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Comments on the dilemma in the June issue: Resisting the urge to prescribe vancomycin
  1. Steven McCulloch

Abstract

In the dilemma discussed in the May issue of In Practice, you are treating a dog with pyoderma, which has had poor clinical results follow a week of topical antibiotics. You test and find meticillin-resistance Staphylococcus pseudintermedius. You prescribe oral doxycycline but the client asks why vancomycin has not been prescribed (IP, June 2017, vol 39, pp 294-295). Manuel Magalhães-Sant’Ana argues that relying on third tier antibiotics is strongly discouraged. While one can be tempted to appease the client, the vet has a moral duty not to. Depending on results from sensitivity tests, it may be that first or second tier antibiotics can resolve the pyoderma.

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Richard Brown qualified from the University of Cambridge in 1981. He gained an MSc in tropical veterinary medicine from the Royal (Dick) School of Veterinary Studies in 1986. He has served as a veterinarian with various overseas governments and has practised for over 20 years in the UK. He is currently an associate director at the School of Veterinary Medicine at City University in Hong Kong.

Magalhães-Sant’Ana cogently argues against using vancomycin. The situation represents a tragedy of the commons. Antibiotics are a common resource for both present and future generations of human and veterinary patients, and so it may seem that from a rational selfinterested point of view prescribing vancomycin is justified. However, if vets do this, resistance will develop and the resource will cease to exist. Thus, vets have a strong duty to not prescribe antibiotics critical to human health, such as vancomycin.

Given the above, the results of the poll are surprising. Of 33 respondents, 19 would prescribe vancomycin in the first instance; five would prescribe another antibacterial, and then vancomycin if it is unresponsive; four would only use vancomycin as a last resort; and five would treat the infection in whatever reasonable way, but not using antibiotics critical to human health. In a very small sample size of 33, it is not possible to make inferences to the whole population of practising vets. However, if these results do reflect the beliefs of vets, it suggests a failure of responsible antibiotic use campaigns aimed at our profession.

There are two possible defences for prescribing vancomycin in the first instance. The first claims there is insufficient evidence for AMR transmission between veterinary and human patients, and so there is no need to limit vancomycin use in animals. However, to counter this, it has been demonstrated there is significant evidence for transmission between animals and people (RAR 2016). The moral argument claims that dogs are of equal moral importance to people, and so use of vancomycin shouldn’t be limited in dogs. However, whether or not dogs and people are equal, overuse of vancomycin will lead to AMR in both humans and dogs.

Veterinary surgeons have a fundamental role of stewardship and should only use antibiotics critical for human health when absolutely necessary.

Appendix

Box 1:

Everyday Ethics Poll

Last month's poll asked:

You have diagnosed MRSP from a pyoderma case. It is sensitive to vancomycin, an antibiotic critical for human health. Do you:

19 prescribe vancomycin in the first instance

5 prescribe another antibacterial, and vancomycin if it is unresponsive

4 prescribe another antibacterial, and vancomycin only as a last resort

5 treat the infection in whatever reasonable way, but not using antibiotics critical to human health such as vancomycin

(33 respondents)

Vote for this month's online poll at:

inpractice.bmj.com/content/current

References

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