Assessment of antimicrobial stewardship practices in small animal veterinary hospitals: A cross-sectional survey

Introduction

Few challenges in modern medicine unite human and veterinary health professionals as squarely as antimicrobial resistance. The World Health Organisation has designated AMR among the top ten global public health threats, and the veterinary profession-responsible for an estimated 30 % of total antimicrobial consumption in the United Kingdom-faces mounting pressure to demonstrate responsible prescribing [1] . In companion animal practice, the stakes are uniquely complex: veterinarians must balance individual patient welfare against population-level resistance concerns, often under direct pressure from owners who equate antibiotic prescriptions with quality care [2] . Antimicrobial stewardship encompasses a suite of coordinated strategies-prescribing guidelines, culture-guided therapy, dose optimisation, treatment duration limits, and prescriber education-designed to improve antimicrobial use and minimise the emergence of resistance [3] . In human hospitals, AMS programmes have reduced inappropriate prescribing by 20-40 % without worsening patient outcomes [4] . In veterinary medicine, the evidence base is thinner but growing, and professional bodies including the BVA, the Federation of Veterinarians of Europe, and the American Veterinary Medical Association have all issued calls for structured AMS adoption [5] . Several UK surveys have explored antimicrobial prescribing patterns in farm animal and equine practice, but small animal hospitals have received less attention [6] . A 2018 survey by Mateus et al. found that 27 % of antimicrobial prescriptions in first-opinion small animal practice were classified as inappropriate, with empirical broad-spectrum use and inadequate treatment durations as the main concerns [7] . Whether the intervening years of professional advocacy and guideline development have shifted practice is unclear. This research aimed to evaluate the current state of AMS knowledge, attitudes, and practices among small animal veterinarians in the UK, identify predictors of higher AMS scores, and characterise the principal barriers to guidelineadherent prescribing. The expectation was that while awareness of guidelines would be high, actual implementation of structured AMS programmes would lag behind, particularly in smaller practices with fewer resources.

Material and Methods Material

A cross-sectional online survey was distributed to 312 small animal veterinary hospitals across England, Scotland, and Wales between March and September 2024. Practices were identified through the Royal College of Veterinary Surgeons (RCVS) register and stratified by region and practice size (solo practitioner, 2-3 veterinarians, 4-6, 7-10, and 11+ veterinarians). The survey link was emailed to practice managers with a request to forward it to all veterinary surgeons; two reminders were sent at four-week intervals. The questionnaire, developed in consultation with the BVA AMS taskforce and piloted with 12 veterinarians, comprised 42 items organised into four sections: demographics and practice characteristics (10 items), AMS knowledge (15 multiple-choice items scored 0-100), attitudes toward stewardship (10 Likert-scale items), and self-reported prescribing practices (7 items). The survey was administered via Qualtrics (Provo, UT, USA) and took approximately 15 minutes to complete. The research was coordinated from the Centre for Veterinary Antimicrobial Stewardship at the Royal Veterinary College, London (51°32′N, 0°04′W; maritime temperate climate, Cfb, Köppen). The Centre serves as a national resource for AMS training, research, and policy development in the UK veterinary sector. Eligible respondents were registered veterinary surgeons (MRCVS or equivalent) currently practising small animal medicine for at least 20 hours per week. Locum veterinarians, veterinary nurses, and those working exclusively in referral or emergency settings were excluded to maintain a primary-care focus.

Methods

AMS knowledge scores were calculated as the percentage of correct answers out of 15 questions, scaled to 0-100. Attitude scores were computed as the mean of 10 Likert items (1 = strongly disagree to 5 = strongly agree). Bivariate associations between AMS score and continuous predictors were assessed by Pearson correlation; categorical predictors were compared using independent t-tests or one-way ANOVA. Multivariable linear regression identified independent predictors of AMS score. Barrier frequencies were summarised as proportions. All analyses used R v4.3.2; significance was set at p<0.05.

Ethical considerations

The research received ethical approval from the Royal Veterinary College Ethics and Welfare Committee (Reference No. URN 2023-0184-3, dated 22 January 2024). Participation was voluntary, anonymous, and based on informed consent obtained through a mandatory information page preceding the survey. No personal identifiers were collected.

Results

Comprehensive interpretation

The data reveal a profession that is aware of the antimicrobial resistance problem and familiar with published guidelines, but that has not yet translated awareness into systematic practice change. The mean AMS score of 58 suggests room for improvement in core knowledge, and the finding that only one in three hospitals has a written policy indicates that stewardship remains ad hoc in most settings. The strongest modifiable predictors-CPD participation and written policiespoint directly to where interventions should be targeted. The barrier analysis adds nuance: client pressure and empirical habit are behavioural challenges that guidelines alone cannot address, while diagnostic cost is a structural issue that may require subsidisation or point-of-care innovation.

Discussion

The finding that only 34.7 % of UK small animal hospitals operate under a formal AMS policy is concerning, given that professional bodies have been advocating for such policies for over a decade [5] . This figure is, however, consistent with the limited data available from other European countries: a Dutch survey reported written policies in 29 % of companion animal practices, and a German study found 38 % [8,9] . The international consistency of these low figures suggests that the barriers are structural and behavioural rather than unique to any one regulatory environment. The 8.7-point knowledge advantage associated with AMS CPD attendance is perhaps the most actionable finding. Unlike years of experience or hospital size-which are not easily modified-CPD participation is directly amenable to professional and regulatory intervention. Making AMSspecific CPD a mandatory component of annual licensing requirements, as has been proposed by the RCVS, could close much of the knowledge gap. The existing voluntary approach clearly reaches the already motivated: 57 % of respondents had attended AMS CPD, and these individuals scored substantially higher. Client pressure emerged as the single largest barrier to guideline-adherent prescribing. This echoes findings in human medicine, where patient demand for antibiotics has been shown to increase prescribing by 10-20 % [10] . In veterinary practice, the dynamic is complicated by the financial transaction: owners paying directly for care may perceive an antibiotic prescription as tangible value for their consultation fee, and veterinarians may feel commercially pressured to comply. Communication training that equips veterinarians to explain why antibiotics are not always necessary-and to offer alternative management plans-should be a core component of AMS education [11] . The use of critically important antimicrobialsfluoroquinolones (38.7 %) and third-generation cephalosporins (29.8 %)-without prior culture and sensitivity testing is a specific area of concern. These drug classes are designated as highest priority critically important antimicrobials by the WHO, and their empirical use in veterinary practice has been directly linked to the emergence of resistant Escherichia coli and methicillin-resistant Staphylococcus pseudintermedius in companion animals [12] . Shifting from empirical to culture-guided prescribing for these classes should be a primary stewardship target, supported by faster and cheaper in-clinic diagnostic options.

Conclusion

This research set out to evaluate the current state of antimicrobial stewardship in UK small animal veterinary practice. The results reveal a profession that recognises the problem of antimicrobial resistance, is broadly aware of prescribing guidelines, but has not yet built the institutional structures-written policies, mandatory education, affordable diagnostics-needed to translate awareness into consistent practice change. Two practical recommendations emerge directly from the data. First, making AMS CPD a mandatory annual requirement for RCVS registration could substantially raise baseline knowledge across the profession; the 13-point score difference between CPD attendees and non-attendees makes a compelling case. Second, reducing the cost barrier to culture and sensitivity testing-whether through subsidised rapid diagnostics, in-clinic culture systems, or insurance coveragewould address one of the most commonly cited obstacles to guideline-adherent prescribing. Several avenues for future investigation follow. Linking selfreported practices to actual prescription audit data would provide a more objective measure of stewardship compliance. Evaluating the effectiveness of specific AMS interventionssuch as prescribing decision-support software, peer benchmarking, or client-facing educational materials-in a randomised controlled trial design would build the evidence base for investment in these tools. And extending the survey to emergency, referral, and mixed-practice settings would capture the full spectrum of companion animal antimicrobial use in the UK.

Acknowledgement

Acknowledgements Funding sourcesThis research was supported by the Veterinary Medicines Directorate (VMD) under its antimicrobial resistance surveillance programme (Grant No. VMD-AMR-2023-SC07). No industry funding was received.

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