Hello, it's Anthony Chadwick from the webinarett welcoming you to another episode of Vet Chat, the UK's leading veterinary podcast. I'm really excited today to have Ian Battersby and Fergus Allison on with me. We're gonna be talking about all things antibiotic stewardship, and of course we're gonna also be talking about the amnesty that's coming up in November.
We'll share a bit more of the details of that later, but perhaps first, just to . Start Ian and Fergus, do you want to introduce yourselves to the audience, please? Ian first.
Oh, Ian first. So, my name's Ian Bassersby. I'm a double boarded internal medicine specialist, and my current, well, I used to run the medicine department at Davies's Veterinary Specialist, but my current role, is now responsible for pharmaceutical stewardship lead for Mars Veterinary Health, and my interest in this area started about 10 years ago, and, I, created the Protect PSAVA Protect scheme, and, that's a nice seamless link because Fergus took over that mantle, in about 2016, I think it wasn't, was it Fergus, so over to you.
Yep. So my name's Fergus. I'm an internal medicine clinician working at Willows in the West Midlands.
And after becoming the chairman of SAMSOC, I did launch the second iteration of Protect, which was Protect me, and I have been really interested in the area of antimicrobial stewardship since then. And we're now looking at more and more ways that we can improve the way we're using antibiotics in the veterinary profession. How can we engage with our stakeholders, our clients, our owners, how can we make sure that vets can optimise their antibiotic use?
And I think that's something that Ian, set the ball rolling, some time ago. We've still got a way to go, and we've really got to keep working hard to optimise that. It's definitely an area that we've been interested in webinar vet for a long time, and I remember also going to the Gava in Dublin and we were talking about antibiotic stewardship with David Lloyd, obviously professor at RVC at the time, and it was in a very small room and the room wasn't full.
So it's been a topic that perhaps hasn't been, As exciting as it maybe should be or or as worrying as it should be, because obviously we have these antibiotics, and I know I see some scary figures, you know, in the human world of deaths that are now due to antimicrobial resistance. We obviously, you know, that part of our responsibility as vets in a one health situation is that we use antibiotics responsibly as well as, Obviously the, the doctors and so on. So perhaps tell us a little bit about Protect first, how that has first of all started Ian, and then how it's iterated with you, Fergus.
So how it started, it was like it was a personal experience really that started it for me. I went to the, I had a really bad wound on my my hand that hadn't responded very well to the empirical course of antibiotics prescribed by my GP, and I ended up in A&E, and I will admit that I was asking for some potent antibiotics because my hand was very, very swollen and I was very worried about it. And the doctor was amazing, really.
He was very patient and he explained some of the stewardship measures that were in place at the hospital, you know, he said for the drugs I was asking for, he'd need a positive culture and he'd need the microbiologist for the hospital to sign that off. And you know that you know that was just like mind blowing considering that some of those drugs we could just prescribe as vets, you know, without, you know, on our own. So posted on the SAMSOC forum, you know, has anybody got any stewardship protocols in place?
And I think it was only Cambridge who had some protocols in place. So then it just evolved really. It was like, well, we need to do something about this.
We need to start talking about it. We need to start creating some guidelines that people can use because One of the challenges is you talk about the principles, but we're all busy people and making those decisions on what you need to use at the right time, you know, and things like that, which in certain conditions it takes time to formulate that. So we created the Protect poster.
We tried to, we wanted it to be positive, you know. It's, it's a bit of a doom and gloom situation when you talk about antibiotic resistance long term, but we are, we do have an opportunity to, you know, protect these drugs from not working anymore and pres and protect our prescribing rights as well. So I have to admit it went, you know, I look back now about 10 years ago, and You know, you know, I guess it was a You know, there wasn't quite the engagement on it, so it was a bit of a poisoned chalice, I think, to some respect, and you know, and the guys who helped me produce it, they were amazing, you know, we had members of primary care, Allie Woodward and Mark Maltman, and we had a couple of referral clinicians.
Ian Ramsey helped as well, and we created this thing that actually did a lot better than what we realised, really. So and then Fergus took over the mantle. He took over chair of Samsok and took over the mantle and Evolved it beautifully in the way it needed to go.
So that was that was that was me linking to you at the end. Yeah, but I was gonna say just very quickly, it's always nice to know the end of the story, so I, I need to know a wound on the hand, was that a dog bite or a cat bite or where where did the wound come from or would you rather not say it was a it was a it was a cat bite, a really nasty one, And I'm embarrassed, I can't even remember the name of the cat, but obviously that cat started a cascade that massively influenced my career, really, not only the doctor who chatted to me, but you know, if, if that cat hadn't bitten me, I wouldn't have ended up where I am today. And how did the treatment go?
What, what happened after that? Was it just a case of more localised lavage or how did he treat it to get you hopefully back with your hand working again? Yeah.
Well, ironically, he just used a higher dose of amoxicla and Lavage as well, you know, and it did resolve, you know, he, he didn't take a culture at the time, but yeah, it, it all got, it took about a month in total to get better. He just had a bad, you know, week where it really swelled up and Yeah, I, I, I did a lot of important things with my left hand. I'm right handed, but you know, that's quite important.
You see, well, it's still nice to have both of them, isn't it? And maybe, maybe I, you just look lighter and slimmer than you actually are, maybe they just didn't weigh you properly to, to do the dose as I always say with dogs, you know, with dermatology problems, the number of times I would have cases referred where it was the dog's 25 kilogrammes, but they're only giving it a 250 milligramme amoxicillin clavulinate acid, and of course you're trying to keep it cheap, but actually you're not serving anybody by giving. A bit less of a dose than you should do for a bit shorter time than you should do, isn't it?
You know, at least at that time that was sort of the, the rationale that treats long and properly rather than, you know, half-heartedly. Well, I mean, I'm gonna go in and tell us, tell us the end of that story jumping at the bit. Well, I, I, I think we have to be careful with the recommendations and what you say, long and high dose and proper, it has been a mantra for a long time, but I think that that is shifting and shorter is better and we are.
It is important that you give the right dose so that you can achieve effective concentrations that will treat the bugs in the site where they're at. We must remember that not all antibiotics penetrate equally in certain sites. But I, I, I'm really interested in antibiotic duration and course length has historically been an arbitrary number based on how many fingers we've got on our remaining hands, so it might be shorter for Ian.
It has been sort of multiples of 7 as well. Yes. I think that.
We lack the evidence to offer sensible recommendations for antibiotic duration, and that's something that we need to work on together and to try and change because it may be that we can achieve an effective clinical outcome with shorter courses. And if we can bring the typical course length down, it will reduce our overall consumption. There is no point using antibiotics when the condition has been resolved.
So I think that. There are some really interesting things and that's one of the limitations, I think of all the guidelines we have. They are historical timepieces, and they reflect the.
And they lack the evidence that we require. And hopefully, they highlight some of the gaps in that evidence so that people can go and ask those questions and provide us with the evidence moving forward. We would love to be able to tell people how long a course of antibiotics to use, what's the ideal antibiotic, what's the ideal dose, and definitively, what's the difference between using antibiotics and not using antibiotics?
Because it, it may be that antibiotics do confer a small benefit, but is it a benefit that justifies their use? And there was a paper recently that showed that metronidazole could very marginally reduce the duration of acute diarrhoea. But is that a justification to give all acute diarrheas metronidazole?
I, I certainly don't think so. And I think that we should try and do these studies and see what actually we need, where we can avoid using antibiotics and be able to hang our hat on that, work. Did you know the webinar vet has a public community Facebook group?
We want to ensure veterinary professionals have a place to stay in the loop with everything that's happening here at the Webinar vets. In this public group, you can chat and network with other veterinary professionals from across the globe, get exclusive updates, content recommendations, and so much more. Pop and say hello to a community of over 2000 veterinary professionals by searching.
The webinar that community on Facebook. Focus is right. I mean, certainly, you know, the ethos now is treat well, you know, treat optimally and for as short as possible, you know, and it's a real area of interest in human field now.
They're doing studies looking at, you know, I remember reading one, you know, comparing, you know, 10 days of antibiotics for 1 day of antibiotics for otitis media in children, and there was no difference, you know, you know, like Fergus was saying, you know, traditionally it was multiples of 5 or multiples of 7, which are convenient numbers. Why would a bacteria know 5 days is a time concept that it's going to respond to, you know, it's, it's, it's just we use these measures and it's really important that, you know, particularly in companion animal because we, we haven't got that evidence that we Get involved in studies to try and shorten these lenses of courses that we're using. I was about to say one of our lecturers on Webinar vet is a guy called Mike Willard, professor over at Texas A&M.
He's just retired and, you know, he's a very humble guy and he says, you know, what I taught you 10 years ago was a lie I just didn't realise, and you know, it's really, it's really true, isn't it? You know, some of the stuff I did on dermatology 10 years ago, it's obviously adapted using shampoos. You know, trying to use adjunctive therapy so that you don't need to use as much antibiotics.
And of course, you know, we've seen some success with those measures in, I think I saw, some results recently about the amount of antibiotics used in farm animal medicine now has really reduced because of that stewardship and because of that care of, right, you know, you really need to think about this before you can use a, you know, an antibiotic drug on a. On a a cattle or a sheep or whatever, a cow or a sheep. And Ruma, who've led the way in many respects, they have achieved a lot, but one of the ways that they've done that is through engagement of all the important stakeholders.
So they've talked to the farmers, they've talked to farm vets. They've talked to the buyers of some of these products. So if you want to buy, sell your milk to Tesco's, they will set a certain antibiotic threshold.
So that does put a pressure on the farmer not to use them unless they absolutely have to because there is economic advantage in it. So I think we need to do something in our own way, in the companion animal, small animal field, and make sure that we do engage all the important players, from vets to owners wherever possible, to make sure that everyone's on the same page. Rema done fantastic and from a farm animal point of view.
I guess we've just got a different dynamic to manage, you know, because Fergus highlights some of the different areas where they're able to target because if you've got a purchaser of your product saying, I want you to reduce how much antibiotic you're using, that's a driver, whereas we've got to consider the, you know, the pressure of the consult room, you know, and we want to support vets in that difficult situation where you've got an owner who's very worried about their animal, and we don't want people to use antibiotics just in case. We want them to feel confident that they use it when it's indicated. And you know, it's what, you know, when you've got that emotional situation, you know, it's, it's a harder thing to, to, to step away, you know, to, to, to use that barrier.
So that's what we've got to work on supporting getting culture in a practise to support all the vets in the practise to make those, those, you know. I'm not going to do this just in case decisions. Obviously one of the problems though, is also around compliance and sometimes we will give a course of antibiotics and perhaps rightly, perhaps the clients know more about this than we do, and after 2 days, 3 days, they do stop.
And but they're left with 3 or 4 days of antibiotics at home. And I suppose. You know, with, with a sort of careless hat on, you could say well we can throw that in the bin which will go to landfill, or we can flush it down the toilet, which will get rid of it.
But of course a much safer way of doing this is that we actually get those medicines back into the practise, isn't it? Absolutely. You raise a very important point there, and we do know from human studies that about 1/3 of people keep hold of their antibiotics, and then they'll use them either for themselves, for something else.
They've got a cold and they'll think, well, I'll go and check the kitchen cupboard or the, bathroom cupboard. For some antibiotics, they, maybe they'll help. So they're using them inappropriately, or they'll give them to their friends, or children, or things like that.
So they will become the prescriber, and this risks significant adverse effects associated with those antibiotics because they may not be used in an appropriate way. And it also risks . Well, the, the antibiotics are not going to where we, we want them to go.
I think that we are really keen to offer safe disposal to all antibiotics that have been left over, all unused antibiotics. And at the moment, roughly 8% of antibiotics are returned to the pharmacy. And we want that to be far greater where they are left behind.
Veterinary antibiotics count for this, because, as you say, if they go down the toilet, if they go into landfill, they will potentiate the problem of antimicrobial resistance, and they will act as a pollutant of the environment. So we want to avoid those roots and get. These antibiotics back so that they can be appropriately disposed of.
And over the course of November, that's what we're asking owners to do, to return their unused leftover antibiotics back to their vet practises so that they can be safely disposed of. And I think that if we can encourage that, we will bring some Antibiotics safely out of the environment, and that will be a massive gain. But the other gain will we get more people thinking about this important topic of antimicrobial resistance, getting those conversations going, and people will suddenly realise, actually, these are things that we need to treat respectfully so that they can be useful in the future.
Let's keep antibiotics working for when we really need them. Any thoughts in? No, I mean, absolutely.
I mean, I, I think this is such an important initiative, really, you know, these are biologically active agents, you know, so naturally if they go into the environment, they will have an effect and you know, if you, if you, you know, if you talk to people who research antimicrobial resistance, one of the places where they'll go and sample is sewers because that's where a lot of these products end up and obviously then you've got a cocktail of optimal. You know, conditions for bacteria to select for resistance. People, you know, if you flush them down the toilet, that's where they're going to end up.
So, you know, antibiotic, I mean, the principles the same for all drugs, really. You know, we don't, we want to dispose them appropriately, but obviously with the AMR issue, you know, this is a fantastic initiative to combine both, those topics really. The amnesty is, is set to go for November, isn't it, Fergus?
It is, it will run for the whole of November, and this is a one health initiative. This is something that the veterinary profession, I'm proud to say, have really bought into across the board. So we've got support from the Veterinary Medicines Directorate, from BVA, BSAVA, NOAA, all the big corporates are behind this idea.
They really want to encourage vets to get involved. But we also know that NHS Midlands are doing it. They're trying to get human antibiotics back to their pharmacies.
Local dentists are trying to do it as well. We're all in this together. And as Ian said, we're looking at 6, or rivers in 6 out of 7 continents are showing signs of antibiotic residue.
Now it's not all from throwing them in the bin, they, they go through us and end up there as well, but it is a significant route that they could end up in our environment. So let's stop that at source by not disposing of them into those environments. So I think the idea Ian or Fergus is that if people.
The the veterinary practise, is there a way that they can advertise this to their clients, are there some resources on the internet, are there posters that practicess can perhaps get hold of? How, how will that work? We've created quite a lot of resources already, and these are from, well, we will be hosted on the rumour Companion Animal and equine website and the RCVS AMR Knowledge hub.
So you can access those and we are encouraging vet practises to. Download posters that they can put up in the waiting rooms to make owners aware. They can mention it in consultations, they could put it in any newsletters that they're running on social media, we've created a little animation that we hope that practises can share with their clients base, and anything that enriches awareness, we would like to learn from this experience.
This is the first time an amnesty has been run in this format, in the UK certainly. And we want to try and learn from the process. We are set, we have set up a little research study to run alongside it.
This will be QR code linked, so if you see the poster is in your vet practise, you'd be able to scan that and access a short survey that tries to assess owner awareness of the importance of antibiotic disposal, and also. Asks them the question, why have you ended up with a tonne of enrofloxacin in your bathroom cabinet? And we can hopefully establish, well, what are the driving forces for that?
Is it that we are giving too long courses? Is it that some cats or some dogs are impossible to tablet? Do they have adverse effects that we're blindly unaware of?
Because we, we probably underreport these things in veterinary medicine. So we hope that we can get more. Information that will inform our recommendations in the next iteration of Protect me as to how we should be prescribing in the first place.
Because there's no point in giving unnecessary medication. We don't want people to end up with this product in the first place. So as you say, some of this will be about the amount of antibiotics we give in the first place and maybe we have been too generous with that in, in past history.
Absolutely, and I think that we don't always know and we all would rather sort this problem definitively in one go, but owners, like all of us, will use antibiotics for as long as they feel they can manage to do it, and that it is achieving what they want to, to achieve. So there will be situations where they end up with leftover medication. If we can work out what they are, we could guide future prescribing habits.
Fantastic, Fergus, any, any last thoughts Ian on this? I know this is an area that obviously you're very passionate about and it's great to see one of the corporates actually having, you know, somebody who's just responsible for this area as well. Yeah, no, I No, I mean, you know, I guess if we take it a few steps farther back, you know, if you think about the principles of sustainability and better for the environment, you know, by identifying areas where we're using medications unnecessarily prescribing too long a medication, there's less medications need to be produced, you know, so you've got all that manufacturing and transport and stuff, so there's that aspect right at the top of the tree.
Then you've got, you know, the, the, the patient, we want to make sure it's optimal treatment and, you know, we kind of have a, a, when I was at vet school, it used to be the more antibiotics to cover, you cover all quadrants. That was the ethos. And there wasn't a perception that there was any, any harm really from doing that.
But we're now starting to understand how important the microbiome is, you know, for health and So you know, by minimising these courses, we may be improving, we're still learning about the microbiome, but we may improve patient outcome by shortening the courses. So there's lots of benefits in this area. And when you start, you know, it's like, it's like a, it's like a spider's web when you start thinking about all the different impacts it can have.
And so, you know, I'm just really excited. This is a fantastic initiative and you know, the first time it's happening in the UK for the veterinary profession, it's brilliant, brilliant, absolutely outstanding. And I think as Fergus said, it's very much a a one health thing because it's obviously beneficial to us as humans, but also to animals.
But as you said, even with the just less production of antibiotics, it's great from a sustainability and a regenerative perspective from the environment as well. So I think it's a fabulous initiative, fabulous thing that, that, you know, rumour and I know Fergus, you've been very involved in setting up and. I, I just hope it's a rip roaring success and maybe we can do another podcast, to see how it's actually gone, you know, after it's finished and everything.
That would be brilliant, but I, I, I really hope that we can all get behind this, and I, we are conscious that vets are very busy at the moment, so we've tried to keep this something that people can get engaged with at whatever level they want to. If you can, and it is going to be. Across the vet practise, so the staff at the front of house will be able to mention it to owners as they're in the waiting room and encourage them.
Nurses who are helping discharged patients can hopefully bring it up with owners and obviously vets during consultations as well. I think that raising awareness is going to be a real benefit from this study, and any antibiotics we can reclaim will be an added bonus. So I really encourage all practises to, to reach out, get involved, have a look on the RCVS knowledge and the rumour Companion Animal equine websites, and it.
Let us know how you get on. Let us know your feedback, what was good about this process and what was difficult, and how much antibiotic did you get back. And in doing so, you get access to a free draw that will, well, it's one of those lotteries, so you can hopefully win either a free Congress ticket.
There are some RCVS knowledge. Library accesses, Noah companions, BSAVA manuals, and I think Anthony, you were going to a webinar membership as well. Yeah, so it, it, it sounds like it could be fun.
I hope so, and that that's the carrot to try and get people involved. We want to say this is so valuable for everyone, please look into it, consider getting involved as a practise, and let's see what we can achieve together. We're all gonna be much, much stronger together.
There's a massive cumulative effect as well, you know, with this kind of situation, you know, as Fergus highlighted, people are incredibly busy on clinics, but. You know, for practise, you know, if somebody in a practise just has one or two conversations throughout the entire month altogether if everybody does that, that makes a massive difference. It really does.
So you know, and it's a win-win as well. There's a draw, prizes, what's what's what's not to get involved. And it just makes great sense as well, doesn't it?
Yeah. Ian Fergus, thanks so much for giving your time, really appreciate it. I know how busy both of you are.
So thanks for coming on the episode of Vet Chat and . Yeah, hopefully we'll, we'll, we'll find out results very soon and we can feed that back as well. Thanks both of you.
Thanks for having me.
