Hello, it's Anthony Chadwick from the webinar be welcoming you to another episode of Vet Chat. We're going to be talking about antimicrobial resistance today. I'm particularly honoured and I'm pleased to have Jill Moss on the line with me, who is the founder of the Bella Moss Foundation and also a very good friend of mine from the dermatology world, Tim Nuttall, ex-L Liverpool, now up in up in Edinburgh.
Teaching dermatology at the university there, so thanks so much for both agreeing to come on. Jill, perhaps just to start, tell us a little bit about your story about how you formed. I know it is a, it is a sad story, but, you know, the foundation of the Bellamos foundation is nevertheless an inspirational story, so perhaps you can just tell us a little bit about how that all er started.
I think any loss of a pet is always so devastating, but Bella was out chasing a squirrel. She was 10 and she was my beloved companion, and she ruptured a cruciate ligament in her knee. What should have been routine surgery back in 2004 turned into a horror story.
Little was known about MRSA in animals at the time. I didn't even know about it and my vet didn't know about it, so her infection that she acquired, which was, human strain of MRSA, went undetected for too long, became systemic, and she lost her life. But on top of that, I had a cut in my foot, and there was some hesitance from staff about treating Bella.
They were worried and I brought in a locum vet, but the infection got into the car and I developed the same strain. Obviously bacteria reports confirmed this. I nearly died and I'd lost my beloved companion.
So what do you do? You should really just, accept it, but me being me, I was a journalist at the time. So I rang up my friends at the BBC and IT and and Sky, and I said, Did you know that MRSA is moving from pets to, from people to pets?
And they said, Really? Oh wow, there was a big media campaign, and I was telling my story through the press over and over. Meanwhile being bombarded by pet owners, saying, I've also got the same thing, similar thing.
To me, cases were coming forward. So I thought, well, what do I do now? So I rang up people like Professor David Lloyd and Doctor Tim Knuckle, and I, I spoke to a lot of academics, and they all said, you know, you, you've got a good story here.
It's sad, it's devastating, but you have the opportunity to do something now and turn that into a positive. And with their help, at the fact that the time that rumour was forming and the O'Neill reports coming out about antimicrobial resistance, and I'd opened up everybody's, you know, senses with my media campaign, Chris Lawrence, who's now treasurer of the charity, sat down with me with Tim and other well-known academic and researchers and said, well, what are we gonna do? We have the opportunity, to do something really productive.
Let's turn it into a charity that looks at the, prevention. Of the spread of diseases between humans and animals and, DeA approached me and they were forming a committee at the time looking at MRSA and livestock, and I became the layperson of that committee, which led to academic conferences, which led to opening up platforms of collaborations with all the veterinary bodies, which then led to a one health movement, and it's just flourished and flourished from what was my story as devastating as it was. And I think I remember GLus meeting at the Carver conference in Dublin in probably 2010, something like that.
And there were at that stage then lectures, all about antibiotic, resistance and stewardship. And I think it's fair to say at that point, you know, it was in a fairly small room and it wasn't full, so it was still early days, but now we've just had an antibiotic amnesty that the pharmacists. The doctors and the the vets have been working on, and I think it is a lot more mainstream because you recognised what was, An emerging problem, but it's becoming a bigger, bigger problem which is antimicrobial resistance, isn't it?
Yeah, and I think now we're coming out of the pandemic and, and obviously people's focus has been on hygiene, though COVID we know was a respiratory disease, but we, we have got the, the world waking up to hygiene, and I think now more than ever as a society, biosecurity is really important and we We need to keep that momentum going. So what we do, as a charity is we provide free resources, and I have to say this, and this is important, people like Tim and all of our scientific advisors give up their time freely, that nobody gets paid. Nobody in the Bellamos Foundation gets a penny.
But we provide really good resources for veterinary practises and also advice and help for pet owners and, But some of these resources have actually been formed by people that worked at the practise Standards scheme. So if you download our resources, you can actually collect points towards the practise Standards scheme. So everything we're doing is valuable educational resources freely available just to help really continue the fight against antimicrobial resistance.
And it is such an important fight that we make, isn't it, Tim, because obviously, antibiotics, we want to be able to continue to use them, and if we use them incorrectly, then the, we won't be able to use them into the future because they won't be effective anymore. Yeah, I mean, antibiotics are a life savers and the, the advent of an antibiotic era has led to the development of all sorts of areas of, you know, what we would now regard as routine, modern standards of medical and veterinary health care that would have been impossible before attics. And I think the danger is that that there are no new newer drugs on the horizon, certainly for that new practise and you know, if, if anybody wants to.
Have a think about what it would be like to practise in a a pre-antibiotic era, go back and read some of the James Harriot books. Mm, yeah, no, absolutely, because really antibiotics only came into the fore in the. In the 40s and 50s and, and very quickly there were evidence of resistance beginning to develop, wasn't there?
The antibiotics were introduced, then, then the resistance followed on their coat tails, and Sir Alexander Fleming in his Nobel Prize winning speech for the discovery of penicillin, which I think was mid 1950s, made the point that resistance is inevitable. And he also, and if I apologise if I misquote him. Stated that the person who misuses antibiotics, which leads to resistance, is morally culpable for the person that dies of an antibiotic resistant infection.
You know, and that was what, 70 years ago, nigh on and it's taken us a long time to really wake up to the threat of antimicrobial resistance. And I look back at some of the things we used to do. You know, way back when I was a young dermatologist and, and cringe a little bit now.
But I think, you know, yourself and Jill are right, the, there's huge sea change in attitudes in, in the last 10 years has been amazing. I think when David Lloyd and and I and others started this back in the early 2000s. You know, we were to a certain extent, you know, voices crying in the wilderness and I, I, you know, it, it's been hugely gratifying to see the way that everybody's now on board with antimicrobial stewardship.
No, that's really interesting, Tim, and you know, thank you for all the work you and David and others have done. Just for those listening, spoiler alert, Alexander Fleming won his Nobel Prize in 1945. And those of you who are down in London, do go down to Paddington because there is a nice blue plaque, just, I think below the window where the er the bit of fungus blew in his window.
So, . Yeah, I mean, I think it's a really important point because we now see more and more antimicrobial deaths, antimicrobial resistant deaths in the human population and obviously in the animal population as well, don't we? Yes, and I, I mean, fortunately not too many at the moment because we, we always have that third line back up to go to.
But we euthanize the dog last year that essentially had an untreatable infection. As you said, we're seeing this in people, you know, I think this is the early warning and it's one of those situations where we don't want to wait until there's a crisis because then it will be too late. What we need to do is take action now.
So that we preserve these treatment options for the future. And I think it's, it's as you said before, quoting Char Alexander Fleming. It's about us using antibiotics correctly.
I, I, I think I remember when I was fairly new in practise, and we would do a cat spay or a cat castrate and it was kind of deemed necessary to give something white and and milky at the end in a syringe. And you know, I always sort of went against that because I said, well, if we are doing this operation in a clean and sterile manner, we won't get an infection. And if we are getting lots of infections, then that says more about.
The hygiene and the sterility of the, of the operation, so. Using antibiotics almost in a prophylactic sense makes absolutely no sense. And I think that's a really good example of where as you say, if there's a problem with, with postoperative infections in what should be a reasonably simple operation in a healthy animal, we need to look at the surgical technique, the asepsis.
The, the cleanliness of the of the environment and so on. We can't use antibiotics to paper over the cracks there. And the way I teach it now is antibiotics are amazing, you know, they, they are lifesavers already said they enable a lot of modern healthcare, but their use comes with consequences and, and that is we will impact the microbiome.
We're learning that a a a diverse microbiome is really important for health, and we need to preserve that and we also select for resistance. So if we're going to use antibiotics, we need to be able to justify the use. And I think a lot of this.
Just in case, you know, somewhat careless approach to using them has to stop because as I said, you know, we need to realise that. Using them, and, and I'll go back one step, you know, we're not looking for net zero here, because of their importance, but when we use them, we need to realise that there are, there's a price to pay, and we need to be able to justify that use. I suppose a part of the problem is that there is a dogma about how we use antibiotics in dermatology, in general infections, how many days that we give them, and a lot of that has not been based on evidence, has it, at the start, so just because it's, we've done it for, you know, 50, 60, 70 years, we, we continue to do it, you know, why do we give 5 or 7 day courses, whereas the.
Science for that this is an area that we really need to work on, isn't it? Yeah, and I, I, I think, you know, you and I have worked in terminology for a long time now and you know, we look, we look back and, and cringe at what we did 20 years ago. And it, you know, the, we, you know, we accepted dogmas, you know, the two, the two that I think dermatologists have been particularly guilty about are, this minimum 3 week course of systemic antibiotics to treat reasonably simple skin infections.
And then, you know, what we used to call weekend therapy. I don't know if you remember that where, you know, the dogs all got amoxiclav or cephalexin on each Saturday and Sunday. And we now know a lot more, you know, we know that these weren't secondary infections, that it's, it, it, it was a dysbiosis of the microbiome, and that's purely secondary to the underlying atopic dermatitis.
And, and so our first line now really is. You know, better manage that underlying inflammatory skin problem, get that under control using anti-inflammatories and, and topical emollients and all the other options that that we have now. And then if we do need to use an antimicrobial, a topical shampoo, foam pads, you know, again, there are lots of options available these days.
Should be the absolute first line, and we should be reserving the systemic drugs for, for only those cases that need it. And in my practise now, you know, if I look, I look at the antibiotics that I dispense. Now compared to what I did 20 years ago and it's a tiny fraction by using all of these other .
Treatments, and I, I remember years and years ago and I, you know, being taught as a young resident that cephalexin was a steroid sparing treatment because. because it, it, it kind of, and it did work, but you know, we're paying the price now in terms of resistance. And I turn it around and say with a better understanding of how this microbiome dysfunction takes place, you can regard prednisolone as an antibiotics bearing agent.
You can add all of the other, you know, treatment options that we have for atopic dermatitis in there as well. I think this is a recurring theme. One of my favourite lecturers at our Webinar bet is Mike Willard, who's ex from Texas A&M just retired in in gastroenterology, and he, he says, everything I taught you 10 years ago was a lie.
I just didn't realise, and of course he's been slightly flippant, but in a sense, we, we did all of those things with the best intention and as we make progress, you know, Jill's obviously helped us. There was the sadness of the death of Bella, but there's been so much good come from it, and I think Jill, you were also using the example of, of COVID. I mean, terrible, terrible thing that's happened, but there have been a number of silver linings around, you know, more appreciation of nature.
We're not travelling as much on, on unimportant trips to have a meeting for an hour and then travelling back again. But I think your big point, Jill, was all around hand hygiene, but I think general sterility, I know, I remember seeing a paper from, I think it was David, but it may not have been, just talking about the general bacterial counts on things like stethoscopes and door handles and mouses and and computer keypads. In, in, in veterinary practises, so that cleanliness is so, so important, and I think the pandemic has really helped to sort of ram that home, hasn't it?
Yeah, certainly, and when we do exhibitions, which we don't do so much of now, but BSAVA kindly do actually give us a charity stand for free, but we do send people off to the toilet to wash their hands and come back and put them under an ultraviolet. And, and you'd be surprised. People think they've washed their hands correctly, but haven't.
And so hand hygiene might seem a simple thing, but it actually, you know, is something that we really want to promote, as well as antibiotic stewardship. We're very much supportive of the antibiotic amnesty because it's not just about how to use antibiotics safely, but how to dispose of them safely as well. So that's a fantastic campaign that's going on at the moment.
But also the antibiotic. Not sharing them or flushing down the toilet seems sensible thing to do. Yeah, yeah, and so it's very much encouraging people to return them to their vets and their, their pharmacists, and we're very much supportive of that.
But what I was gonna say is that on this topic, compliance is something to consider because. You know, many pet owners call me up and say, well, I went and paid £60 for a consultation, and my vet wouldn't give me any tablets. You know, I said, don't I need an antibiotic.
So it's getting that communication between the veterinary practise and the pet owner to be on the same page is very important. Yeah, and I, I, I, I, we looked at this a few years ago now with a group from Glasgow Caledonian University who specialise in treatment decisions and and medical communication. And interestingly, what we found was that whilst the vets felt under pressure from the clients to give antibiotics, the clients evidenced a high degree of trust in their vet and trust in their decision making.
But there was a communication breakdown around the necessity for, you know, whether antibiotics are needed or not needed. And so we would really encourage, an openness about the conversation there. And it is again, I said earlier, it's not about net zero, but it's about only using antibiotics where they're necessary.
And it is important to, to, to communicate that clearly and confidently to a client and also to reassure them that you know. It's not going to compromise the outcome if, if it, you know, a week later it does turn out that your, your, your dog or your cat or other animal needs antibiotics, and I think. You know, it can be challenging in short consult periods, but I, I think a lot of clear messaging from the outset, you know, just, just to say, look, you know, this doesn't, you know, there's no infection here, or even if there is an infection, it doesn't need a systemic antibiotic.
There is another way to manage this. I might be able to cope with it, with its own innate, you know, a topical antiseptics and anti-itch medication and other symptomatic treatment. And then, you know, in a slightly sort of broader picture, client education, you know, can really help, .
Prepare the client for that situation. So practises can use their websites, their blogs, social media, information in the waiting room, engage with the and, you know, campaigns like the antibiotic Amnesty campaign, the antibiotic Awareness Week, and so on. BSAVA produce a no prescription pad, which has got lots of useful preprinted information on.
You know, and all of these things just, just come together and help that immediate decision making when. You're under under time pressure in the consultation. And, and that's where we come in too, because we're producing lots of short, very animated, simple films on this topic, which are going out to the public through our veterinary practises as well as the public domain social media.
So it's just getting, as Tim said, getting that message out. I the other thing, sorry. I was gonna say Ian Battersby's done a podcast with us as well and he obviously helped with BSA BA developing things like the Protect.
Poster and I think for some of it, it is education amongst vets. When I was practising and seeing dogs with dental problems, particularly, you know, that old Yorkshire terrier that you were pulling, you know, 20 teeth out of, and the mouth looked disgusting. Actually, just the fact that you'd released all of that puss was, you know, possibly enough, but I, I always felt happier giving a week of antibiotics, but again, we're seeing those sort of changes and I think it's.
It's important that just because I qualified 30 years ago doesn't mean I need, I know everything about how to use antibiotics as the world changes as we learn more. We as as vets have to be lifelong learners to keep up to date with technology. I remember he Tim talking about his er vet who didn't give antibiotics to cat bite abscesses, but he liked to flush them out well and and clean them up that way and.
I think there's more work that needs to be done in that area that we really have a very strong evidence base so that we know what works and what doesn't. And I know that is coming and then just make sure that that information comes over to, you know, GP vets like myself so that we're in in a good position to be using these drugs correctly. Yeah, I, I think adopting practise guidelines really helps because it, it focuses the whole practise team and I would include nurses and and receptionists here.
On, on the same message, and it, it stops that conflict between, you know, and there is some evidence that vets over 40 are less good at microbial stewardship than vets under 40, and I, I, you know, I, I'm, I'm well over 40, let's put it that way. And, so we'd like to think it, you know, we, we don't, us oldies don't necessarily have a closed mind. But you know, the younger vets are coming out of university with different and more up to-date education on antimicrobial stewardship.
And it's important that the whole practise engages with the guidelines because it does stop, you know, you know, if you have one vet in the practise who, who will give antibiotics, it undermines everybody else and, and really undermines that stewardship message. And you know, countries that have very strong, clear national guidelines like the Netherlands and Sweden. Again, you can't even go to the next practise because everybody's working to the same standards and, you know, it's not rocket science.
They have low the lowest levels of antibiotic use anywhere in the world and the lowest levels of resistance, and that's both in humans and animals. I think it became a sort of legal thing in Holland where they just said. You need to reduce antibiotics by 50%, and of course the Dutch managed to do that, and I remember reading recently also that in agriculture, there has been a massive drop in antibiotic usage in in the UK so obviously these messages are starting to get across, which is very gratifying, isn't it?
Yeah, the, the, I mean, the, it, it's not often you can say that, you know, government-led policies actually exceed their targets, you know, more rapidly. But they did it in, in, in farm animals, but again, it was, it was bringing everybody together. So, you know, the farming groups, the farm vet groups and societies and the regulators all got together.
Agreed that everybody wanted to improve the situation and then worked out how to do it. And, you know, again, the, the evidence from the Netherlands, from Sweden shows that this, this bottom up approach to antimicrobial stewardship is a lot more effective than a punitive top down method. We're getting there in companion animal work, it's just the, the progress has been much slower than we've seen in, in livestock.
This is great where Jill has, you know, obviously helped with connecting with people like Rua, the responsible use of. Antimicrobials and obviously working with Dera as well, Jill, so have you been? Have you been making sure things happen that I'm gonna, I'm just gonna stop you there because it's lovely that you've credit me with all of this and I'd love to put my halo on, but really it, I couldn't, the Bellamos Foundation could not exist or survive or fulfil its mission without people like Tim, Chris Lawrence, Professor David Lloyd, and all our USA advisors, Doctor Scott Weis.
I mean I so I can at the Oscars at the moment. But there's a whole team of people behind the Bellamos Foundation, and these collaborations are instrumental in promoting change. And, and I've always said that it was my story initially, and I might have founded the charity, but, you know, really, it's being led behind the scenes by some very important people like yourself, Tim, that just do things for nothing.
And, and we are so grateful. Pretty much with anything that works successfully, as you said with the, the government and and the UK case of reducing antibiotic in in farming animals, the key word is collaboration, isn't it? Absolutely, you know, you, because the regulators, you know, and I would include, you know, the veterinary associations in this as well as, as government, can produce the guidelines, can produce the regulations, can produce practise standards.
You know, that it's certainly in the Netherlands and Scandinavia, there are legal restrictions on antibiotic use, so the, you know, but the big stick is kept behind the back. The effort has gone into ensuring that people want to do better and work together to, to achieve that. And obviously thank you both of you and all the other people who are, are helping in this really important field because it's, it's massively important, as you said earlier, Tim, that we have these drugs that we can use in the long term rather than er in a, in a few years' time or in a couple of decades time.
They're, they're all unusable and we haven't got the next generation to help. OK. Yeah, so, you know, and I think my take home messages here would be.
You know, for practises to adopt guidelines. And there are lots available. It's about finding the one that really works, works for, for you and your situation around diagnosis of infection, the treatment advice for infections in different areas and, and then, the, the hygiene and the biosecurity.
But, you know, again, as, as, as you've said, crucial that the clients are brought along with this. And that's by using a lot of the resources are out there and again Bellamos Foundation videos, you know, sort of thing I could never write as an academic, but they give, they give, they're that important piece of information very succinctly, very clearly in a in a in a in a very passionate way. We have asked you to write them, but you're always too busy.
No, I, I, I get, I way too, I'm typical academic. I get way too involved in the detail. It it's the simplicity of the messages.n't that great because Antony, this is the thing, we need the academics to reach out to the practises and to the vets and the practise managers and nurses, but we also need the charity to do its work in reaching out to the public.
And so that's really important to have that balance. It, it's again, it's that whole collaboration, it's having that holistic approach that if it's just the vets that think it's important not to use antibiotics, but the the owners are not being brought along on that journey, we will have that continual sort of pressure in the consulting room to give out antibiotics and I, you know, I accept Tim's research from Glasgow that. Suggested that that's all well trusted and and you know we're very privileged to be in that position where that, where, you know, the general public do trust us, so we, we don't want to lose that trust either, so we need to stay up to date to make sure that we're doing the absolute best for the animals.
Thank you for the opportunity of of having us come along and talk about this important topic. Well, it's such an important topic and I think it's great that we're we're talking about it and we're highlighting it over. A few different podcast episodes with the Amnesty and all those important things that are going on, showing that this isn't just a veterinary problem, it's something that we have to work with the medics and the farmers and everybody with.
Thank you so much Jill, thanks, Tim. I know time is precious for both of you and I really appreciate you taking time to speak to us today. This was Anthony Chadwick from the webinar vet, and this was Vet Chat.
Take care, bye bye.
