A first look at perceptions and practices of brazilian veterinarians on antimicrobial use and resistanceABSTRACT
Veterinarians play a critical role in antimicrobial stewardship, balancing the need for effective treatment with the growing threat of antimicrobial resistance. This study explores the factors influencing veterinarian antimicrobial prescription behavior, including clinical decision-making, professional experience, and external pressures. Using a cross-sectional survey distributed from February to August 2022, data were collected from 46 veterinarians regarding their prescribing habits, awareness of antimicrobial resistance (AMR), and continuing education participation. The results indicate that diagnostic tests and clinical signs are the primary drivers of antimicrobial selection with penicillin, sulfonamides and quinolones being the most frequently prescribed classes. While most respondents acknowledge the rising prevalence of AMR, they often attribute responsibility to other sectors. Continuing education significantly impacts prescribing behavior, with trained veterinarians demonstrating greater caution in their choices. Challenges in client communication remain a key barrier to effective antimicrobial stewardship. These findings highlight the need for enhanced educational initiatives, improved diagnostic accessibility, and strategic interventions to ensure responsible antimicrobial use in veterinary practice.
Keywords:
antimicrobial stewardship; antimicrobial resistance; companion animals
RESUMO
Os médicos-veterinários desempenham um papel fundamental na administração responsável de antimicrobianos, equilibrando a necessidade de tratamentos eficazes com a crescente ameaça da resistência antimicrobiana. Este estudo explora os fatores que influenciam o comportamento de prescrição de antimicrobianos por veterinários, incluindo tomada de decisão clínica, experiência profissional e pressões externas. Utilizando-se um inquérito transversal distribuído entre fevereiro e agosto de 2022, foram coletados dados de 46 veterinários sobre seus hábitos de prescrição, percepção sobre resistência antimicrobiana e participação em educação continuada. Os resultados indicam que exames diagnósticos e sinais clínicos são os principais determinantes da seleção de antimicrobianos, com penicilinas, sulfonamidas e quinolonas sendo as classes mais frequentemente prescritas. Embora a maioria dos respondentes reconheça o aumento da prevalência de RAM, frequentemente atribuem a responsabilidade a outros setores. A educação continuada exerce impacto significativo no comportamento de prescrição, com veterinários treinados demonstrando maior cautela em suas escolhas. Desafios na comunicação com os tutores permanecem como uma barreira importante para a implementação eficaz da gestão de antimicrobianos. Esses achados destacam a necessidade de ampliar iniciativas educacionais, melhorar o acesso a métodos diagnósticos e implementar intervenções estratégicas para assegurar o uso responsável de antimicrobianos na prática veterinária.
Palavras-chave:
administração de antimicrobianos; resistência antimicrobiana; animais de companhia
INTRODUCTION
Antimicrobial resistance is a global threat to human and animal health and represents one of the greatest challenges of this generation. The exposure of microorganisms to antimicrobials is considered the most important factor in the emergence of resistance, and when the use of antimicrobials is reduced or eliminated, a decrease in the prevalence of resistant isolates may occur (Endale et al., 2023).
In Brazil, with a population of 215 million, the Federal Council of Veterinary Medicine recorded 166,000 active professionals by the end of 2022. According to the Ministry of Education, there were 536 active undergraduate Veterinary Medicine programs. This makes Brazil the country with the highest number of veterinary professionals and courses in the world (Wouk et al., 2023). Veterinarians are responsible for prescribing and overseeing the use of antimicrobials in animals (Van Boeckel et al., 2015). Therefore, addressing the behavior of these professionals in prescribing antimicrobials for animals is crucial. A variety of extrinsic and intrinsic factors beyond scientific knowledge and clinical evidence influence veterinarians. These include antimicrobial preferences and professional experience; perceived antimicrobial efficacy; ease of administration to the patient; perceived owner compliance; animal characteristics; biosecurity measures; cost of diagnostic tests; and even certain social norms. Research linking the frequency of antimicrobial use across different types of veterinary practice is essential for the success of international and national efforts to control antimicrobial resistance (Norris et al., 2019).
Understanding the factors that influence veterinary prescribing behavior and their perceptions can contribute to a better understanding of the AMR problem. It has been reported that antibiotic prescribers tend to externalize the concept of who is most responsible for AMR, attributing greater responsibility to other individuals (e.g., other veterinarians) and professional sectors rather than themselves (Zhuo et al., 2018). Within the veterinary sector, there may be significant variation in "blame attribution" due to the diverse nature of the species treated and the general stratification of the workforce. The social role of the animal is also likely important: whether it is a companion animal or an economic commodity and component of the food chain. To ensure the success of national and international efforts to reduce AMR, it is essential to simultaneously compare the frequency of antimicrobial use across different types of veterinary practice and directly relate this to factors influencing prescribing behavior (Norris et al., 2019).
This study aimed to explore the perceptions, practices, and factors influencing veterinarians antimicrobial prescription behavior, with a focus on understanding how clinical, diagnostic, and external factors shape decision-making.
ETHICAL ASPECTS
The study was approved by the Ethics Committee under number 146397/2020.
MATERIAL AND METHODS
This study employed a cross-sectional survey design to assess the perceptions and practices of veterinarians regarding the use of antimicrobials and antimicrobial resistance. The survey was distributed electronically, and participation was voluntary and anonymous.
Data collection took place between February and August 2022, and a structured questionnaire was developed using Google Forms® and distributed to veterinarians from Rio de Janeiro state. The questionnaire was based on previous studies (Gibbons et al., 2013; Visschers et al., 2015; Hardefeldt et al., 2018; Norris et al., 2019) and collected data on the following key areas:
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Demographic information: Gender, age, highest academic degree, and species treated.
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Clinical Practice: Number of consultations per week, situations in which antimicrobials are prescribed (therapeutic, prophylactic, or subtherapeutic), and clinical signs prompting antimicrobial use.
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Antimicrobial Prescription Practices: Types of antimicrobials prescribed, routes of administration, and factors influencing prescription decisions (e.g., clinical signs, culture results, client expectations, risk of resistance).
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Perception of Antimicrobial Resistance: Awareness of increasing AMR, perceived contributors to resistance, and challenges in communicating with pet owners.
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Continuing Education: Participation in training programs focused on antimicrobial use and AMR in the past three years.
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Support Measures: Perceived usefulness of measures to support appropriate antimicrobial prescription (e.g., education, public awareness, rapid diagnostic tests).
After data collection, the responses were exported from Google Forms® to a Microsoft Excel® spreadsheet for organization and analysis.
Descriptive statistics were used to summarize the demographic and clinical characteristics of the respondents. Frequencies and percentages were calculated for categorical variables (e.g., gender, highest degree), while measures of central tendency (mean, median) and dispersion (range, standard deviation) were used for numerical variables (e.g., age, number of consultations per week).
RESULTS
The demographic data showed that most respondents were female and held a bachelor degree, followed by specialization, master, and doctorate. Most veterinarians treated dogs and cats (93.47%), with smaller proportions attending birds (13.04%), reptiles (10.86%), ruminants (4.34%), equines (2.17%) and wild animals (2.17%). Weekly consultations varied, with 34.8% seeing 11-20 patients, 32.6% handling 1-10, 21.7% managing 21-30, and 10.9% exceeding 31 consultations per week. Table 1 details the demographic profile of the respondents.
Antimicrobials were prescribed therapeutically by nearly all respondents (44/46 - 95%), primarily for systemic signs (55%), enteric conditions (35%), respiratory issues (30%), and dermatological infections (25%). Penicillins, notably amoxicillin and ampicillin, were the most prescribed antimicrobial class (97.73%), followed by sulfonamides (59.09%), quinolones (45.45%) and tetracyclines (40.91%). Prophylactic use was less common and penicillins (48.48%) and tetracyclines (27.27%) were the preferred choices (Table 2). Oral administration dominated (84.6%), though intravenous (10.9%) and topical routes (4.5%) were also reported. Decision-making on whether to prescribe antimicrobials relied heavily on clinical signs (91.3% strong influence + moderate influence) and culture results, whereas client expectations had minimal impact. Tab. 3 presents the correlation between multiple factors and their impact on antimicrobial prescription decisions.
Antimicrobial classes prescribed by veterinarians, including therapeutic and prophylactic use
Factors influencing antimicrobial prescription decisions among veterinarians, including level of influence
A total of 43.47% of respondents perceived a rise in antimicrobial-resistant infections, particularly among younger veterinarians (75% of those under 30 years) and those holding advanced degrees (80% of master or doctoral degree holders). In contrast, the absence of an increase in antimicrobial-resistant infections was more frequently reported by practitioners aged over 30 years (57.7%) and those with only undergraduate qualifications (53.8%). Contributors to resistance included overuse in general practice (86.9%), unregulated global use (84.8%), usage in human hospitals (82.6%) and companion animal care (67.4%). 24 respondents (52.2%) indicated at least one antimicrobial or class they avoid or hesitate to prescribe, while 22 (47.8%) reported no such concern.
The most frequently mentioned antimicrobial was meropenem, cited by ten respondents. Ceftriaxone followed, with six mentions, often associated with concerns about indiscriminate use. Fluoroquinolones, including marbofloxacin, enrofloxacin, and general references to the class, were mentioned by five respondents. Three participants expressed hesitation in using cefovecin. Additionally, two respondents referred more broadly to carbapenems such as meropenem and imipenem, while others pointed to sulfonamides, or expressed general discomfort with broad-spectrum or recently released antimicrobials.
A few responses included more reflective comments, highlighting a reluctance to use certain antimicrobials as a first-line therapy or criticizing what was perceived as the indiscriminate use of drugs like ceftriaxone. Other individual mentions included cefalexin, metronidazole, tetracyclines, and penicillins. These findings reflect a notable level of awareness among veterinary professionals regarding the impact of antimicrobial use on resistance development, particularly regarding drugs considered critical for human medicine. Communication challenges with pet owners were widespread (82.6%), often due to poor understanding of protocols or non-adherence to recommendations.
Continuing education influenced practice: 56.5% had attended AMR-focused training in the past three years, primarily through lectures (65.4%) or online courses (65.4%). Veterinarians with such training were more likely to prioritize resistance risks (69.2% vs. 60%). Respondents emphasized the need for access to information related to antibiotic resistance (76%), public awareness campaigns (71.7%) and antimicrobial stewardship education (67.4%) as key support measures, while restrictive policies (e.g., mandatory specialist approval) garnered less support (15.2%). Qualitative feedback highlighted demands for stricter prescription regulations, client education to reduce unnecessary use, and interdisciplinary collaboration to address resistance holistically.
DISCUSSION
The findings of this study provide a comprehensive overview of antimicrobial prescription practices among veterinarians and their perceptions regarding antimicrobial resistance (AMR). The results align with existing literature and emphasize critical areas in which veterinary antimicrobial stewardship could be improved.
Diagnostic results and clinical signs were the primary factors influencing antimicrobial prescription decisions, a finding consistent with previous research by Norris et al. (2019). This suggests that veterinarians prioritize clinical evidence in their decision-making process, although empirical treatment remains notable. Notably, the preference for penicillins, quinolones and tetracyclines as the most frequently prescribed antimicrobial classes, in both therapeutic and prophylactic practices aligns with Galarce et al. (2021), who reported similar trends in Chilean companion animal veterinary practices. However, our findings also indicate a degree of hesitation in prescribing higher-risk antimicrobials, such as carbapenems and third-generation cephalosporins, reflecting a growing awareness of AMR concerns within the profession (Goggs et al., 2021).
The high level of consideration given to previous antimicrobial use aligns with established antimicrobial stewardship principles, which emphasize the importance of avoiding repeat or inappropriate use of antimicrobials that may contribute to resistance selection. Prior exposure to antimicrobials can alter microbiota, select for resistant organisms, and affect the efficacy of subsequent treatments (Caneschi et al., 2023). Therefore, reviewing the history of antimicrobial therapy is critical for selecting effective and appropriate agents, minimizing resistance risks, and improving patient outcomes.
Beyond prescribing patterns, the clinical context of antimicrobial use provides additional insight into therapeutic decision-making. The predominance of systemic, enteric, respiratory, and dermatological conditions as indications for treatment highlights the heterogeneity of clinical presentations that require antimicrobial therapy. This diversity necessitates careful drug selection, integrating patient history, prior response to therapy, and the risk of clinical deterioration. Although penicillins, sulfonamides, and quinolones remain common therapeutic choices, the hesitancy to prescribe carbapenems and third-generation cephalosporins demonstrates alignment with contemporary stewardship guidelines, which emphasize restricting “reserve” antimicrobials to cases where first-line options are ineffective (Schmerold et al., 2023). Furthermore, the predominance of oral administration, with limited use of intravenous and topical routes, indicates that therapeutic decisions are shaped not only by clinical factors but also by practicality in outpatient settings and the characteristics of the patient population. Together, these elements reflect how veterinarians balance clinical demands, therapeutic feasibility, and stewardship responsibilities when managing infections (Caneschi et al., 2023).
A significant aspect of this study was the impact of continuing education on antimicrobial prescription behavior. Veterinarians who had participated in AMR-focused training were more likely to consider resistance risks in their prescription decisions. This corroborates findings from Mangesho et al. (2021), who emphasized the necessity of stewardship training, particularly in regions with weak regulatory frameworks. The high level of support among respondents for educational initiatives and rapid diagnostic tools underscores the professional willingness to engage in evidence-based antimicrobial use strategies (Allerton et al., 2021).
Challenges in client communication were also reported, with many veterinarians indicating difficulties in conveying the importance of responsible antimicrobial use to pet owners. This issue has been documented in previous research, where pet owners often fail to adhere to prescribed treatment regimens due to misconceptions or lack of understanding (Zhuo et al., 2018). Improved client education strategies, such as clear communication on treatment adherence and AMR risks, are necessary to bridge this gap.
Comparisons with studies in other contexts, such as Maasai pastoralist practices described by Mangesho et al. (2021), further illustrate the complexity of antimicrobial prescription behaviors. While Maasai livestock keepers largely rely on self-treatment and avoid consulting veterinary professionals, our study respondents showed a stronger inclination toward evidence-based prescription practices. This contrast underscores the importance of tailored AMR interventions that consider cultural and structural differences in veterinary medicine. A similar need for context-specific understanding was highlighted in a nationwide study on Chilean companion animal veterinarians (Galarce et al., 2021). The study revealed that, although the link between antimicrobial use and resistance is well established, information on antimicrobial use in companion animals remains limited. The findings showed that critically and highly important antimicrobials were commonly prescribed, especially for conditions like pyoderma, otitis, and abscesses. Notably, only 15% of veterinarians reported using laboratory diagnostic tools, despite 67% being aware of official antimicrobial classification systems. These results emphasize the gap between knowledge and practice and highlight the importance of implementing guidelines and regulations that reflect both clinical realities and public health priorities.
Despite the valuable study insights, certain limitations must be acknowledged. The relatively small sample size may not fully capture the diversity of antimicrobial prescription behaviors across different veterinary settings. Additionally, self-reported data may be subject to response biases, particularly concerning socially desirable answers regarding AMR awareness and stewardship practices. Future studies should consider larger, more representative samples and potentially incorporate direct prescription data to corroborate self-reported behaviors (Goggs et al., 2021). Furthermore, integrating antimicrobial stewardship guidelines, such as those assessed in European veterinary practice (Allerton et al., 2021), could enhance adherence to best practices (Allerton et al., 2021).
In summary, the data paints a picture of a profession grappling with the dual pressures of clinical demands and resistance risks. While clinical signs and diagnostic results drive decision-making, younger, highly educated veterinarians exhibit heightened awareness of resistance trends. Oral penicillins, sulfonamides, and quinolones remain therapeutic choices but concerns about carbapenems and cephalosporins reflect caution toward high-risk agents. Communication gaps with clients and a preference for education over restriction underscore the need for strategies that balance practicality, compliance, and stewardship. Despite the relatively small number of responses, this study provides valuable insights into the factors influencing antimicrobial prescription practices and highlights critical areas for intervention, such as education, diagnostics, and client communication. These findings serve as an important starting point for more robust, large-scale studies that can further explore these issues and inform targeted strategies to combat antimicrobial resistance. These findings align with global AMR challenges, emphasizing the urgency of tailored interventions in veterinary practice to mitigate resistance while maintaining therapeutic efficacy.
CONCLUSION
Our study provides valuable insights into antimicrobial prescription practices among veterinarians and their perceptions of antimicrobial resistance. Diagnostic results and clinical signs are the primary determinants of prescribing decisions, while concerns over resistance influence the use of high-risk antimicrobials like carbapenems and third-generation cephalosporins. Younger and highly educated veterinarians show greater awareness of AMR trends, underscoring the impact of continuing education. Communication challenges with clients remain a significant hurdle in promoting responsible antimicrobial use. Future efforts should focus on strengthening veterinary stewardship programs, enhancing rapid diagnostic tools, and implementing targeted educational campaigns. Addressing these key areas will be crucial for mitigating AMR risks while maintaining effective treatment options in veterinary medicine.
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The research data are available upon request.
