Antibiotic resistant bacteria are something that the scientific community has been aware of and attempting to raise concern about for some time, indeed meticillin-resistant Staphylococcus aureus (MRSA) was first reported to have been isolated from animals in 1972 (DEFRA, 2010). And, like other inconvenient truths, it has taken some time for the wider community to appreciate the full extent of the problem. Now, however, antibiotic resistant bacteria are a well recognised problem and reports on the issue occur regularly, even in the general media.
Not so long ago hygiene was at the core of human and veterinary medicine. Admittedly this was because before the advent of modern drugs, there were often very few options available to medical professionals for treating bacterial infections so they relied on a fundamental strategy of cleanliness and sanitation. Now, with advances in medicine there is far less reliance on such basic tenets, to the point where they may have been regarded as peripheral rather than central to health and veterinary care. This is flawed thinking, and is part of what has led to the overdependence on antibiotics and the current antibiotic crisis. As Nuttall identifies ‘high standards of clinical practice and hygiene are vital to prevent the spread of these organisms [bacteria]’ (Nuttall, 2015). Used together, good clinical protocols, proper hygiene and appropriate antibiotics can readily combat bacteria. Used singly, none is as effective: a multi pronged approach must be used to treat infections and, crucially, to tackle antibiotic resistance.
The problem
Many bacteria are now resistant to antibiotics that have been effective against them in the past: they continue to survive following treatment with one or more antibiotic that they have previously been susceptible to (resistancy is usually classified as resistance to four or more antibiotics). The result is bacteria that are now hard, if not impossible, to treat and an increasing number of infections from resistant bacteria are now seen; for example, a study published in Germany in January 2014 found that MRSA accounted for 62.7% of canine, 46.4% of feline and 41.3% of equine S. aureus isolates (Vincze et al, 2014). As a result doctors and veterinarians are having to be increasingly aggressive in their efforts to treat infections; prescribing higher doses and longer courses of antibiotics, resorting to higher generation antibiotics, and combining antibiotics. Higher generation antibiotics are third and fourth generation antibiotics. These are drugs that have been developed more recently than first or second generation antibiotics and it is less likely that bacteria have developed resistance to them as yet. Ultimately however, bacteria could become resistant to these antibiotics too, and options for control of certain bacteria may run out. There are a finite number of antibiotics and developing more is an expensive and lengthy process. Bacteria may develop resistance faster than pharmaceutical companies can develop antibiotics (see Box 1), leaving the veterinary and medical professions with no effective treatments. The stage has already been reached where people are dying from previously treatable infections, but which medicine is now unable to combat (World Health Organization, 2015). This problem could become wide-spread with devastating consequences where even minor infections are untreatable and death rates from infection or even routine surgery return to the levels seen pre antibiotics.
Box 1.Antibiotic resistanceȘAntibiotics exert selection pressure that allows the resistance genes to spread within the population. This is natural selection and evolution in action. Bacteria pass on genes more readily than animals … so resistance genes can spread quickly. Selection pressure for antibiotic resistance is exerted on both pathogenic and commensal bacteria whenever an antibiotic is used.’ (Nuttall, 2015)
The causes
Many factors have contributed to the advent of antibiotic resistant bacteria and the medical, veterinary and farming communities as well as the general public have all played a role. Causal factors include those mentioned in Table 1.
Table 1. Causal factors for antimicrobial resistance
| Medical community | Veterinary community |
|---|---|
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| Farming community | General public |
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While it s important to recognise the factors that have contributed to antibiotic resistant bacteria it is equally important not to be distracted by attempting to apportion blame. The primary reason for seeking to establish the cause of the problem is to know how to best address it. Information such as the fact that the carriage rate of MRSA and meticillin-resistant Staphylococcus pseudintermedius (MRSP) in healthy, non-vet visiting animals in the community is less than 1%, but the carriage rate in vet-visiting animals is higher, reaching 3–10% in secondary and tertiary referral cases (Nuttall, 2015) gives a clear indication that most instances of MRSA in animals are hospital acquired and therefore making changes to hospital protocols and environment will have the biggest impact on reducing MRSA in animals. Of utmost importance is the need to acknowledge the problem of antibiotic resistance and for veterinary and health professionals to work together to address it.
The solution
While the problem of antibiotic resistant bacteria is certainly grave it is not insurmountable. There are things that can be done by individuals and by communities but, ultimately, ‘the responsibility and means for reducing the incidence of MRSA and MRSP infections in animals lies with the veterinary profession’ (Nuttall, 2015) and veterinary nurses have an important role to play within the veterinary community (Table 2).
Table 2. Roles of the veterinary team for reducing the incidence of antibiotic resistance in animals
| Role of the veterinary nurse | Role of the veterinarian |
|---|---|
| Judicious prescribing | |
| Implementation of clinic protocols to avoid the unnecessary use of antibiotics, e.g. surgical technique to avoid the use of prophylactic antibiotics during routine surgeries | |
| Excellent hygiene standards; both personal and clinic | |
| Education of clients; both in terms of setting expectations and in the correct use of prescribed antibiotics | |
Veterinary nurses and veterinarians can and must work together to counteract antibiotic resistance in bacteria. Prescribing antibiotics is clearly the domain of veterinarians and while the duties of educating clients, clinic protocols and hygiene are relevant to both veterinarians and veterinary nurses, veterinary nurses are far better placed to assume overall responsibility for these. Simple measures (high standards of clinical practice, good hygiene and responsible use of antibiotics) have greatly reduced the prevalence of MRSA in medical hospitals (Nuttall, 2015); applying the same approach to veterinary hospitals with equal rigor should result in the same success.
Client education
Client education falls in to two categories: managing client expectation and impressing on clients the importance of following dosing instructions.
Managing client expectation
Within the consulting room, management of client expectations is the role of veterinarians. However, by the time a client reaches the consulting room their expectations are often well established. Therefore it is important, and possible, to influence client expectation before their actual appointment. This can be achieved through clinic newsletters and information in the waiting room.
At many doctors' surgeries, notes in the waiting room regarding antibiotics are now common place. Such signs inform patients that antibiotics will be prescribed only if the condition warrants it and requesting that people respect that not all conditions do require antibiotics, and therefore to understand if they are not necessarily prescribed antibiotics. It is very easy for veterinary nurses to produce similar signs for their pet owners and it would also be possible for them to have discussions regarding the issue of antibiotic prescribing with clients prior to their appointments and perhaps to design an information display in the waiting room to attract their attention.
The importance of following instructions
Veterinary nurses are most often responsible for the dispensing of medication and for conveying instructions to clients. It is of paramount importance that in every instance where antibiotics are prescribed it is explained to clients that instructions should be followed exactly and that the course must be completed even if their animal's symptoms appear to have resolved.
Clinic protocol
Depending on current clinic protocols there is the potential to both establish new protocols and to review existing ones in order to minimise the use of antibiotics in the practice. It is beyond the scope of this article to list extensive examples of clinic protocols, but attention should be paid to areas within the clinic where antibiotics are currently used and areas that are perceived to necessitate their use. All these areas have the potential for revision, the obvious example is the use of antibiotics prophylactically.
Antibiotics are often prescribed prophylactically and often unnecessarily (Ferguson, 2004). However, if such a practice is current clinic protocol staff often follow it without hesitation or question. It is important to review such protocols, such as the administration of antibiotics to all animals undergoing dental treatment, to be certain that it is actually warranted in each case. Could the protocol be altered so that grade one dentals with no evidence of gingival involvement are not given antibiotics? Do human dentists give antibiotics when people visit the hygienist for a scale and polish?
Equally it is not uncommon to administer antibiotics to patients undergoing ovariohysterectomy or orchidectomy. It may be possible to review surgical protocol to preclude the assumption that it is necessary to administer antibiotics following routine, elective surgery. If sterile technique is adhered to and there is no breach in asepsis, antibiotics should not be required for clean surgeries.
Hygiene standards
Following on from clinic protocols are hygiene standards which could very easily be established by clinic protocol. Again this is a huge area which it is outside of the remit of this article to discuss at length. However, there are some extremely pertinent general comments which can be made.
The overarching aim of hospital standards must be to prevent patients from acquiring nosocomial infections and this is dependent to a large extent on hospital sanitation. There is considerable, and understandable, reluctance among the veterinary nursing community to view cleaning as a veterinary nurse's role. In some practices the responsibility of general cleaning is outsourced and this is hailed with much acclaim by veterinary nurses. However, much as the use of qualified veterinary nurses as cleaners is to be derided, hospital hygiene is extremely important and there is much to be said for veterinary nurses having overall responsibility for this since they are well placed to understand its importance given their veterinary nursing training. Even if specialised cleaners are used it must be the role of the veterinary nurse to fully explain the requirements of clinic hygiene to them, including the reasons for its importance. If people understand the reasons they are doing something it seems likely they will take it more seriously and adhere to established policy rather than attempting to take short cuts. For example, MRSA contamination rates in human hospitals have declined where cleaners have been trained in microbiological rather than visual cleanliness (Nuttall, 2015). Equally, veterinary nurses must oversee hygiene standards to ensure that they are acceptable at all times.
Personal hygiene is an equally important area, although easily overlooked, and can have a considerable impact on practice hygiene. Beside scrupulous hand hygiene, it has been suggested that uniforms, including footwear, worn within the clinic should not be worn outside it and, equally, street wear should not be worn inside the clinic other than to enter a changing area where uniforms are donned. This would require all uniforms to be laundered by the clinic, resulting in more work and more power, water and detergent consumption and, possibly, the requirement for more uniforms. However, such a policy could have a major impact on reducing the spread of bacteria and transfer from clinic to home and vice versa. In addition to general clinic uniforms, separate footwear and clothing should be used (as per standard protocols) for theatre and isolation wear. While the use of uniforms is generally widespread for veterinary nurses it is important that clothing policy includes all members of clinic staff which may necessitate a shift in clinic policy. The Bella Moss Foundation has published a series of practice guidelines which could be used or adapted as appropriate for practice use (see references for the link to the website) (Mosedale et al, 2015).
Conclusion
Antibiotic resistance among bacteria is a considerable but not intractable problem. Veterinary nurses are extremely well placed to make a significant contribution to addressing this problem. Fortunately it is possible to make changes that are relatively simple and inexpensive and yet have a major impact. Encouragingly, a great deal could be achieved by a ‘back to basics' approach to hygiene and sanitation as an integral part of clinic routine. But, as with all inconvenient truths, the longer it is left, the harder it will be to overcome.
Key Points
- The longer it takes to act in such a way as to prevent antibiotic resistance in bacteria the harder it will be to find a solution.
- Dealing with antibiotic-resistant bacteria requires a total shift in the mindset currently dominant in veterinary practice.
- Antibiotic resistance is one of the greatest threats to human, and animal, health.