Antimicrobial Stewardship: An Ethical Imperative
Antimicrobial stewardship is something we have all heard about. But are we really aware of how big of a problem antimicrobial resistance(AMR) really is?
Perhaps most important, have we recognized the role we play in contributing to this global crisis, and accepted our responsibility to be part of the solution? It’s important for us to recognize that how we use antimicrobials in our daily practice has impacts well beyond our own professional bubble. And making responsible decisions about antibiotic use is an ethical imperative.
According to the World Health Organization, AMR is one of the biggest threats to global health of current times. Recent estimates tell us that AMR is directly responsible for over a million deaths each year, and has played a contributing role in more than 4 million deaths world-wide. While these impacts are felt across all geographic and socioeconomic groups, they are felt most acutely in poverty-stricken areas—and they are expanding rapidly. It’s estimated that AMR could lead to more than 10 million deaths world-wide by 2050 (Antimicrobial Resistance Collaborators 2022).
Inappropriate or unnecessary use of antibiotics, often associated with inadequate diagnostics, is one of the most commonly cited drivers of AMR. While it may feel like antimicrobial resistance is more of a distant problem, local actions make a difference. In fact, as equine veterinarians, three of the antibiotic classes that we use most frequently (third generation cephalosporins, aminoglycosides and sulfonamides) are high on the lists of antibiotics of high, or even critical, importance to human heath. That means we play an important role in helping to solve this problem both through responsible use of antibiotics in our daily practice, and by working with our clients to help them understand why our commitment to promoting judicious use of antimicrobials is so important. As a first step, we need to follow the science and pay close attention to rapidly evolving recommendations about antibiotic use,
Case in point. Including antibiotics for prophylaxis in a routine joint injections has historically been routine practice for many equine practitioners—with good reason! No one wants to experience a potentially fatal septic joint. Yet recent studies report not only that the incidence of septic arthritis following joint injections is extremely low (<0.1 %), but that rates of infection aren’t significantly impacted by including antibiotics (Pezzanite 2022). Add to that the fact that many of the antibiotics most commonly included in a joint injection can be cytotoxic to cartilage, and we can conclude that not only is including antibiotics in most routine joint injections unnecessary, it’s could even be harmful. It’s also contributing to the antimicrobial resistance problem.
Another commonly cited scenario in equine practice is the client or farm manager who calls requesting antibiotics for a horse with a fever, swollen leg, or snotty nose. Or the client who requests an examination because their horse’s condition isn’t responding to the antibiotics they “had on hand.” While dispensing bottles of antibiotics for farm use may have been common in years past, times have changed. With the emergence of antimicrobial resistance as a significant threat to both human and animal health, it’s especially important that antibiotic prescriptions be limited to cases where they’re really needed. The Center for Disease Control’s National Action Plan for combating antimicrobial resistance urges us to “use the right antibiotic, at the right time, for the right duration.” (Centers for Disease Control 2023) As veterinarians, we’re the ones who have the education necessary to formulate those treatment plans, and to educate our clients about why it’s so important. While it can be difficult to change client expectations, most of our clients mean well. If we take the time to explain that antibiotics not only aren’t likely to be needed, but can even be harmful, owners will be more willing to accept our recommendations. And older, seasoned practitioners can lead the charge by embracing these changes.
By keeping current on evolving research, demonstrating a willingness to change our treatment strategies, and committing ourselves to educating others, we can make a difference in the fight to overcome the devastating impacts of antimicrobial resistance. It’s an ethical imperative.
For additional information, refer to the AAEP’s guidelines for judicious use of antimicrobials.
Antimicrobial Resistance Collaborators. (2022). Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet; 399(10325): P629-655. DOI: https://doi.org/10.1016/S0140-6736(21)02724-0
Centers for Disease Control (CDC), National Action Plan, (Accessed December 28, 2023), https://www.cdc.gov/drugresistance/us-activities/national-action-plan.html#:~:text=The%20U.S.%20National%20Action%20Plan,the%20health%20of%20all%20Americans.
Pezzanite, L. M., Hendrickson, D. A., Dow, S., Stoneback, J., Chow, L., Krause, D., & Goodrich, L. (2022). Intra-articular administration of antibiotics in horses: Justifications, risks, reconsideration of use and outcomes. Equine veterinary journal, 54(1), 24–38. https://doi.org/10.1111/evj.13502
