Antimicrobial prescribing education: in an already overloaded curriculum, how can we do better?
Laura Hardefeldt BSc BVMS MPH PhD DACVIM
Melbourne Veterinary School
Antimicrobial prescribing decision-making by veterinarians is complex to say the least! While not understating the complexities, there is widespread evidence that antimicrobial use by veterinarians can be, and should be, improved in the fight against antimicrobial resistance and in the fight for maintaining the social license of veterinary practice. Surveys of veterinary students have identified areas for which they report being under-prepared for antimicrobial prescribing, and a lack of identified “authentic” learning in the early years of study – student value their clinical experiences (the “real world”) above didactic experiences.
Antimicrobial prescribing education is multifactorial. The European Society for Clinical Microbiology and Infectious Disease (ESCMID) has developed competencies for antimicrobial prescribing and these have recently been adapted for veterinary prescribing. The competencies are diverse and include competencies related to microbiology, pathophysiology, making a diagnosis, pharmacology, record keeping, legislation, and antimicrobial stewardship. However veterinary curriculum have become overloaded, with the pandemic adding to this problem in many schools. The Royal Veterinary College, American Veterinary Medical Association and Australian Veterinary Boards Council have recognised this and have re-evaluated the day 1 competencies to have a greater focus on general veterinary practice skills but changes to curriculum are likely to take time to catch up. The added challenge for antimicrobial prescribing and antimicrobial resistance is the ever-evolving knowledge base. This is not a static area – clinical guidelines for antimicrobial use, understanding of pharmacokinetics, and even antimicrobial importance ratings change over time and sometimes over relatively short periods of time. Our students, and our current clinicians, must develop habits of checking guidelines for updates and dispelling the often-held belief that checking guidelines in front of clients and colleagues portrays a lack of knowledge. Our medical GP colleagues have managed to succeed on this front and there should be no reason we cannot. Another skill to teach in the packed curriculum!
The answers? This relies on veterinary educators considering antimicrobial stewardship across the curriculum. The development of online resources and interactive modules or games may help with knowledge acquisition for competencies related to pharmacology and microbiology, but the real key lies in the “real world” learning that our students do – and now more frequently the learning they do in a distributed practice model. We must take a collaborative approach to ensure that the large number of clinicians who are now responsible for teaching our students are responsible antimicrobial users. The utilisation of the veterinary competencies for antimicrobial prescribing can assist with this, giving students the responsibility to ensure that they have gained the competencies by graduation and encouraging environments of open discussion about antimicrobial use in clinical cases.
A greater emphasis on continuing education for veterinarians is also important. It is difficult to get people interested in continuing education about antimicrobial stewardship – the topic should be refined to have a clinical focus and thereby engage with more veterinary practitioners.
In conclusion, as clinicians across the spectrum of practice, we all need to take responsibility to improve antimicrobial prescribing, discuss prescribing decisions with students and recent graduates, be open to changing prescribing based on evidence and guidelines and reflect on the challenges to appropriate antimicrobial use within our practices and find solutions at a grass-roots level. Our students value our experiences highly and we can have a big impact on the next generation of prescribers and the longevity of the antimicrobials we rely on to treat our patients.
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