Understanding antimicrobial stewardship: Disease severity treatment thresholds and antimicrobial alternatives among...

Reductions in livestock antimicrobial use (AMU) can be achieved through identification of effective antimicrobial alternatives as well as accurate and stringent identification of cases requiring antimicrobial therapy. Objective measurements of selectivity that incorporate appropriate case definitions are necessary to understand the need and potential for reductions in AMU through judicious use. The objective of this study was to measure selectivity using a novel disease severity treatment threshold for calf diarrhea, and identify predictors of more selective application of antimicrobials among conventional dairy producers. A second objective of this study was to describe the usage frequency and perceptions of efficacy of common antimicrobial alternatives among conventional and organic producers. The cross-sectional survey was mailed to Michigan and Ohio, USA dairy producers and contained questions on AMU attitudes, AMU practices, veterinary-written protocols, and antimicrobial alternatives. The treatment threshold, defined based on the case severity where the producer would normally apply antimicrobials, was identified with a series of descriptions with increasing severity, and ordinal multivariable logistic regression was used to determine the association between the treatment threshold and individual or herd characteristics. The response rate was 49% (727/1488). Overall, 42% of conventional producers reported any veterinary-written treatment protocol, and 27% (113/412) of conventional producers had a veterinary-written protocol for the treatment of diarrhea that included a case identification. The majority (58%, 253/437) of conventional producers, but a minority (7%) of organic producers disagreed that antibiotic use in agriculture led to resistant bacterial infections in people. Among conventional producers, the proportion of producers applying antimicrobials for therapy increased from 13% to 67% with increasing case severity. The treatment threshold was low, medium, and high for 11% (47/419), 57% (251/419), and 28% (121/419) of conventional producers, respectively. Treatment threshold was not significantly associated with the use of protocols or frequency of veterinary visits; however, individuals with more concern for the public health impact of livestock AMU had a significantly higher treatment threshold (i.e. more selective) (p<0.05). Alternative therapies were used by both organic and conventional producers, but, garlic, aloe, and "other herbal therapies" with little documented efficacy were used by a majority (>60%) of organic producers. Overall, findings from this study highlight the need for research on antimicrobial alternatives, wider application of treatment protocols, and farm personnel education and training on diagnostic criteria for initiation of antimicrobial therapy.