Antibiotic Amnesty with Danny Chambers

VetTeamAMR Podcast: A conversation with Danny Chambers and Pam Mosedale

RCVS Knowledge:

The views expressed in this episode are that of the interviewee and are not necessarily held by RCVS Knowledge.

Welcome to this VetTeamAMR podcast from RCVS Knowledge, leading responsible antimicrobial use in farm, companion, and equine Teams.

Pam:

Hi, everyone. Today I’m going to talk to Danny Chambers. Danny is well known to a lot of you. He’s an equine vet. He’s on RCVS council. He’s also a trustee of RCVS Knowledge, which is great for us, and of Vet Life, and one of the founders of Vet Voices. Hi, Danny.

Danny Chambers:

Hello.

Pam:

Hi. We’re going to chat today, if that’s all right with you, about this antibiotic amnesty that’s coming up.

Danny Chambers:

Yes. No, this is fantastic. As a trustee of RCVS Knowledge, I think it’s probably one of the most important things that we do because it’s probably engaging both with the veterinary profession and with owners in a very meaningful way. Especially, it’s not just about animal health. It’s about public health as well. So, I think these initiatives, we did it last year and the year before, I think, didn’t we, and I think they’re really important.

Pam:

Definitely last year, yes, and it was quite successful that I think they’ve done them in human healthcare before. How did you get interested in antimicrobial stewardship?

Danny Chambers:

I’ve always had a big interest in epidemiology and infectious disease control, and I did an MSC in that when I was halfway through my vet course [inaudible 00:01:20] at Liverpool. Certainly from a global health point of view, the World Health Organization has antimicrobial resistance in its top 10 risks to global public health, and that’s alongside things like the risk of pandemics, which they actually had on the register well before the COVID-19 pandemic, and climate change, vaccine hesitancy. There’s quite a few of them. But antimicrobial resistance is up there in about number three.

It’s probably sobering to think that if we don’t take very urgent action as a global community on this, we’ll probably find more people die every year from antimicrobial resistance or bacterial resistant to antibiotics than they did from COVID, and that’ll become the new norm. The worst case scenario is you go back to sort of a pre-antibiotic world where antibiotics, which have saved so many lives and have made treating infections so much easier and have made them little cuts and scrapes that used to occasionally kill people just become trivial injuries. We could go back to being in a situation where people can die from what we’d consider now to be a minor trivial infection.

So, we don’t take it seriously enough, even though we’re all academically aware of the problems. Until it really starts to start seeing people die of it, then I guess people just don’t … There’s always something more urgent, isn’t it? There’s always a bigger pressure or something else to think about, and especially when we’re thinking about standing in a consult room or standing in front of a horse, you’re busy, you’re running late, and often, you don’t have time to think about the rationale for prescribing sometimes.

Pam:

No, that’s right, and that’s a really good point about COVID. I think at the least, that’s sort of drawn it to people’s attention that these major things can happen and can have mega impacts on human health. Like you say, when you’re standing there in front of an owner, and sometimes there’s pressure from owners too, isn’t there, to prescribe antibiotics?

Danny Chambers:

Yes. We’ve talked about this before. I would say especially in the equine world, as someone who does … My main job is being a horse vet, but I do some small animal [inaudible 00:03:43] and I used to do a lot of mixed work with farm as well. But I think the horse owning community puts a lot of pressure on vets to leave them antibiotics and they often phone up almost demanding antibiotics without a visit even, and they think they can judge whether a wound is infected or not or whether it will get infected or not, and there’s this perception that antibiotics are required for everything from a snotty nose to any type of injury. Certainly, my experience of treating certainly horse wounds and dealing with owners for a long time now is that I’d say the majority of time that the owner thinks they need antibiotics, they don’t, and you can normally avoid using them.

Most of that is down to how you handle the owner and how you communicate with them and how you reassure them and take them on that journey. I guess one thing that I find very interesting, some people will know, I’ve done a lot of research and campaigning on the use of non-evidence based therapies, like different types of alternative medicine, and I find that the horse owning community on average is really into that kind of thing. If you address their concerns in a way that shows that you’re looking at the good of the whole horse, so just for example, if I see a wound, I often say, “Well, we don’t want to give drugs unnecessarily and we don’t want to have any unnecessary side effects. At the moment, this wound isn’t infected, so they wouldn’t actually do any good, these antibiotics.”

But if we can use something like Manuka honey, horse owners, they love that stuff. They love it. If you get out Manuka honey, they think it’s some kind of magic and they think you’re really progressive and that you’re using natural remedies and they’re really happy about this. It’s also managing expectations as well. I think if you see an animal that maybe it will need antibiotics in a couple of days time if you see a wound, maybe it won’t. But it’s managing that expectation where you say, “Look. At the moment it’s not infected. If we can keep it clean enough and with strict wound management and diligent wound management, it probably won’t need them. Maybe it will, and if it does need antibiotics, then we’ll prescribe them, but we’re not going to give them until it’s necessary.” It sort of avoids that thing that we all worry about where a wound gets infected three or four days later and then the owner’s on the phone very angry going, “Why didn’t you leave antibiotics? This has happened because you didn’t leave antibiotics.”

You can almost take them on a gentle journey where the onus is on them to avoid the antibiotics by equipping them and empowering them to manage a wound and giving them things to put on it. Some of the time, I think what we put on the wound, I don’t know how much of a difference it makes, but the fact that they have to clean it twice a day before they replace the Flamazine, it means they are cleaning it twice a day. They’re seeing it twice a day. Often, you tell them to keep it out the mud, keep it in a nice, clean … I think that it’s all those kind of things that you can do to enable them to manage the wound better so that antibiotics are seen as a last resort, and then if they’re necessary, they’re necessary, but you’re not just giving them anyway, and you almost want the owner to feel like we’ve all failed if we have to resort to antibiotics.

Pam:

Yeah. It’s like they say, you’ve got to use them when they’re really necessary. That’s the thing, and other things like infection control are so important. In small animal BSAVA have non-prescription pads that you can actually write these things down for owners, which I think’s a great idea. But how do you think we can reassure the vet team that they can do these things, give them the confidence? Especially, like maybe people who don’t see horses as often or newer graduates. How are we going to give them the confidence to be able to manage this with owners?

Danny Chambers:

I think there’s a very big thing we need to do as a veterinary community, both within a practice and as a profession in general is all to be genuinely singing from the same hymn sheet. So, especially as a new graduate, and this has happened to me, you go out, you see a horse, the owner demands antibiotics, and I remember a case when I was a fairly new graduate. Went to see a foal, nothing wrong with it, the owner wanted an injection of penicillin because she always had an injection of penicillin for her foals when they were 24 hours old, even though there was nothing wrong with it whatsoever, and I said, “I don’t see why we need to give a one-off injection of penicillin,” and refused to give it, and I got told off by my boss and they gave a free visit, which I had to do and I had to go and give this injection.

No, it wasn’t me that went. Someone else went out and they did the free injection and she got a discount off the next visit and it was all arranged so I wouldn’t have to go to that yard again to keep her happy. It completely undermines you because now I’ve got more confidence and experience, it probably wouldn’t have got as far as her complaining to the practice. But in my naivety, I just turned up, saw a completely healthy foal, didn’t see why it needed a one-off injection of antibiotic, and that was perceived by the client as the wrong thing to do and that instead of taking the opportunity to educate her, the practice gave her discounts, free visits, and changed the rotor so I’d never have to go there again. That’s where it completely undermines you, doesn’t it-

Pam:

Absolutely.

Danny Chambers:

… and the client is then the justified in their complaint.

Pam:

That practice, I would say, they should have had some guidelines in place looking at the evidence as well as you said, and maybe protect me, and Beaver have got lots of protect me resources, haven’t they? We’ve got great VetTeamAMR resources at Knowledge, but they should have had guidelines in place so, as you say, everybody finishes up singing from the same hymn sheet where appropriate.

Danny Chambers:

That’s between practices as well. So, there’s nothing more infuriating than going seeing a horse, saying we don’t need the antibiotics, and then finding they got a box off another practice that possibly didn’t even see the horse because they’re registered with everyone. They gave them a call and said, “I need a box.” Then you’re the difficult practice that won’t give them for no reason and they’re the helpful practice that gives them out all the time. I think there shouldn’t be an option where if one vet says no, they phone up another practice and get them. Actually, just touching on that, not to go into the detail of it, but everyone’s aware that we’ve got a new guidance from the RCVS about prescribing under care. I was on the standards committee of that and one of the things that I was very pushing was that antimicrobials, and we took the definition from the World Health Organization to include wormers and antifungals and antiparasite, as well as the antibiotics, is that you can’t be prescribing these without seeing an animal.

Pam:

No.

Danny Chambers:

Now, with a few limited exceptions, which I won’t going to here. But the reason I think it’s really important for RCVS to have guidance like that is that it does protect vets because it sometimes is hard to say no to difficult clients and to clients that are stuck in their ways or had a long relationship with a practice where they’ve always managed to get the antibiotics they want. Actually, if you can almost say, “Look, this is out of my hands. The rules say I’m not allowed. You can’t just phone up and get a box of antibiotics. I’m not being awkward. The RCVS says I’m not allowed to do this,” and you can almost use that as a shield to take the right course of action and they can’t be annoyed of you personally about that. People often see RCVS rules as a hindrance or problematic, and actually, I think we should be using them as a way of managing situations to our own advantage, and I think that’s a really good example of how we can do that.

Pam:

Definitely. My background is very much in practice standards and I know that lots of practices used the practice standards in order to get things done that needed doing, that maybe someone in the practice wasn’t so keen on doing. So, yeah. Sometimes, rules are really useful, aren’t they? But there’s also loads of free CPD resources aren’t there, at VetTeamAMR? Have you looked at those at all?

Danny Chambers:

Yeah. On the RCVS Knowledge website, brilliant in general for free CPD and really useful quality improvement stuff. But yeah. The vet team stuff on AMR is excellent and I think speaking specifically about the equine world, I think compared to farm animal and small animal, antibiotic auditing is not as good. For understandable and practical reasons, we often don’t do culture and sensitivity before we prescribe antibiotics, and there’s a couple of good reasons for that. One is that we don’t have many oral antibiotics we can give anyway. So, if you’ve got a broad spectrum TNPS, it’s pretty much the only thing the owner can have. So, you’re going to end up using it and it is appropriate most of the time. But one reason that we’re not sure how much multi-drug resistance there is in equine is because we only tend to swab especially wounds if it’s not responding to treatment.

So, rather than in the ideal world, in an ideal world, you’d swab everything before you prescribed it, and we’re only swabbing when there’s a problem. So, it does make it hard to work out just what the prevalence of antimicrobial resistance is in equine. But yeah, no. There’s some of the resources on the VetTeamAMR thing does show how you can do antibiotic auditing in equine practice, and it’d be really good if equine practices really engaged with that. A lot of practices do these audits anyway, and I work for Equicore, which is part of CVS, and we know that equine vets and CVS have certainly significantly reduced the antibiotic prescribing over the last few years, and I think that’s a really positive step in the right direction.

Pam:

Yeah. I’ve talked to some people who won some of the antimicrobial stewardship awards that we had at Knowledge for podcasts, and they found, for instance, a small animal practice that stopped using antibiotics generally for cat bite abscesses and they had great results with that. But also as a knock on from that, everybody in the practice started thinking about all the other places where they might use antibiotics. So, yeah. I think once you’re aware of it, it makes you start to think about it. Doesn’t it?

Danny Chambers:

It really does, and the bolder you get, the more you confidently get not to use antibiotics, even as a clinician. I think there’s two things that have informed me massively over the years is one, I’ve done a lot of work in India and parts of Africa, and often we give no drugs at all. But we get if a wound [inaudible 00:14:37] in horse wounds, lower limb horse wounds, and simply having people who are having the resources for someone to clean a wound maybe up to eight to 10 times a day, it’s amazing what heals, like deep wounds, boiled water that’s still warm sometimes ideally. Just rigorous wound management, these horrific wounds that you definitely give antibiotics to in the UK and you’d be really worried about will heal up. The other thing I’ve found is all the stuff we did a few years ago talking about different types of alternative medicine, just finding that people are using implausible treatments instead of veterinary treatments and getting better, and you’re just like, “Well, it’s clearly not the homeopathy. It never needed antibiotics.”

Pam:

Could have got better anyway.

Danny Chambers:

I think that’s really humbling, isn’t it, that half-

Pam:

Yes. Yeah.

Danny Chambers:

… the interventions we’re doing are possibly not benefiting or possibly not necessary. It’s also then having the confidence to go, “Well, if in two days time, it turns out it needed antibiotics, that wasn’t because I was a terrible vet or I completely misjudged it.” It’s just that’s medicine, isn’t it. You’re better off not giving it to most wounds and occasionally going and seeing it a second time and then giving the antibiotics than you are just giving it to absolutely everything.

Pam:

Yeah. It’s first do no harm, isn’t it? Because there isn’t a medicine that exists that doesn’t have side effects. There’s always a risk benefit analysis. So, yeah. Apart from the AMR aspect. But another thing that was really interesting from the survey, they did a survey last year around the antibiotic amnesty and 46% of owners had disposed of antibiotics that were left over from courses of treatment, because animals have got better hopefully, in their domestic waste, and that’s really worrying because of where it finishes up. But 38% hung on to their antibiotics thinking they might be useful for treating another animal, which is equally as worrying, isn’t it?

Danny Chambers:

It is, and I think especially in the horse world, most owners really, really want to have a few antibiotic sachets in just in case. People will even ask you when you go to give a vaccination, “Could you leave me a few antibiotic sachets in case I need them or in case there’s an injury?” They borrow them off each other, they share them, they split doses because it lasts longer. I think some of our first line antibiotics should almost be treated like controlled drugs, and I think it’s that serious and that ourselves and the owners should see this, an antibiotic has something like handling ketamine or something. It’s really something you only give when absolutely necessary and not anyone should be able to use it and it needs the judgment of a clinician and not someone just demanding it.

Pam:

But if they’ve hopefully given them in at the amnesty, then they won’t have them, and hopefully that may not happen. So, I think it’s well worth encouraging them, and there’s quite a lot to do around owner education, isn’t there?

Danny Chambers:

Absolutely. Yeah. I would love to see the difference between the response to an antibiotic amnesty between horse owners and dog and cat owners. I’d love to see how many horse owners would really want to cling onto them and how many dog and cat owners probably wouldn’t know what to do with their drugs. It’s probably why they’re flushing down the toilet. They don’t actually know what to do with them or don’t want to keep them anyway. They don’t see any perceived use for them. But yeah, no. It’d be very interesting to see how many people come forward with this amnesty, especially in equine practice.

Pam:

Yeah. Absolutely, and that’s maybe something that when they’re designing surveys to go along with it, it would be a good idea to follow up. So, practices that want to do this, there are the RCVS Knowledge resources, like we’ve said, but there’s also resources on [inaudible 00:18:32] website, and I think we just want to encourage them to get involved, don’t we?

Danny Chambers:

Oh, definitely. Yeah. It’s actually not that much hassle to get involved. You think, oh, that’s another thing I have to do and I don’t have time. Actually, these are really accessible. They’re really clear, they’re really quick, and they’re really useful, and they really do improve the standard of clinical practice and they make you feel like you’re actually contributing to global public health, [inaudible 00:19:01] be a bit grandiose. But if we can reduce the amount of antibiotic usage, it will make a huge difference.

Veterinary’s only one sector, which can help tackle this massive issue. But we all have to do our part in this and I think it helps our human colleagues and vice versa as well, whereas if we can educate people that antibiotics aren’t something you can just demand in inappropriate situations, they might not do the same from their GP either. We tend to have slightly more time to speak to our clients in equine practice. We have a slightly better, let’s say, better relationship, a repeat relationship. We often go back to the same places, same yards, the same cases again and again and again. Because people like their vet as well, they trust their vet, and you can use your status in that relationship to really educate people. Then when they go to the GP with a cold, then they hopefully won’t be going and thinking, I’m not going to leave here until I get my antibiotics.

Pam:

It could be quite good PR for the practice too, I think, that your clients can see that you are being socially responsible and trying to reduce these issues.

Danny Chambers:

Yes, definitely, and it’s looking after the health of their horses longterm. What are they going to do in 20 years time if they can’t treat their horses for cuts when they need to, when they do need antibiotics?

Pam:

Well, they get something horrible like strangles or something major, major [inaudible 00:20:31].

Danny Chambers:

Yes.

Pam:

Oh, brilliant. Well, thanks so much for talking to us about it. So, what would your final message be to our listeners then?

Danny Chambers:

Definitely make more use of the RCVS Knowledge website in general, and I think it’s really well thought out. There’s a heck of a lot of useful accessible information on there. But also, use these initiatives, like this Vet AMR situated as the stepping stone to start using it regularly. So, I think if people actually engage, if they go on a look at it and start using it, they’ll realize that they wish they’d started doing it five years earlier. It really is excellent.

Pam:

Thank you. And they’re all free, the resources too. Even better.

Danny Chambers:

Yeah. It’s free. It’s free. It counts as CPD. You can record it-

Pam:

Exactly.

Danny Chambers:

… on your 1CPD app. It really is excellent.

Pam:

Perfect. Thank you very much.

Danny Chambers:

Thank you, Pam. It was really nice to chat to you.

Speaker 1:

Thank you for listening to this VetTeamAMR podcast from RCVS Knowledge. Visit rcvsknowledge.org/amr for free CPD benchmarking and audit tools to improve your antimicrobial use.