Veterinary Vertex

Insights for Antimicrobial Stewardship in Small Animal Medicine

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Dr. Jennifer Granick takes us deep into her groundbreaking research on antibiotic prescribing patterns in companion animal practice, revealing both challenges and opportunities for improvement.

This conversation unveils the complex reality of veterinary prescribing. Perhaps most surprising is the finding that preventive antibiotic treatments typically last the same duration (10 days) as those targeting confirmed infections—a practice without scientific justification.

What makes this discussion particularly valuable is Dr. Granick's practical approach to creating change. Rather than overwhelming practitioners with an insurmountable challenge, she advocates starting small: "Pick one common condition, check prescribing guidelines, and make one small change." This accessible strategy empowers veterinarians to contribute meaningfully to antimicrobial stewardship without complete practice overhauls. Meanwhile, pet owners gain crucial perspective on when antibiotics truly help versus when they might cause harm.

As Dr. Granick's team explores innovative methods using electronic health records and AI to gather prescribing data while maintaining privacy, the future of veterinary antimicrobial stewardship looks promising. Her parting wisdom serves as both warning and hope: antibiotics are indeed life-saving, but only if they continue to work. Join us for this essential conversation at the intersection of companion animal medicine, public health, and our shared responsibility to preserve these precious medications for generations to come.

Open access JAVMA article: https://doi.org/10.2460/javma.24.11.0716

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Sarah Wright:

This is Veterinary Vertex, a podcast of the AVMA Journals. In this episode we chat about how measurement of antibiotic use in cats and dogs presenting to US primary care and Practices provides insights for antimicrobial stewardship. With our guest Jennifer.

Lisa Fortier:

Granik, Welcome listeners. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Thank you so much for taking time to be with us here today.

Sarah Wright:

Thanks for having me. All right, let's dive right in. Dive right in. So, Jennifer. Your JAVMA article discusses how measurement of antibiotic use in cats and dogs presenting to US primary care and referral practices provides insights for antimicrobial stewardship. Please share with our listeners the background on this article.

Jennifer Granick:

Yeah, so I think most practicing vets have experienced an increase in antimicrobial resistant or AMR bacterial infections in their patients, and we know that AMR is a global health concern in people and animals. If you were paying attention to the news, back in September there was a high-level meeting about AMR at the United Nations General Assembly, so there's a lot of attention focused on this topic, not so much in companion animals. So that's one of the things that I have wanted to address, and there are certainly lots of different actions needed to address AMR. But the use of antimicrobials, including antibiotics, is a really important risk factor for the development of AMR and the cool thing is it's under all of our control. If we're prescribers right, it's something that we can directly impact, and a colleague of mine who's a co-author on this study, Dr Amanda Bedoin, always says you can't manage what you don't measure. So that was our goal was to measure antibiotic use in cats and dogs.

Sarah Wright:

I like that phrase. Actually, we actually I don't know if you know this, but we have an antimicrobial-themed collection of freely accessible articles published in JAVMA and AJVR on our website. So far, that's a resource for our readers.

Jennifer Granick:

Yeah, AVMA has a lot of really wonderful prescribing resources.

Sarah Wright:

Definitely so. What are some of the important take-home messages from this JAVMA article?

Jennifer Granick:

So there's a few. I think one of the big ones was that in this study we saw a lot of use of metronidazole for the treatment of diarrhea in dogs and we have a lot of really good evidence now that using antibiotics can further disrupt intestinal microbiome and we know the microbiome has all these wonderful positive impacts on the whole body. So there's sort of hidden effects of using an antibiotic in that situation that I don't think we always think about when we're prescribing for diarrhea. There's also a handful of studies that show that even though it makes us feel better using antibiotics in that situation, it doesn't actually resolve diarrhea faster. So I think one of the outcomes for me from this study is that this is an important area that we need to focus not only education for veterinarians but really importantly, client education. Clients are really used to receiving an antibiotic when their dog has diarrhea. They don't have a lot of tolerance for diarrhea, but I don't think they know all that we've learned about this disease and how antibiotics affect it, not always for the better. So that's one thing.

Jennifer Granick:

The other thing that we saw a lot of was the use of third-generation cephalosporins, so things like cefavescin and cefpidoxime I think most people know as, like Convenia and Simplicef, in situations when other first-line agents that carry a lower risk of the development of AMR could have been used, and I think we see this most frequently in cats, and cats are also prescribed more fluoroquinolones than dogs. So things like pradofloxacin, enrofloxacin, marbofloxacin and those drugs also carry a bigger risk for AMR. So I think that's maybe another takeaway. And lastly, we just didn't see a whole lot of use of bacterial culture and susceptibility.

Jennifer Granick:

We know this is true, it's expensive, there are a lot of barriers to it, but there are other diagnostics that are more accessible and less expensive, like cytology, and in our study, only a third of the situations in which antibiotics were prescribed to treat infection were actually confirmed infection and 11% there was actually no evidence of infection. So I think that kind of gets to the. Sometimes we're prescribing antibiotics and we don't really know what's going on, because we want to do something. But this is an area I think that we really need to focus a lot on in vet med this sort of like fear-based prescribing or just-in-case prescribing, especially as we learn about the impacts of antibiotic use when we don't need to be using it.

Lisa Fortier:

Yeah, Jennifer, you might know I'm an equine specialist, though for us it's the same. But it's trimethoprim, sulfa, sulfamethodoxazone. Like every scratch, every cough, everything starts shaking out the white pills.

Jennifer Granick:

Yeah, yeah, I think I mean there's a lot of similarities. I would say like I wish we used more TMS in companion animals, because at least it's a first tier drug. I mean, a lot of times we're using kind of higher tier drugs, maybe a riskier drugs in terms of AMR, when we don't need them in small animals. But yeah, it's a. You know, it's an issue in human health care too. You know, I think sometimes we just feel like we need to do something and historically we've thought that providing an antibiotic is less risky than not and I think we really need to investigate kind of outcomes based studies to see if that really holds up.

Lisa Fortier:

Yeah, on the flip side, you could think of a spectrum of care and like helping veterinarians not make clients feel guilty for not dishing out 100 or 200 or whatever they need for a 10-day course of antimicrobials.

Jennifer Granick:

Yeah, yeah for sure, antibiotics are not inexpensive, especially those higher tier drugs.

Lisa Fortier:

Sure what sparked your interest in antimicrobial stewardship.

Jennifer Granick:

Um, my interest really sparked because I saw a change just in my practice lifetime of you know, when I first started practicing antimicrobial resistant infections were really rare, you know, it was just.

Jennifer Granick:

It was almost like exciting when you saw it because it was so uncommon and um, and it got to the point where I was seeing these like weekly and you know now it's daily, I would say. So that was alarming to me. You know I work in a referral population setting so I'm certainly seeing more than maybe in primary care settings, but I definitely saw a trend care settings, but I definitely saw a trend. So I felt compelled to do something, figure out what's going on and do more and kind of at that same time, here in Minnesota our Department of Health started a One Health Antibiotic Stewardship Collaboration which is across professional groups including, like pharmacists and physicians and dentists and veterinarians and, you know, food commodity groups too, and I learned a lot from that group about what was being done on the human health care side in terms of antimicrobial stewardship. So I think I really got excited that maybe those things were translational to us Fantastic.

Lisa Fortier:

I love this, the idea of that group. Earlier, Sarah asked you what are some of the big take-home messages, but whenever we do something like this, we're always surprised. What were some things that surprised you in this article?

Jennifer Granick:

Okay, so the biggest thing that surprised me was that the duration of prescriptions for antibiotics for treating infections the median duration was like 10 days. So if you know you have an infection, you're treating for 10 days, but it was also 10 days for prophylactic treatment. So when we have no infection and we're just trying to prevent it, we're using antibiotics for the same duration, which I thought was wild and clearly an area that needs some guidance, because there's not a lot of prescribing guidance. Good news is that there's a group working on that, so I think we'll see some guidance within this next year, but that was really shocking to me.

Sarah Wright:

You actually teed me up perfectly for my next question, which is what are the next steps for research in this topic?

Jennifer Granick:

Oh, so I mean I think that you know we're interested in looking at our own prescribing in our hospitals, see if we can make some impacts there. I think studies like this provide some baseline data. So repeating studies, especially if there are new things that come out like new guidance, can tell us whether there's uptake of those things over time. But another area that we're focused on is new, different methods for collecting this data. So we had a group of amazing volunteers at all the practices that participated in this study and they manually, you know gathered data and put it into our online data capture system, and we couldn't have done this study without that. But it's a lot of work and so it makes it hard to scale up. So what we're working on is gathering prescribing data directly from electronic health records at a large scale, so that there is really no effort on the practice level and solve work that we need to do. So that's what we're working on right now. Do you think AI could help with that at all? Yeah, absolutely.

Jennifer Granick:

What we found with working with electronic health records is that you know there are things called standard fields, where you know there's a limited number of selections from a drop-down menu. They're not utilized a lot. We don't have standard coding for diagnoses or for billing in vet med like they do in human health care, so most of that rich information that we're interested in is in what we call free text fields, so it's where you just type whatever you want so in your soap notes, your doctor's notes and we really need AI to get that information out, and we've done some experimenting with that already. The one thing that we are constantly thinking about when we use a methodology like that is that we need to do it in a way that keeps data private. It in a way that keeps data private. So that's what we're working on right now and, yeah, ai, I think, is I think we're going to see amazing impacts of AI, but I think we need to do it carefully.

Sarah Wright:

And speaking of AI, just putting in a plug here we have our AJVR Artificial Intelligence Supplemental Issue coming out in March of this year, so very exciting for that. So be on the lookout.

Jennifer Granick:

I'm looking forward to that. That's cool.

Sarah Wright:

Yeah, yeah, no, it should be awesome. And for those of you just joining us, we're discussing how the measurement of antibiotic use in cats and dogs, presenting to you as primary care and referral practices, provides insights for antimicrobial stewardship. With our guest Jennifer.

Lisa Fortier:

Jennifer, how does your training in previous work prepare you to write this article?

Jennifer Granick:

Well, I think that's just as a group are really well trained in one health. So I think for me, just my veterinary training made it pretty natural to look for methodology for data collection used on the human health care side and see how it could be adapted for vet med. And then we've done a number of these what we call point prevalence surveys, to collect this data. So we tried it out in our own teaching hospital. We did it every month for a year and got some really cool insights into what we were doing and how we could, you know, change our practices. And then we expanded that next to practices in Minnesota, north Dakota and then in academic teaching hospitals across the US. So this was the biggest study that we had done at that point, but we had a lot of practice. We refined our methods. So that just makes perfect, I guess. Well, it makes better. I don't know what perfection really looks like yet.

Lisa Fortier:

I was a little just about to say that I'm from North Dakota. Jennifer, I don't hear too much Minnesota in your accent.

Jennifer Granick:

Oh, no, I was born in Philly, yeah, but I'm a Midwesterner at heart, so I would never go back. I've been here, I think, longer than I ever lived on the East Coast Very good.

Sarah Wright:

Midwest is best, I have to say. So, Jennifer, this next set of questions is going to be really important for our listeners. We're going to try to boil all this great information that you shared with us today down to like one important point. So what is one piece of information the veterinarian should know about antimicrobial stewardship in small animal primary care and referral practices?

Jennifer Granick:

Yeah. So I think this idea of antimicrobial stewardship kind of feels like this big idea and maybe not something that is accessible. But honestly, improving prescribing which is one of the goals of antimicrobial stewardship can start with like one little action. So I think that's an important thing to remember. So pick, you know, picking a common condition, checking out prescribing guidelines and making one small change like treating lower urinary tract infections for three days instead of 10, can make a really big impact. And once you have that under your belt, you can look to the next thing. But I think just taking small steps towards improving prescribing is the biggest take-home message. So it's like diet driving is the biggest take-home message.

Sarah Wright:

So it's like diet. Speaking of UCIs, we actually had a really cool article published in a subsequent podcast episode where we interviewed the authors about in-house urine cultures to see how feasible that was and how practical. So definitely some cool stuff, a spectrum of care happening in the antimicrobial stewardship world. So, on the other side of the relationship, what's one thing clients should know about this topic?

Jennifer Granick:

I think clients know antibiotics are life-saving, but what they need to know is that's only true if they still work, and I think we probably don't talk about some of these undesirable side effects. So in clients, you know, what I would encourage for clients is to advocate for using antibiotics, but only when they're needed.

Lisa Fortier:

Yeah, very well said. Thanks again, Jennifer. I learned a ton and it's always good food for thought. I love your idea of starting small. Just pick one thing because you're right, it sounds very esoteric, academic to think about, and the word stewardship, yeah. So, thank you for distilling it down for me and hopefully a lot of our listeners. As we close, we'd like to ask a fun fact and for you, we'd like to know what is Jennifer's favorite animal fact?

Jennifer Granick:

Well, I love octopuses or octopi I'm not sure what the correct plural is but they have three hearts. But what I didn't know is that they have nine brains. They have a central brain and a brain for each arm. I think that is amazing.

Sarah Wright:

So that's my fun animal fact. So, I think what Lisa and I have learned because he was laughing, so she knows is that the octopus fascinates veterinarians. I'm not kidding, Jennifer. I think almost everyone has answered this question with a fact about octopus.

Jennifer Granick:

But different facts. The ophthalmologist answered about that. They have a little perforation in their anterior chamber. Somebody else said the three hearts, you added nine brains. The octopus is fascinating. Yeah, it really is. I'm a sucker for those nature documentaries that focus on octopuses.

Sarah Wright:

They're so cool. Double pods are cool. Well, thank you again, Jennifer, for being here today, for sharing your manuscript with JAVMA and just for sharing the information, too, with our listeners on our podcast.

Jennifer Granick:

Yeah, thanks a lot for having me.

Sarah Wright:

It was fun to share a little bit more about the study and to our listeners, you can read Jennifer's article in 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

Co-host
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Sarah Wright, DVM

Co-host
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Jennifer Granick, DVM, MS, PhD, Dipl. ACVIM (SAIM)

Guest