Position Statements

Antimicrobial Stewardship in Veterinary Medicine

January 21, 2021

Background

1. The emergence of antimicrobial resistance (AMR) is a global concern and threatens human and animal health, animal welfare and societal well-being (1,2). The CVMA holds that the veterinary, medical, agricultural, environmental, and regulatory communities must work co-operatively to minimize the emergence and continued spread of AMR.
2. Veterinarians employ antimicrobial drugs to control and treat disease and to support animal health and welfare. Veterinarians are best qualified to assess the benefits and risks of antimicrobial use (AMU) in animals and to communicate to their clients on the importance of prudent use.
3. The term “antimicrobial stewardship” has been used to describe the multifaceted and dynamic approaches required to sustain clinical efficacy of antimicrobials by optimizing drug use and whenever possible use alternatives including vaccination, management changes, facility changes and antimicrobial alternatives. When antimicrobials are required, “antimicrobial stewardship describes the optimizing of the choice, dosing, duration, and route of administration, while minimizing the emergence of resistance and other adverse effects” (3).
4. Veterinarians should strive for effective antimicrobial stewardship, optimizing AMU in animals to mitigate the risks of AMR. Stewardship practices must incorporate strategies that balance prudent use of antimicrobials with desirable animal health and welfare goals and objectives.  Strategies to help avoid unnecessary AMU should include veterinarians working with animal owners and caretakers in the development of comprehensive vaccination, nutrition, and biosecurity programs; in designing and providing optimal housing environments and husbandry practices to support effective disease risk management; and in encouraging the use of alternatives to antimicrobials when appropriate.
5. The principal goal of One Health (4) is to improve health of animals, humans, and the environment.  The CVMA strongly supports a “One Health” approach that brings expertise together from animal and human health, and  environmental sciences to collaborate on critical cross-cutting health issues, including matters such as how AMU in animals relates to the development of antimicrobial resistance.
6. In Canada, the CVMA and Canadian Council of Veterinary Registrars have produced a framework for veterinary oversight of AMU (Veterinary Oversight of Antimicrobial Use – A Pan-Canadian Framework of Professional Standards for Veterinarians, 2016) (3).
7. As stated in the Pan-Canadian Framework, “Veterinary oversight is a key element of antimicrobial stewardship. It encompasses the professional involvement of licensed veterinarians in providing guidance or direction for appropriate use of antimicrobials in animals with the objective of ensuring prudent use and minimizing the emergence or spread of antimicrobial resistance. Veterinary oversight is the entire process or mechanism whereby veterinarians, through their education, experience and accountability, provide guidance or direction for appropriate use and distribution of antimicrobials”.
8. In 2018, new policies and regulations were introduced and implemented by Health Canada (5) for the use of medically important antimicrobials (MIA) in animals and for drugs that did not previously require a prescription, including those in feed. Since all MIA were moved to the Prescription Drug List, a veterinary prescription was made a requirement under a valid Veterinary Client Patient Relationship (VCPR) for use of MIAs in animals.
9. In issuing a prescription, veterinarians must meet relevant professional obligations including:
   • Establish and meet conditions of a valid VCPR with respect to the specific animal or group of animals,
   • Make an evidence-based determination of medical need,
   • Complete appropriate documentation in the medical record, and
   • Provide oversight of use and follow up (3).
10. The professional conduct of veterinarians providing veterinary oversight of AMU is regulated in Canada by provincial and territorial veterinary regulatory bodies that establish professional standards.  These include the conditions that determine what constitutes a valid VCPR as well as any provincial or territorial requirements for the use of antimicrobials (on-label and extra-label) by veterinarians. Provincial and territorial regulatory bodies provide mechanisms to ensure that veterinarians possess required credentials and are held accountable to meet the acceptable professional standards when overseeing the use of antimicrobials.
11. In promoting antimicrobial stewardship, veterinarians should take an approach of continuous improvement based on responsibility, reduction, refinement, replacement, and review (4,6). Good stewardship practice is a dynamic approach that includes the elements of: ongoing continuing education, ensuring owner compliance, following relevant practice guidelines, pharmacokinetic and pharmacodynamic considerations affecting dosage, the use of clinical microbiology data, good infection control practices, and compliance with national regulations, among other considerations (7,8,9). The CVMA supports veterinary continuing education on AMU in animals that emphasizes good stewardship practice.
12. Veterinary antimicrobials approved by Health Canada for the treatment of the diagnosed condition and for the animal species in question should be used whenever possible. The appropriate dose, frequency, and duration of administration should be followed in accordance with label direction (6). Although there are circumstances in which appropriate extra-label drug use (ELDU) is essential in veterinary medicine, antimicrobials should not be used in an “extra-label” manner unless there is evidence-based support for efficacy, dosage regimen, indication, and withdrawal times (10). A decision tool such as the CVMA therapeutic decision cascade is a useful model to follow with respect to ELDU (11).
13. The CgFARAD is recommended as an appropriate resource for avoiding residue violations when contemplating extra-label uses of antimicrobials. If an antimicrobial is selected for extra-label use, the veterinarian must provide (in writing) to the client the appropriate information on dose, route, frequency, duration, and withdrawal time (if applicable) to avoid any risk to human health (12). 
14. Veterinarians should be familiar with the Health Canada’s, Veterinary Drug Directorate “Categorization of Antimicrobials Based on Importance in Human Medicine” and, along with consideration of relevant information on the product labels, make antimicrobial selections within less important categories whenever such selections would still allow the patient to be appropriately treated (6). This applies to on-label and extra-label use of antimicrobials.
15. The CVMA promotes general and specific guidelines for the prudent use of antimicrobials by the veterinary profession as well as resources on decision making and alternatives to antimicrobials (9, 11). 

References

1. World Organisation for Animal Health  (OIE).  Antimicrobial Resistance. Available from :   https://www.oie.int/en/for-the-media/amr/. Last accessed January 2021.
2. Council of Canadian Academies. When Antibiotics Fail: The socio-economic impacts of antimicrobial resistance in Canada (2019). Available from : https://cca-reports.ca/reports/the-potential-socio-economic-impacts-of-antimicrobial-resistance-in-canada/. Last accessed January 2021.
3. Canadian Veterinary Medical Association. Veterinary Oversight of Antimicrobial Use – A Pan-Canadian Framework of Professional Standards For Veterinarians. Available from: https://www.canadianveterinarians.net/policy-advocacy/framework . Last accessed January 2021.
4. World Organisation for Animal Health (OIE). One Health.  Available from : https://www.oie.int/en/for-the-media/onehealth/. Last accessed January 2021.
5. Government of Canada. Responsible Use of Medically Important Antimicrobials in Animals (modified in November 2019). Available from:  https://www.canada.ca/en/public-health/services/antibiotic-antimicrobial-resistance/animals/actions/responsible-use-antimicrobials.html. Last accessed January 2021.
6. Health Canada. Veterinary Drugs Directorate’s Categorization of Antimicrobial Drugs Based on their importance in Human Medicine (2009). Available from: https://www.canada.ca/en/health-canada/services/drugs-health-products/veterinary-drugs/antimicrobial-resistance/categorization-antimicrobial-drugs-based-importance-human-medicine.html. Last accessed January 2021.
7. Government of Canada. Antibiotic Resistance and Animals (modified in May 2018). Available from : https://www.canada.ca/en/public-health/services/antibiotic-antimicrobial-resistance/animals.html. Last accessed January 2021.
8. National Farmed Animal Health and Welfare Council.  Antimicrobial Stewardship in Food Animals in Canada. National Farmed Animal Health and Welfare Council (2016). Available from : https://www.ahwcouncil.ca/pdfs/council-updates/NFAHW%20Council_Recommendation_AMU_AMR_2016.pdf. Last accessed January 2021.
9. Canadian Veterinary Medical Association.  CVMA Guidelines for Veterinary Antimicrobial Use (2018). Available from: https://www.canadianveterinarians.net/AMU-UAM. Last accessed January 2021.
10. Canadian Veterinary Medical Association. CVMA Extra-label Drug Use (ELDU) — Position Statement (2015) . Available from: http://www.canadianveterinarians.net/documents/extra-label-drug-use-eldu. Last accessed January 2021.
11. Canadian Veterinary Medical Association. Therapeutic Decision Cascade for Animal and Public Safety. Available from: https://www.canadianveterinarians.net/documents/therapeutic-decision-cascade. Last accessed January 2021.
12. CgFARAD. Available from: https://cgfarad.usask.ca/language.php. Last accessed January 2021.