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Are you PROTECTing your antibacterials?

PROTECT Write your practice policy on empirical antibacterial use in the boxes below

Periodontal disease
Skin infections
Bite and other traumatic wounds: Lance, debride and lavage. In cat bites amoxicillin first choice; otherwise
choice as for Pyoderma. Heavily infected/deeper injuries: metronidazole OR amoxicillin/clavulanate +
Surgical prophylaxis
Prophylactic antimicrobial use is not a substitute for good aseptic

P
amoxicillin OR amoxicillin/clavulanate OR ampicillin OR clindamycin OR metronidazole + spiramycin. With or fluoroquinolone are appropriate while awaiting culture results. technique.
ractice policy without chlorhexidine mouthwash. Practice Policy: Perioperative antibiosis is appropriate:
Practice Policy: for prolonged surgery (>1.5 hours)
Infected traumatic wound: amoxicillin/clavulanate OR 1st generation cephalosporin.
A practice policy for empirical prescribing for implant introduction
(whilst awaiting cultures) can optimize therapy, Practice Policy:
where infections would be catastrophic (e.g. in CNS)
and minimize inappropriate use of Respiratory infections Pyoderma: where there is an obvious break in asepsis
antibacterials Bacterial pneumonia (including aspiration): Empirical choice of antibacterials suitable for surface and superficial pyoderma (if no resistance or treatment
for bowel surgery with a risk of leakage
cats: amoxicillin/clavulanate OR doxycycline. failure) but culture required for deep pyodermas.
dogs: aminoglycoside* + metronidazole* OR amoxicillin + fluoroquinolone OR amoxicillin + metronidazole* Topical: chlorhexidine AND/OR fusidic acid OR silver sulfadiazine*. (Antifungals for concurrent Malassezia for dental procedures where there is periodontal disease

R educe prophylaxis OR doxycycline OR oxytetracycline. often useful.) for contaminated wounds or pre-existing infection.
Systemic: amoxicillin/clavulanate OR cefadroxil OR cefalexin OR cefovecin (if problems expected with
Practice Policy: administration/compliance) OR clindamycin OR fluoroquinolones (if others inappropriate). Continue 1 week In most cases:
beyond resolution of clinical signs. intravenous amoxicillin/clavulanate OR first-generation cephalosporin.
Antibacterials are not a substitute for Bacterial rhinitis, chronic rhinitis and sinusitis: amoxicillin/clavulanate
Practice Policy: Where anaerobic involvement is highly likely (e.g. periodontal disease):
surgical asepsis Practice Policy: add or substitute metronidazole.
Prophylactic antibacterials are only Pyoderma (idiopathic recurrent):
Kennel cough: no antimicrobials in mild cases; more severe: amoxicillin/clavulanate OR doxycycline Topical therapy important: antimicrobial shampoos/rinses, especially chlorhexidine. For significant bowel leakage in an otherwise metabolically stable
appropriate in a few medical cases OR oxytetracycline.
(e.g. immunocompromised patients) Systemic: Alternatives to antibacterials include immunostimulants (Staph Phage Lysate, autogenous vaccine). animal:
Practice Policy: Last resort is pulse therapy 23 consecutive days/wk. combination may be most appropriate, e.g. ampicillin +

Practice Policy: aminoglycoside (e.g. gentamicin)


O ther options
Suspected Mycoplasma:
cats: azithromycin* OR doxycycline. Pyoderma (confirmed MRSA/MRSP): choice based on sensitivity. If sensitivity not known, use topical if patient volume-depleted, replace aminoglycoside with
dogs: azithromycin* OR doxycycline OR oxytetracycline. chlorhexidine AND/OR fusidic acid OR systemic tetracyclines OR trimethoprim/sulfadiazine. fluoroquinolone.
Reduce inappropriate antibacterial prescribing Practice Policy: Practice Policy:
Practice Policy:
(e.g. due to client pressure, in uncomplicated Pyothorax: Pyogranuloma: as for Pyoderma but culture essential and may need to be repeated. Filamentous bacteria:
viral infections or self-limiting disease) by cats: amoxicillin/clavulanate clindamycin OR doxycycline OR trimethoprim/sulphonamide. Mycobacteria: fluoroquinolones doxycyline.
providing symptomatic relief (e.g. analgesia, dogs: ampicillin + fluoroquinolone OR clindamycin + fluoroquinolone OR metronidazole* + fluoroquinolone.
Practice Policy:
cough suppressants) Practice Policy:
Use cytology and culture to diagnose bacterial
infection correctly Ear infections
Effective lavage and debridement of infected Gastrointestinal infections Otitis externa (erythroceruminous):
Antibacterials not indicated unless cytology
material reduces the need for antibacterials Acute diarrhoea with complications: amoxicillin/clavulanate OR 1st generation cephalosporin. Topical: fusidic acid OR framycetin OR gentamicin OR marbofloxacin OR orbifloxacin OR and/or culture is positive
Using topical preparations reduces selection polymixin B/miconazole. (Antifungals to treat concurrent Malassezia will often be useful.) Combine with
Practice Policy: effective antibacterial ear cleaners with a low pH (chlorhexidine, chloroxylenol, isopropyl alcohol, PCMX.)
Cardiorespiratory
pressure on resistant intestinal flora Chronic bronchitis/allergic airway disease
Anal sacculitis: lavage plus topical installation (saline or chlorhexidine); amoxicillin/clavulanate. Systemic: choice as for Pyoderma.
Aspergillosis
Practice Policy:
T
Practice Policy: Congestive heart failure
ypes of bacteria and drugs Confirmed Campylobacter (if clinically significant): enrofloxacin OR erythromycin*.
Otitis externa (suppurative) or otitis media:
Urinary
Topical: Choice (including ear cleaners) as for erythroceruminous OE. Enrofloxacin, marbofloxacin, aqueous
gentamicin appear to be safe in the middle ear. Multidrug-resistant infections: 1.7% ceftazidime OR 2.8% Feline lower urinary tract disease (including struvite urolithasis)
Practice Policy:
Consider which bacteria are likely to be clavulanate/ticarcillin OR 0.6% enrofloxacin OR 0.2% marbofloxacin OR 0.10.5% silver sulfadiazine (diluted in Urinary incontinence
involved, e.g. anaerobic/aerobic, Gram +ve Cholangitis/cholangiohepatitis: amoxicillin OR amoxicillin/clavulanate OR ampicillin OR cefalexin. trisEDTA).
versus Gram -ve Metronidazole* may be added in dogs. Systemic: choice as for Pyoderma.
Gastrointestinal
Acute vomiting (uncomplicated)
Consider the distribution and penetration of Practice Policy: Practice Policy: Acute diarrhoea (uncomplicated)
the drug
Consider any potential side effects Gastrointestinal bleeding or bacterial translocation: metronidazole* + amoxicillin/clavulanate OR Chronic gastroenteritis (unless 4-week treatment trial for
metronidazole* + 1st generation cephalosporin. Add fluoroquinolones or aminoglycosides* to improve
Gram -ve cover. Eye infections antibiotic-responsive diarrhoea)
Pancreatitis (uncomplicated)

E Practice Policy: Bacterial conjunctivitis:


mploy narrow spectrum Topical: cloxacillin OR fusidic acid OR gentamicin. Surgery
Suspected Helicobacter: amoxicillin + metronidazole* OR azithromycin* + tindizole OR clarithromycin* Routine castration and ovariohysterectomy
Practice Policy:
+ metronidazole*. In combination with bismuth (caution in cats) OR famotidine OR omeprazole Removal of uninfected skin mass
It is better to use narrow-spectrum OR ranitidine. Suspected Chlamydophila:
antibacterials as they limit effects on Systemic: doxycycline OR enrofloxacin. Topical fusidic acid may be added if desired.
Metabolic
commensal bacteria Practice Policy: Polyuria, polydipsia (unless pyogenic focus suspected)
Practice Policy:
Avoid using certain antibacterials as first line Weight loss

agents; only use when other agents are Skin and ears
ineffective (ideally determined by culture and
Genitourinary infections
Malassezia dermatitis
Cystitis: amoxicillin/clavulanate OR trimethoprim/sulfadiazine. Many cats with cystitis do not have bacterial Miscellaneous
sensitivity testing) infections routine antibacterials not required. Non-specific pruritus, scaling, nodules, crusts, etc.
Endocarditis: amoxicillin/clavulanate + enrofloxacin OR amoxicillin/clavulanate + metronidazole*.
Practice Policy: Practice Policy:

C ulture and sensitivity Endometritis/Pyometra: amoxicillin/clavulanate OR trimethoprim/sulfadiazine. Mastitis: amoxicillin/clavulanate OR trimethoprim/sulfadiazine.


Practice Policy:
DO NOT USE
Practice Policy:
Culture promptly when prolonged courses are There are very strong arguments that antimicrobials with restricted use in
Suspected Leptospira: ampicillin OR pencillin G; doxycycline for carriers. Aminopenicillins treat bacteraemia Suspected Mycoplasma haemofelis (formerly Haemobartonella) (feline infectious anaemia): doxycycline OR human medicine (e.g. imipenem, linezolid, teicoplanin, vancomycin)
likely to be needed (e.g. pyoderma, otitis but do not address carrier state. fluoroquinolone.
should not be used in animals under any circumstances.
externa, deep/surgical wound infection) or
Practice Policy: Practice Policy:
when empirical dosing has failed
Prostatitis (acute): fluoroquinolones OR trimethoprim/sulfadiazine. Culture required in chronic cases. Neutropenia: Mild: no antibacterial required. Severe but asymptomatic: trimethoprim/sulphonamide. Severe and
with clinical signs: 1st generation cephalosporin + fluoroquinolone.

T reat effectively
Practice Policy:
Pyelonephritis (acute): trimethoprim/sulfadiazine. Culture required in chronic cases.
Practice Policy:
Septic peritonitis: amoxicillin/clavulanate OR ampicillin + cefotaxime OR ampicillin + gentamicin* OR
Second and Third Choice Antibacterials
These include: amikacin, 3rd generation and 4th generation cephalosporins
Practice Policy: clindamycin + enrofloxacin OR fluoroquinolone + ampicillin. Add metronidazole* if anaerobe suspected. (except cefovecin) and fluoroquinolones. These antibacterials should be
Treat long enough and at a sufficient dose
used only when other agents are inappropriate (e.g. in penicillin-sensitive
and then stop Struvite urolithasis (dog): amoxicillin/clavulanate OR trimethoprim/sulfadiazine. Practice Policy:
individuals) and/or ineffective, and culture/sensitivity testing indicates that
Avoid underdosing Septicaemia: ampicillin + cefotaxime OR ampicillin + gentamicin* OR clindamycin + enrofloxacin OR
Practice Policy: they will be effective.
Repeat culture after enrofloxacin + ampicillin OR fluoroquinolone + amoxicillin/clavulanate.
long courses Practice Policy:
Orthopaedic infections Follow the Cascade
Discospondylitis/Osteomyelitis: amoxicillin/clavulanate OR 1st generation cephalosporin OR clindamycin.
Long courses (68 wk) may be needed. Suggested antibacterials are listed in alphabetical order. Order of selection

Practice Policy: *
should follow the Prescribing Cascade. The following agents ( ) are not
authorized as sole agents for systemic use in small animals: aminoglycosides,
Septic arthritis: amoxicillin/clavulanate OR 1st generation cephalosporin.
For further information on individual drugs and dosages, azithromycin, erythromycin, gentamicin, metronidazole. Metronidazole is
BSAVA 2011. The publishers, editors and contributors cannot take responsibility for information provided on dosages and
methods of application of drugs mentioned or referred to in this publication. Details of this kind must be verified in each case by
see BSAVA Small Animal Formulary, 7th edition. authorized for oral use in combination with spiramycin. Oxytetracycline is not
individual users from up to date literature published by the manufacturers or suppliers of those drugs. Veterinary surgeons are
reminded that in each case they must follow all appropriate national legislation and regulations (for example, in the United
Practice Policy: authorized for use in the cat.
Kingdom, the prescribing cascade) from time to time in force. Other than adding practice policy, the poster may not be altered
in any way or used for any other purpose without prior written permission of the copyright holder, and may not be sold.