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

15 November 2018

BVA's Voice of the Veterinary Profession survey reveals that 6 in 10 vets across species felt that unquestioningly using the cascade could result in decisions that did not meet the criteria for responsible prescribing

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.

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.

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.

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

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.'

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