Knowledge Award Audio Overview: Auditing metronidazole use for acute canine diarrhoea by Medivet

Hi everybody, my name’s John Beel. I’m the Clinical Services Director here at Medivet and I wanted to chat to you about our project in canine acute diarrhoea, which was recognised as the third place champion in the RCVS Knowledge Awards for Antimicrobial Stewardship. I’d start by saying this was a group project. This wasn’t just us, there was a lot of people that were involved in this and I’m sure they’ll be very, very proud and I’m sure I speak for them as well to say thank you so much for this award. Thought I’d tell you a little bit about the project that we’ve got.

It was based on what we think is one of the most common presentations in veterinary medicine, which is acute uncomplicated diarrhoea in dogs. I can certainly speak from bad habits of years gone by where many of us would have prescribed metronidazole for some of these cases, whether that was just because it was kind of what we’re used to, was that what we were taught at the time? Was it just habitual that we just said, well, you know, that tended to work? And I think that from my experience, that was probably all anecdotal at the time.

Over recent years, we know that emerging evidence has said that actually it doesn’t really help most of these cases recover. And in fact, some studies suggest that actually no better than placebo. And there’s actually concerns about going the other way where we are affecting gut microbiome and the wider importance of antimicrobial stewardship is certainly not going to be helped by us using these antibiotics where we shouldn’t be. So that prompted the question, was prescribing metronidazole actually evidence-based? Did it make a difference, or was this just our feeling?

So we decided to do an audit across our group. We audited 57 practices, reviewed more than 600 cases of acute diarrhoea, and many of them actually had metronidazole prescribed at first presentation. The results showed that metronidazole is still being pretty frequently used across the group, and there was really no rationale that some of these cases were given metronidazole at that time.

So working with our QI committees, our quality improvement committees, we’ve reviewed the literature, we kind of aligned an approach we wanted to take with the ENOVAT guidance. We created, and this was I think part of the beauty of it was just keeping it simple, we created a one-page guideline and sort of decision-making flowchart that encouraged clinicians just to kind of give it a little bit of thought about before picking up the antibiotics and consider better first-line options like dietary management, maybe pre and probiotics, that sort of thing.

The key with this also was that it was clinician-led. In fact, the whole subject started as a clinician-led project. They decided this is what they wanted to look into. And then keeping the clinicians involved in the intervention as well, because we wanted to make sure that the interventions were based in line with what clinicians could actually recognisably do in a busy consultation.

We wanted to take the thinking process out of it and make it really visual, very easy to follow to make that decision process in the consultation as well. We implemented the guidelines across all the practices that were involved through divisional discussions, through audit feedback, and through ongoing communications. And then we re-audited it three months after that. We found a 41.9 % reduction in the use of metronidazole, and no increase in deleterious effects seen in our patients at the time, which was an important one to see.

And certainly an increase in other first-line management options like dietary modification and probiotics and prebiotics. Perhaps one of the most surprising things was how quickly behaviors changed. I have got to say, I think that was probably because I think we all knew we shouldn’t be doing it anyway, and it was just breaking old habits.

So it was really easy to get some evidence out there to the group to make sure that people engaged with it – seeing a written easy to follow guideline. And I think that just was that swing that made everybody say, yes, well, I’ve heard about it and I know I shouldn’t have, so let me try this. And the more we found that actually it didn’t have deleterious effects by not giving it, the more this improvement increases. There was still a little bit of variation in our results. One of our divisions actually increased in use of metronidazole despite the rest significantly decreasing.

And that could be in variations in how that was communicated at the time. There’s a couple of hypotheses on it. But it did give us a new target to continue ongoing education, local engagement, and improving understanding in that division. So we’re really proud of it. If somebody had to ask me, know, how did we make a success of that? I’d say that A, it was clinician-led. You we went with what the group wanted. We picked something that was common. We picked something that we felt that making small changes to that could make a big difference.

And importantly, we kept it simple. We didn’t look at complicated ways of trying to go around it. And we kept our auditing and re-auditing fairly simple as well. So I’m incredibly proud of this project and what we’ve achieved. I want to thank everybody that’s been involved in it from the start. And really, I think people should be really proud of what they’ve done, not just for our group and what we’ve done to change the prescribing habits of our clinicians, but also what we’ve helped with and to help with the future preservation of antimicrobials in the industry. Thanks very much.