The non-clinical factors of antimicrobial prescribing: critical to consider for stewardship
Laura Hardefeldt BSc BVMS MPH PhD DACVIM
Melbourne Veterinary School
In my last blog I noted that antimicrobial prescribing decision making by veterinarians is complex. Of course, there are bug and drug factors – so called “clinical” factors of prescribing but the non-clinical factors are arguably more important and often overlooked. Veterinarians sometimes prescribe antimicrobials even when they know or suspect that they are unnecessary. Understanding why is critical as addressing these issues is as important, if not more important, to antimicrobial stewardship efforts.
Just as socioeconomic factors affect human healthcare, financial constraints are commonly cited as critical factor in veterinary antimicrobial prescribing. Pet owners’ financial limitations may influence veterinarians’ decisions when choosing antimicrobials for their patients, when choosing whether or not to pursue diagnostic testing and whether to re-check an animal before prescribing (delayed prescribing). In some cases, this might lead to a preference for cheaper but less effective antimicrobials, and commonly leads to “treatment trials” of antimicrobials potentially leading to overuse of antimicrobials. Veterinarians must strike a balance between clinical necessity and the financial capabilities of pet owners to ensure the best care for animals.
The development of assertiveness and strong communication skills—to explain to an expectant client why antimicrobials are not required—also enables a decision to withhold or delay prescription of antimicrobial treatment for an animal. However, regardless of confidence and communication skills, the prejudices some clients held about younger and female veterinarians made it more difficult to convince them that antimicrobials were not needed. Client expectations are exacerbated by client capacity – capacity financially as discussed above but also capacity to monitor and medicate their animals. Veterinarians who don’t have a relationship with clients that allows them to judge clients capacity to identify deterioration or clients self-identify that they won’t be able to medicate or give non-antimicrobial treatments (such as wound care) also leads to increased use of antimicrobial drugs when they may not be necessary. This fear of deterioration is a powerful influence.
Workplace culture that is receptive to change is a powerful enabler of avoiding unnecessary antimicrobials. Regular meetings where veterinary staff discuss clinical cases and protocols is an enabler of AMS. Similarly, a supportive workplace culture—where veterinarians had confidence their colleagues would support their decision we found to enable withholding of antimicrobial treatment – somewhat mitigating the fears discussed above.
The pharmaceutical industry also plays a role in veterinary antimicrobial prescribing. Marketing, advertising, and the development of new animal antimicrobials can influence veterinarians’ choices. They may be inclined to prescribe newer, more expensive antimicrobials due to marketing efforts rather than clinical necessity and the use of long-acting 3rd generation cephalosporins is a good example of this. It is essential for veterinarians to critically evaluate the evidence supporting new antimicrobials and prioritise their use only when necessary, considering the animal’s well-being and the need to combat antimicrobial resistance.
AMR can seem like a distant threat, even though every use of an antimicrobial selects for resistant bacteria, which can persist in the animal for months to years and present a risk to veterinary staff, clients and future patients. Multiple studies have described the trade-off veterinarians make between the invisible risk of AMR and their more immediate concerns of sick pets and angry clients. Pressure from clients and colleagues to resolve a problem in a single visit is a barrier to withholding antimicrobial treatment and is supported by a survey of Australian pet owners one-quarter of whom indicated that they would be annoyed if their animal was not fixed the first time and they had to return to the clinic.
High workloads and a related lack of energy are also recognised as contributing to decisions to prescribe when there was no clear indication, especially in combination with a client who appeared to expect antimicrobials. Increasing veterinarian workloads, partially due to increasing rates of pet ownership during the COVID-19 pandemic, and attrition from the veterinary clinical workforce may therefore increase inappropriate antimicrobial prescribing. Being time-poor and lacking access to paywalled scientific journals also inhibits veterinarians from staying up to date with current antimicrobial use recommendations. Open-access publications and summaries of research in blogs such as this can help with dissemination of important information.
The use of antimicrobials by companion animal veterinarians in the absence of a clear indication is often powerfully driven by behavioural beliefs, chiefly, fears of clinical deterioration and of failing to meet client expectations. This can be mitigated by a good practice culture, feeling supported by our colleagues and strong communication skills.
Laura is a 2003 veterinary graduate from Murdoch university, an internal medicine specialist and completed a PhD at the University of Melbourne in 2017. In 2019 she was awarded a prestigious ARC Discovery Early Career Researcher Award which funds her continued research into antimicrobial stewardship and in 2022 she was promoted to senior lecturer. She is an international leader in implementation of veterinary antimicrobial stewardship programs and her research includes collaboration with social scientists, medical doctors, pharmacists, computer scientists, nurses, epidemiologists and implementation scientists which has been crucial in promoting the role of veterinarians. She is a co-investigator on several national and international grants, with grant funding of > $5 million, over 40 publications, 4 book chapters and over 30 conference presentations.
Dr Laura Hardefeldt (she/her) BSc BVMS MPH PhD Diplomate ACVIM (Large Animal)
Senior Lecturer, ARC Discovery Early Career Research Fellow
President Elect, Equine Veterinarians Australia
Registered Specialist in Large Animal Medicine
Melbourne Veterinary School
The University of Melbourne
