‘Brave Enough’: A Qualitative Study of Veterinary Decisions to Withhold or Delay Antimicrobial Treatment in Pets

Abstract

Veterinarians sometimes prescribe antimicrobials even when they know or suspect that they are unnecessary. The drivers of this behaviour must be understood to design effective antimicrobial stewardship interventions. Semi-structured interviews were conducted with 22 veterinarians who treated companion animals in Australia. The Theory of Planned Behaviour was used to organise interview themes, focusing on a decision to withhold antimicrobial therapy in the absence of a clear indication. Many background factors influenced antimicrobial-withholding decisions, including the veterinarian’s communication skills, general attitudes towards antimicrobial resistance (AMR), habits and energy levels. Client awareness of AMR and the veterinarian–client relationship were also important. Beliefs about the consequences of withholding antimicrobials (behavioural beliefs) were dominated by fears of the animal’s condition deteriorating and of failing to meet client expectations. These fears, weighed against the seemingly distant consequences of AMR, were major barriers to withholding antimicrobials. Normative beliefs were primarily focused on the expected approval (or disapproval) of the client and of other veterinarians. Control beliefs about the difficulty of withholding antimicrobials centred around client factors, most importantly, their capacity to adequately monitor their animal, to pay for further investigations, or to undertake non-antimicrobial management, such as wound care, at home. The use of antimicrobials by companion animal veterinarians in the absence of a clear indication is often powerfully driven by behavioural beliefs, chiefly, fears of clinical deterioration and of failing to meet client expectations.

Understanding the role of veterinarians in antimicrobial stewardship on Canadian dairy farms: A mixed-methods study

“…On the other hand, livestock veterinarians are at the center of discussions regarding AMU in food-producing animals and its consequences for AMR in human and animal medicine. In addition, veterinarians from this and other studies [ 38 ] feel that they are unfairly blamed for AMR in people. This situation leads veterinarians to feel frustrated and stigmatized, which may contribute to redirection to other antimicrobial prescribers and users, such as farmers, small-animal practitioners, and human doctors and patients for inappropriate AMU and AMR.…”

Cross‐sectional evaluation of a large‐scale antimicrobial stewardship trial in Australian companion animal practices

“…However, this research, along with our previous quantitative evaluation, shows that infectious disease training and dedicated time from specialists is not a requirement for successful implementation of ASPs in veterinary practice. The role of nurses and technicians was not evaluated in this research but should be evaluated in future studies, as nurses play an important role in medical ASPs 25,26 and the involvement of paraveterinary staff in stewardship has been found to enable appropriate withholding of antimicrobials when they are not required 27 …”

One Health antimicrobial resistance: stewardship in Australia

“…Lack of awareness and knowledge and lack of access to education and expertise have been found to be key barriers in both medical 10,11 and veterinary 12 fields, particularly in primary care settings. Scarcity of resources 12,13 and pressure from patients, carers and owners 12,14,15 are also barriers to AMS affecting doctors and veterinarians. A common facilitator, however, is the desire of prescribers to gain knowledge and contribute to reducing the emergence of AMR.…”

“…The common challenge that is faced is that of uncertainty, where the risk of patient deterioration, in conjunction with the prescriber's own comfort with risk, is perceived as more important than the future risk of AMR. 17 The hierarchy of hospitals and veterinary clinics, 12,18 fear of loss of autonomy of prescribing 12,18 and fear of the moral and legal consequences of patient deterioration 15 are also challenging to address and can only be overcome by strong leadership within organisations and reinforcement of evidence-based information on patient safety and quality of care. Although the barriers and facilitators are often common across prescribing settings, the interventions required to implement change are often sector specific and need to be targeted.…”

“…20 Support of AMS network arrangements involving rural health and veterinary services may also be a useful method, especially since research shows that messages in one sector have influence on the public's opinion in other sectors. 15 Support of nurses and pharmacists to run AMS programs has been successful in Australian rural hospitals, 21 bolstered through network arrangements, and is currently being trialled in veterinary hospitals and may overcome some of the resourcing challenges that are faced in rural and primary care -both veterinary and medical.…”