Preventing the post-antibiotic apocalypse

I think we may soon lose the battle to keep our right to prescribe most antibiotics for animals, with apocalyptic visions of a “post-antibiotic” era in medicine being mooted.

Antibiotics are a victim of their own success. I remember the vet I “saw practice” with in the 80s and 90s having huge glass jars behind him filled with pills and capsules. It was rather like a sweet shop. His favourite were the yellow-orange pills that looked like M&Ms. He believed one day someone would find oxytetracycline cured cancer – he dispensed it a lot.

These days, for reasons I’m not entirely sure of, oxytetracycline isn’t used much. We tend to use the bactericidal antibiotics rather than bacteriostatic ones. For a quick spot-check I looked in our “quick-access injectables” cupboard and I found only penicillin derivatives (amoxicillin was there in a few different forms), a cephalosporin and some metronidazole. You have to go through to the store room to find anything else – fluoroquinolones are there alongside narrower spectrum amikacin, erythromycin and so on. There’s also a bottle of trimethoprim/sulfamethoxazole as well.

I wonder how much of our drug selection is simply the need for speed – in the typical 10-minute consult we have very little time to look up dose rates in a compendium that spans more than 1,000 pages, while each drug monograph is around two pages of tiny writing. Then you should cast your eye over contraindications and adverse effects, unless you know the drug very well.

Or you could just prescribe a dose and course of something broad spectrum you know off the top of your head.

If we are going to change our habits, a big step will be in ensuring these things are more easily accessible. A practice could have a wall chart with conditions and dosages (volume or tablets per kg, per 10kg etc) for normal courses of drugs and quick notes of contraindications.

I do read and hear about “the pressure to prescribe antibiotics” in my reading, but haven’t experienced it much myself. Occasionally, there will be an expression of relief when I tell an owner I’d recommend using them in a case, but most people take an explanation of the reasoning to use or not use them well. If I take a client through the signs of infection and check this against my physical exam findings, just about everyone comes out agreeing with me. It can take a lot of time, though.

This makes me wonder if the “pressure” is actually inside our heads – whether we’re worrying about the “what if?” possibilities. What if I’m wrong and the animal gets worse, will I be accused of negligence for not prescribing antibiotics? That’s where broader discussion between colleagues and authorities will help.

What do you use, if anything, in puppies with diarrhoea, versus a pyrexic dog with haemorrhagic gastroenteritis? The veterinary school student answer was “base it on culture and sensitivity”, but that doesn’t answer the question for at least three days.

So this is where a body like NICE (National Institute for Health and Care Excellence) comes in in human medicine. In human medical negligence cases the standard of care is to be compared with a “responsible body of opinion” (the Bolam test, since further modified and refined by other cases like Bolitho), but there is increasing reference these days to the guidelines laid down by NICE and other professional bodies.

By laying down more specific guidelines for the use of antibiotics in common situations – for example, herd health, growth rate improvement, puppy diarrhoea or haemorrhagic gastroenteritis – a similar veterinary body would not just provide “back up” for colleagues wanting to get on board and change their antibiotic use, but also provide a measure for applying stronger pressure on those who did not want to do so.