Antimicrobial stewardship (AMS) in equine practice rests on five interconnected pillars: restricting use to confirmed or highly probable bacterial infections, prioritizing first-line narrow-spectrum agents, obtaining culture and susceptibility data before escalating therapy, limiting perioperative prophylaxis to the day of surgery, and implementing formal tiered prescribing frameworks with mandatory justification for higher-tier drugs.
The threshold question is whether antimicrobials are indicated at all. Approximately 30% of equine patient visits at a northeastern US veterinary teaching hospital received antimicrobials in 2021, and very few of those cases were given antimicrobials without clinical evidence of infection.Journal of the… Avoiding prescriptions in cases with no clinical evidence of infection, and in clean surgeries when appropriate, is the foundational stewardship act.Journal of the… Antimicrobials are indicated only when thorough patient evaluation and sound clinical judgment indicate a high likelihood of bacterial infection and that antimicrobials are needed to promote recovery.Veterinary Clin…
First-line injectable therapy should be procaine penicillin combined with gentamicin sulfate in most infectious scenarios, with trimethoprim-sulfadiazine (TMPS) as the recommended first-line oral agent — and in the UK, TMPS is the only licensed oral choice in horses.Journal of Vete… Potentiated sulfonamides are the most commonly used antimicrobial class in equine practice across Europe and the UK.Equine Veterina… Aminoglycosides and potentiated sulfonamides are the most commonly prescribed classes in equine referral practices in the US.Journal of the… Although aminoglycosides are classified as critically important antimicrobials (CIA), their use in equine practice is considered standard of care because no alternative gram-negative spectrum antimicrobial of lower human health importance exists.Journal of the…
High-priority critically important antimicrobials (HPCIAs) — fluoroquinolones and third- and fourth-generation cephalosporins — must be reserved for cases with documented resistance to first-line agents or comorbidities that preclude their use, such as azotemia precluding aminoglycosides. In one equine pneumonia cohort, HPCIAs were used in 67% of cases, and in 63% of those cases no justification for their use was documented; this rate declined from 78% in the earlier period to 62% in the later period, yet 60% of cases in the later period still lacked documented rationale.Journal of Vete… Despite increased awareness, enrofloxacin continues to be dispensed as a first-line intervention without culture and susceptibility testing to justify its use.Journal of the… Third-generation cephalosporins and fluoroquinolones appear on the WHO's highest-priority critically important antimicrobials list, and drugs in this category should be used only when culture and susceptibility testing indicates the choice is warranted.Journal of Vete…+1 In the UK, 44% of surveyed equine veterinarians reported using enrofloxacin in the prior year, and 66% used third- or fourth-generation cephalosporins.Equine Veterina…
Culture and susceptibility submission is the critical enabling step for de-escalation, yet it is severely underutilized. Submission rates at a US veterinary teaching hospital were very low despite the institution primarily seeing referral cases.Journal of the… Over half of UK and European equine veterinarians surveyed performed no environmental surveillance, no audit of clinical infections, and no audit of infection control.Equine Veterina… When initial empiric therapy fails, repeat sampling for culture and susceptibility is indicated to ensure judicious antimicrobial selection.Journal of Vete… Submission of a bacterial culture was associated with an increased likelihood of an antimicrobial prescription in ambulatory equine practice, suggesting that culture-guided prescribing is already shaping clinical behavior in some settings.Preventive Vete…
Perioperative antimicrobial use is a major target for reduction. Prophylactic antimicrobials before clean surgery were prescribed frequently or always by 48% of surveyed equine veterinarians, and 24% frequently or always prescribed antimicrobials postoperatively in clean surgery.Equine Veterina… The goal for surgical antimicrobial use is to limit administration to the day of surgery in clean and clean-contaminated procedures.Journal of the…
Resistance trends in horses reinforce the urgency of stewardship. 66.3% of Staphylococcus spp cultured from horses between 1993 and 2009 were resistant to at least one antimicrobial, and 25% were multidrug resistant, with the highest resistance rates to β-lactams and aminoglycosides.Journal of the… Resistance in E. coli and Streptococcus spp to enrofloxacin, ceftiofur, gentamicin, tetracyclines, and trimethoprim-sulfa increased over the period 1999 to 2012.Journal of the… Many antimicrobials on the WHO prioritized critically important list have shown increased resistance in horses.Journal of the… Antimicrobial-associated diarrhea, immune-mediated diseases, and nephrotoxicity are recognized adverse sequelae of antimicrobial therapy in horses, reinforcing that drug selection carries patient-level as well as population-level consequences.Australian Vete…
Formal AMS program implementation requires a tiered formulary structure with escalating justification requirements. The recommended framework organizes antimicrobials into first through fourth tiers, with second- through third-tier agents requiring documented clinical justification, culture and susceptibility submission or documented reason for not submitting, and a second sign-off from a clinician not involved in the case.Journal of the… Antimicrobial use guidelines should be living documents updated every two years in accordance with current literature and subject matter expert input.Journal of the… The British Equine Veterinary Association "Protect ME" toolkit, introduced in 2012 and updated in 2020, provides a structured model for developing practice-level protocols and policies.Journal of the… Approximately 54.4% of UK and European equine practices had a written antimicrobial use or stewardship policy at the time of a recent survey.Equine Veterina… Polymyxin B, when used, should be limited to 24–48 hours and always administered in combination with other broad-spectrum antimicrobials.Journal of the…
Client education and clinician engagement are non-negotiable components of any functional AMS program. Stewardship in equine practice requires extensive client education to achieve compliance, and freely available resources from multiple organizations exist to guide prescribing decisions and support de-escalation.Journal of the…+1 Studies in human medicine demonstrate that when physicians practice better antibiotic stewardship, antibiotic resistance decreases — confirming that prescribing behavior directly shapes resistance outcomes.Journal of the…
Would you like guidance on how to structure a tiered antimicrobial formulary specifically for an equine hospital, including which drugs belong at each tier and what documentation is required to escalate?