Jan. 21, 2022

#60: Antibiotic mythbusting. With Dr Ri Scarborough

#60: Antibiotic mythbusting. With Dr Ri Scarborough
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Season 1

Dr Riati Scarboroughis is a researcher at the National Centre for Antimicrobial Stewardship and a PhD fellow at the University of Melbourne. Her PhD focuses on improving our understanding of the conscious and subconscious motivations behind suboptimal antimicrobial prescribing in Australian veterinary practices, and designing sustainable strategies to support better antimicrobial prescribing in veterinarians. Ri is particularly interested in the use of social norms and nudges to modify behaviour. 

And it's these behaviours that we discuss in this episode. Ri highlights some common areas where many vet practices could rethink their antibiotic prescribing protocols, with a great discussion on WHY it's so important.  We cover topics like

  • Why the old antibiotic mantra 'finish the course' is giving way to 'shorter is better"
  • Antimicrobial dosing: you can't always trust the label
  • UTIs - choose Amoxycillin over Amoxyclav or Convenia
  • Bacteriuria does not always require antimicrobials
  • Catfight abscesses - antimicrobials rarely needed
  • Surgical antimicrobial prophylaxis - get the timing right

A word of warning: some of these topics might wake up an annoying little voice in the back of your head that will bother you every time you head into the dispensary for those AB's, but we think it's worth it. See it as a little nudge!

Here are the resources as promised in the episode. 

 

Thanks to the SVS Pathology Network, who our Australian listeners will know as Vetnostics in NSW, QML Vetnostics in Queensland, TML Vetnostics in Tasmania, ASAP in Victoria and Vetpath in WA, for supporting the podcast and introducing us to Ri and her work. Have a look at this video about Maldi TOF spectrometry - the technology that explains why SVS clients will now get super-fast turnaround times for their microbiology testing.

Go to thevetvault.com for show notes and to check out our guests’ favourite books, podcasts and everything else we talk about in the show.

If you want to lift your clinical game, go to vvn.supercast.com for a free 2-week trial of our short and sharp high-value clinical podcasts.

We love to hear from you. If you have a question for us or you’d like to give us some feedback please leave us a voice message by going to our episode page on the anchor app and hitting the record button, via email at thevetvaultpodcast@gmail.com, or just catch up with us on Instagram.

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Because there was a time before.Convenient and cats live been to know, know what happens.Convenient?Just helps keep little nasty cat's alive the one.Yeah, so so now, I think we're selecting for nasty bacteria.
Nasty cats.You could do a PhD on that.I'm Gerardo Poli.I'm you became strap and this is the vent valve.Hello.
Vit vaulters and welcome back.Our guest for today is dr.Reality Scarborough re is a veterinarian and a researcher at the national Center for antimicrobial stewardship, and a PhD fellow at the University of Melbourne.A PhD focuses on improving our understanding of the conscious and subconscious motivations behind suboptimal antimicrobial, prescribing and Australian Veterinary practices and designing sustainable strategies to support better antimicrobial.
Prescribing, and B RI is particularly interested in the use of social norms.Not just to modify behavior.And it's this topic that we'll be discussing today.The first of all, a huge were going to thanks to the SBS pathology Network for supporting this episode and introducing us to re-enter work.
But why would a pathology business want us to talk about how we use antibiotics?You would have heard some of the other episodes with their Stellar crew of pathologist.And you would have noticed it was all about pathology tips and insights.So why this topic?Well, if you think about it, your path lab is there to help you make decisions.
Ins on how to treat your patients, right?And one of the goals when it comes to microbiology, is to help you decide which drugs, to throw at your patients, to help them.Get rid of infections, note here that I said, help them, get rid of, and not drugs to get rid of infections, which is an important shift for me.
And I think once you've listened to this, it'll be the same for you, but I digress when we send our microbiology samples the answers.We want to get our do I need an antibiotic and be if so, which one should I?Use now traditionally for me personally, and I'm sure for many of you, I would interpret the answer of, which drugs are choose from as a, what is the biggest gun that I can bring to this fight?
So I can blow this infection out of the water.But what you learn in this episode is that we need to flip that around and say, what is the least aggressive approach that I can get away with?What is the most basic least important?Antibiotic.That will help me fix this patient or before that even do I even need any antibiotics?
So again, why does the team at SVS pathology Network want us to talk about this?Well, it's because they realized that the decisions that they will help you make for your patience now goes, well beyond.Now, they've been providing a lot of data for the research that has shaped findings that you'll hear discussed in this episode and the recommendations that will share with you in the show notes.
So they know that it is a big deal.I suspect that they would hate to be in a position, say 10 years from now when they have to start sending out.That's a resistant to everything just as much as you would hate to be on the receiving end of that.
So here's the deal.You're going to listen to this and a word of warning.Some of this might be a little bit challenging to you.I know it is for me and the next time you send your sample to qml or tml or witness things or red path or ASAP Labs or whichever one.Your local is vs lab is and here's the cool, but they know I'm going to sit that sample in the incubator for two to three days and wait for it to grow or not to grow.
Row to identify the bug.They're going to put it in their new multi tough analyzer, which we talked about in our previous, pathology episode with dr.Kristen todhunter, but, if you haven't listened to that, what it basically means is that a laser will obliterate the bugs in your sample down to molecular size and said molecules will then get sucked up in a tube and onto a sensor which will magically identify your bugs, pretty much instantly instead of only after two to three days.
We've put a link to a video about this in the episode description and in the show notes.Then when you get your answer way sooner than you were before, you're going to use your newfound knowledge and the resources that will share with you in the show notes.You're going to think twice about which drug you'll pull off the shelf.
You're going to think about your dose.And you're going to think very hard about how long, your course will be because your current courses are probably too long as you're here.I can tell you from my own experience since recording.This episode that in the short term.This might be a bit uncomfortable.But what I'm hoping is that in the long run the short-term discomfort.
Will mean it in 10 years time.We'll still be happily and effectively.Treating our bacterial infections, please enjoy.Dr. Reid Scarborough.Welcome to the vet.Well, thank you very much.It's great to be here.I'm slightly.
Well, I'm very excited for this topic and I'm also slightly nervous because I feel like you might kill some of our holy cows, this cash.Not at all.Not at all.And I think before we even get started, I would like to declare But I have never been a perfect antimicrobial prescriber.
I've done all the things that I now discovered a probably not the best to do in my PhD, but I think the key message with antimicrobial stewardship, which is that very long-winded, way of saying encouraging responsible.
Prescribing is that it's not about being a perfect prescriber.It's just about making incremental changes to make better antimicrobial, prescribing decisions.And when we make good decisions will, Reduce the risk to Future animals and future humans down the track.
So yeah, I would, I'm not going to throw any stones at anyone I'm not without sin, but I think I've got some insights that can help bets to make better decisions.Mmm.So I started with a very silly.
Question is no such thing.But just so we can get clarity on antibiotic resistance.How does it actually happen?I thought I've got a good idea, but is it is it literally just Every time you give an antibiotic, the only ones that are going to survive, other ones that are going to be inherently resistant.
So we selecting for resistance.You're not creating resistance.It's not like you are helping bacteria become resistant somehow.That's right.You're the ability to resist that antimicrobial have to be there in the bacterial population.But you are applying that that darwinian selection pressure to all of the bacteria who are exposed.
And I think one of the things that vets Sometimes forget is that when you give a systemic antimicrobial, you're not just exposing the pathogens where you want to actually kill bacteria, you're not just exposing, then you exposing all of the bacteria, all over the skin, all of the bacteria in the gut in the mucous membranes in the mouth everywhere.
All of those commensal bacteria are being selected for the resistant strains.And then, I guess the next step after that is that we know that bacteria will transfer genes of resistance between each other.So you might select in a perfectly benign bacterium.
You might select for a resistance to say.A careful of Thorin.But then, that benign bug just sitting around, might then pass on that resistance Gene to an adjacent pathogen.How, how does that happen?
Well, see, I'm not a microbiologist, but there's multiple different mechanisms.They can do it.And one of them, one of the important ones is plasmids and problem with plasmids is that the essentially mobile genetic elements that will jump from one bacterium to another and often.
You get in those plasmids is a cluster of multiple different genes that are all differ different, resistances to different antimicrobials.So you might in one Fell Swoop, a bacterium might pick up resistance.It's too careful aspirins penalty, penicillins carbapenems, all of the things that we have that can happen in one go because of plaids and pleasant, its kind of collecting these resistance genes together.
So that's why it gets a little bit scary, but I don't I'm not here to scare people today.I'm I'm All About like what can we do that?Be sensible.I'm going to ask that because that's new to me.It's I thought it's just well if there are some that are resist, but that that passing it on.That is a bit scary.It is a little bit scary.
Yeah, so I think it's important to bust some of the myths that are holding us back from better.Prescribing so that we can reduce our risk of those.Sorts of events that will give us some really difficult to treat infections in the future.Obviously the way to do not like to do that.
The way to manage this plasmid thing is, obviously not to just add more antibiotics and just trying to kill everything.It's like kill everything.Yes.Look, it's funny.I've done some interview studies with vets, and with clients, as well to understand what they, what they think.
The point of antimicrobial treatment is and people do often say things like, oh, we need to wipe out all the bacteria in the infection.I need to wipe them out and I guess one of the messages I would like, that's to take on board is that you will remember your lectures back in microbiology, that we're not dealing with just an isolated population of bacteria.
Just sitting in a dish, where actually, it's a balance between the animals immune system and the replication of the bacteria.Right?So, the point of giving antibiotics is not to completely wipe out all the bacteria that are present in the even the point of it is to tip the balance in favor of the immune system.
The immune system's already doing its thing trying really hard to get rid of these pathogens, right?All you need to do is slightly tip the balance in favor of the immune system and all of those amazing lymphocytes and macrophages will come in there and do the rest of the job and the neutrophils, they will clean up the rest of it.
But we just need to tip the balance in favor of the animal rather than the bacteria.And so one of the antibiotic myths that I wanted.But today is the, is this really old concept of?We must finish the course of antibiotics in your order to avoid antimatter world were always told that just recently.
Who told you that Dorado.I'm fairly certain.You bird told me.I saw it on Facebook.It's not, it's not saying that having a certain number.Of treatments is not important.It's that there are a few problems with this mantra', a finish, the course that we've all become so attached to and I think they're at the root of that.
Is that theory that I was just saying that the aim of antimicrobial therapy is not to wipe out all the bacteria.I'm going to interrupt because I'm glad you said that because when you say it, I go.Yeah, but in my head, I am when I put that animal antibiotics, I'm like that.
Yeah.Yeah.Yeah.I've traded this UTI the year and should be clear of bacteria.Right?That's another thing that people do like, well, do another sister centerpieces.Oh, there are bacteria.There shouldn't be bacteria in normal urine from the bladder.Let's keep giving an antibiotic.
So that happens a lot.So subclinical bacteria does not need to be treated.That's when you that's a real quick.That's a weird one film, come back to that.Okay?Okay.Well, I'm willing to be told of but the guidelines say unless their symptoms you don't treat but the issue.
With the finishing, the course is that the traditional courses of antivirals have been determined in a really very arbitrary way.It's not.I mean, have you ever thought it slightly strange?That we do so many multiples of the number five, or the number seven in our antimicrobial courses?
As if that's some sort of magical threshold for bacteria or like it's not it's something that people people do five days and seven days in the Quite well, because their heads revolve around a week, but there is nothing special about that.
And actually a lot of the trials that have sent your led to us saying, well, we need to treat this for 7 days or 14 days or whatever.It was.They are done by drug companies and they need to do it to register their product.Their motivation is not to discover.
What is the minimum effective duration in a condition.They just want to find a generation that works.And in fact, if If you're a cynic you might say they're actually motivated to find out what a longer duration is necessary because they would like you use more of their product.
But actually wherever clinical trials have been done in human medicine and increasingly now in vet medicine to discover.How far can we cut this course of treatment, back before we start having an inferior result.Almost in all cases.
We found that shorter courses work just as well and reduce the Of adverse effects from the direct adverse effects, as well, as antimicrobial resistance.So yeah, we we talk in multiples of three instead of five or seven.Well, I guess if you keep you keep on going, you get multiples of 3 in 5 x, 21.
Mm.Yeah.Yeah.How do you decide when where what does long enough?Well, I mean, I guess it depends if the answer to that Dorado I think about and how do you decide I think?You know for common conditions, there are independent, prescribing guidelines.
Guidelines available from the University of Melbourne website and you can also find them on the rare, a pretty new website, called the am our vet Collective.That's an Australian University based website where you can find lots of free resources, so you can find guidelines to give you an idea of how long Common conditions need to be treated for, obviously not all of the cases.
We see in clinic clinical, practice, are going to fall into those common lists, and they're also, you know, There's variability in different cases, some animals that have less of it, competent immune system.All of that.So it's not, it's not saying you must use this amount, but starting with what's written in the guidelines is probably a good way to go.
So you might look at the guidelines.Say, for a sporadic, UTI, in a dog and it says, three to five days of amoxicillin or trimethoprim sulfonamide and that is it.So, yeah, so I've a lot of vets are spoke to were really surprised about Out that they haven't got the guidelines and they have been treating for 14, sometimes 21 days to really wipe out those bacteria.
But actually it's just not necessary.And if you think about how much extra exposure, all of the commensal bacteria have had in that time, that extra ten days that you've given that you didn't need to give.That's that those those are easy wins for us in terms of reducing our impact on Antimicrobial resistance.
So we can just get to the guideline recommendations.We will be making a huge difference.I think that makes sense in a way to really would like rolling what you said before which was tipping the balance in favor of the immune system, you know, like we don't want an aisle eight them because would be annihilating other things as well and we just need to make sure that we get the low enough.
We'll get rid of enough that the immune system continue on with the job or something like that.Yeah.So does that come down to the clinical side?Ines then?Yeah, I think where we don't have a clear guideline, I think you need to be guided by clinical signs in human medicine.
They're increasingly using, especially in the hospital setting.They're using biomarkers such things like procalcitonin and C-reactive protein to see where patients are at in terms of their recovery from an infection, especially when they're infections.
You can't really see.Your don't have really obvious signs on the outside there.Those sorts of things that using those as markers to see, when can we stop antibiotics?Those are going to be a little bit harder to do in veterinary medicine, but I think clinical signs is a really good way to gauge how you're going with the infection where you don't have guidelines.
So would on the biomarkers, be things like, you know, the second part of freitas's and then you had an as a team here or something, clinically looking better.But then the other team you still there, you'd continue for longer till the The other team you might resolve or is it?That's only a biomarker that that's yeah, like I think that's a tricky one because it's that's more about regaining function, isn't it rather than the inflammatory process coming down?
I think what what if you wanted to look for a biomarker?There would have to be something more to do with the response to the infection like, like inflammatories numbers, cell numbers or CIP when we it'll be interesting one because in my last Clinic we used, we started using CRP.
Canine reactive protein quite a bit and that might be useful.But again, we won't dig down that rabbit hole too far.I don't understand.So unless you know, anything specific.I know I'm certainly no expert in that area.But I think that that is that just to just to have the concept that that's where we would like to move towards thinking about.
How is this animal going rather than saying, I need to treat this for exactly 21 days?Like that some sort of magical thing and then it that if I get to that point, then I will somehow avoid an time.Hi Bo resistance, unpack, the theory that started the whole world.
If you don't finish the course, you're more likely going to get resistance.So what's the thinking that if you haven't killed it properly, and they still bacteria hanging around, he's going to rebound, and it's going to be the ones that are more resistant.Is that that's, is that sort of our, I thought about it.
And is that not true?Well, that is, that is why it came about.It's the idea that, you know, if you did not finish off the pyelonephritis earlier.If you didn't get rid of the bacteria in the kidney, that those ones that were remaining, when you took off the brakes of the They would be really difficult to treat and then you would end up with a bigger problem.
That's, you know, that and that is I guess true to some extent.But I guess what I'm saying is that the courses generally that we've decided for a lot of things far more than we need to get to the point where the body is winning the fight, you know, in the kidney in the bladder in the skin where we just generally overdoing it and it makes Us feel safe and it makes us think, oh, well, I can sleep better at night knowing that clients not going to come back with something returning, but we need to start looking more closely at following the guidelines, which are based on evidence.
What are the kind of things that we do as a practice like, you know, humans vets, you know, what are the kind of thing?You talk about, the, our recommendation to finish the course, what are the things increase resistance?Couldn't be like under dosing or something or or in not like going to the right frequency of do, surging or yeah, I think all of those things do contribute and are responsible for encouraging resistance, but I think every attack It's hard to say what contributes the most, but I think underdosing at the concepts to focus on is this mutant selection window, which is sort of that the concentration that is enough to select for the mutants that have the resistance genes, but not enough to kill them.
So the longer you put an animal into that, that sort of Band of antibiotic concentration.Where you are selecting for mutants, but not actually getting rid of them, the more resistance you get now, that's not to say that the immune system won't get rid of some of them, it will, but consistently giving to lower dose, is definitely problematic because it tends to keep animals in that, Newton, selected selection window.
So, if you stuck to the general dosage regime's, it's pretty hard to underdose well.Depends when you get them from.So if you get your dosage guidelines by reading the bottle that is not always going to be correct.
Some of my supervisors have written articles about the problems of antimicrobial labeling in Australia.Some of the label claims of dosages have been subsequently shown to be completely incorrect.Particularly in equine medicine.
There's been some serious It's under dosing of Gentamicin, so that there's some attempts to get that rectified.So I guess and I couldn't possibly tell you all the ones that are correct or incorrect.I think in small animal medicine.There are fewer problems, but I think in general, it's best to look up a different resource other than the label to figure out what dose you should be giving.
And how often So yeah, I'll put we got from the University of Melbourne as long as well as the prescribing guidelines, which will tell you which drugs to choose for how long.We now have a new resource called the antimicrobial where we've been calling it, the flip book.
It's like a little book with dog and cat in front and it has also recommended dose rates and frequencies for the drugs based on evidence.So that's the kind of place you might look for a really reliable.Dose rate.So so basically the message is that when you use an antibiotic, you are potentially going to help select for resistance.
So be mindful about when using a neurotic basically.Just don't do it.Unnecessarily use it when you need to because every time you do there is a small risk that you are going to select for the the ones you don't that does that about it's stronger than that, I would say.
Every time you use an antibiotic Selecting for resistance.You don't know about it because you're not testing for it.But when they've done studies of say fecal, samples in an animal, that's been exposed to systemic antibiotics.The resistance that has been selected for, in all of those commensals that live in our guts or in the animals, got, you can still see the evidence of that course of antibiotics years down the track.
So, I used to think, I will surely, you know, after a few months.Everything's kind of.Once you've taken off that selection pressure.It will all settle down and everything will be back to normal, but actually the resistance that you've selected for can persist for years.
And I think that the, the study that I read most recently said, even in some animals, there was evidence even four years after the course of antibiotics.I mean, those are, those are probably just resistance genes.You're sitting there not Really doing very much not affecting anyone.
But every time we select for those, we are increasing the risk and that animal can then pass on those genes know that those those gut bacteria end up somewhere, maybe in the owner, may be in the water supply may be in wild animals.
We are living in one.Big microbial, soup and everything that we do has flow-on effect to other species.He's and each other.Now, you mentioned something earlier sort of in passing.
But my my ears perked up his head amoxicillin instead of a Moxie clave.When you talked about it, you know, is that specifically for you?I just go I haven't used them straight amoxicillin almost ever.It really is made me smile, gets there on the Shelf credits.
It shouldn't be using it more a good.It's just that looking Moxie clubs.Subject.Probably the most used small animal antibiotic and I know it's it's kind of like the it's like yeah anybody you want to thank you and I know for a lot of instances.
It's probably too heavy-handed.But again, it comes back to that thinking which listening to you now.Sounds like it's erroneous, but that well, I'm going to do it properly.If I'm going to treat it this printer probably and let's not go half-assed and gang Moxie saline.And then select for a larger number of resistant bugs.
That's sort of what my But my thinking was, but I'm obviously wrong.Well, yeah, which is, it is, that's exactly how a lot of people think about it.And what I would like to do is flip that and say, when you add clavel innate to your amoxicillin, what are you adding it for?
What is the extra spectrum that you want to get from it?Whenever you add the club unaids, just sounds better.No, because It's because a bunch of our now and I would as it's a bunch of the steps of this is going to.
I'm gonna eat all this.Yeah, but then you get it wrong, but they make it wrong.I'll give it a go.After they, their make something that sort of neutralizes your antibiotic that protects them against antibiotic yet every night.Counteract that yes.Yes.So you're talking about beta-lactamase.
Is that?That's the word?Yeah.Yeah.Yeah.Chloe. 18 is good.If you have beta lactamase production in the pathogen, Is that you are targeting, but I think you might be surprised.How rarely you have a beta lactamase producing pathogen really.
It's not as common as vets think.In fact, I got some data from ASAP laboratory in Victoria and looked at all of their culture and susceptibility results from 20 21, and in dogs for non Yuri samples from dogs.
Now, I don't know.Body sites, they came from, they would have been, you know, skin swarms all sorts of swabs 6% of the isolettes.Got a been would have benefited from the addition of clabby laminate.So that's not very many in urinary isolates.
It was 11% would have benefited from globulin 8.So most of the time you will get no benefit from Club, you'll innate and actually in in UTIs.Let's talk about UTIs because I did a big study in UTIs and in dog and cat.
UT is 94% of infections, can be treated with a low importance.Antibiotic now is the importance of Antibiotics are Concepts that you've been exposed to different importance levels, like, first order, second order.
Yeah.So yeah, we sometimes, I think in some cases, they called first second, third line, but we want to wear now switching to calling them, low medium and high importance.And the rating system is about how bad it would be if we got resistance to that particular antibiotic.
And so high importance, really bad.We don't have many options left to Beat the pathogens that affect us, low importance.We put those in green color.Sometimes just to highlight that they are the ones we should be using preferentially.
Yeah, if we get resistance, we've got heaps of options up our sleep, when I say, heaps more options than the other ones.So that's a really good way of thinking about how you use antibiotics, go for the green end of the spectrum, avoid the red end of the spectrum.
I like that.You like it?I can almost Imagine One having this little flip chart book thing with the anybody proof, selection guidelines, but then also just like the color coding system next to the anybody accepts.Like don't touch the red unless they're about to be dead or something like that.
Oh, I love that.Make that make the raid, one's really hard to open.Just like you have to go get a nurse like you make them click, push down, click rotate and peel back and have the cotton ball in there.There as well as make them really, really, really stupid two people to open it and you literally cut it like a button that somebody has to push while.
Yeah.Yeah.It's actually it's actually been done.So we have some really cool little chats for different species of the antibiotics that are available in green, yellow and red dots showing listing, the ones that we should be using more of.
And the ones we should be using less of so agricultural.Victoria has those freely available and Can print them out and put them up here clinic.But yes, putting red dots on the drugs that you want people to avoid.Using is something that we've done is part of a antimicrobial stewardship, trial with a bunch of clinics and it does seem to affect people's behavior and exactly what you said.
He was.Well, making it less accessible know.If you put the antibiotics, you want people to use it.I height and you put the other ones somewhere where you people have signed on to a letter.Guess what people will use?Yeah, but yeah.Using box.To fill in more.
It's a low importance antimicrobial and it's super effective in lots and lots of conditions in animals.So it's a good place to start.Whereas a Moxie clave.You've added Spectrum.It goes into the yellow zone, the median importance antimicrobials, and it's just not necessary so much of the time.
I know we love it, but it's so, I can tell you why we do it as a profession.We don't like failure and we do Not treating the effectively.So if you say the percentage of when it's not going to work, doesn't sound like a lot.
But if you say to me one in 10, out of the cases that you treat is not going to work and your clients are going to be pissed off.They're going to come back and say look we've been here, it's not it's not bad.I'm going to go.I'm not happy with that.So it'll take a mind shift and we'll take better communication with clients and better follow up probably.
Yeah.Just start getting these into a clinic because I don't I don't like failure.I don't want my cases to come back, not better.Yeah, and I totally get that.That and I think that is a key thing for us to keep in mind.But I mean, I guess, yeah, if you can communicate to the client about what what might happen so that it doesn't catch them by surprise.
If, for example, three days into just getting a Moxie amoxicillin that it's not improving.And you've explained what the plan is, if we get to that point and I think most actually the clients that I spoke to I did.These with clients and I did say they did over 500 small, these clients and generally speaking as long as they understand, as long as someone communicates to them, what to expect.
They're generally pretty happy.Whatever you decide is the right thing to do.And a lot of them are aware of antimicrobial resistance and are concerned about it.They don't necessarily understand it in depth and, but that's okay if You explained that the reason that you're doing it is you want to avoid using unnecessarily using Club u18 unnecessarily, for example, and say, well, we might get a situation where you have to come back and we'll have to change you to a different antibiotic.
I think that's okay.Well, look vdd, my dad, that approach that I just said is also very short-sighted because I go like don't like failure, but then I'm setting myself up for massive failure.Ten years down the line because I've got nothing that works.Yeah, I agree with you that they most clients, may not really understand whether you understand, or they know that.
Anybody resistance is bad.What?Right.And now that I've started to have a conversation, give them a choice and go.Hey, look what we could do here.His give some antibiotics, but actually there may not make a difference and Studies have shown that.It actually, you know, your pets will probably do likely just as good without them.
You know, my preference would be to not prescribe anybody expert if you especially when it's not life and death.And it's not like, you're not going to take a gamble when it's all.I think it's maybe septic but let's see how we go.Yeah, especially when there's guidelines saying like the longer you wait, before giving anybody specific patient more likely on the family of it.
I've had that conversation.The times recently, last couple years and owners like like overwhelm overwhelmingly select not to use it and they're aware of the thing.And I type in my notes because we always give a discharge summary.And it says, if you see any of these signs or there's no improvement within the next kind of 24-48 hours or something, then come back, free console or whatever.
We re-evaluate need friends.And that's a really good technique and is to leave the door open.Say, you know, we might have to go down this Spath.I'm not saying no, I'm just saying not yet, which completely changes the conversation with someone who's coming with this expectation of antibiotics.
If you don't say no completely.But you do say look, you know for now, I don't think it's in the best interests of your pet to do this.I think they really respond to that.And a lot of the clients that I spoke to said they saw the vet as an advocate for their And so they, if you frame it in a way that says I am doing this in the best interests of your pet that because I want your pet to get better.
But I also want your pet to avoid complications that can happen when we give antibiotics.So, this is what I think is the best plan for your animal.I think, what I learned from speaking to clients is that saying, I don't want to give your pet antibiotics because Public Health, blah, blah blah, you know.
Heavy cheese, there are people dying in hospitals and tuberculosis that's multidrug-resistant.It's too much of a leap for people to think about in that moment.I mean they, you know, they sort of they do care about that.
But in the moment that they seen you, that's not what they care about.What they care about is their animal getting better as soon as possible.And they want to know that you are doing the best thing for their animal.And I think if you can If you can get them to believe that then they should generally going to be happy with it.
I mean, there's always the odd person who won't be happy with anything but it's really, really important for vets to at least in that situation where you're deciding, not to give antibiotics, appropriately deciding that antibiotics shouldn't be given.
If you make it clear that like you said, you're a do that it won't help giving antibiotics won't help your pet.Get any faster because that is what they think when they come in saying, I really want my dog to get antibiotics.They're saying it because they think it's going to relieve that animal suffering faster and that is their priority.
So if you can underline that it won't help because it's a virus or whatever and that you're also addressing the discomfort that they are seeing in their animals, then that's most of the, its most of the issue sold.
Aft and clients.Really, I think most, you know, 98% of them are going to be fine with that.So you mentioned the back to your bacteria that if it's not.Symptomatic doesn't need treatment, other common clinical scenarios where we probably abuse antibiotics.
We reach too quickly for the bottle of lavor.Talk about conveniently.Can we talk about tableting cats as well?Yes, so we've done some analysis of prescribing of antibiotics across.
Lots of clinics.We looked at Pet Insurance data, which is given us, you know, millions of consultations where claims they made.And we've also had some access to some prescribing data, from a group of clinics contributing vet compass.And what we've found is that there are quite a few inappropriate uses of antibiotics.
One of them, where the guideline says say, no antibodies are required, but So many vets give antibiotics is the catfight abscess.That's, you know, you have this I've heard of this Harris.I've never done that ever.I've never done that.
Once one of its are doing what I need to do, simple.I can when I can see and smell and almost taste the past.I can't not give it antibiotics to clean that up and I'm like, yeah, I get that reflux.Like it's gross.You want to clean it up, but once you've opened up that abscess and it's draining, don't need to give it any antibiotics.
The immune system is going to sort that you've taken out the nidus of infection positively antibiotics.Don't penetrate the Abscess anyway, like you know what, you're getting into.The core of that ball of passed by giving the cat a tablet, or a convenient injection.It's not going to get once.
If you inject a ride into the well, to be honest.I'd prefer that if people are going to shove antibiotics or the catfight answers.I'd prefer it to be in the abscess then given to all of their bacteria in their whole body.But yeah, there's a big problem with convenient and I think it stems from this, you know, owners can't give their cats tablets, which I would say that the truth is that he's owners don't want to give their cats tablets.
I think that most owners can with the right training if they catch tablets.What are you guys working?All right.Look, I'm terrible with bullying kids if I don't really care, but if I had a cat, if it needs, it was a super nice one.I'm leaning towards the ejections.
Normally when it comes to get for the Glad.Yeah, like I must admit it.It's always a question.And I ask the clients, the vast majority would say, yeah, like I can do it, but then it some would say, look know the cat is super aggressive and I can't go near it.
That's when I would pull it out as a, as a all one.Where let's say, if we give him any tablets, he runs away for three days and then he doesn't eat and drink and then you get sick or they can't keep him in the house because it will shred the door and then stuff.Yeah everywhere.So like so there's that select kind of like Super Evil and cat.
Yeah, right.And there.Some of those.And I think those are always going to be a big challenge one, but it sounds like is, if you just don't even need to go.And the fcc's open and trust, you do not need to give antibiotics.
At least.That's what the literature says.I mean, you know, yeah, kick it in the show notes, or I could you be able to share some papers that we could pull this off.That's because that would be your look.It took us as a business about a year and a half to stop giving metronome.
Azure, anybody X2 H GE, right?That was five or six years ago, if not longer, and then it took it.And then we had quite a few client complaints associated with it, because I go back to the referring bet they would start metronidazole and magically 24 hours HG resolves, where he's like, if you were 20 anyway, but it took a while for the, the culture, the shift within our practice.
But also we can now practices that refer to us, but they like cat fight.Anyway, they'll that would.I want every supercooled all out and I have a better idea of how to do that.Now.It's almost like you give me an information sheet about, you know.Catfight abscess not needing anybody X.
Yeah, I think that would be a big win that.Tell me.What are you doing about dentals?Oh, we're good.The good thing about it is that I never use.Never use anybody's dentals.You know, why?Because you never do deadly, emergency never the dentals before before we go.
Dancers.Can I just circle back to convenient?It is very convenient.I'm trying to think based on what we talked about the mechanisms of how resistance happen.Why is convenient bad?If you, let's say, you have an instance that does need anybody.
So it's not.Okay.Absolutely.It's a scam.Swollen get by the city light is and it's got a high fever.And I want to give an antibiotic, why it's going to be a worse than a five-day course of mocked clamp.So, the big problem.So convenient belongs to the third-generation cephalosporin groups group of antibiotics, and it's rated as highest priority critically important by The Who and in a human Hospital.
You can't prescribe anything in that class without some sort of Extra approval.That's what I understand.Anyway, and the reason why it's so these this group of antibiotics is so problematic is because they select for extended Spectrum beta-lactamase producing bacteria.
ESB else.You would have heard about hopefully heard of somewhere.You haven't heard of those Dorado is shaking his head.No, so you can ESP olds are really, they're very scary.So, rather than just being Average staph aureus that produces a beta lactamase and then you have to go from Amoxicillin to treating it.
Amoxicillin Club.You'll innate.You have these beta.Lactamase has that can break down all the Catalyst poisons.They can break down pretty pretty much all of the penicillin group as well.And the end up in a situation where you have for some infections, really almost no options left after that.
So we getting into the territory of having to use those anti.Microbials of Last Resort for infections that have esbl.Third generation, careful historians, and fourth generation Catalyst for intend to select.For those particular bacteria, is just why we really need to only use them when we absolutely have to.
Yeah, it's frustrating that the only antibiotic that we have that is sort of a whole course in one injection happens to be in the highest importance group of antibiotics.I would have, you know, Is it could have been amoxicillin.
Everyone would have been much happier and better off, but unfortunately, that's not how it happened.But I think you know, using long-acting amoxicillin lifts, which lasts about 48 hours is an option for some of those common conditions in cat.
So, I would say to people who are dealing with you and you really cannot tablet this cat consider, whether you might use a couple of long-acting amoxicillin injections, two days.Apart, that would cover you for most UTIs.
Amoxicillin is so well concentrated in the year and that it would really like you would get very high concentrations in the urine from doing that.Otherwise, we should really be trying to teach owners had a tablet, their cats because there was a time before convenient and cap sleeve then to know know what happens, convenient just helps keep little nasty cat's alive.
The one.Yeah, so now I think we're selecting for nasty bacteria.Nasty cats.You could do a PhD on that.I've been.I would love to see some of the drug companies work on a longer acting.Anything that's not a high important antimicrobial so that we have better options for the really really feral cat.
But I think there's a whole band of like actually tablet of all cats who are not getting tablets because it's so easy.Just to give Nia.And I'd love to kind of move away from that and think either, let's really teach this owner had to give tablets and maybe you you're not the person, I don't like doing it but maybe you've got a vet nurse who's really good at it, to teach the client who actually know that.
That's exactly.Who would we get.The other thing is that client said that vets would sometimes do one demo of Oh, this is how you give the tablets when you get home and they go hat and stick it in looks really easy.
Don't explain anything, don't give any handouts, don't give any links to YouTube videos.Just say go home and not do that 10 times for the next over the next five days and people get home in there.Like, this is a totally different scenario.I don't actually don't know how to hold my arms over this cat.
I vaguely.Remember, they just sort of open the mouth and popped it in but they I actually don't really know the steps and to No One explained how to grab the cat's head, where to grab the cat's head, the fact that you tilt, the once you tilt the head back, the door is going to open up.
So they're they're trying to like pull the jaw open with their fingers, getting bitten and scratched and fake.We, if we'd spent a couple of minutes, just giving them some proper instruction and maybe getting them to do it in the club, rather than us just showing them and making it look like it's easy.
So that you can say, okay, I can see that.Approaching the cat in this way.What about you tried?And this way, we find this works a little bit better.You know, what about?We put the cat on a different surface.What about we put the cat's bottom near the wall.So it can't back away from us.
All those things that you think is so obvious, but to a client who's never had a cat before or have never had to tablet account before it's not obvious.So we could do a lot better.I think generally as a profession in teaching people how to do stuff at home.
I will clarify one thing.So is is the worst in terms of its importance than a maxi?Clamp.Yes, it is.So I'm actually collapsing in.Yeah, I'm actually Club is rated as medium importance and convener is in the high importance category, along with enrofloxacin.
It's interesting that that seem to really have embraced their, like, we shouldn't use fluoroquinolones.Favorite people have, got that message loud and clear and fluoroquinolone use is pretty low in Australia, but We haven't really got the message that we shouldn't be using convenient.
That's a contradict, but we had a discussion with Prop Joe medicine about antibiotics.And she talked about this kind and she said I should acknowledge that it's she said we shouldn't be throwing it around.Just like a maxi, Claire.We shouldn't be throwing around said that it's still better than missing every second days.
Everybody does because you can't find the cat because it's running away or something rather that then have missed doses of antibiotics.Skip a day.Do you like do something?I think he's, it's better to make sure you get the whole course, then to have potentially miss doses.
Well, at least not missed, at least not miss though.She didn't say she said, it's been way too long.We don't need two weeks.It's an excessively long, cause for most things and it's just the same boat as you.We had this discussion because she was saying we are abused and Robotics, but then she said, people get really upset about convenient.
She'd rather a cat gets its three.Four days of antibiotics and I give it.And then soon eyes.I can't get it in and it tomorrow the cat's outside and it's just sort of.She said it rather rather get it in or don't do it then.Yeah, look, I don't think that's a fair point.
But what about in that cat if we talked the owners how to give the tablets they gave it their best shot and they went home and they couldn't give the amoxicillin tablets.What if they called up and said, can't get the amoxicillin tablets in what can we do.And you see ya.
Can you bring the camera back in will give it a long-acting amoxicillin injection today?And again, on Wednesday.Would that be an option?I just reckon that just sounds much better to begin.We have like Unless the cat's a demon to put in the cage and to bring back in.
But like this, this long-acting amoxicillin.I never heard of this stuff.There's a girl thing is before.Nice.No, I never treated a ball and it's available for.
Yeah, you're right.It is, it's just not an emergency.Don't he's not a drug.You'll see on the shelf and most I'd love to the other thing that I love.You don't want to tell me.Got trimethoprim sulfonamide on the Shelf.Yeah, that's good.Yeah.Yeah, be using, that's a really good choice for urinary tract infections.
And people are scared of it because, you know, Casey s, in whatever Doberman Pinschers that, I can't even what breed was supposed to all of these and HEPA type of these.Those things do happen, but they happen with longer courses than recommended in the guidelines.
So sure if you treat for 14 days, You're running some heavy risks of some complications from those, from the sulfonamide component.But if you use 3 days for a urinary tract infection, which is recommended you probably almost certainly not going to get those complications.
So this idea of, let's the first look at the guidelines, which have much shorter durations than we've been traditionally using.It reduces side effect, it then opens up possibilities in terms of using drugs that we're scared of using because of potential.
Side effects.It also makes it a lot easier for owners who don't enjoy tableting the cats or have trouble.Remembering if they only have to remember for three days or struggle with their cat for three days.That's a lot more doable than 7 days or 10 days.Right?Like it just becomes a much smaller problem when you have a shorter duration, which is more appropriate in most cases.
Yeah.I'm excited.And I apologize if it sounded like I was argumentative, the reason I'm happy.I know.About it is, I know what happens.You listen to this.You're in a busy practice to go.Well, that's interesting.I shouldn't be doing that but it's so fucking convenient and the clients.When you, as you say we did was use just do fine without it.
But we also used to define with that mobile phones, trying to take that away from people never.So at least, we have a decent, not super in convenient.Alternative.People will just say, yeah.Probably shouldn't be doing it, but I'm still going to do it.Yeah, easy.
I think that's true.Not, it might take more than a year for people to get out of the habit.But I would point out that the label of convenient says, you should only use it when you've done a CNS that says, you need to use this drug.And I can tell you now that almost never is that the case in Veterinary practice in Australia, we've looked at CNS people using CNS and people using convenient and those things are not aligned.
People are generally not doing CNS before applying convenient and it's problematic.I mean, I don't want to put the fear of God into people.But we do not want to encourage ESV else in our animals.It is not going to turn out well for us.
I think you picked a really good color.I'm looking at your guidelines here and it's red is kind of like a good color for like don't touch like, you know, like I don't feel like I want to touch the bottle anymore now in the fridge, but you got black here.Yeah, what's black?Black is really you cut me it's you shouldn't go there.
I mean that is it's going to be life saving as go to be a life-saving situation.And really I mean it's those are things like carbapenems, any pain and these are in human medicine.Last Resort, drugs and should really be last Last Resort.
In veterinary medicine has well, except with them, with the branding of black.It does make it sound pretty special.So I'm like, if I, even if I ever get sick, I want the black if you want the black one.Now, I give him cold.I think I need the black.
I need the black antibiotics for my cold.It is funny.Said it earlier then the concept of having a stronger antibiotic and I it is a funny thing to think of any I got X's being stronger or weaker because that's not really hmm how they work.
You know, they either do affect a certain type of bacteria more don't, and I think when things are broader spectrum that doesn't necessarily make them more effective or stronger, but you're right.Some people do want something for the newest while or the strongest one or whatever and we need to get them out of that mindset.
We need to be saying, actually the aim here is let's go.All right, let's go.Low importance.And let's go short duration.Yeah, which is a miser, but I think it's vital to, to listen to this, obviously, will attach the show notes, the the guidelines, but I literally just Googled agriculture, Victoria antibiotics and then it just came up as you feel like seven pages.
Poster things with the three dots, the green In yellow and red dots showing the different antibiotics that are available for those species.You asked to read dentals earlier.Why did you ask what do we use for details?Chris when I when I worked in mix practice we gave and this is a classic example of, you know, habit based sort of myth based prescribing.
We used to give every Dental seven days of antimicrobials before the dental, and then another.Days after is that, it's that still a thing.Well, I haven't done GP practice for dick.But if I was gonna Dental, I would want that.
So there's poking the bear the bear, but is it, what is it?Like some kind of endocarditis kind of.So that's the, that's the idea is you've got to, you know, the animals got really bad valvular disease that you have to protect it from the spray of bacteria, that are going to come off in this Dental into the Bloodstream, but actually it's not that it's not critical.
There are a couple of instances where you and these are in the prescribing guidelines that you're going to post on this.And there are a couple of instances where you might consider giving antibiotics.At the time of the dental, you certainly do not need to pre dos anyone before a dental and in almost all cases, will not require any antibiotics at all.
So you'd want to have a really immunocompromised, really problematic animal before you started thinking.Giving antibiotics for dental, you know, we all know how good the blood supplies to the math, you just that you just don't need them.The immune system is going to sort of what about the common practice of antibiotics during surgery clean surgery or let's say you doing a big slap or something like that.
It is the thing about what is it?If it's more than 90 minutes, then it should have an antibiotic because the length of an aesthetic increases infection risk.The anything that can.Interacts or supports that the timing of giving the antibiotics is really important for surgery.
So you actually need to get reach, sort of peak plasma levels of antioxidants of the anti biotic at the time, you make your cut and the mistake that most vets are making is giving it much later, say, around the time of making the cut.
It's when you might Chuck in the covers Olin and that is too late in the Sager to have the best effect.So you actually need to be doing it about 30 minutes prior to your cut and that's that's in the guidelines as well.
And it depends on which agent you using it which way you're delivering it.But if you giving, I think I'd be kept as Olin.It's about a half an hour beforehand that you should be giving us but check the guidelines for that.But generally speaking, what you're saying is correct about the length of the surgery does matter as well.
Well, I just actually got two guidelines up here and they're super good.It would assist leaders like the timing though.So, 60 Minutes that he's 36 years prior, right?But if you got too close and it's actually every four hours, it's just like, won't like, you know, sometimes it takes me four hours to do a surgery for dogs being mauled, to Pieces by three other dogs in the dragon the same time, but but if it's like a simple, laparotomy moving foreign body you're in and out in less than an hour.
You're not gonna need that.Second dose.Well, I feel like I need a cup of tea and my comfort blanket to go to process some of it.This is exhausting.I'm like, can't wait to like share this around the halls were going.Hey, this is we're going to now, I would love you just shared.
I would love vets to know about the guidelines because I the ones I interviewed only probably to out of 22 had actually heard of these guidelines.A lot of them had heard or had a copy of some drug company.Sponsored guidelines, which coincidentally recommended?
And reflect we use this.And then it was amazing.How many applications they were for their particular antibiotics, but I think we probably need to get these ones out there.These are not sponsored by any drug companies and they are based on evidence.
I mean, have to say that you'd veterinary medicine, as you know, this is hardly any money for research.And so often the evidence base is fairly thin, but wherever research is being done, we're finding that they were ways to reduce the cost.Causes to reduce the importance of the antibiotics that were using.
And so we just, I just what I want to give the guidelines to get out there as far and wide as possible.And for people to actually look at them and think about how they might alter what they're doing without risking patient Health.We don't want animals to be suffering longer than they need to be.
Don't want animals to be not treated with genuine infections.That is not the aim of antimicrobial stewardship.We're not saying stop using antibiotics.You must use less.We're saying is when they're needed when they're not needed, don't use them because that's just sort of hitting against a wall.
It's basically stop being lazy because it is important because it's what it is.Really, I have to confess for myself.It's even if it's in the back of my head, if it's not important, I'll go.Mmm.I've heard of this stuff, but I really busy and I just want to.
Yeah, and I don't want people to complain and I, so I'm just really being a bit lazy.Yes.I've have something together.I'll get it.Take the convenient bottle out of my pocket and stopped using it to be refrigerated.Oh shit.
Gerardo.We should see if we can get Zoe to sponsor this episode.Thank you so much for that tree.That's the love your work.I love your fashion.And it's it's one of those things that you know, is really important and and we should probably just be a little bit more mindful about it.
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Dr Ri Scarborough