title: Antimicrobial prescription in canine and feline gastrointestinal clinical presentations: a mixed-methods approach using Electronic Health Records
Creators: name: Salgueiro Fins, Ivo
Publisher: name: University of Liverpool Repository
Year: 2022

description: Canine and feline gastrointestinal (GI) presentations are one of the most common clinical presentations for which antimicrobials are systemically prescribed. The use of such products may hasten antimicrobial resistance (AMR), which is a major worldwide health concern. Thus, currently we face the need to preserve antimicrobial efficacy, which requires identification of opportunities to safely reduce antimicrobial prescriptions. Although practice-level prescription guidance is widely available, a greater understanding of antimicrobial prescription at a population level is needed for the veterinary profession, especially for antimicrobials considered Highest Priority Critically Important Antimicrobials (HPCIA). To address this, we used a mixed-methods approach, harnessing veterinary health informatics data, in order to focus on two main objectives: (i) Characterising canine and feline GI clinical presentations and reappraising the use of antimicrobials: using data from the Small Animal Veterinary Surveillance Network (SAVSNET), we collated 23,337 electronic health records (EHRs) from canine and feline GI consultations, from 225 volunteer veterinary practices between April 2014 and September 2018 in the UK. Most of the canine and feline GI presentations were reported as mild, with non-haemorrhagic diarrhoea and vomiting being the most frequent clinical signs. Systemic antimicrobial prescription occurred in 28.6% of canine GI consultations and 22.4% of GI feline presentations, with HPCIA prescription occurring more frequently in feline consultations. Bacteriological and/or parasitological diagnostic tests were uncommonly used. Results of multivariable modelling showed the presence of non- haemorrhagic diarrhoea (canine GI presentations OR 2.11, 95% CI 1.91-2.33, p&lt;0.001; feline GI presentations OR 1.77, 95% CI 1.48-2.11, p&lt;0.001) and haemorrhagic diarrhoea (canine GI presentations OR 4.22, 95% CI 3.80-4.68, p&lt;0.001; feline GI presentations OR 3.05, 95% CI 2.44-3.82, p&lt;0.001) were significantly associated with systemic antimicrobial prescription when compared with the absence of diarrhoea. In addition, moderate/severe GI presentations were also associated with significantly increased odds of receiving a systemic antimicrobial (canine GI presentations OR 1.85, 95% CI 1.65-2.07, p&lt;0.001; feline GI presentations OR 2.03, 95% CI 1.68-2.46, p&lt;0.001). Older dogs were more likely to receive an antimicrobial prescription. (ii) Exploring justification and reasoning around antimicrobial use, particularly associated with HPCIA prescription: in a subset of the data, we used a complementary qualitative approach to identify the extent of discussion recorded in EHRs around reasoning for antimicrobial prescription (n=200 EHRs), and to further identify drivers, reasoning and attitudes within the clinical narrative of canine and feline GI consultations around HPCIA prescription (n=516 EHRs). Thematic analysis of clinical narrative content allowed the identification of nine recorded extrinsic factors underpinning reasoning for HPCIA prescription, related with perceived compliance; owner’s behaviour; perceived risk of infection; clinical signs; recent clinical history; perceived (positive) previous response to antimicrobial therapy; geriatric patients and euthanasia; concomitant conditions; and diagnostic testing. Moreover, the perceived veterinarian-client relationship and a behavioural trend led by the veterinary professional in trialling antimicrobial therapy indirectly shaped the decision-making process around HPCIA prescription in GI cases. By taking a complementary mixed-methods approach to EHRs, these studies have identified novel and valuable insights into antimicrobial choices made by veterinary professionals in GI presentations. The results of this work can help inform targeted interventions aimed at helping to preserve the most critical antimicrobials, contributing towards effective antimicrobial stewardship. Intensifying interdisciplinary efforts is crucial to ensure clinical compliance with currently published prescription guidance.