Using Antimicrobials Responsibly in Dermatology

Veterinarians are all too familiar with the importance of using antimicrobials responsibly. After all, they’re the ones tasked with determining the best course of treatment for an itchy dog with a recurring skin infection that’s become resistant to various antibiotics.

How Communication and Client Education Can Help Prevent Drug Resistance

by Kristen Seymour

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“Pyoderma is rarely a primary disease process; 99.9% [of cases] are driven by an underlying disease that disrupts the skin’s natural barrier function. For most dogs with recurrent pyoderma and/or otitis externa, the causative factor is an allergic skin disease.”

—DANIEL O. MORRIS, DVM, MPH, DACVD, PROFESSOR OF DERMATOLOGY AT THE UNIVERSITY OF PENNSYLVANIA SCHOOL OF VETERINARY MEDICINE

Veterinarians are all too familiar with the importance of using antimicrobials responsibly. After all, they’re the ones tasked with determining the best course of treatment for an itchy dog with a recurring skin infection that’s become resistant to various antibiotics.

But it’s one thing to understand why the judicious use of antimicrobials matters; it’s another to convince a client that bathing her unruly Newfoundland with a topical is a better treatment for his skin infection than easier options, like a round of pills or a one-time shot.

And that’s without even going into diagnosing and treating the actual cause of his itchy skin.

However, addressing and controlling the underlying disease process is the most important aspect of the management and prevention of staph infections, said Daniel O. Morris, DVM, MPH, DACVD, professor of dermatology at the University of Pennsylvania School of Veterinary Medicine. “Pyoderma is rarely a primary disease process; 99.9% [of cases] are driven by an underlying disease that disrupts the skin’s natural barrier function,” he said. “For most dogs with recurrent pyoderma and/or otitis externa, the causative factor is an allergic skin disease.”

Challenges of Treatment

Preventive measures—like moisturizing dogs with excessively dry skin to restore the skin’s barrier function or providing antiseptic prophylaxis regularly—can help in some instances, noted Morris. However, while veterinarians used to resort to the use of maintenance antibiotic therapy prior to the mid-2000s, the advent of multidrug resistance in Staph. pseudintermedius and Staph. schleiferi has put a stop to that technique. “Those days are long gone,” he said.

Today, in dermatology, knowing whether or not there’s an infection that would benefit from antibiotics isn’t so much the question. The bigger challenge is twofold: first, treating whatever is causing that infection, and second, choosing and administering the safest treatment that provides the greatest benefit—with the least possible risk of creating drug resistance.

Addressing the Real Cause

“One of the big things we have in dermatology is the inciting cause, and the problem you run into is that we have cases where people won’t—or haven’t been asked to—address the inciting cause,” said J. Scott Weese, DVM, DVSc, DACVIM, FCAHS, a professor at the Ontario Veterinary College’s Centre for Public Health and Zoonoses and one of the coordinators of the educational website Worms & Germs. For instance, if a dog has a food allergy, you can treat the active pyoderma, but if you don’t address the food allergy causing it, that pyoderma will just come back, he said. “We all know the ‘frequent flyer’ dogs that have had multiple rounds of pyoderma, and now, not surprisingly, they’ve got an MRSP infection because they’ve been exposed to all these antibiotics, but we still haven’t treated the underlying disease.”

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“We all know the ‘frequent flyer’ dogs that have multiple rounds of pyoderma, and now, not surprisingly, they’ve got an MRSP infection because they’ve been exposed to all these antibiotics, but we still haven’t treated the underlying disease.”

—J. SCOTT WEESE, DVM, DVSC, DACVIM, FCAHS, PROFESSOR AT THE ONTARIO VETERINARY COLLEGE’S CENTRE FOR PUBLIC HEALTH AND ZOONOSES

While treating the underlying cause the first time is ideal, Weese understands why owners may be reluctant to do it, especially with a suspected food allergy. “Veterinary diets are expensive. Food trials are a bit of a pain,” he said.

But that’s when client education becomes so critical—and the more personal and real you can make it, the better.

“You explain to them, okay, you have a two-year-old dog. You’ll need to see me three times a year for antibiotics for this. And in a year or two, the antibiotics will be a lot more expensive because the infection is going to be a different bug,” Weese said. “Then we’ll get to the point where it’s an injectable antibiotic; that’s more expensive, and you’ll either be doing an injection or paying me a lot to do it. And, really, your dog is going to be really unhappy for a significant portion of its life.”

This type of conversation puts the inconvenience of a food trial and cost of a prescription diet in perspective. It might take a little extra time to relay that information, but Weese insists it’s well worth the effort. “The medicine is easy,” he said. “The human brain is the biggest barrier to stewardship.”

Understanding your client’s biggest motivator helps, too. “Sometimes that motivator is cost,” Weese said, in which case explaining that they’ll spend more money in two weeks if they don’t take action now may do the trick. But other times, it’s truly all about the animal’s health, which is when Weese will explain, “Look, your animal is uncomfortable. We want to make sure this infection doesn’t come back—that’s why we need to go on a food trial now.”

Administering the Appropriate Treatment

Client education is also a key element when it comes to treating the infection itself.

“Everyone wants a pill or shot to cure everything, of course. Clients want the easy way out, and veterinarians often don’t have the time, or perhaps the knowledge, to have these lengthy discussions,” Morris said. “But clients have to be told that, at some point, we will likely run out of safe oral antibiotic options for their pet. Doing the hard work now will hopefully save them some heartache later,” he said.

Morris spends a lot of time educating his clients about the dangers of drug resistance and the need for culture and susceptibility testing. He uses that discussion as a springboard to encourage them to treat minor or local infections with topical antiseptics rather than systemic drugs. “Save systemic drugs for deep infections or superficial infections that are too widespread for a client to reach effectively with topicals,” he said. “Also, don’t play ‘musical antibiotics!’ If your first attempt at empirical therapy fails, perform a culture/susceptibility to guide drug selection. Multidrug resistance makes it impossible to predict what might work.”

The fact that he still sees so many veterinarians using beta-lactams and fluoroquinolones as their go-to drugs concerns Morris. “In the age of extreme drug resistance, we should be relying more on topical therapy and also using culture and susceptibility testing for systemic drug selection,” he said. “We need to rely less on empirical selection of systemic drugs—especially the beta-lactams and fluoroquinolones—for treatment of pyoderma.” Use of other drug classes, such as clindamycin or trimethoprim-sulfa, may help prevent the acquisition of broadly drug-resistant strains, he added.

Communication and Support

Still, it’s important to remember that a conversation goes two ways. Making an effort to understand your client’s situation and concerns can make a huge difference in choosing the best treatment for their pet.

“We sometimes make decisions for owners without knowing the whole story,” Weese noted. For example, if you have a really large, energetic dog and an elderly client, you might assume that your first choice of treatment—bathing the dog with a topical—is out of the question. “But maybe they’ve got a neighbor or a kid next door who can come over and take care of it,” he said.

Weese suggests understanding—but being flexible with—your hierarchy of treatment options, prioritizing the best choice for the given scenario.

“Sometimes, it’s about how we present it,” he said. “For derm, our optimal therapy is topical. Ask them, ‘Can you do that?’” he said. If the client can’t, take a moment to discuss why and whether there’s another option, like a mousse or a spot treatment. “If we have to use oral therapy, can we use a lower-tier drug? Maybe we can’t because it’s resistant, or maybe they can only give the pill once a day. Then we’re bringing in the bigger guns. Can they do that?”

And still, the answer might be no. Weese gives the example of an 85-year-old type-2 diabetic with a bichon frise who’s a biter. “She’s not going to be able to bathe it, and she’s not going to be able to give it a pill, so yeah, give it a shot,” he said. “You know it’s overkill, but it’s the best thing for that owner and pet as opposed to no treatment or the owner being bitten.”

In some cases, a demonstration may be in order. “We could probably do a better job of showing people how to administer,” Weese said. “If they give their dog a pill all the time, fine! But if not, or if they tried but it didn’t go well, okay, let me show you,” he said. Providing them with a moment of support on the front end can prevent them from having to come back for help—or worse, having them not be able to pill their pet but being too embarrassed to call, then come back three months later with a real mess of an infection.

The Importance of Treatment Compliance

The client education aspect regarding antimicrobials in dermatology doesn’t end with the writing of a prescription; it’s also vital that the client understands the importance of giving their pet all the pills prescribed, said Weese.

“I tell them, yes, their dog is going to look better after three or four days. That’s what I expect to see. But that doesn’t mean he’s fixed,” Weese said. “If you don’t give the medication until we say stop, this infection might come back. Then I’m going to want to do a culture to see if it’s resistant. That’s going to cost more money, and the other drug I give you in the interim is going to cost you more. So, instead, let’s just treat the extra few days.”

Shortening Duration Use

At the same time, he realizes that the duration of use of antibiotics, especially in veterinary dermatology, may go a bit overboard. “Antibiotics tend to be used for a long time, and the longer you use them, the greater the risk of resistance,” Weese noted. And while other areas of veterinary medicine have used data from analogs in people to reduce that duration, there’s no data to support that in dermatology—yet, anyway.

And even when we have that data, he said, it may still be difficult for some practitioners to change their mindset. “We default to a defensive approach a lot in veterinary medicine,” he said. “We like to do something. We accept the consequences of us doing something more than we accept the consequences of us not doing something.”

Weese and his colleagues have launched a free, open-access app to provide antibiotic prescribing support based on prescribing guidelines for small animal veterinarians using the Firstline platform, which he hopes will help with that issue. “It’s a work in progress, but we’re trying to make it easy,” he said. Veterinarians can simply pull up the app, select the species and type of infection, and view the recommended treatments. If their client, boss, or anyone else is concerned about a change in treatment, the app is a simple way to show that their choice is a proven method of treatment.

Judicious use of antimicrobials begins before a prescription is even written. Addressing the underlying disease and using preventive measures, when applicable, are the best first lines of defense in dermatology cases. And when it comes to bringing in antibiotics, using the lowest-tier drug for the shortest approved duration is a great next step. But, at the end of the day, without the client education aspect, treating these itchy dogs and cats will be an uphill battle. “It’s basic communication,” Weese emphasized. “It’s about making sure that medicine is right for the patient—and for the owner—and that the owner understands why. The why is really important.” 

 
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Kristen Seymour is a freelance writer based in Sarasota, Florida. She’s a frequent contributor to many pet-focused publications including HealthyPet Magazine, USA Today’s Pet Guide, Vetstreet.com, DailyPaws.com, Happy Paws, and more.

Photo credits: Thirawatana Phaisalratana/iStock via Getty Images Watcharin panyawutso/iStock via Getty Images; MJ_Prototype/iStock via Getty Images; 

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