Antimicrobial Resistance and Stewardship

Over the past few years, as I have progressed through my veterinary degree I have become increasingly aware of the importance of antimicrobials and the huge impact that resistance is starting to have on both animal and human health and welfare. As I have mentioned previously, my involvement in the RVC Global Health Society has been linked to this. Antimicrobial resistance is of course a Global Health issue, affecting both animals and humans globally, and is an issue that has developed due to the use and misuse of antimicrobials both in human and veterinary medicine.

We are now taught so much about the issues involved with antimicrobial prescription and use, it is hammered into us that blanked prescription causes more harm than good in the long term, population situation. This is also becoming an issue which is increasing in the public’s eye which is needed as many people even now are unaware of the huge impact that this issue will/is causing.

As a vet to be, I am more passionate about this theme than I may be as a human medic. The main reason for this is the knowledge that if resistance become uncontrollable and antimicrobial usage is greatly restricted, it is vets who will loose prescription rights first, i.e. this is an issue which will definitely be part of my future career. Many people blame the agricultural industry for this shocking amount of resistance that is currently around. Obviously this is not the only reason, as it appears that resistance was first recorded very soon after the first discovery of penicillin (1940s). But at this stage, pointing fingers is not going to help anything, this is an issue that needs to be addressed by everyone if we want any sort of success.

Due my interest in the topic, I have elected to do a research project over the next year (as part of the course) looking at the success of antimicrobial stewardship programmes in small animal practice. This will be a very interesting topic as little research has been done in this area so far, and programmes like the ones I will be looking at, are a major part for the proposed control of resistance, and it important to know if they will help or not.

So far, the small amount of research I have started looking at has shown some positive outcomes, however, restricting prescription rights does decrease prescriber autonomy and so relies largely on compliance with the suggested regulations.

 

I will try to keep an updated log of the reading I do, with sources included, which will help me as a record for my project.

Antimicrobial Awareness

I went along to an event held by the RVC Global Health Society (which I am proudly involved in) discussing antimicrobial awareness, mainly regarding veterinary medicine, but also with regard to human medicine, as in this instance these two couldn’t be much more closely related.

I had always known and been told the importance of awareness of resistance developing in antimicrobials and knew that the situation was getting worse, as vet students we are always reminded that if and when the situation gets worse we could loose the rights to prescribe antimicrobials, as priority would go to people. Hearing the three speakers throughout the evening really opened my eyes more to the importance and the severity of the situation at the moment.

The idea that at the moment there are no completely new antimicrobials being produced (most new ones are variations on those we currently have and use) which means that as resistance get worse then there is no plan b. If we do not change the way that we are using antimicrobials both in animals and humans then we could end up in a position that a simple infection could kill an individual, this would send us hugely back in time in terms of medicine.

Even now there have been cases of individuals who have become exposed to highly resistant bacteria. This is a serious sitiuation both for the individual and the people around them. If these bacteria spread this could cause many unessasary deaths. Even if there are one of two drugs that are affective against the bacteria in question there is a risk in using these to treat the most minor infections as exposing them to the remaining affective drugs could increase the chance of them developing further resistance to even these meaning that there would be no way of treating them at all.

The livestock industry are playing a huge part in increasing resistance. Intensive farming across the world needs antimicrobials in large amounts to keep the unnatrually large number of overbred animals in a very small space, as the conditions and genetics of these animals mean that without prophylactic antibiotics they would not survive. This is one of the many reasons from a global and one health point of veiw why factory/intensive farming is a wildly unsustainable for the future. Cheap meat is not worth a future where a simple bacterial infection is fatal and these two are most definatly linked.

Raising awareness of these issues is the first step in making a difference and we all need to realise how serious this issue is. This is not something that is just happening to some one on the other side of the world, and is not something in developing countries. This is something that will affect us here in Europe (and America) and could affect anyone, bacteria are everywhere, all the time, without them we could not survive, but they are also gaining the power to have a serious impact on our survival.

Beavers in Britain?

So this evening I went to an event given at ZSL London Zoo about the future of beavers in Britain. I had heard about the reintroduction of beavers in Devon (after having been extinct from the UK for around 400 years due to hunting to extinction,as well as being hunted nearly to extinction in the rest of Europe) recently which made me interested in this event.

My initial thought of the beavers was positive and excited about the idea of them being native to this country again. but then as i thought about it i did wonder if it was a positive thing after all. beavers do have a huge impact of the environment around them. they are thought to be one of the only species (only with us) that drastically modify their environment according to what they need (i.e. building dams and canals to create deep, still water). I felt that going along to a event as this one I could find out more about the impacts of beavers and make an informed decision on my thoughts of the reintroduction of this species.

 

The reintroduction began in Scotland long before they reached devon. currently there are two populations of beavers in scotland which are both being carefully monitored to assess their impact on the environment around them. a report on the last 5 years of investigations ‘Beavers in Scotland’ (http://www.snh.gov.uk/publications-data-and-research/publications/search-the-catalogue/publication-detail/?id=2273) is currently being assessed to decide whether they should remain in britain or be removed.

It does look positive for them though. it has been shown that beavers do have a positive impact (or neutral) on many native species in the investigated area due to the creation of new habitats and diversity. this could be a great way to increase biodiversity! However, there are some native habitats (such as Aspen woodland) which are limited and could be damaged by the presence of beavers…

Equally in Devon they have seemed to have a positive impact on the environment, as in one location they created 13 ponds and a number of canals which both created a number of new habitats (huge increase in the amount of frog-spawn found) but also in the flow of water through the area. The dams created appeared to create a constant flow of water even after a high rain fall (when there would usually be a surge in water flow) the dams and ponds create a buffer, meaning that the overall flow is not affected. Equally the water leaving the area appeared to have less sediment in it, i.e. it was cleaner!

However, the dams, if build in the wrong place can interfere with monitoring systems set up by the Environment Agency to monitor the flow of water.This would need to be monitored if beavers became more widespread.

Additionally, looking at soco-economics, they have seen that generally most of the population would benefit or be unaffected by this reintroduction. however, those who would have problems (agriculture, forestry etc.) need to be considered as well. equally, some fishing industries (such as the atlantic salmon in scotland) could also be negatively affected by beavers, and need to be considered.

In Europe the beaver population was nearly destroyed. Hunting was widespread and had it not been controlled, the whole of europe could have ended up like Britain. however, now the overall beaver population of the whole of europe is back up again, to around 1 million! However, this genetic bottle-necking has had a slight damaging effect on the genetic diversity of the beaver population as a whole. there is also an issue with the genetic diversity of the UK populations. one of the populations in devon stem from just one breeding pair and so at the moment interbreeding is a serious problem. they are looking into importing a few more breeding pairs to the area to increase diversity as at the moment this is not a sustainable population.

The introduced beavers in Scotland where originally from Norway and were carefully quarantined and checked before being released. It is important when reintroducing a species in this way to insure that any diseases are not brought along with the animals! being an island we have the ability to eradicate a disease, but this needs to be maintained and importation of animals is a easy way for a disease to come back, or a new disease to be brought over.

some of the beavers now in the UK are from an unknown origin. this is a problem from a disease point of view as they then need to be caught and tested after having been in the environment for a while, which means they could already have brought in a new disease!

One of these diseases is infection of the parasite Echinococcus Multilocularis. It has been found to be in 5% of beavers in Bavaria but it has been confirmed that it is not present in the current british wild populations. This problem is that it has been seen in a captive beaver in this country and as no one knows where some of these wild beavers are coming from any new ones need to be tested to make sure that they cannot bring the parasite in to the environment (which is also a zoonotic parasite and so poses a public health risk).

 

Overall, it was a fascinating and very enjoyable evening and I do think that actually beavers in this country would not be such a bad thing. In the end they did used to be native here  and if introduced carefully and slowly could really benefit our natural ecosystem. It is important to remember, however, that it is still early and this project could still fail. I will definitely be keeping an eye out for more developments.

Horse AHEMS – Easter 2015

So I have just completed my 9th and 10th weeks of AHEMS (only two weeks to go this summer!) on a Arabian horse stud farm in Devon. It was defiantly my favourite placement and I really do feel like I have learned a great deal, not just about the horses and husbandry, but also about the horse industry as a whole.

To start with, even though I really love the breed, I have not done much work with Arabians at all and was a little nervous on the first day as they are often known to be very highly strung and can be difficult. But on this farm they not only breed the horses carefully to improve temperament and behaviour, but also the way they train and handle the horses is very different which both meant that considering the reputation of the breed and age of some of the horses that I was handling they where surprisingly calm and accepting.

As the horses there are bred to be riding horses (rather than to be shown in-hand, with which they are often bred and trained to be very highly strung and energetic) they are from bloodlines of horses who are calm and easy to handle. On top of this they are in direct contact with humans from the day they are born. Even taking the foals in and out of the field, they are lead (not with a head collar straight away, but still with physical contact to a human) meaning that they soon are easy to deal with and calm around people.

The young horses are kept in large groups for a few years, separated regularly to be handled etc. until they are broken in. This is unusual in some ways, but does seem logical as it is a much more natural way to keep the young horses meaning too that they are happier, not lonely and so from this good experience will be much easier to train and handle.

I learned more about the breed as a whole too, they are unique in that they have one less rib than other horse breeds. They are one of the oldest breeds around as so have naturally spread rapidly across the world. In different countries/continents they have established as sorts of sub-breeds, each with different characteristics, for example, egyptian arabs are one of the oldest sub-breeds and are one of the only sub-breeds which can be traced back to the founding horses and is said to be 100% pure. This means that they are a fairly rare breed and so are some of the most expensive arabians, but at the same time are also quite inbreed giving them some genetic disadvantages to other arabians. An example of these genetic disadvantages is that they have a tendency to have imperfect legs, and are more prone to lameness and deformities than other arabians. At this farm they did have a egyptian stallion, but most of the horses they

Dairy AHEMS – summer 2014

For the last 2 weeks of my summer AHEMS, I worked on a dairy farm. This was great experience as i had no previous experience with dairy cows (just a little with beef).

I learned more on the general husbandry and handling of cattle, as well as the procedures of milking etc. in the dairy. The importance of hygiene in the milking parlour was emphasised throughout my whole time there, in every step from milking to transport of the milk there are set regulations which the farm needs to stick by to allow them to sell their milk on.

Feeding of the calves was an important role for me too. As the rumen (first and largest chamber of the stomach in which most bacterial fermentation takes place) needs to develop slowly in the calf, so that by the time they are weaned off milk they are able to digest forage and hard feed properly, even at a very young age (a few days) calves are left with hay and concentrate feed (cake), so that they are encouraged to eat small amounts in order to allow the required development.

Lameness is a large problem in the whole of the dairy system worldwide. in my 2 weeks I did get a chance to do some hoof trimming, and look at foot ulcers which caused severe lameness in some of the cows. ideally the cow’s hooves  (or claws) should be trimmed around 2 times a year, as the surfaces that we keep them on do not wear down the hoof as fast as it is growing, so left alone they would overgrow and cause more problems. for the treatment of foot ulcers, one of the best things to do is remove some surrounding hoof wall, flush out the wound and then put a block onto the healthy claw. this means that the claw with the ulcer is raised off the floor and so is both less painful and safer from external insult (pathogens etc.)

The farm i visited had only recently been declared TB free. this showed me more of the issues surrounding bovine TB, and how on a farm level it can really be damaging to the income of the farmer.

Overall, this also was a very benificial placement and allowed me to become much more confident handling cattle and have a better understanding of the dairy industry, both at a farm level and as a whole.

 

Horse AHEMS – summer 2014

In the summer holidays last year I did 5 weeks altogether of animal husbandry work experience as part of my course. 2 of those weeks were at the equestrian centre of an agricultural college, which had both school and livery horses.

Seeing as I already had a good amount of of experience with horses already, many of the tasks that I carried out were familiar to me, such as grooming, mucking out stalls, field management and tack cleaning. hot clothing, bathing and the management of horses with sweat itch (midge saliva allergy) were also things that we did, which were specific to the hot summer months. As it was an agricultural college they were able to show and teach me the ‘correct’ (or BHS) way to carry out these procedures, which could help me to try to remove any bad habits that I have picked up over the years.

We also discussed the issues of bio-security that the yard could face. talking about strangles (a respiratory infection caused by streptococcus equi), and whether getting a official strangles free status was worth it for the yard. It was decided not, as with so many people and horses moving in and out of the yard there would be too much of an issue and danger to justify trying to achieve this status.

Overall, this was a very beneficial placement, as not only could i confirm and improve the knowledge and skills that I already had, I could also see the workings of an establishment such as this one as well as work with livery horses, which are not as simple and easy to handle in many ways than riding school horses.

Donkey AHEMS – Summer 2014

I spent one week in the summer at the donkey sanctuary. This is a world wide charity helping donkeys and horses.

Mucking out, grooming and cleaning routines were regular and efficient. feeding for the majority of donkeys was in one large trough. while those in need of medication were fed separately to ensure that they got all of their what then needed. The donkeys are much less intense to look after than horses.

Treatment of foot problems was a frequent occurrence, as none of the donkeys had shoes and many where quite old. I was able to do a fair amount of foot bandaging. Sarcoids (pretty much infective tumours) where also a major issue and I was there during a routine vet  visit checking for sarcoids during which we discussed the issues with them and their treatment using a toxic cream.

Overall, this was a very interesting and informative placement in which I learned a great deal more about a species I knew little about, as well as learning more about the charity.

Cats AHEMS – Easter 2014

Last easter, not only did I do two weeks of lambing (see previous post) but I also spent a weeks at a cats protection shelter.

I loved this placement, as it meant I spent a whole week pretty much just stroking cats. But at the same time I did learn quite a lot. I found out about more about the charity as a whole, as well as that particular shelter. Every morning the pens were cleaned out, and some were disinfected (if a cat was moved out, and before a new one took it’s place). This made me realise the importance of hygiene, especially when there were FIV (Feline Immunodeficiency Virus) positive cats present.

The general the handling of nervous cats was very beneficial to me, as I came to realise that I was used to cats who knew me, and my behaviour towards unknown and nervous cats was very different.

Overall feeding and treatment of the the cats was important, as every cat which was re-homed needed to be in the best health as possible. This involved neutering, vaccination, deworming and defleaing as well as any underlying health problem. Each cat was treated individually according to what it needed.

Overall, this was a great placement which was very enjoyable and rewarding.

Lambing AHEMS – Easter 2014

I know this is over a year ago now, but last year I spent 2 weeks working on a sheep farm in Somerset during the time which they were lambing. Even though it was probably the toughest 2 weeks of my life (long hours, no pay. We spent the whole 12 days either working, eating or sleeping) I have to say I learnt a great deal and have become very confident with lambing.

By the end I had seen so many lambs being born that I was confident with both normal and difficult births and knew well when and how to intervene if the ewe was struggling. Post-partum care of the lambs was also a major part of my work. bottle feeding, stomach tubing (if the lambs were too weak to suckle), adoption (wet and dry, giving ewes with just one lamb a second from a triplet, in order to try and get each ewe with just two lambs each). Dealing with the orphaned and rejected lambs was also important, as they needed to be bottle fed regularly and then taught to suckle from artificial teats built into the pen wall (to reduce bottle feeding time).

Once the lambs where a few days old (under 7 days) they needed to have their tails docked and the males were castrated (rubber ring method).

Hypocalcemia (post lambing) and pregnancy toxemia (twin lamb disease, pre lambing) were common conditions on the farm (as many of the ewes did have triplets). we treated both with an injection of calcium into the milk vein, if it was pregnancy toxemia, i.e. if she had not lambed yet, she was also given Propylene glycol orally, which can be metabloised by the liver to produce glucose (through gluconeogenesis), which is lacking in this condition.

We also had to deal with vaginal and cervical prolapses, using warm water and sugar to replace the prolapse, and then a held in with a prolapse spoon, to prevent any further prolapses coming up to lambing. These ewes needed to be monitored more carefully as the spoon needed to be removed as they started to show the first signs of lambing.

Overall, this placement was hard work and frustrating at times, but I did learn an great deal. This is only a brief summary of the placement giving a basic idea of the things that I learnt.

Year 2

I am very aware that I haven’t posted of over a year now! I am defiantly going to try and get into it again!

I am now in my second year of vet school. Since I last posted I have done 8 weeks of animal husbandry placements in my holidays (pretty much work experience which is required for the course, on farms etc.) and am currently writing a Research project looking at the types of small animal pets that people own in rural, suburban and urban areas of the UK, and if this varied between the 3 regions.

I will follow this post with quick summaries of the AHEMS (work experience) which I have carried out, and what I learnt during them.