think is that if you've been treating those for a week as a regular, that's your approach.
Sometimes it can be a bit scary to just go not to treat them at all.
But we don't have to be that hardcore about stewardship.
We can say, okay, I've been treating for a week.
These guys at the University of Melbourne say that's you don't need it.
How about we'll just do it for five days instead of seven days.
And then in six months time, when all of those have been completely fine, then you can say, OK, five days was all right, how about I'll try 3 days.
And like we can take this stepwise approach.
We don't have to subject ourselves to all of this worry and keep ourselves up at night worrying about these cases.
We can just take a step by step.
Baby steps is fine.
We're happy with baby steps.
Speaker 1
Better than nothing.
But I, I just go look, look at the science.
It's veterinary science.
If there's data that says very clearly this is all we do, just jump in and fucking listen.
Speaker 2
Not everyone's as brave as you are, and that's OK.
Speaker 3
It's OK.
Speaker 2
And I guess the other thing that we are hearing quite a lot about is subclinical bacteria area.
Sorry to always bring this back to urine a lot.
We know a lot of vets are still when they see bacteria in the urine or they culture bacteria in the urine and the animal has no clinical signs, they are treating with antibiotics and that is not what we need to be doing.
Asymptomatic Bacteriuria and TMS Dry Eye Reassessment
Bacteria.
I mean, I think when when we graduated, we were taught that the bladder is sterile.
So if you get a cysto sample and their bacteria in there, then that's a problem.
The bladder is not a sterile site, so we need to get comfortable with that and stop treating animals who don't have UTI signs.
Speaker 3
And I think a really important thing is to stop culturing them when they don't have UTI signs because then you won't be tempted to treat them.
So particularly this culturing after they've finished treatment, they've had an acute cystitis case, you've treated them and then you get them back in three or four days after you've finished treatment to reculture them.
That's out of the guidelines now.
So that's not recommended anymore.
And I think the reason that that has taken that out of the guidelines is because it just introduces that temptation to treat them if we get a positive culture.
Speaker 2
Yeah.
So that's the old adage.
We are treating the patient, not the lab results or the cytology results.
We are.
We're treating them when they have clinical signs.
Speaker 1
But this is obviously a conversation for this the simple kind of first time offender or haven't had a UGI for ages.
The complicated ones like recurrent Dtis or things like that.
In those ones, I still want to, I want to know if I, I literally, I'm asking this because I had a case recently that it kept coming back and I was like, well, is it coming back or have I not sorted out the infection properly?
And because I'm going so short with my antibiotics courses and then that one I wanted to culture, I wanted to see is it gone or is it not gone and just coming back as soon as I stop my.
Speaker 3
Yeah.
So I guess there's two different scenarios there.
There's one where you've like the infection hasn't cleared and we've got an ongoing infection.
And then there's the recurrent infection, which is typically not the same bacteria.
It's, you know, the dog has a predisposition for whatever reason, and it keeps getting recurrent Utis.
And for the recurrent ones, there's no point culturing them afterwards, right?
Because it's just picking up the next bacteria that comes along.
And when it tips over and gets clinical signs, then you want to treat it.
Ideally you would address whatever is causing it to be susceptible to the recurrent UTI's in the 1st place.
But the ongoing cases where you're not for whatever reason not clearing the infection, then that's a different scenario.
And we need to be thinking about why the infection is persisting.
And so if it has continues to have clinical signs, then culturing it absolutely because maybe it's got a resistant bacteria and doing additional diagnostics is 100% indicated.
Speaker 1
Right, so that's culture.
What about just cytology?
I diagnose it in house.
I'd have a look at a smear.
Yep, it's Philip E coli or rods.
I treat it for three to five days, right?
I said to people, I send you home with, this is what I do now.
I'll send you home with five days of antibiotics.
But by day three, if your animal is no longer symptomatic, you can stop.
And then because I'm going so short that I kind of want to know I haven't gotten rid of it.
So then I want to say treat for three days.
If it's asymptomatic, bring me in a urine sample the next day.
So I just want to look at it.
I'm going to culture it.
No, don't even look just clinically gone the crust, the.
Speaker 2
Signs are gone.
The infection.
Speaker 1
Thrust the immune system.
Yeah.
OK, wow.
Yeah, I thought I was being thorough.
Speaker 2
Well, you are, but it's probably not helping you.
All the animals, yeah.
Speaker 1
Anything else really, we.
Speaker 2
We, we could share our results of the study we've done on TMS because we've been recommending TMS and the international guidelines recommend TMS for urinary tract infections.
They're really good.
It's really good for rods.
But the one thing that vets keep saying to us is, well, we're nervous about using TMS because we're worried about dry eye and other things.
And we've done a really nice study.
I'll let Laura talk.
Speaker 3
To that, yeah.
So the evidence around dry eye is actually was really crap.
So the the study that showed that it was a problem was of 33 dogs.
And so that's not a very good evidence.
And so we did a study last year, it's going to be published in January, hopefully that looked at about 2000 dogs that were treated with TMS.
This was a retrospective study.
And so it's a little bit tricky to tell exactly.
You know, if the vet says it's got dry eye and the Cherma T test was 0mm, then you're like, Oh yeah, case.
But some of them came back with ocular disease.
And so we called those possible.
And when we combined our definite dry eyes and our possible dry eyes, we had an incident of KCS of 1.8% out of all of those cases.
And the previous study suggested 15% of cases treated with TMS.
And so the other thing was in that study as we looked at the dose and the duration of therapy and there was seemingly no association between how long they were treated for and what dose was used.
And so we think that this is a very idiosyncratic response of course, like some dogs just get dry eye.
So there's a baseline incidence as well which we didn't take into consideration here.
So probably the TMS inducing rate is even lower than 1.8%.
So you know less than two dogs in 100 treated with TMS are going to have issues with dry eye.
Speaker 2
And Laura, what do you say about Dobermans and TMS?
Speaker 3
Well, there was no Dobermans in that study, so we can't really say anything about Dobermans.
There were some breeds that were over represented, so Rottweilers and Westies and Boxers seem to have a higher incidence.
But I think we need to do a bit more research to really understand if that's an association.
It's not causation, so we need to do some more work to understand if that's real.
Speaker 2
There are other adverse effects of TMS, just like there are other adverse effects of Amoxiclav and Keflex and all the other drugs we're we're using every day.
Without perhaps thinking about it too hard.
I would stress that TMS is still a really good drug and I think it's good news that the prevalence of getting of KCS is quite low.
But the bad news, I guess, is that it seems quite unpredictable who's going to get it.
Speaker 1
So this is challenging.
So, so I will preface this by saying when I went through uni, that was our number one drug, Amoxiclav Cynilox was new and it was expensive.
So that was sort of on the shelf.
Well, when we need this is at our vet hospital, You use it when you need it, but it's expensive.
So everything else gets TMS and we saw no problems.
So I was used to be very brave with it, but then I read the studies from a clinician standpoint, the resistance is still and I, and I feel this when I reach for the TMS 2 in 100, as you said, when we talk to the clients, we want to do what's best for the clients, want to do what's best for their patient.
If I say to them, I want to use this drug for antibiotic stewardship reasons, there's a 2 out of 100 chance that I'm going to cause eye problems in your dog with this drug.
They're going to go, I don't want that drug.
Give me the one that there's a 0 out of 100 chance of causing issues.
I can't remember.
Does that dry eye resolve when you stop?
Is it a temporary thing or are we doing potentially?
Speaker 3
We couldn't tell from this study whether the dryer resolves, but the anecdotally, in most cases the dryer goes away.
Speaker 1
That resolves when you stop, OK.
Speaker 3
And in this study, not many cases got very short durations.
So it's really hard to assess the safety of that.
It's just that the Super long durations didn't seem to cause any more than like a a regular 7 to 10 day course.
So.
Simple In-Clinic Strategies and Final Thoughts
Cool.
Anything else?
Speaker 2
Well, one really interesting thing that I'm not sure if we've spoken about before in this forum is that we did a trial of antimicrobial stewardship interventions with a whole bunch of clinics.
More than 130 clinics took part in this and there was someone really simple thing that vet clinics did that helped with improve the antibiotic prescribing.
And it comes back to what we were talking about before, those importance ratings from the Australian Strategic and Technical Advisory Group.
So there's the low, medium and high importance antibiotics and we have traffic light cards, so the red ones are the high importance ones we want to stay away from.
And just going into your pharmacy and labeling all the shelves with red, green and yellow dots to tell you every time you reach for that antibiotic, how important you are, how important that drug is.
It really helps to remind people on a daily basis.
It takes 10 minutes to do it one time and it stays there.
We've seen people use dots.
We've seen people wrap the shelf in colored contacts where they keep their drugs with the color code.
It might be a bit easier, but that's really effective.
And also sticking the red drugs in a harder to reach spot is really effective too.
So having doing that kind of supermarket psychology, sticking the green drugs where they're really visible, really easy to use to reach for, and keeping the red ones a little bit further away does seem to make a difference to what people.
Speaker 1
You need to have a.
You need to use a step to get to the to the red ones and then nobody will use them like I come for that but.
Speaker 3
Just that as your reminder every time you walk into the pharmacy, it's really powerful and yeah, and such an easy intervention.
Speaker 2
Yeah.
Speaker 1
That's cool.
I like that.
All right, I am done with my questions.
Thank you so, so much for making time, and we'll keep hammering on the topic until everybody's on.
Speaker 3
Board amazing.
Speaker 1
Before you disappear, I wanted to tell you about my weekly newsletter.
I speak to so many interesting people and learn so many new things while making the clinical podcast.
So I thought I'd create a little summary each week of the stuff that stood out for me.
We call it the Vet Vault 321 and it consists of three clinical pearls.
These are three things that I've taken away from making the clinical podcast episodes, my light bulb moments, two other things.
These could be quotes, links, movies, books, a podcast highlight, maybe even from my own podcast.
Anything that I've come across outside of clinical vetting that I think that you might find interesting.
And then one thing to think about, which is usually something that I'm pondering this week and that I'd like you to ponder with me.
If you'd like to get these in your inbox each week, then follow the newsletter link in the show description wherever you're listening.
It's free and I'd like to think it's useful.
OK, we'll see you next time.
Dr Ri Scarborough
Dr Laura Hardefeldt