Veterinary Vertex

Rethinking Antibiotic Protocols: Shorter Treatments for Uncomplicated Canine Pneumonia

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Discover the surprising study with Dr. Erica Reineke that challenges the conventional thought process of antibiotic treatments for canine pneumonia. What if a mere two-week course could be just as effective as the traditional four-week regime? We explore Erica's findings that shake the foundations of veterinary medicine practices, revealing that clinical signs are a far more reliable guide than radiographic signs for discontinuing antibiotics. This revelation not only promises to revolutionize treatment protocols but also sparks a crucial conversation about the potential risks of prolonged antibiotic use, including the looming threat of resistance and the disruption of the microbiome.

Join us as we unravel the significant implications of these findings for veterinarians and dog owners alike, emphasizing the need for evidence-based practices. By potentially reducing the duration of antimicrobial courses, anxious dogs could be spared the stress of multiple clinic visits, while owners gain confidence in monitoring their pets' clinical signs. 

JAVMA article: https://doi.org/10.2460/javma.24.04.0259

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Sarah Wright:

You're listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode we chat about the clinical course and radiographic resolution of pneumonia in dogs treated with a shorter versus longer course of antimicrobials with our guest Erica Reinecke.

Lisa Fortier:

Welcome to Veterinary Vertex. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Today, we have Erica joining us to talk about the very important topic of antimicrobial use in our animals. Erica, thank you so much for being here with us today and sharing this important information.

Erica Reineke:

Well, thanks for having me. I'm excited to talk to you today.

Sarah Wright:

All right, let's dive right in. So, Erica, your JAVMA article discusses the clinical course and radiographic resolution of pneumonia in dogs treated with a shorter versus a longer course of antimicrobials. Please share with our listeners the background on this article.

Erica Reineke:

All right. So yeah, as a background for you know, why we elected to do this study is that there are evidence-based veterinary consensus recommendation for which empiric antimicrobial we should choose in dogs with pneumonia. However, there are no evidence-based guidelines on how long we should be prescribing these antimicrobials for, and if you were to open up a textbook and look for some guidance on this topic, pretty much the recommendations are based on expert opinion, which has suggested that antibiotics should be prescribed for one to two weeks past radiographic resolution of pneumonia, which means that in some cases we may be prescribing antibiotics for four weeks or even longer. So, the problem with this is that prolonged use of antimicrobials can lead to resistance, especially if they're no longer needed. They can disrupt our patient's gut microbiome and then, of course, on the client side of thing, it can increase cost to the clients and decrease pet owner compliance with actually administering the medication.

Erica Reineke:

Right, we've all been there. It can be a challenge on week two or week three of a twice a day medication. So certainly, prolonged use can be a challenge. So, we elected to study duration of antimicrobial use in dogs with uncomplicated pneumonia. So, we randomized dogs to a shorter course, a two-week course followed by placebo versus the kind of standard of care. Four-week course of antibiotics.

Sarah Wright:

Yeah, super important. Like you said, it's really hard sometimes to get that owner compliance and a lot of times you see, oh, you know, my dog stopped coughing, so I stopped the antibiotic and you're like, no, don't do that yet. So really good information for both clinicians, I think, and hopefully pet owners too.

Erica Reineke:

Agreed

Sarah Wright:

So, what are some of the important take-home messages from this article?

Erica Reineke:

Yeah. So, I think the big take-home finding from our study is we found that dogs receiving the shorter course, which was still two weeks, had similar outcomes compared to the dogs that were treated with the longer course of four weeks, and there were no dogs in either group that experienced a relapse of pneumonia, which I think is fabulous. What I think maybe is even more interesting than that, though, is because we serially followed these dogs with thoracic radiographs. We found that clinical signs are actually more useful than the radiographic signs for guiding when antibiotics should be discontinued. So, when we looked at our study, we found that at that two- week mark, only 60% of dogs that were treated for pneumonia had complete resolution of their pneumonia on radiographs, and this did improve at the four- week mark, where 83% of dogs had complete resolution. But there were still a few dogs I think it was five dogs that still had some radiographic signs of their previous pneumonia. It was mild but they were still there. So, again, the take-home point would be that probably the clinical signs like the example you gave of the dog that stopped coughing and is back to normal it actually might be okay I'll put a big might there it might be okay to stop those antibiotics because clinically they have resolved and this has already been something that's been well documented in people that the clinical improvement is going to precede radiographic improvement and so they don't recommend repeating just thoracic radiographs to assess resolution of pneumonia.

Erica Reineke:

And I guess I had one final point I think that I was thinking about from our study. Just the difficulty in doing our study is that performing really timely controlled trials in veterinary medicine is particularly challenging, and likely is why we don't have evidence-based guidelines for how long we should use antimicrobials for, Because we had significant challenges in this study recruiting patients for a variety of different reasons, Like we had almost 50 dogs with uncomplicated pneumonia that declined participation and a large number of dogs that were excluded because they had what we would consider complicated pneumonia, that you know conditions: they were immunocompromised or conditions that could lead to recurrent pneumonia that were ultimately excluded from the trial. So, I guess that would be my last take-home point would be like these types of studies can be incredibly challenging to do.

Lisa Fortier:

For sure, any of these clinical studies and you know, I think that's a call out to the owners who are listening, you know, enroll your animals like we need. We need this evidence. It's also, I think it's fascinating about don't treat the radiographs right, Like I always say to horse owners, you know, for in the horse world it would be take a radiograph of the hawk and there's a little bit of a spur there. I'm like, yeah, I'm not treating the x-ray, I'm treating your horse, and your horse didn't read the x-ray, so it doesn't know it has a spur.

Erica Reineke:

I think that's a really, really important point, but it kind of certainly was contradictory to how I was trained, especially regarding pulmonary diseases. We would, in pneumonia in particular, we would treat the radiographs rather than clinically what the pet was doing. So this is a little bit of a change in how we are approaching these cases.

Lisa Fortier:

What was the impetus? What sparked your interest in comparing these two different time periods for antimicrobials?

Sarah Wright:

Okay.

Erica Reineke:

So actually, there are a number of different reasons I think that we ended up doing this study. So, first off, being a veterinary criticalist, I do see a lot of dogs with pneumonia in my clinical practice and, honestly, throughout my career I've kind of questioned why we were treating for so long and seeing these dogs back for recheck so frequently when clinically they were doing well. And I remember one time I was treating a physician's dog for pneumonia and when I told her what our recommendations were for treatment you know I recommended coming back in two weeks and then we would continue antibiotics for an additional two weeks she looked at me kind of funny and made a face and was like, well, that's not what we do in people. And you know I was like, yeah, I understand that. And so, she had some more questions for me and ultimately, she's like, well, I'll just, you know, I'll do what you do in veterinary medicine. But she thought it was a little bit odd that we would treat for so long.

Erica Reineke:

And I guess the last reason we did this study is prior to COVID. I was part of a large antimicrobial stewardship committee at Ryan Veterinary Hospital and we were developing some treatment guidelines for various conditions and antimicrobial use and this was one of the conditions that we wanted to tackle and develop better guidelines, at least for our internal people. You can see from the authors on our paper, we have a multidisciplinary team that was involved, so a veterinary microbiologist, we have a criticalist, we have internal medicine doctors and a veterinary epidemiologist that has a real interest in antimicrobial stewardship. So, kind of this team formed and we were able to design the study and ultimately, you know, complete it. It took a long time.

Erica Reineke:

It took a long time, because it started even pre-COVID, but we finally finished it.

Lisa Fortier:

Well, thank you for sharing it with us and for being here in the podcast to share it with a little even more broadly

Erica Reineke:

You're welcome, thank you.

Lisa Fortier:

Sarah asked you a little bit earlier what were some of the big take-home messages, but always when we do these studies, we find things we definitely didn't expect. What were some of the most surprising findings from this article?

Erica Reineke:

Yeah, I mean I think I don't know if I'm going to say anything I haven't said. I think that we weren't that surprised, honestly, that the outcomes were similar between the two groups of dogs, because I do think, as time has passed, even though we didn't have evidence to do shorter courses of antimicrobials, that people were just changing their practice because of what is being done in people. So, we were seeing less longer-term antimicrobial use, as it was during the course of the trial. So, I think we weren't really surprised that these dogs did great. I think I was actually surprised though at how many of the dogs still had radiographic changes at two weeks that you know only 60% of the dogs had complete resolution. So, I was a little bit surprised by that. And that the ultimate finding of really maybe we shouldn't rely so much on the radiographs to guide our treatment decisions. I did think that I was.

Erica Reineke:

I thought that was a really good finding because I think this will be helpful for conserving veterinary resources, which we know are limited, and also conserving resources for our pet owners that, hey, we don't need to see them back in two weeks if they're clinically doing fabulous and spending another you know, $100, $200, $300 on a recheck exam. I was surprised at the lack of owner interest in participating in the study as, just to repeat that, you know, going into this, we're like, hey, we're going to pay for everything, we're going to pay for the re-exams, we're going to pay for the antimicrobials we're going to pay for the thoracic radiographs. That's a fair amount of money and that's what we would recommend anyway. And so many people just didn't want to do it for various reasons. It's understanding. I understand people are busy, and I think a lot of them. Actually, some owners elected not to do it because they didn't want to be the four -week group, and which was kind of interesting.

Lisa Fortier:

Well, that is interesting. So what's next?

Erica Reineke:

Oh, okay. So next steps, I think, would be probably to investigate antimicrobial duration in dogs with what we would call complicated pneumonia. So these were the large number of patients that we excluded. So, dogs with immunocompromised say they are receiving cancer treatment, or dogs that have conditions that predispose to recurrent aspiration pneumonia events, so that was a large group that you know we didn't look at for duration of antimicrobial treatment. We did have one protocol deviation in that we included a dog with a pyothorax in our study and interestingly that dog was in the short course group and that's what did great. So, I think that you know I was like we kind of accidentally included him, but he did fine. So I think that I want I wonder if probably this other large group of dogs that were treating for potentially a long period of time with antibiotics, those that treatment duration could be shortened as well.

Lisa Fortier:

Oh, fascinating. As we look towards the future, do you see a role for artificial intelligence in this area of research?

Erica Reineke:

Yeah, I think about this one for a while. I find artificial intelligence incredibly interesting, as I'm sure a lot of people out there do. Maybe AI could be helpful for future researchers and for myself for identifying, maybe, questions about antimicrobial use or questions about pneumonia that maybe we haven't even considered. And I wonder, as we accumulate more and more evidence about different types of pneumonia, maybe breed patterns or certain patient characteristics that I don't know. I think AI has probably has unlimited possibilities for maybe even asking AI a question like hey, I have this patient with this pneumonia, with this bacteria, these concurrent diseases, how long do I need to treat or what antibiotics should I use? I could see us maybe getting there at some point.

Lisa Fortier:

A super smart customized plums.

Erica Reineke:

Yes, wouldn't that be nice?

Lisa Fortier:

That would be nice yeah.

Sarah Wright:

Very cool. Yeah, the possibilities are endless. I was thinking too what you said just about kind of like the different benefits of a shorter course from like the owner perspective. I think too, if you have like a fractious or very anxious dog, the less happiness transfer it to the veterinary clinic, you know, probably the better too. So, another thing too that potentially help owners.

Erica Reineke:

I think that's a really, really good point. We don't often consider the effect of that visit on the dog, and certainly the relationship with the vet, right If it's stressful and they have to be restrained for the imaging. You know it's a lot, honestly. So yeah, I think if we can avoid it. Now the caveat to that being of course we would recommend repeat imaging in a dog with pneumonia that isn't clinically improving or is worsening. Now that's a different story. Those dogs should certainly be brought to a veterinarian and have you know, at least a physical exam, if not repeat imaging, to make sure you know that we have the right diagnosis, and we have instituted the appropriate treatments. So, this is this is only before the dogs that are clinically better.

Sarah Wright:

Yeah, important distinction, for sure.

Erica Reineke:

Yeah

Sarah Wright:

And for those of you just joining us, we're discussing canine pneumonia with our guest, Erica Reinecke. So, Erica, how did your training prepare you to write this manuscript?

Erica Reineke:

Well, I've been on the faculty at Penn Vet for a while now, since 2007, which kind of dates me a little bit and as part of our mission at, you know, the veterinary school is to perform research and advance the practice of evidence-based veterinary medicine, and my personal goal as a clinical researcher is to perform clinically relevant studies based on questions that come up in my daily practice, and this is one of them right, so for years I've been questioning this practice and I think just kind of my previous experiences performing prospective clinical trials helped me to design the study, you know, along with the experience of my co-investigators, and to then write the manuscript.

Erica Reineke:

I think when I talked to, like early researchers about, like how did I develop my personal skills, I think you know, reading the veterinary literature a lot is very helpful. Like reading your JAVMA that you get every month is really helpful in evaluating the study designs that were done. And then you know, developing your own writing style, like I remember finding authors I really liked how they wrote their manuscripts, and then you kind of, you know, emulate them or look to them. I'm like how did they, how did they say this and how did they respond to that? So that would be my advice, I think.

Sarah Wright:

Yeah, read your JAVMA. I selfishly tell all our listeners. So, this next set of questions is going to be very important for our listeners. The first one is going to be from the veterinarian's perspective. What is one piece of information the veterinarian should know about pneumonia in dogs treated with a shorter versus longer course of antimicrobials?

Erica Reineke:

Okay, I think we've tackled this. So, what I would recommend to veterinarians would be that you don't need to repeat thoracic radiographs at that kind of two-week mark on every dog that you treat with uncomplicated pneumonia, and the decision to retake thoracic radiographs should be based on the patient's clinical sign. So, if the patients clinically are improving at home, the owner feels like they're almost 100% or 100% back to normal, then it's probably unnecessary. But if the clinical signs are not improving or they are worsening, then certainly we would recommend that that patient come back in for a reevaluation.

Sarah Wright:

And then on the other side of the relationship, what's one thing clients should consider around pneumonia and dogs treated with a shorter versus longer course of antimicrobials

Erica Reineke:

Okay, so I would say, no matter which duration of antimicrobials their dog is prescribed, one they should give the antimicrobial for the course that was recommended. And then I would say that they should you know course watch their dog for clinical signs that are related to the pneumonia, for either improvement or not improvement or worsening of the signs, because they know their dogs the best. They know when they do know when things are just not getting better, and they should kind of listen to their gut if it's, if they're feeling like their pet is not getting better than they should, certainly should seek a re-examination. But if their dog is clinically doing well, and that is great, they should finish their course of antimicrobials and likely, you know it's going to resolve and their dog will go back to living its best life.

Lisa Fortier:

Yeah, yeah, very good, Erica, thank you again as we wind down, and you, you said how long you were at Penn Vet, so we'll see if this does date you. We'd like to ask a little more personal question, and for you I would like to ask what was the first concert you attended?

Erica Reineke:

Okay, okay. So I had to think about this because I am getting older. I tell my kids I'm 25 and that's where I'll stay, but I'm not sure. This was the first concert I went to, but it was one of the most memorable and if you guys know this band, Milli Vanilli.

Lisa Fortier:

Oh yes.

Erica Reineke:

Okay, good, okay. So, I went to Milli Vanilli and just to kind of remind people out there who don't know who Milli Vanilli is is, they were this duo group that ultimately got exposed for not actually singing their own music and they were lip singing the entire time. So I went to that concert, I watched them lip sing, had no clue that you know they were lip singing. I enjoyed it, but I feel like it's kind of a funny story now that I spent money on that.

Lisa Fortier:

That's awesome. We often, with Sarah, who's a fair bit younger, we often play. Have you seen this? You know all kinds of things in the office, so now she'll have to look up Milli Vanilli.

Erica Reineke:

It's a treat. You should look them up. They were fabulous.

Lisa Fortier:

They were great!

Erica Reineke:

I don't know who's actually sang their music.

Erica Reineke:

They were quite good, but as like an entertainment group, they did a great job

Lisa Fortier:

Agree yeah

Sarah Wright:

I was at a publishing conference for the last two days and one of the speakers had a slide up where she was kind of showing where we used to be in publishing, compared to where we are today, and she was talking about how authors would literally send in the mail like their manuscript to have it be looked at in person by the associate editors of the office, who would then, like you had a computer like any office, you couldn't take your laptop home because there weren't laptops and we're just a whole mailing process that took forever. It was very crazy for me to hear that. I cannot imagine that workflow or how long that took.

Lisa Fortier:

Sarah, I typed my manuscripts

Sarah Wright:

oh my goodness

Lisa Fortier:

Typed them and I remember how, being so excited when the first typewriter came out, that when you hit the reverse button it actually reversed a whole word, not just one letter at a time. And then, yeah, like you said, you would go and develop the black and white or the color photos and send in three copies. So the editor had one and yeah, it was. It was a much bigger process than hitting the submit button on a computer.

Erica Reineke:

That is crazy. Or like when you talk to people about speaking engagements and they used to carry their you know, have to get their slides made, and then they would carry their you know slides and the reels to their presentation. That, to me, blows my mind because I'm always like tweaking my presentation up to the last second before I give it. So I would definitely have failed if that.

Lisa Fortier:

Actually it made for a better experience at the conference, because now you can wait until 20 minutes before your talk and you're tweaking stuff and you're not present at the conference. Really Sometimes I'm guilty of it now too, but it used to. Yeah, you know it was. It was hectic leaving, but and then when you're if the little twisty thing on the top fell out and your slides fell out, you're like oh, oh, now I'm in trouble.

Erica Reineke:

Yeah, yeah, that's. That's a really good point, so we benefit from it, but also probably suffer from having everything right at our fingertips all the time. Yeah.

Sarah Wright:

Oh my gosh, that's crazy. No, I did not know that about the slides and presentations, cause I also like to tweak things till last minute and I feel like I've done that more and more, so that's crazy. Thank you so much, Erica. We appreciate you being here today, sharing your knowledge with us and our listeners and submitting your manuscript to JAVMA.

Erica Reineke:

Oh well, thank you.

Erica Reineke:

It was a lot of fun

Sarah Wright:

And to our listeners. You can read Erica's article on JAVMA. I'm Sarah Wright with Lisa Fortier. Be on the lookout for next week's episode and don't forget to leave us a rating and review on Apple Podcasts or whatever platform you listen to.

People on this episode

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Lisa Fortier, DVM, PhD, DACVS

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Sarah Wright, DVM

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