Vets urged to apply professional judgement to make responsible antibiotic prescribing decisions under the cascade

For World Antibiotic Awareness Week (12-18 November) and ahead of European Antibiotic Awareness Day (18 November), the British Veterinary Association and Veterinary Medicines Directorate are highlighting that vets should continue to exercise their professional judgement when prescribing antibiotics under the cascade to minimise the risk of development of antimicrobial resistance. This renewed advice comes on the heels of figures from BVA’s Voice of the Veterinary Profession survey, which reveal that 6 in 10 (60%) vets across species felt that unquestioningly using the cascade could result in decisions that did not meet the criteria for responsible prescribing, such as using a licensed Critically Important Antibiotic (CIA) when a non-licensed alternative would have been more suitable.

The survey shows that the perceived conflict is apparent across all major practice specialisms, though large (production) animal vets were significantly less likely to identify it, with only 41% observing the issue and 24% seeing it often or sometimes.

In terms of the species most affected, companion animal vets observed the conflict most with prescriptions for dogs, rabbits and cats and large animal and mixed practice vets observed it most with cattle and sheep, with mixed practice vets experiencing it with prescribing decisions for exotics too.

British Veterinary Association President Simon Doherty said:

“The cascade provides much needed flexibility in allowing veterinary surgeons to treat animals in situations where a licensed product for a condition in a particular species is not available in the UK, but we are concerned that it could in some circumstances lead to decisions that could exacerbate antimicrobial resistance.

“While there is a legislative requirement to use a UK-authorised veterinary medicine before applying the cascade, there is concern among our members that there are instances where following the procedure could lead to inappropriate prescribing decisions. This is especially true when vets are trying to balance the use of the cascade with the responsible use of critically important antibiotics.

“With antibiotic resistance a very real and urgent concern, our message to vets is to continue to use their professional judgement, on a case-by-case basis, in considering alternative prescribing options, after giving full consideration to potential risks. A commitment from each of us within the veterinary profession to maintain the highest standards of stewardship in using antimicrobials, most especially CIAs, is the only way we can preserve these essential medicines for future generations.”

The cascade is a risk-based decision tree that allows veterinary surgeons to treat an animal with an alternative if there is no UK-authorised veterinary medicinal product (VMP) available for a particular condition. The VMD originally issued guidance on the responsible use of antimicrobials under the prescribing cascade in 2014, after concerns were raised over a perceived tension in balancing the responsible use of antibiotics with the legislative requirement to use such a VMP before applying the cascade.

VMD’s guidance supports and encourages the responsible use of antibiotics, stating that ‘it is justified, on a case-by-case basis, to prescribe an antibiotic on the cascade in the interests of minimising the development of resistance, particularly where culture and sensitivity data indicate that a particular antibiotic active substance is effective against a bacterial pathogen and where knowledge of pharmacokinetics indicates that the selected product is likely to be safe and effective for the animal species and condition being treated; that is, the prescription of a narrow spectrum antibiotic on the cascade over a broad spectrum antibiotic that has a specific authorised indication for that condition.’

For more information, see VMD’s guidance on responsible antibiotic use under the cascade and BVA’s guidance on the responsible use of antimicrobials. Vets can also download BVA’s Antibiotics 7-point Plan poster to display in veterinary practices.