Ok, that doesn’t sound very sexy, but it was one of the reasons why I was so looking forward to working for a while in Scandinavia – I wanted to see at first hand how a far more reduced use of antibiotics in clinical practice can be achieved and how cases, where I normally would have used this form of medication are responding without them. Seeing is believing !…..
Let’s make one point clear though right from the onset: There is no doubt that we have been extremely lucky to live at a time where we can defend ourselves against bacterial infections which would with some certainty have killed us a hundred years ago. The availability of antibiotics has revolutionized both human medicine and veterinary medicine and even here in the Nordic countries no-one wants to imagine working once again without them.
However, in order to prevent resistances against antimicrobials, we have to use them more prudently. We need to choose the right kind of antibiotics for the right infections and we need to ask us constantly, if the use is necessary at all. This again goes hand in hand with excellent hygiene in all aspects of the treatment process.
There is no place in the world where this more strictly applied than in the Nordic countries and the results are striking:
Most small animal vets in the North are using less than 1/4 of the antibiotics than their counterparts in the South of Europe or in other parts of the world and the results at the clinics I have worked at, are even better.
So, how are they doing it ?
As mentioned above, it starts with good hygiene and this again begins with the right building and interior design. Most of the clinics here are purpose build and so designed that there are very few surfaces where dust and bacteria can accumulate.
This is then followed by clever storage solutions so that there is very little clutter.
Regular deep cleaning and alcohol bottles (which are used all the time) on every corner are also important features. In addition to this, all clinical employees are changing into scrubs when they enter the building and street shoes are left at the entrance. There has even been a call for mandatory showers before the change of clothes (something that is for many years the routine in large poultry and pig farms).
The next step is a change in the general mindset: in Scandinavia you nearly feel guilty if you dare to reach for the antibiotic bottle and if you do so, you are never using one of the critical antimicrobials which are reserved only for resistant infections or after confirming with an antibiogram that they are indeed the right choice.
Detaching the right to dispense antibiotics (and all other medication) from the right to use them and at the same time turning a profit from it, has also been discussed many times and personally I think that this is probably the right thing to do. Whenever follow on medication has to be given here in Sweden, I have to issue a prescription and the client has to collect the medication from a pharmacy. The downside of this system is that the clinical work becomes more expensive and a normal consult to see a vet is in the region of 80 Euros.
Compared with individual clinics like my previous one in Virginia Water, the large corporate organisations – like Anicura, who I am at the moment working for – have the advantage, that they can afford a clinical board that can work on the most up to date advice and they can employ someone to implement and to monitor the policy and they can produce the necessary data to back up the results.
While in Kumla I finally had the opportunity to meet one of these people: Ulrika Grönlund, the group’s Medical Quality Manager.
I have been in touch with Ulrika for many years in connection with the production of a set hygiene posters, which were written by a dedicated group of colleagues for FECAVA and which – in a range of different translations – are now hanging in veterinary clinics all over Europe and even in China. The working group , led by another Swedish colleague: Alex Vilen, had benefited from Ulrika’s advice especially when the posters were recently reviewed.
Although exchanging e-mails from time to time, I had never met Ulrika in person. In my first week in Kumla she happened to not only make one of her routine visits, checking on common hygiene problem areas using equipment from the food processing industry, where stands are even higher,
she also gave an evening presentation to the whole team, which – despite the fact that it was in Swedish – left me captivated (admittedly the power point slides helped considerably to understand what she was talking about….).
And indeed – over the last few weeks it has been a revelation for me to see, how many cases do well only with painkillers and often only with locally applied antibiotics and I will certainly take this knowledge back to my patients in the UK (and where ever else I am going to work).
Admittedly – to not appear too blue eyed about this issue – there are a few other reasons why vets in the North have it a bit easier to use less antibiotics: due to the colder climate and due to the interior design of Scandinavian houses (usually wooden floors with only a few soft furnishing elements) ectoparasits play a far smaller role. Another factor is the lower population density which also helps to reduce the infection risk. So moving up on a mountain and starting to shop at IKEA might not be such a bad idea after all!…….