An article authored by Renzo Di Florio DVM, MRCVS, Technical Veterinary Adviser for Krka.
Renzo Di Florio qualified from the University of Bologna in 2007 and is Technical Veterinary Adviser for Krka, one of the leading generic pharmaceutical companies worldwide with core principles in sustainable development, community and maintaining a positive impact on the environment.
Antimicrobial resistance (AMR) remains one of the most urgent global challenges impacting both human and veterinary medicine. While policy change and surveillance play an important role, real progress starts in the consultation room. Renzo Di Florio, veterinary surgeon and Technical Veterinary Adviser for Krka and Professor Tim Nuttall share practical tips to embed antimicrobial stewardship into everyday clinical decision-making.
Antimicrobial resistance (AMR) is one of the most pressing One Health challenges of our time. Antibiotics are a finite resource. With no new classes of antibiotics licensed for veterinary use since the 1970s, we are relying on a limited and increasingly fragile resource.
In the UK, an estimated 66,730 serious antibiotic-resistant infections were reported in human healthcare in 2023, up from around 60,000 in 2019.¹ Looking ahead, global modelling studies highlight the importance of sustained action, with projections suggesting AMR could have an even more significant impact on public health by 2050 if left unaddressed.²
For the veterinary profession this is not just a theoretical concern. From recurrent skin infections to urinary tract issues, inappropriate prescribing decisions can accelerate the development of resistance. Antimicrobial stewardship (AMS) has never been more important.
The Three Rs: a mindset for everyday
At its core, AMS is about preserving the efficacy of antibiotics for the future. As RCVS Specialist in Veterinary Dermatology, Tim Nuttall explains in Krka’s latest podcast series:
“If we don’t preserve the efficacy of these drugs, we are going to see a crisis and possibly be moving back into a post-antibiotic era. And this is a true One Health problem.”
In veterinary practice, AMS means making informed, responsible prescribing decisions about antibiotic use – prescribing only when necessary and replacing, reducing and refining antibiotic use. These ‘Three Rs’ of AMS provide a practical framework for guiding antibiotic use (Table 1).
| Replace | Reduce | Refine |
| Use alternatives to antibiotics | Reduce antibiotic prescribing – audit and benchmark | Diagnose bacterial infections |
| Practise preventative care | Reduce owner expectations for antibiotic treatment | Use the right drug for the right bug |
| Treat the underlying disease | Use 1st tier & narrow-spectrum antibiotics | |
| Use symptomatic treatment – let the immune system tackle the infection | Justify the use of 2nd or 3rd tier & broad-spectrum antibiotics | |
| Use antiseptics | Treat to clinical cure – avoid over-treating |
Informing the right choice
Making the right antibiotic choice starts with confirming whether a bacterial infection is present. This involves a structured approach:
- Check clinical signs are consistent with a bacterial infection
- Use in-house cytology to confirm infection
- Use bacterial culture and antimicrobial sensitivity testing where needed
Tim explains that cytology should always be performed prior to culture. As well as confirming the presence of infection, the most likely bacteria involved can be identified based on morphology – for example, staphylococci form pairs, groups of four and irregular clumps, while streptococci and enterococci form pairs that align into chains. Cytology also shows the relative numbers of bacteria present at the site of infection and helps with interpretation of culture results. In mixed cultures for example, interpreting the results alongside cytology means it is possible to target treatment to the most important bacteria.
Did you know? Culture and sensitivity testing is poorly predictive of treatment success when selecting topical antibiotics. Cytological diagnosis is the preferred approach.
Current challenges in practice
Despite growing awareness and widespread support for the principles of AMS, there are barriers to implementing it consistently in practice. In first opinion clinics, where consultations are typically limited to 10-15 minutes, it can be tempting to reach for antibiotics as a ‘safe’ option – especially when the diagnosis is uncertain. But ‘quick fixes’ can come at a long-term cost, selecting for resistance and increasing the likelihood of treatment failure due to resistance later.
A key strategy is to build cytology into everyday workflow – making microscopes accessible, ensuring all the clinical team are trained and encouraging routine use. Tim advises, “Have the tape, slides, stains and microscope ready to go. If it’s quick and easy, it becomes part of the consult flow, not an afterthought.”
When is empirical therapy appropriate?
- Topical therapy
- First episode of infection
- No systemic antimicrobial therapy within preceding 3 months
- Simple infections e.g. surface or superficial pyoderma
- Cytology shows bacteria with predictable antibiotic susceptibility e.g. staphylococci in skin infections
- Antimicrobial resistance is unlikely
Supporting responsible prescribing
When indicated, the selection of an antibiotic should always be guided by the site and severity of infection, the likely pathogens involved, and the results of cytology or culture where available. Antimicrobial stewardship does not mean never using broader-spectrum or second-line antibiotics – it means reserving them for situations where they are clinically justified, and ensuring their use is backed by clinical reasoning and diagnostic tests.
Cost can sometimes be a barrier to best practice, particularly if the most appropriate product is prohibitively expensive for the client. Generic pharmaceuticals can support responsible prescribing – helping to maintain compliance, reduce under-dosing and avoid the temptation to prescribe a broader-spectrum product based on price rather than clinical need.
Communicating with confidence
Effective client communication is fundamental to antimicrobial stewardship (AMS). Yet it can be one of the most challenging aspects of responsible prescribing. However, as Tim explains, owner demand for antibiotics is often overestimated, with research suggesting that quite a lot of the ‘demand’ is perceived rather than real. For example, a pyrexic dog is treated with both an NSAID and an antibiotic and subsequently improves. The owner assumes the antibiotic was key to recovery, so next time the dog presents with similar signs they say, “Last time he had an antibiotic and he got better.” In this scenario it is easy to think that the client is demanding antibiotics and so feel pressure to prescribe when the client is just trying to be helpful.
Having the whole practice team on board is essential. As Tim observes, “If the practice is working as a team, then the client is going to get a consistent message and they’ll trust a consistent message.” He adds that for conditions like cat bite abscesses or acute gastro-intestinal upsets, the majority will get better in five to seven days with or without an antibiotic. Reframing the conversation and educating clients is key.
Stewardship in action
Krka is committed to supporting practice teams in delivering responsible, evidence-based care. Their Vet Knowledge Hub provides a growing bank of free educational resources, from clinical guidance to practical how-tos. This is complemented by their podcast series on antimicrobial stewardship.
Antimicrobial resistance is a shared challenge – but also a shared responsibility. As veterinary professionals, we have the expertise and the opportunity to lead by example. By embracing stewardship principles, using diagnostics to guide treatment, choosing antibiotics thoughtfully, and delivering a consistent message as a team, we can protect the effectiveness of these vital medicines for the future.
Prof. Tim Nuttall is the Head of Dermatology at the Dick Vet School and is a globally recognised veterinary specialist in dermatology, canine atopic dermatitis and antimicrobial resistance. Tim has written over 100 clinical / scientific publications and has served on numerous scientific committees. Currently he sits on the RUMA independent Scientific Group. His current research programme is studying antimicrobial resistance and skin infections. In 2014 he received the BSAVA Woodrow Award for outstanding contributions to veterinary medicine.
Access Krka AMS materials with Professor Tim Nuttall here:
Listen to the podcast series on Spotify here: https://open.spotify.com/show/0uphORU03q29WncwmN2EIa?si=bb8f2119639946d9
Useful resources
References
- Kennedy, B. (2024) Antibiotic resistant infections in England surpass pre-pandemic levels. BMJ. 387:q2560 doi: https://doi.org/10.1136/bmj.q2560
- Mohsen, N. et al. (2024) Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050.The Lancet. 404, Issue 10459, 1199 – 1226
Don’t forget to sign up to our monthly newsletter for exclusive content and news from Veterinary Woman!
You may also like:
Leading in a Customer-Oriented Business
Inspired Vet Profile – Bridget Adcock
Inspired Vet – Download Issue 3