Every Patient, Every Time

Two members of the task force behind the 2022 AAFP/AAHA Antimicrobial Stewardship Guidelines—chair Erin Frey, DVM, MPH, DACVPM, and Jennifer Granick, DVM, MS, PhD, DACVIM—help us simplify good stewardship for the entire veterinary team.

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Veterinary Teams and Antimicrobial Stewardship

An Interview with Erin Frey, DVM, MPH, DACVPM, and Jennifer Granick, DVM, MS, PhD, DACVIM, for Central Line: The AAHA Podcast

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Erin Frey, DVM, MPH, DACVPM

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Jennifer Granick, DVM, MS,
PhD, DACVIM

When we think of our most precious resources, we don’t necessarily think about drugs. But antibiotics, or antimicrobials, are among the most important resources we have to protect both animal and human health, and antibiotic resistance has never been more ubiquitous. Two members of the task force behind the 2022 AAFP/AAHA Antimicrobial Stewardship Guidelines—chair Erin Frey, DVM, MPH, DACVPM, and Jennifer Granick, DVM, MS, PhD, DACVIM—helped us simplify good stewardship for the entire veterinary team.

Erin Frey: We’re doing better than we were, and I think we’re making strides in the right direction, so that’s what got me involved in this task force.

Jennifer Granick: The cool thing about antimicrobial stewardship is that it’s an actionable thing that every single prescriber can do to help decrease this really scary onset of antimicrobial resistance that we’re seeing in our patients. It’s tangible for everybody. And the other cool thing about it is that probably whether you know it or not, all practitioners are already doing some aspect of stewardship, so just changing the focus and the intention in small ways can do a lot.

Katie Berlin: I like the idea that you don’t have to change everything you do. It makes it a little bit less intimidating; less like a culture shift and more of just an expansion of something that is already second nature.

EF: I think there’s a general feeling that doing antimicrobial stewardship, you’re going to have to start something new, but we’re not saying, “Start a stewardship program.”

“I feel like medicine is a team sport, and if you’re doing it alone, you’re probably not having the best experience and your patients may not be either.”

—JENNIFER GRANICK, DVM, MS, PHD, DACVIM

The guidelines that were out before this, it had been a few years since they’d been updated, and there have been a lot of new things done and a lot of new work done, and I think one of the big things that we wanted to address here was that the [title of the] previous ones [used the phrase] “judicious use.” We wanted to expand the focus from not just thinking about that time when you have an animal in front of you and you’re choosing if you are going to use an antibiotic or not, but to say it’s part of this global thing that happens at your practice. The vaccines that you recommend, the nutrition that you advise clients to do, all of those things are part of stewardship. So [we are] really reframing it in terms of this bigger picture rather than just that moment.

JG: No one has time these days to read through pages and pages of recommendations—that’s intimidating. But I think everyone can probably find one action item just to start with. And if you pick one thing and focus on that and then build upon that momentum, I think small steady change is really impactful.

KB: I love that these guidelines are accessible to the whole team. You could hand this document to anybody on your team, and they could probably read it, understand it, and be like, “Oh, that’s something that I could keep in mind when I’m communicating with clients who ask me certain questions,” or “This is why that doctor does things a slightly different way than I’ve seen before.”

I was thinking, “Okay, I already do most of these things, but do I do them enough? And do I have this conversation every time?” And the answer, of course, is no. I thought maybe we could just start addressing some of the common [objections we hear from colleagues and clients], and that will cover a lot of the reasons why people maybe don’t do this every case, every time.

Clients often are expecting you to prescribe oral antibiotics, and even if they understand it’s important to be good stewards, they’ll say, “Well, can’t you just do it this one time? I’m going on a trip,” or “My son is sick,” and we’re worried that if we don’t do what they’re asking, they’ll go someplace else, they’ll leave a bad review, or they won’t follow up with us, and they’ll sue us if the pet doesn’t get better or take us to the board. How do you feel like the best way is for people to address that concern?

EF: Yeah, it’s tricky and it’s real. I think one of the things we talked about in another conversation was maybe not everybody at your practice does it the same way. Mrs. Jones [is used to calling] in whenever Fluffy has a rash, then Dr. So-and-So gives 30 cephalexin and two weeks of prednisone or something like that.

I think of it like any other difficult conversation, right? We have the tools. We use these tools when we talk about money; we use these tools when we talk about convenience euthanasia. Some of the same things that work in those conversations can work here. And one of those is being very clear. There’s a great paper in human medicine that talks about what’s called foreshadowing. We already know when we describe what we’re doing in our physical exam that clients take value from that.

No_Antibiotic_Handout_27Feb2020_Final.pngThe Antimicrobial Resistance and Stewardship Initiative website provides clinical resources including a non-antibiotic prescription pad.

So, Fluffy comes in with a cough, and if I’m saying, “Yes, I can hear today that she has a cough, but I’m listening to her lungs and her lungs sound clear. Oh, good news. She doesn’t have a fever today. Oh, she’s not dehydrated. That’s great. Oh, you’re telling me that she’s eating and drinking okay at home.” Fluffy is running around the room. “Look how excited she is to be here today.” You sort of set the situation for saying, at the end, “Hey, because of all of these things, Fluffy doesn’t need an antibiotic today. Let me make some other recommendations for how you can help Fluffy at home.” Jen’s college, the University of Minnesota, has a really great—what is it called? Non-prescription pad?

JG: Non-antibiotic prescription pad! It’s on our website, the Antimicrobial Resistance and Stewardship Initiative website: arsi.umn.edu. It’s got a bunch of clinical resources including this. The idea is not just withholding antibiotics; that feels negative. It’s providing positive actions. It explains that a lot of these conditions will improve on their own and that we just need to provide some supportive care, and it allows you to fill in the actions or supportive care things that you’re either going to prescribe or tell the owner to do at home. So for the upper respiratory infection example, put the cat in the bathroom when you’re taking a shower or humidify the air and warm up their food so that they can smell it better because their nose is stuffy.

And then also [it discusses] when should you be concerned, when to notify us if things aren’t improving, or what things you should look out for. It’s providing positive things for the client to do so that they’re helping their pet, because they came to you because they want to help their pet. It’s communicating that you’re both on the same page. Your goal is helping the pet too, which helps to bond the client to you and to your clinic. And it provides an “if/then” sort of scenario. If your cat stops eating well or is still snotty in a week or whatever your parameters are, then we have a plan, come back in, or at that point it would be appropriate to prescribe an antibiotic.

I think providing things that the owners can do rather than them just leaving without anything [may keep them from] the bad Yelp review. But it’s a lot of client communication. Right?

EF: [In a] paper [that’s] coming out sometime soon, one of the things that the people in our focus groups really homed in on was, “Answer all my questions. Tell me why they don’t need an antibiotic. Tell me what I should be doing.” And then it’s really critical to say, “These are the things to watch for, this is how I will know if it’s getting worse or if it might need antibiotics. I’m saying they don’t need it today, but I’m not saying they might not need it in 24 hours or 48 hours. So at home, I’d like you to watch for. . . .”

You have a plan, so this is where the team comes back in. Whether it’s you who are going to call them back, or my technician is going to call in 24 hours to check on Fluffy and see how things are going, or we’ll email you, or you have an automatic system that just sends them a text message that they can respond to. I think it’s really critical here: what are you going to go home and do today, what are you going to look for, and when are we going to talk again?

The tendency for them to call back and get angry is less if you say what they’re looking for and say when you should talk again. Then when they call or they text in, they say, “Hey, you told me that this might happen, well, now it has. And you told me that if it did, we would use antibiotics or we would use this other medication. I think it’s time for that.” I find it less combative.

AAHA Guidelines

Find the 2022 AAFP/AAHA  Antimicrobial Stewardship Guidelines and other resources, including an animated infographic to share with your team and clients, at aaha.org/antimicrobials.

People really don’t care so much about these big public health or grand ideas, but they really care about their pets. Clients really want to know, “What’s the best thing for my dog or my cat? And what are the pros and cons of using it?” I think if you keep it to that animal and the impact on that animal and that client, you’re going to get a lot more traction in terms of going away with everybody feeling okay about it.

KB: Basically, veterinary medicine is a communication science with some medicine thrown in. Without that communication, we’re just not going to be successful at treating hardly anything.

JG: A hundred percent. Get the care team involved, because it may be a different doctor seeing a patient every time, but maybe it’s the same technician who could speak up and say, “Oh, you know, this dog was just in two weeks ago for this problem and two weeks before that.”

EF: So many times, it could be a kennel staff, it could be a tech, it could be your receptionist who has a relationship with this client or with that animal based on their own interactions [that] are separate from yours, and we should really celebrate their passion and the way that they advocate. I have had that situation many times where the technician will come to me because they really care about a certain patient and like, “Oh my gosh, they have this again,” and then you’re like, “Okay, tell me more about that.”

I would welcome a team member to share that with me if they have this insight that maybe I don’t have. Again, that’s a little bit of culture too, and I think that’s one great thing about AAHA in general—it’s celebrating teams. That is in the nature of the culture of AAHA, to celebrate teams and to encourage involvement and empowerment of the team.

JG: Yeah, 100%. I feel like medicine is a team sport, and if you’re doing it alone, you’re probably not having the best experience and your patients may not be either.

KB: One of the best ways to find and keep really good people is to get them involved!

If we’re trying to do diagnostic tests on more patients to really justify when we do need to use antimicrobials and decide what those antimicrobials should be, then maybe we can find a way to make them a little bit more affordable for the average client. Would you say that that’s realistic to think about?

EF: I know a number of commercial labs do give sort of a quantity discount. I would also say there are a lot of diagnostics that are not that expensive, that can be done in the hospital and really can give you a better sense of whether this is something that needs to be treated. I am a huge fan of cytology for everything. A slide and a cotton tip swab or a piece of double stick tape can really tell you a whole lot and really help you.

The other test that’s, I think, very much underutilized is doing a dry mount urine cytology. So once you spin down your urine, people are used to putting a little drop on the slide and doing a wet mount. Well, you can take one drop and spread it like a blood smear, dry it out and stain it, and you can actually see the neutrophils and you can see if you have rod-shaped or cocci-shaped bacteria.

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“So many times, it could be a kennel staff, it could be a tech, it could be your receptionist who has a relationship with this client or with that animal based on their own interactions [that] are separate from yours, and we should really celebrate
their passion and the way that they advocate.”

—ERIN FREY, DVM, MPH, DACVPM

JG: I couldn’t agree more. I’m definitely a cytology cheerleader.

KB: It’s scary when you’re first starting because you don’t know what you’re looking at, but the more you do it, the more fun it is, I think, and the more fun for your technicians to do too, because they’re perfectly capable of reading cytologies. And a lot of them really, really enjoy it.

EF: Here’s a way that the team can get really involved. How many times have you walked in a room and the technician says, “Mrs. Jones is in room two, and I’ve already got the ear swab, and I can tell you on the cytology that I see this.” And a well-oiled team, they already know that you want to get the cytology. They get in, take the history, get the cytology, and by the time you’re walking in the room, you already have that information to put together then with your physical exam, so I think everybody wins in that situation.

JG: You have to weigh the balance, right? What are the consequences if the patient has an infection and I don’t treat with an antibiotic? What are the consequences if they don’t have an infection and I do treat with an antibiotic? And cytology is such an easy, quick, and powerful tool to help reduce some of that uncertainty.

EF: If we can back up a few steps to “What is the thing that’s going on with this animal that puts them in a position of over and over again having that situation?” that’s really what we want to address. And so, to your point about the cost of diagnostics, that’s another thing to say. One way or the other, we’re going to spend money, and I think the best way that you could spend your money is really getting to the bottom of what’s going on here. Because my ultimate goal is that we try to fix the thing [so] you’re not coming back over and over again.

KB: The front office staff, I know, is like, “Yes, please find out what’s wrong so that we don’t have to deal with Mrs. Smith calling six hundred times wanting antibiotics and then having to tell her no.” It affects the whole team’s mental health as well, to practice this way.

EF: And the thing we say sometimes is: We know more now. Since last time we saw you, the guidelines are out, or—in the case of a young dog where we’re not sure if they have a seasonal allergy or a food sensitivity—a pattern is emerging, right? We couldn’t really know that the last couple of times. She always is itchy in March. Well, let’s do something with that information.

Now “there’s more we can do,” rather than “we were wrong.” So [we’re] really making it a positive. “Now that we know more, this is what I would recommend today for you.” 

Catch a new episode of Central Line: The AAHA Podcast every Tuesday on all major podcast platforms, YouTube, and aaha.org.podcast. Send us feedback or questions anytime at [email protected].

 

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Katie Berlin is AAHA’s Veterinary Content Specialist, and host of Central Line: The AAHA Podcast. 

Photo credits:andresr/iStock via Getty Images; gpointstudio/Envato

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