Veterinary Vertex
Veterinary Vertex is a weekly podcast that takes you behind the scenes of the clinical and research discoveries published in the Journal of the American Veterinary Medical Association (JAVMA) and the American Journal of Veterinary Research (AJVR). Tune in to learn about cutting-edge veterinary research and gain in-depth insights you won’t find anywhere else. Come away with knowledge you can put to use in your own practice – along with a healthy dose of inspiration to remind you what you love about veterinary medicine.
Veterinary Vertex
Strategies for Affordable and Effective Canine Bacteriuria Screening
Discover innovative strategies for revolutionizing veterinary care as we tackle the complex issue of urinary tract infections with Drs. Kayla Sample, Jennifer Grady, Gregory Wolfus, and Claire Fellman. Learn how affordable, in-house bacteriuria screening tests, such as the SediVue, RapidBac, and in-houes cultures, can redefine practices in veterinary clinics, especially those catering to financially constrained clients. Kayla, Jennifer, Gregory, and Claire share their cutting-edge research from the JAVMA article, providing insights into cost-effective diagnostic methods that can significantly enhance antimicrobial stewardship while improving accessibility and quality of care.
This episode dives into the practical application of in-house urine cultures, revealing a tiered diagnostic approach that not only slashes client costs but also addresses the critical issue of antibiotic resistance. With Greg offering a strategic guide for implementing these practices in clinics, and Kayla, Jennifer, and Claire emphasizing the importance of educating future veterinarians on responsible antibiotic use, listeners will leave with a clear understanding of how to improve veterinary diagnostics. Tune in to learn about the utility of in-house screening tests for bacteriuria.
JAVMA open access article: https://doi.org/10.2460/javma.24.05.0307
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You're listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode, we chat about how affordable in-house tests for bacteria urea can improve antimicrobial stewardship and access to care with our guests Kayla Sample, Jennifer Grady, Gregory Wolfus and Claire Fellman. Thank you all for being here today, so we're going to start with some introductions. So, Greg, can you kick us off?
Gregory Wolfus:Sure. Thanks for hosting us, Sarah. My name is Greg Wolfus and I'm a veterinary small animal clinician. I'm also an associate professor at the Cummings School of Veterinary Medicine at Tufts University and I'm the founding director of Tufts Tech Community Veterinary Clinic, which is a teaching clinic where we partner fourth-year veterinary students with high school students and together they provide subsidized veterinary care.
Sarah Wright:Thank you so much, Claire. Would you like to go next?
Claire Fellman:Sure, I'm Claire Feldman. I'm an associate professor at the vet school at Tufts and my discipline is small animal internal medicine, and I'm also a clinical pharmacologist, thank you.
Sarah Wright:Awesome. And then, Jenny, how about you?
Jennifer Grady:Thanks, Sarah. My name's Jenny Grady. I graduated from Tufts in 2012, and my background is in primary care, traditional practice and also community medicine and shelter practice, and I've been a professor at Tufts with Kayla and Greg since about 2016, working at Tufts at Tech.
Sarah Wright:And last but not least, Kayla, take it away.
Kayla Sample:Thanks, Sarah. I am also at Tufts at Tech and an assistant professor at Tufts University. I also had the. I was able to complete my internship and residency at Tufts EdTech, and so my background is primarily in community medicine.
Sarah Wright:Thank you so much. All right, so let's dive right into it. So, Kayla, your JAVMA article discusses how affordable in-house tests for bacteria urea can improve antimicrobial stewardship and access to care. Please share with our listeners the background on this article.
Kayla Sample:Okay, so, just as we began talking about, the majority of my clinical practice has been in community medicine, and so I see a lot of the patients that are coming in, similar to many general practices in the area, and a lot of these animals are presenting with lower urinary tract signs, and lower urinary tract signs can present clinically similar for UTIs, for transitional cell carcinomas, for stones and many other presentations, and so what we were doing is really looking for a way to sort of figure out which of these animals needed to have antibiotics and which of these animals don't, and so, clinically, we wanted to figure out a way to differentiate which animals had bacteria and which animals did not, and so we would traditionally do a urinary culture with a sensitivity.
Kayla Sample:Unfortunately, if you're working with a population that has significant financial barriers, those cultures can be cost-prohibited for those clients, and we have to figure out a different way and figure out what we should do for those in particular animals, and so our clinic has been performing in-house urine cultures where we are plating urine in-house for many years, and when we were looking for data, we couldn't really find any data to support this practice, and so what we were trying to do with the study was to publish some data to support this individual practice, and really we had two clinical questions that we were hoping to answer, and so, one, what can I do on the same day for that particular animal if I'm worried about bacteria contributing to their clinical signs?
Kayla Sample:And two, how can I avoid spending all of this money for an animal that has a negative culture? And so an animal that has a negative culture, which really is about 75% of the cases that are being submitted, that animal is still paying this or that client is still paying the same price for that culture and sensitivity as if an animal was positive, and so that was really frustrating for us, and so we wanted to figure out sort of what can we do in-house to prevent that negative culture from coming back and prioritize client finances towards further diagnostics or further treatment if needed?
Sarah Wright:I think this is a super, super awesome manuscript and I think it's just so important. It has really great implications for both veterinarians and clients alike, so thank you so much. So, what are some of the important take-home messages from this JAVMA article?
Kayla Sample:So some of the biggest take-home messages from this were really that we looked at three in-house ways of detecting bacteria. The first thing we did is an IDEX SETI view, which is really a computer-analyzed urinalysis, and that is a really nice product produced by IDEX, because it gives us little pictures of the individual UA and so you're able to, as a clinician, also look at the pictures as well as the readout of the urinalysis. And in addition to that sort of just running the regular UA, we also paired that with their bacterial confirmation kit, which is provided through IDEX with that same machine, and in that bacterial confirmation kit is designed to make to dissolve the rest of the cells and give you a bacteria confirmed or there's no bacteria present, and so that's a really nice way for busy practices to be able to evaluate urine, because it's a very quick readout and it's done the same day. The second test that we looked at was a rapid bag, which is a really nice rapid amino assay that uses monoclonal antibodies to detect gram-positive and gram-negative bacteria in urine, and that one was also very nice because it provided the same day results and it could be read out quickly in a busy clinical practice.
Kayla Sample:And then the last thing we did were we took our culture plates that were in-house and so we cultured urine and plates in an incubator that's here in the clinic for us and unfortunately that result does not give us.
Kayla Sample:That test does not give us a result on the same day, but the results were available in 24 to 48 hours and that is really a very inexpensive test that takes very little setup. And so when we're looking at those three specific tests, all of those have very high negative predictive values and actually the negative predictive values for those were all 89% or greater. And when we think about what that actually means because I think we sort of like throw out the words negative predictive value and positive predictive value and all these things a lot and I personally sort of need to think about what all of those mean every single time and so what that means is if all of these have a negative predictive value of greater than 89%, really what that means is 89% or greater, depending on which one you're looking at of the patients who test negative or who do not have evidence of bacteria on their results truly do not have bacteria, and so that's a really nice way for us to truly rule out that bacteria is contributing to this animal's clinical science.
Sarah Wright:Yeah, those same-day tests too, I imagine would be potentially a game changer. Sometimes it's hard to have that follow-up with owners who might not be compliant, might not be able to like come back into the clinic to get those like antibiotics if needed, etc. So, Claire, how does this publication contribute to antimicrobial stewardship?
Claire Fellman:Well, thank you for that question, and I think when we talk about antimicrobial stewardship, it's important to recognize that it's actually a really big field and so it encompasses a lot of things, from infection prevention and control all the way to drug selection and dosing. But, as Kayla has been talking about, and I think with urinary tract infections specifically, a lot of what we're trying to figure out is are these signs that they presented for related to bacterial infection? Are antibiotics indicated? And, as she just said, what we showed in this paper is there's several different tests that you can figure out what is best for your clinic, that you can have a lot more confidence in that clinical decision making. And really that's what we're trying to do when it comes to tests to support antimicrobial stewardship is if you can make a prescriber feel more comfortable, that antibiotics don't need to be prescribed, that we can avoid that just in case prescribing. That's really the goal of those diagnostics, and so I think that's all really relevant and timely and it's something a lot of people are interested in is what is the best test? What can we use? And, as Kayla just said, any of these are going to make you feel more comfortable that there truly aren't bacteria there.
Claire Fellman:And I think the other thing, since you were talking about same-day tests that it's important to recognize is, you know, yes, it's nice that some of these were same-day, but, as Kayla alluded to, one of the things we wanted to do with this study is look at in-house culture, and that does require waiting till the next day, but a lot of the time that's okay.
Claire Fellman:You know, many of these patients have had signs for more than a day. They're rarely life-threatening, and so in our study only about 25% of cultures grew, and so, if you think, you know, not all of those patients would have probably gotten antibiotics, because some were just having cultures due to polyuria and polydipsia and other things, but nonetheless, in the majority of cases antibiotics are not needed, and so if we can wait the day to get that confirmation and have that security, really what we're trying to do in the direction of antimicrobial stewardship is reduce unnecessary prescribing. So there's some good options out there. You can figure out what fits for you and just don't be afraid of that day. It is a little harder to get in touch with owners, but we found in-house cultures to be really accessible in our practice setting.
Sarah Wright:Yeah, thank you for clarifying that. Really appreciate it. This is going to be super important, I think. Like I said, clients and veterinarians alike. So, Jenny, how does this publication contribute to education and teaching?
Jennifer Grady:Well, Kayla has her background blurred so you can't tell, but she's currently zooming from the janitor closet of a high school because that's the only space in our busy high school, because that's the only space in our busy small teaching clinic, tufts of Tech, where Greg, Kayla and I work. That's not overrun with veterinary and veterinary assisting students in any given moment of time. So, we work the three of us work in this really unique teaching community medicine clinic that just has this whole fleet of veterinary assistants and veterinarians in training and they're all plating these in-house urine cultures themselves and running the SETI view analyses and they can see how much these simple techniques are improving affordability and access to care for the clients. And so now they also have this publication that can support this practice and give some evidence base to doing this in practice. And so then they can take it to their clinics wherever they go in their professional lives and sort of disseminate that message as well.
Sarah Wright:It's always cool to see it paying it forward and helping with the next generation. So very, very cool. And, Greg, what are the financial implications of this publication on small animal general practice clinics?
Gregory Wolfus:The implications are potentially huge. I'm a pretty strange dude running this community clinic but I'm also the veterinary faculty advisor for the VBNA for our school, so I actually care about these economic issues greatly. From a business perspective, if you consider a scenario where you have a clinical caseload of 1,000 UTIs per year, understanding that I recently yesterday inquired to local veterinary clinics how much they charge for a mixed sensitivity study where you send out a urine culture, and the average was $256. One of those clinics is currently charging $89 to do an in-house urine culture, understanding that about a quarter of all urine cultures that are submitted end up growing bacteria. This means that if we ended up deciding to do these diagnostics in a stage fashion where we perform the in-house urine cultures first for a thousand cases, that would be eighty, nine thousand dollars and only 250 of those thousand cases would be grown and sent out for the 256 dollar out culture fee, with mixed study to total an additional 64k, meaning the initial cost of the in-house culture, 1,000 cases and the 250 grown cultures that are sent out would total the client cost of $153,000.
Gregory Wolfus:This is, alternatively, if we didn't have this tiered step and we just went directly to out send out mixed studies. It would cost the clients $256,000 for that thousand cases, understanding only 250 of them would end up being positive. So simply by adding this first step of a lower cost screening test in a urine culture, of an in-house urine culture, this can easily save clients or the clinic $100,000 a year in that scenario that I posted. So from an accessible care perspective, I think it's really important for the audience to know that in-house culture plates are dollars and an in-house incubator could be as little as $500,000 or somewhere along that line. And the staff necessary to plate an in-house urine culture is minimal, so it really can actually be run for as little as $20. And that step of entry level would be huge because there's so many clients that can't afford to send out urine culture.
Sarah Wright:Thank you. It's cool to have the perspective also from, like, the economic side of things too. It's something that we don't often talk about actually on this, too, in the literature, so thank you for sharing that. So, kayla, what are the next steps for research in this topic?
Kayla Sample:As all of us have sort of alluded to. We're all very excited about this, and we really the goal is to actually for everybody to do this, and so what are? What we're hoping to do now is sort of create a how-to guide for any clinics that are interested in starting this and sort of put together the resources in like a really compact way so that any general practices could sort of pick up a little guide and then they too could start to begin to train their staff, could purchase the necessary supplies, and really it would be able to be disseminated to anybody who wanted to begin to do this in their clinic, and we're sort of figuring out exactly what that looks like or how to best disseminate that information. But really the goal is a step-by-step sort of how-to guide on how to make it possible.
Sarah Wright:Ooh, I have an idea actually. So I don't know if you guys have heard about our technical tutorial videos, but they are peer-reviewed video manuscripts and this could actually be a really cool one, I think, like how to do an in-house like urine culture, like at your clinic, especially if you have eager students who want a publication and want to assist in creation of said video. It's definitely a good, I think, first step to like publication opportunity for our next generation. So I'll send you some information after this about that, but that could actually be something nice, and then it can also be cited in the future too if you pursue future studies on this topic as well. So something about that idea. Yeah, yeah, right, I was like, oh, that'd be perfect. So we talked a lot about the importance of antimicrobial stewardship and how this manuscript is also taking strides to helping with that. ,So, J enny, what sparked your research interest in antimicrobial stewardship?
Jennifer Grady:Well, I've spent most of my career working in community medicine with client populations who really historically haven't had great access to high quality veterinary care and generally these are the people who aren't going to be able like Greg alluded to, they're not going to be able to afford the $250 or $300 send out urine culture and sensitivity to the lab every time their dog pees in the house or whatever symptoms their dog's having.
Jennifer Grady:And I feel like a lot of times when vets are seeing clients, pets who have limited resources, their kind of knee-jerk reaction is let's just give them antibiotics just in case or because it's the easiest or cheapest thing to do in that moment and it feels sort of like the right choice when finances are limited.
Jennifer Grady:But in reality for a lot of the pets we're actually not solving the problems. You know we've talked about how 75% of these canine urine cultures they don't actually grow when you submit them and actually I think for some animals we're making things worse for them over time when they do develop resistant infections down the road which we see in community medicine, and then all of a sudden we actually can't manage their infections inexpensively just because of limited antibiotic choices. So for me, I'm really passionate about teaching students and other vets how to practice good antimicrobial stewardship without spending a ton of client resources. I think it's going to improve the overall quality of care for this client population that my team is serving and really help vets increase care accessibility. Out in the quote unquote real world.
Sarah Wright:And Claire, how about you?
Claire Fellman:Yeah, this is a field I'm really passionate about also and I had had a longstanding interest in antimicrobial resistance and just not had a chance to really dive in. But I was super excited when I came to Tufts that there were a variety of people working in this space and that's how I got involved with the team at Tufts Tech, and I think what's really exciting about companion animal antimicrobial stewardship right now is just that people are recognizing that it's really important. For a long time, people have talked about antibiotic use in people. They've talked about antibiotic use in animal agriculture, but the thing about dogs and cats and exotic animals is that they are in your house, they're in your space and specifically for dogs and cats, which are what I with most and we're using many of the same antimicrobial classes, often the exact same drugs as what people are.
Claire Fellman:And there's a lot of recognition now that there's shared carriage of multidrug-resistant organisms with different household members, so it can go from the pet to the animal and vice, from the pet to the owner and vice versa, and so it's really important that we be asking these questions and trying to work on this and it was really rewarding and I'm super excited to be able to contribute to this effort to improve access to care because, like Jenny said, it's so expensive and it's hard to practice, it's hard to do the test that you want, and so if we can find in all cases and so if we can find lower cost alternatives, that's really rewarding and this is really a great example of One Health where we're really benefiting and actively impacting the home and the resistance that's found there.
Sarah Wright:So, Greg, we talked about some of the important findings from this article, but what was the most surprising finding?
Gregory Wolfus:The most surprising finding is that everyone isn't already running in house urine cultures. I want to give a shout out to an old friend of mine. Dr Lori Klein was my first medical director after I graduated from veterinary school and she had a really strong microbiology background and when I started GP general practice she was already growing in-house urine patient cultures for years before I had gotten there and for my entire career I've been doing this. The group of people that you have here are all amazing people and I am so proud of them. For each of the parts that they contributed to this research project because it's so rewarding for me to have a research document that justifies this practice that we've been doing for all these years. And it's not rocket science. There's high school kids in our clinic that are plating in-house urine cultures and the science is based on that plating culture experience. So I'm not at all surprised by what the findings of the paper showed us. What I'm really surprised is just that the world isn't doing this already. So now I'm here talking to the ether and you kind folks hoping to spread the good word.
Sarah Wright:We're happy to give you a platform to do so. So AI is a very hot topic right now. Kayla, do you see a role for AI in this area of research?
Kayla Sample:I thought a lot about this question and I think it's important to sort of be talking about the hot topics. That we've sort of talked about doing is creating sort of like a library of positive cultures and just making sure that everybody feels comfortable reading the plates, determining, like, which ones they think are contaminants, which ones they think are real growth, and really thinking about the different characteristics of the different bacteria that are grown on the in-house plates. And so I think one role of AI might be to be able to upload a picture of a positive plate and get some information about that individual bacteria from an app or something like that.
Sarah Wright:Yeah, super cool area. We actually have a artificial intelligence supplemental issue coming out in AJVR in March. So, to our listeners, stay tuned for that. That will be open access online only. And for those of you just joining us, we're discussing how affordable in-house tests for bacteria can improve antimicrobial stewardship and access to care with our guests Kayla, Jennifer, Gregory and Claire. So, Jenny, how did your training or previous work prepare you to write this article?
Jennifer Grady:Well, pretty much all my time as a veterinarian has been in this weird intersection point of academia ivory tower medicine, but then also this sort of gritty in-the-trenches community medicine practice where we're taking care of pets of people that have pretty limited resources and a lot of other barriers to care, and so I feel like that, like breadth of experience and in my training, has given me a pretty broad understanding of the spectrum of care that's available for pets, and it's also motivated me to figure out what are some creative ways that we can continue to practice some really high quality and evidence-based medicine in this low-cost primary care setting. I really also want to see the students to see that and to see that being creative and being flexible in their medicine, and not just like cutting corners and practicing poor quality medicine, are what they're going to be able to do to improve access to care for their clients in their future careers.
Sarah Wright:I love hearing about all your different career paths. I think it's really cool to see people from different backgrounds and area of veterinary medicine comes together to put this study together and then publish the article so super fascinating. Now this next set of questions is going to be very important for our listeners. So, kayla, what is one piece of information the veterinarian should know about these affordable in-house tests for bacteria and how they can improve antimicrobial stewardship and access to care?
Kayla Sample:So one of the big takeaways that I want this paper to sort of share with everybody is that you can do this too. So all of these tests are something that we've talked about, we've said it before, but I want to say really clearly that our high school students are running, and so these are all tests that are very reasonable for any practice to consider incorporating into their daily routine. And I want to focus for just another second on the in-house urine cultures, and so, as Dr Wolfess already said, really we're talking about dollars for an in-house plate that you're plating in-house, and when we're thinking about that in-house plate that has a negative predictive value of 99% and so that is really dollars to rule out the fact that this animal has bacteria that's contributing to their clinical signs. And especially for many, many conditions, we're thinking about how, okay, how can I rule out bacteria? And so we can think about that for things like incontinence, for proteinuria, for stones, for azotemia, for diabetes.
Kayla Sample:Really there's many different diseases that make us want to rule out bacteria being a part of the clinical picture, and so, for dollars, you can rule that out with a paper that says it's going to have a really high negative predictive value for that individual animal. And even if that test, that in-house plate, ended up being positive, as we proved in the paper, you can also send out that in-house plate. And so it's really nice, because if you're pretty sure it's going to be negative anyway, you can rule it out really quickly. And then, as we proved in the paper, you can also submit that in-house plate as well as the saved refrigerated sample, and so it's a really nice thing that really everybody can be doing. And that's what I want the take-home message to be is this is an accessible thing that anybody can accomplish.
Sarah Wright:I can see this being a really powerful tool also in like a busy ER setting where maybe everything costs a little bit more. And then if you have that one thing that might give the clients more wiggle room to pursue some more advanced diagnostics down the road that can actually help them get to a diagnosis or better treatment for their animal, that would be super helpful. So on the other side of the relationship, Claire, what's one thing the public should know about these affordable in-house tests?
Claire Fellman:Yeah. So we've talked a lot about the you know, the just-in-case season of antibiotics and, like Jenny said, I feel like a lot of people say, well, you know, I'd rather just get the antibiotics, I'd rather just be safe, and that comes from both the prescriber as well as the public. You know they'd rather not do the test. And I think what is really important to recognize is in a lot of cases there aren't bacteria there, and so we really do need to figure out what's the reason the animal is presenting with those signs. And so if we can do the test that will confirm that bacteria are not the reason, then we go looking for the actual diagnosis and the actual thing that we can treat and fix. And so I think that's really important that you know those few dollars spent can save you a lot of money and time and rechecks in the long run.
Claire Fellman:The other thing I think that's important to recognize when we think about antibiotics is being benign it's not a big deal just to do a few days of antibiotics is that every time we use antibiotics we do cause resistance, and so I think that's really a key point for us all to remember, and one of the things we're recognizing more and more now is the fact that sometimes that's resistance in the GI tract, and so that E coli in the GI tract becomes more resistant.
Claire Fellman:Sometimes that causes a resistant infection in the pet later on, but it can also transmit to the person, and so we really do have to think in this One Health manner. We have to think about the fact that we really need to reduce unnecessary use of antimicrobials, and that's really where diagnostics and antimicrobial stewardship tasks are trying to support that decision, and so keep in mind that, yes, it is an expense, but antibiotics aren't free either, and neither is the follow-up testing, and so I think there's a lot of times that Kayla pointed out where we don't think bacteria are likely, and it's a much better decision to do a test to rule that out than to give antibiotics just in case.
Sarah Wright:So now we've gone to the fun part of our podcast. It's more personally. Greg, what is your favorite animal fact?
Gregory Wolfus:Uh, Sarah, my favorite animal fact is actually the name of groups of animals. For example, everybody knows about a pack of dogs and a school of fish and a pod of whales, but did you guys know that a group of rhinos is a crash? Or a group of ladybugs is a loveliness, isn't that amazing? A loveliness, um. And a group of flamingos is a flamboyance. Who doesn't want to be a flamboyance?
Gregory Wolfus:That's what I like.
Sarah Wright:That's awesome. We learn something new every time we ask that question and you're actually one of the first people to not give an octopus-based answer. I don't know why, but a lot of people have really fun facts about the octopus
Gregory Wolfus:Because they have three hearts dear.
Sarah Wright:That has been shared before. We've heard about their eyes. We've heard about their brains, their hearts. The cephalopods are fascinating, but thank you so much for sharing that Super cool and just thank you all again. This is important work, this is practical work and I'm really glad that we got to share this to you on our podcast today with our listeners.
Sarah Wright:So, thank you so much for being here.
Claire Fellman:Thanks, Sarah
Sarah Wright:Thank you and to our listeners. You can read Kayla, Jenny, Greg and Claire's article in JAVMA. I'm Sarah Wright. Be on the lookout for next week's episode. Don't forget to leave us a rating and review on Apple Podcasts or whatever platform you listen to.
