A multimodal approach to antimicrobial stewardship

This content is sponsored by Nextmune. Take the CE to earn .5 credits.

Dr. Galia Sheinberg

Relying on antibiotics for dermatologic conditions has raised a red flag when it comes to bacteria mutation. The more resistant bacteria are to antibiotics, the less effective the treatment may be. Adam Christman, DVM, MBA, of dvm360® Live, spoke with Galia Sheinberg, DLACVD, about how antimicrobial stewardship is more important than ever. She discusses the definition of antimicrobial stewardship, how to consider a multimodal treatment plan, and the necessary education.

Adam Christman, DVM, MBA: Can you elaborate on specific mechanisms by which bacteria develop resistance to antimicrobial agents in veterinary dermatology?

Galia Sheinberg, DLACVD: As dermatologists, we were trained to use antibiotics as a first-line treatment, especially for common conditions such as pyoderma. Changing how we worked was difficult. There is now a lot of pressure around antibiotic use and antibiotic production in veterinary and human medical fields because of how they can generate resistance. Bacteria mutate faster than new antibiotics can be created. What this means is clinicians should verify the need for an antibiotic when treating a patient.

Christman: For recurrent skin infections, how do you select an antimicrobial agent while considering factors such as cultures, sensitivity, and cost?

Sheinberg: Expenses worry us as clinicians because we know pet owners may not be able to afford treatment. So we must be smart about what treatment to use and when. The goal is to treat topically before using a systemic antibiotic. If I’m not using a systemic antibiotic, then I don’t necessarily need a culture. Superficial pyoderma and external ear infections are good candidates for topical therapy, and that is how I’ll approach the subject with pet owners.

Christman: What would be your first choice of treatment for superficial pyoderma?

Sheinberg: It is important to remember that pyoderma is a secondary condition, not a diagnosis. We need to find out why a dog is having this condition—usually it is caused by an allergy, but it could be an endocrine disease.

Chlorhexidine is the best overall option. However, it is preferable to use cytology to determine exactly what you are treating. For example, if there is a bacterial infection such as Staphylococcus aureus, additional treatments may be needed. Not all topical therapies work the same. It could also mean using a different chlorhexidine percentage mixed with an antifungal to potentiate the effect. A product we use a lot has 2% chlorhexidine and 2% miconazole, which has been shown to create a synergistic effect. What is great about this product is it works for fungal infections too.

Christman: What are some other options out there, especially with a Spectrum of Care approach?

Sheinberg: You have to work with each patient and their needs. Gels, wipes, spot treatments, and sprays are quick tools that don’t involve the same level of work as a bath. If bathing is possible, I like to scale down treatment over time. Baths could be given 2 or 3 times a week but slowly go down to 1 with spot treatments to prevent flare-ups.

Client adherence is a big factor to consider, so we try to educate clients about primary disease. Canine atopic dermatitis, for example, is a common diagnosis. It is also a relapsing problem with the potential for infection. Recurring infections are not only dangerous but also costly. We want to combine this information with a demonstration of the products so pet owners feel better equipped to handle their pet’s care. Other tricks, such as taking dogs for a walk beforehand to tire them out or having treats ready, can ease treatment application for pets.

I tell clients, “Give me 5 days.” With a multimodal approach, usually patients will improve. If the treatment fails, we go back and try something else. This is with the hope of not having to use antibiotics unless we have to. If given permission, I take photos of the skin to be able to say this is where we started, and this is where we are now. Dermatology is very visual.

Christman: How do you educate colleagues about antimicrobial stewardship?

Sheinberg: Changing how you work is hard. Sometimes you’ll be motivated. Other times you’ll have seen a lot of patients and don’t have the same space for an explanation. I recommend preparing links and images to show both clients and colleagues. We have to change because the world changes all the time. I believe microbial resistance won’t wait for us to change.