The increasing threat of antimicrobial resistance (AMR) to human health has prompted many countries to adopt national action plans to reduce antimicrobial use (AMU) in farm animals. To achieve this goal, it is necessary to gain a deeper understanding of the factors driving AMU in farm animals. While previous research has focused on gaining a better understanding of AMU from the perspective of farmers and veterinarians, less emphasis has been placed on examining the systemic and contextual factors that influence AMU from multiple viewpoints within the food supply chain. To this end, this paper describes a participatory approach involving multiple stakeholders from two distinct livestock sectors to identify the underlying drivers of AMU and explore their case-specificity. For each sector, we identified causes of AMU during four online focus groups, by co-creating a \"problem tree\", which resulted in the identification of over 50 technical, economic, regulatory, and sociocultural causes per sector and exploration of causal links. Following this, we analysed the focus group discussion through a content analysis and clustered causes of AMU that were related into 17 categories (i.e. main drivers of AMU), that we then classified as drivers of AMU at sector level or drivers of AMU at farm level. Finally, we compared the two sectors by assessing whether the generated categories (i.e. main drivers for AMU) had been discussed for both sectors and, if so, whether they involved the same causes and had the same implications. Through our analysis, we gained a better understanding of several main drivers of AMU at sector level, that result from systemic and/or contextual causes. As these cannot always be addressed by farmers and/or their veterinarian, we suggest that interventions should also target other actors related to these causes or consider them to help implement certain strategies. Furthermore, based on the results of our comparative analysis, we suggest that systemic structural differences, such as size and level of supply chain integration/fragmentation, may lead to differences in how animal health management is approached. This in turn may influence AMU\'s decision-making and the effectiveness of interventions, if they are generic and not tailored to the specificities of the sector.

Against the backdrop of universal healthcare coverage and pre-existing policies on antimicrobial use, China has adopted a state-governed, multi-level, top-down policy governance approach around antimicrobial resistance (AMR) National Action Plan (NAP). The Plan relies on tightening control over antimicrobial prescription and use in human and animal sectors. At the same time, medical doctors and veterinarians operate in an environment of high rates of infectious diseases, multi-drug resistance, or poor livestock husbandry. In exploring the way policy responsibilities are distributed, this study aims to describe how Guangdong as a province, adopts national AMR policies in a tightly controlled public policy system and an economy with high disparity. We draw on an analysis of 225 AMR-relevant Chinese policy documents at the national and sub-national levels. We adopt a multi-level governance perspective and apply a temporal sequence frameworks to identify and analyse documents. To identify policy detail, we conducted keyword analysis using the Consolidated Framework for Implementation Research (CFIR) on policies that conserve antimicrobials. We also identify pre-existing medical and public policies that associates with antimicrobial resistance policies. Our findings highlight the emphasis and policies around antimicrobial use regulation to address AMR in China.

BACKGROUND: Canine allergic dermatitis is a common diagnosis in veterinary practices which can lead to secondary infections requiring treatment with antimicrobials. A previous study suggested that dogs treated with oclacitinib in an Australian referral hospital required fewer courses of antimicrobial therapy compared to dogs receiving other anti-pruritic treatments. This study aimed to quantify the effect of oclacitinib treatment on the use of antimicrobials and other therapies in general practice veterinary clinics across Australia. A retrospective case-controlled review of patient records was designed to investigate the number of courses of antimicrobials and other therapies in dogs that received oclacitinib (Apoquel®), compared with those who received an anti-pruritic treatment that was not oclacitinib.
RESULTS: The target population included canine patients with a presumptive diagnosis of allergic dermatitis presenting between 2008 and 2018 to general practices contributing to the VetCompass Australia database. Patient records of interest were identified using search terms relating to allergic dermatitis, resulting in over 700,000 observations. Multivariable logistic regression models were developed to determine whether cases were prescribed fewer antimicrobial courses than controls, after adjusting for the presence of concurrent skin infections or infectious agents in ears. Our results indicate that fewer antimicrobial courses were prescribed in the cases compared to the controls. After adjusting for the concurrent skin infections, there was a significant reduction in the use of cefovecin [OR:0.62(0.39-0.98), P = 0.043], chlorhexidine [OR:0.57(0.42-0.77), P < 0.001], neomycin [OR:0.4(0.28-0.56), P < 0.001] and amoxycillin clavulanic acid (AMC) [OR: 0.55(0.39-0.78), P = 0.001] in cases compared to controls.
CONCLUSIONS: This study demonstrates a potential sparing effect of oclacitinib on the prescription of antimicrobials for the treatment of allergic skin diseases in dogs. This information may assist in the planning of treatment for canine allergic dermatitis, with consideration for antimicrobial stewardship.

UNASSIGNED: Antimicrobial agents have saved millions of lives worldwide. However, inappropriate use has become a global concern leading to the emergence and spread of antimicrobial resistance (AMR). In this regard, the dispensing practices of pharmacy professionals in the community drug retail outlets (CDROs) plays a central role. Therefore, this study was aimed to assess the knowledge and dispensing practices of pharmacy professionals in the management of childhood diarrhea in CDROs of Eastern Ethiopia.
UNASSIGNED: A community based cross-sectional study was conducted in 100 randomly selected CDROs in Eastern Ethiopia from 1 August to 30 September 2020. Data were collected with a structured questionnaire matched with a simulated patient case. Descriptive statistics were employed to summarize variables. Cohen\'s Kappa was analyzed to measure the degree of agreement between questionnaire-based and simulated patient-based methods. Binary logistic regression analysis was conducted to determine factors associated with inappropriate dispensing practice.
UNASSIGNED: Majority of the participants were aged 25-34 years (median: 29 years). High proportion of them were male (65%) and had work experiences of two or more years. Majority (61%) of the professionals were knowledgeable about AMR. Out of 2886 scores, 745 scores were agreed on Cohen\'s Kappa interrater agreement scale with the overall percent agreement between the two methods being 26.0%. Besides, about 67% of dispensing practices to the simulated patient case was found inappropriate. On the multivariate analysis, insufficient knowledge of retailers on AMR was significantly associated with the inappropriate dispensing of antimicrobial agents.
UNASSIGNED: A considerable proportion of retailers had insufficient knowledge regarding the emergence and spread of AMR. Only a quarter of their questionnaire-based knowledge response agreed with simulated-patient-based actual practice, indicating weak agreement between the two methods and high level of inappropriate practice. Besides, insufficient knowledge of retailers was significantly associated with their inappropriate dispensing of antimicrobials.

BACKGROUND: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) infection after kidney transplantation (KT) is associated with high mortality.
OBJECTIVE: To analyse an outbreak of infection/colonization with IMP-1-producing CRPA on a KT ward.
METHODS: A case-control study was conducted. Cases were identified through routine surveillance culture and real-time polymerase chain reaction for carbapenemase performed directly from rectal swab samples. Controls were randomly selected from patients hospitalized on the same ward during the same period, at a ratio of 3:1. Strain clonality was analysed through pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing was performed for additional strain characterization.
RESULTS: CRPA was identified in 37 patients, in 51.4% through surveillance cultures and in 49.6% through clinical cultures. The median persistence of culture positivity was 42.5 days. Thirteen patients (35.1%) presented a total of 15 infections, of which seven (46.7%) were in the urinary tract; among those, 30-day mortality rate was 46.2%. PFGE analysis showed that all of the strains shared the same pulsotype. Multilocus sequence typing analysis identified the sequence type as ST446. Risk factors for CRPA acquisition were hospital stay >10 days, retransplantation, urological surgical reintervention after KT, use of carbapenem or ciprofloxacin in the last three months and low median lymphocyte count in the last three months.
CONCLUSIONS: KT recipients remain colonized by CRPA for long periods and could be a source of nosocomial outbreaks. In addition, a high proportion of such patients develop infection. During an outbreak, urine culture should be added to the screening protocol for KT recipients.

The misuse and overuse of antibiotics have resulted in an alarmingly high prevalence of antimicrobial resistance (AMR) in human and animal bacteria. European monitoring programmes show that AMR occurrence in food animals is lower in Sweden than in most other EU Member States and that the use of antibiotics for animals is among the lowest in Europe. In this retrospective country case study, we analysed published documents to identify factors contributing to this favourable situation. A fundamental factor identified was early insight into and sustained awareness of the risks of AMR and the need for the prudent use of antibiotics. Early and continuous access to data on antibiotic use and AMR made it possible to focus activities on areas of concern. Another factor identified was the long-term control and eradication of infectious animal diseases, including coordinated activities against endemic diseases, which reduced the need to use antibiotics. Structures and strategies for that purpose established at the national level have since proven useful in counteracting AMR as an integral part of disease prevention and control, guided by a \"prevention is better than cure\" approach. A third factor identified was consensus among stakeholders on the need to address AMR and their cooperation in the design and implementation of measures.

Intensive livestock farming has become indispensable to meet the rapidly increasing demand for animal-based nutrition in low- and middle-income countries (LMICs) where antimicrobials are frequently used for treatment and prophylactic or metaphylactic purposes. However, very little is known about the trends of antimicrobial use (AMU) in dairy animals in LMICs. The objective of this study was to quantify AMU in two large commercial dairy farms in Pakistan. A retrospective study was conducted at two large corporate commercial dairy farms located in Punjab province for the year 2018. AMU was calculated using three metrics: active ingredient (AI; kg) and milligrams per population unit (mg/PU; mg/kg), which quantifies the amount of AI used, and antimicrobial treatment incidence (ATI; DDDA/1,000 cow-days), which estimates the per-day number of treatments to 1,000 cows. Total on-farm AMU was found to be 138.34 kg, 65.88 mg/kg, and 47.71 DDDA/1,000 cow-days. Measured in ATI, aminoglycosides (11.05 DDDA/1,000 cow-days), penicillins (8.29 DDDA/1,000 cow-days), and tetracyclines (8.1 DDDA/1,000 cow-days) were the most frequently used antimicrobial classes. A total of 42.46% of all the antimicrobials used belonged to the critically important antimicrobials for human medicine as defined by the World Health Organization. Considerably high AMU was found compared to other farm-level studies across the world. This was the first study to quantify AMU in the dairy industry in Pakistan. Our results showed that corporate commercial dairy management practices are associated with increased antimicrobial consumption and highlight the need for antimicrobial stewardship programs to encourage prudent use of antimicrobials in commercial dairy.

BACKGROUND: Serological screening tests for Lyme borreliosis have poor specificity, with potential for misdiagnosis and unnecessary antimicrobial treatment.
OBJECTIVE: To evaluate the impact of Lyme borreliosis seroprevalence and serologic test characteristics on the probability of obtaining a false-positive result and impact on antimicrobial use.
METHODS: Cross-sectional serological survey and modelling.
METHODS: Sera from 303 horses in southern Belgium were analysed by enzyme-linked immunosorbent assay (ELISA). Apparent seroprevalence was derived from serological data and a Bayesian estimate of true seroprevalence was computed. These were a starting point to model the impact of test and population characteristics on the probability of obtaining false-positive results and consequently unnecessary treatments and complications.
RESULTS: Apparent and true seroprevalence were 22% (95% CI 18%-27%) and 11% (credible interval with 95% probability 0.6%-21%) respectively. We estimate that two-thirds of positive samples are false positive in southern Belgium, with one in five of tested horses potentially misdiagnosed as infected. Around 5% of antimicrobial use in equine veterinary practice in Belgium may be attributable to treatment of a false-positive result.
UNASSIGNED: There was uncertainty regarding the ELISA\'s sensitivity and specificity.
CONCLUSIONS: This study highlights the importance of appreciating the poor diagnostic value of ELISA screening for Lyme borreliosis as demonstrated by this case study of seroprevalence in southern Belgium where we demonstrate that a nontrivial number of horses is estimated to receive unwarranted treatment due to poor appreciation of screening test characteristics by practitioners, contributing substantially to unnecessary use of antimicrobials.

Antimicrobial use and resistance, in combination with high levels of mortality, are important challenges facing the veal industry. To improve both the economic sustainability of the industry and animal welfare, measures need to be taken to explore and address reasons for these challenges. Health status at arrival may be an important predictor of calf mortality because substantial mortality occurs early in the growing period on veal operations. The objective of this observational case-control study was to identify clinically measurable variables and metabolic indicators associated with mortality in the first 21 d following arrival at a veal facility. Calves were evaluated using a standardized health scoring system, blood was collected, calves were weighed, and the supplier of the calf was recorded at arrival. The calves were followed until death or 21 d after arrival. Cases were defined as calves that died ≤21 d following arrival. Two controls for every case were randomly selected from calves that survived >21 d, arrived on the same day, and were housed in the same barn as cases. Stored serum harvested at arrival from cases and controls was submitted for measurement of concentrations of nonesterified fatty acids, β-hydroxybutyrate, glucose, cholesterol, urea, haptoglobin, and immunoglobulin G. A conditional logistic regression model was built to evaluate factors associated with mortality ≤21 d following arrival. A total of 4,825 calves were evaluated from November 2015 to September 2016. The mortality risk in the first 21 d was 2.8%, giving 135 cases, which were compared with 270 controls. Six variables were significant in the final multivariable model. Calves with a slightly enlarged navel with slight pain or moisture, and those with severe dehydration had increased odds of mortality ≤21 d following arrival. Drover-derived calves, calves that weighed more, and calves that had higher concentration of immunoglobulin G or cholesterol at arrival were less likely to die. The results demonstrate that calves at elevated risk for early mortality can be identified at arrival using both health and hematological factors. Early recognition of high-risk calves may allow for an intervention that could result in improvement in survival rates; however, prevention of these abnormalities before arrival at veal facilities needs to be further explored.

Inappropriate use of broad-spectrum antimicrobials affects adversely both the individual patient and the general public. The aim of the study was to identify patients at risk for excessively prolonged carbapenem treatment in the ICU as a target for antimicrobial stewardship interventions.
Case-control study in a network of 11 ICUs of a university hospital. Patients with uninterrupted meropenem therapy (MT) > 4 weeks were compared to controls. Controls were defined as patients who stayed on the ICU > 4 weeks and received meropenem for ≤ 2 weeks. Associations between case-control status and potential risk factors were determined in a multivariate logistic regression model.
Between 1st of January 2013 and 31st of December 2015, we identified 36 patients with uninterrupted MT > 4 weeks. Patients with prolonged MT were more likely to be surgical patients (72.2% of cases vs. 31.5% of controls; p ≤ 0.001) with peritonitis being the most common infection (n = 16, 44.4%). In the multivariate logistic regression model colonization with multidrug-resistant (MDR) Gram-negative bacteria (OR 7.52; 95% CI 1.88-30.14, p = 0.004) and the type of infection (peritonitis vs. pneumonia: OR 16.96, 95% CI 2.95-97.49) were associated with prolonged MT.
Surgical patients with peritonitis and patients with known colonization with MDR Gram-negative bacteria are at risk for excessively prolonged carbapenem therapy and represent an important target population for antimicrobial stewardship interventions.