Episode 14 - A Scandinavian Success Story

In this episode of the Skin Flint podcast, Sue, John and Paul welcome Katarina Varjonen to the platform to discuss the Scandinavian approach to responsible veterinary antibiotic usage.

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Chapter 1 – A Scandinavian Success Story

 

(02:46) Katarina introduces herself and her experience as a dermatologist; Sue clarifies she is also the incoming president of the European Society of Veterinary Dermatology.

 

(04:00) Sue talks Katarina's career, working in Scandinavia, the UK and the USA, commenting on how good Scandinavia is on managing antibiotic usage. Sue then asks why responsible antibiotic use is important and Katarina says the one health consideration ties in and is really important across the profession in order to avoid using them longer than needed to prevent resistance. She feels most countries have put a lot of work into eliminating unnecessary use.

 

(06:39) Sue asks Katarina to outline the advanced approach Scandinavia has to this and Katarina says antibiotics are not completely off limits, but the guidelines are strict for recommendations – as well as limitations to what is available on the market. So for a number of years now fluroquinolones and 3^rd generation cephalosporins are limited to life threatening situations, requiring culture tests as proof. Sue clarifies these are classed as critically important antibiotics in humans.

 

(08:23) John says this sounds quite extreme in comparison to what we do in the UK and asks if this would be considered a few years ahead of the UK and what is happening in the US. Katarina comments on it more as a cultural difference, feeling that the smaller industry in Scandinavia has helped to spread the message from within, along with the government and health sector working hard to spread the message to the public. As a result they don’t get pressure so much from clients to use the antibiotics in the first place.

 

(10:19) Sue asks if it is easier to treat a disease in Scandinavia because there is less resistance to antibiotics, or whether it is harder because you have less access to antibiotics. Katarina says that actually they still have the same access, but the big difference in the case management is that in Scandinavia they are far more keyed into preventative approach to a disease, meaning the cases are better managed in the first place and therefore cases are less severe from the outset.

 

(12:10) John asks if this comes at all from the owners side, with them being more in-tune with identifying issues early and Katarina doesn’t believe so – she feels this comes entirely from the veterinary side.

 

Chapter 2 – The Prologue to a Case

 

(13:52) John asks Katarina to share what things would help with that early identification and Katarina says scratching and head shaking is the early sign, and whilst the approach to these first symptoms will be the same for treatment, the conversation about underlying causes is begun at this stage, which is almost always allergy. Katarina herself describes this to owners as the dog equivalent of allergic eczema but in the ear.

 

(16:20) Sue asks Katarina to talk through her approach to a case. Katarina says she would start by feeling the ear canal on the outside, is it firm or soft to suggest issues – it also helps the dog to get used to being handled. Then she has a look with an otoscope down the ear if the dog tolerates - or she may sedate at this stage if not – in order to examine and perform cytology. If the canal is inflamed she will go to cleaners and anti-inflammatories to open up the canal, even before thinking about treatment of the infection.

 

(18:07) Sue asks Katarina to clarify what is meant by Cytology and Katarina describes this as the basic and easy to perform diagnostic tool for these cases, using a Q-Tip (cotton bud) to gather material from the upper ear canal and roll onto a microscope slide before staining with Diff Quick (or similar) to look for bacteria, round or rod shaped, yeasts or inflammatory cells. As well as assessing the level of the load.

 

(19:43) John says this sounds quite straightforward, asking if this is something a specialist needs to do or whether a non-specialist / nurse could perform this; Katarina says that actually even in referral practice it is mostly the veterinary nurse who will do this, taking the sample, staining and even examining under the microscope. It is not specialist cytology and only takes a couple of minutes. Katarina shares that for fractious dogs a clean finger rather than a cotton bud, into the entry to the canal and rolled onto a slide will also work.

 

(23:18) John asks if the cytology is something that is done just initially, or whether this would be done in follow-ups and Katarina shares that she performed cytology all the time at every visit as standard. This is because as she is using anti-inflammatories and other treatments she will see an improvement visually so cytology is the only way to know whether she is resolving the actual infection.

 

(23:57) Sue clarifies then the switch from treatment to maintenance would be made once she observes the levels of microbes dropping to what would be considered normal rather than symptoms.

 

Chapter 3 – Chapter and Verse on Treatment

 

(25:21) Sue asks what kind of actives (stuff in the products) Katarina would use in terms of anti-inflammatories and cleaners having done cytology and found microbes present. Katarina says the texture of the discharge from the ear, whether this is fatty/lipid or ceruminous/waxy in which case she would reach for a squalene based cleaner or if it is a liquid based discharge with pus forming she would use a chlorhexidine/tris EDTA based cleaner. If she suspects a biofilm in the ear as well from slimy discharge she would add in an an-acetal cysteine flush to the cleaner.

 

(26:59) Sue asks what anti-inflammatories she would use and Katarina clarifies this would depend on thickening of the skin in the ear – so if the ear is stenosed/narrow she would use oral steroids in addition to topical steroid in the ear, but if it was more minor she would only use a topical. This also reduces pus formation. Sue asks how you would use a topical steroid without using the other antibiotic and antimycotic treatments that are in licensed, steroid containing topical products. Katarina says she would use a steroid on its own without the others even though the licensed products are next on the cascade, because the antibiotic stewardship wins over the grey zone element of the cascade in these instances. John summarises this and Katarina clarifies that the preparation of the ear and selection for antibiotics is critical to making sure that when she does then reach for it, it is effective as it can possibly be.

 

(32:33) John asks what ear cleaners when used in preparation of the ear also have some effect on the microbes we are seeing in the ear at the same time and Katarina says that actually even just cleaning out the ear gives the body and immune system a chance to start helping in fighting the infection – so begins the process. Then the likes of chlorhexidine and Tris EDTA combined, and an acetal cysteine help further to fight this if they are present in the cleaners, hypochlorous acid as well.

 

(35:30) Sue asks if Katarina feels that maybe in the UK we are tempted to reach for antibiotics too soon and Katarina says often we feel safer doing this because we want to manage these cases, and it is a big step to understand there are steps we can take first before assessing to see how well they have worked, in order to manage the cases which don't need antibiotics and identify the ones which do. She would try for two weeks generally first before reaching for antibiotics if there hasn’t been a reduction in the number of microbes in the ear.

Sue and Katarina summarise the importance of the use of topicals to try and push forward the appropriate use of antibiotics.

 

(37:40) John asks one final question to Sue and Katarina on how important this is, whether people need to really take this seriously and whether there should be any pressure from the authorities on this. Katarina says we do need to take it seriously, perhaps less to with topical antibiotics than systemic (oral/injectable), but this is still very important to strive for this. Sue says that the use of cytology is critical and underperformed in terms of understanding whether there is infection present in the first place, and whether we have completely eliminated the infection at the end of treatment. We need these drugs and we turn on the resistance when we feed the bugs these drugs, and we are moving in the right direction together. Katarina echoes this, showing a lot has happened even in the last few years.

 

Outro

 

(43:55) John and Sue wrap up before John asks his usual silly question (ask your own sensible or silly question by emailing hello@elearning.vet ) – Sue and Paul are asked what frustration they would most like a drug to rid their lives of, walking into a put down by Paul!