Animals & MRSA

Management of MRSA septic B arthritis in a dog using a gentamicin impregnated collagen sponge

Methicillin-resistant Staphylococcus aureus septic arthritis occurred in a dog following elective joint surgery for cranial cruciate ligament rupture. Resolution of the infection was assisted by using a surgically implanted absorbable gentamicin-impregnated sponge. M. R. OWEN, A. P. MOORES* AND R. J. COE

Journal of Small Animal Practice (2004) 45, 609—612

Department of Companion Animal Studies, University of Bristol, Langford, Bristol BS4O 5DU

*Department of Veterinary Clinical Sciences, The Royal Veterinary College, Hawkshead Lane, North Mimms, Hatfield, Hertfordshire

INTRODUCTION

Joint sepsis is a serious and potentially debilitating disease which can occur as a complication of articular surgery in dogs (Bennett and Taylor 1988, Marchevsky and Read 1999). The clinical signs of acute disease can result in severe disability; but the majority of joint infections in dogs are treated and have a good outcome, using appropriate orally administered antibactertial therapy, providing treatment commences before extensive joint damage has occurred (Bennett and Taylor 1988).

However, chronic infections and infected joints in which there is intra-articular non-absorbable suture material may require surgical intervention for resolution (Marchevsky and Read 1999).

The use of antibiotic-impregnated polymethyl-methacrylate (PMMA) beads has proved highly effective in the management of localised bone and soft tissue infections in humans (Henry and Galloway 1995), and in a single dog an indolent infection was successfully treated using gentamicin impregnated PMMA beads (Brown and Bennett 1988).

Using local antimicrobial drug delivery systems, high tissue concentrations of antimicrobials can be achieved without resulting in toxic levels (Dernell and others 1998).

However, a second surgery is usually necessary to retrieve the implants following resolution of infection (Tobias and others 1996). Biodegradable antimicrobial drug delivery systems have been evaluated in the management of orthopaedic infections (Wei and others 1991) and used clinically in humans. More recently, gentamicin-impregnated-collagen sponges (GIGS) have been used for the successful management of septic arthritis in cattle (Hirsbrunner and Steiner 1998, Steiner and others 1999).

While a variety of bacteria have been isolated from septic joints in dogs, the most commonly isolated causal agents are Staphylococcus intermedius and 3 haemolytic Streptococcus species (Bennett and Taylor 1988). Staphylococcus aureus is rarely isolated from canine joints but it is commonly isolated from infected joints in horses (Moore and others 1992) and, in a single horse wound, infection with methicillin-resistant S aureus (MRSA) has been reported (Hartmann and others 1997).

In dogs, MRSA infection has previously been reported in only 11 cases from three teaching hospitals (Tomlin and others 1999); joint sepsis was a complication of surgery in three of these cases.

This case report describes the identification of MRSA infection in a dog following stifle surgery, and the successful elimination of the infection with the assistance of a GIGS.

CASE HISTORY

Four weeks after a stifle arthrotomy and the placement of an extracapsular mono- filament nylon suture for cranial cruciate ligament rupture, a four-year-old, female neutered English bull mastiff presented with marked right pelvic limb lameness. Routine haematology and biochemistry analyses performed prior to surgery had identified elevated urea (8.2 mmol/litre; reference range 2.0 to 7.0 mmol/litre), creatinine (156 pmol/litre; reference range 100 to 133 pmol/litre) and phosphate (1.46 mmol/litre; reference range 0.75 to 1.25 mmol/litre). On the basis of the serum biochemistry, and in the light of ultrasonographic findings, urinalysis and neeropsy findings of a sibling which had renal failure, a presumptive diagnosis of familial renal dvsnlasia was made.

NB It has not proved possible to reproduce the tables and illustrations that appeared with this article

On clinical examination, there was a pyrexia of 39•80C and the right stifle was effused and painful. Radiographs of the right stifle, obtained under sedation, identified periarticular soft tissue swelling and stifle effusion (Fig 1). A joint fluid sample (Fig 2) revealed a nucleated cell count of 60.8 X 109/litre, of which 92 per cent were neutrophils. Bacterial culture produced a scanty growth of Pseudomonas aeruginosa (Table 1). Systemic antibacterial therapy was instituted using 10 mg/kg enrofloxacm (Baytril; Bayer), orally once daily, and a postoperative course of oral meloxicam (Metacam; Boeinger Ingleheim) was continued at a dose rate of 0.1 mg/kg.

Following the institution of antibacterial therapy, there was an initial improvement in clinical signs. However, at re-examination two weeks later, marked lameness with stifel swelling and pain were again evident. A joint fluid sample taken under general anaesthesia was turbid with low viscosity. The cell count was 78.3 X 109/litre, of which 95 per cent were neutrophils, and intra- and extracellular cocci were identified on microscopic examination of the fluid. A subtotal synovectomy was performed and the extracapsular monofilament nylon ‘stabilising’ suture used in the original cranial cruciate ligament rupture surgery was removed.

The stifle was lavaged with 5 litres of sterile saline using a pulsatile lavage system and a ‘closed system’ drain was placed within the stifle joint using fenestrated tubing (Bennett and Taylor 1988). Bacterial culture of the joint fluid produced a profuse growth of S aureus, and scanty growths of Escherichia coli and an anaerobic bacterial species that was not characterised further (Table 1).

Postoperatively, opioid analgesia was given for 24 hours in addition to meloxicam, as previously. Twice daily 20 mg/kg clavulanate potentiated amoxycillin (Synulox; Pfizer) was given orally, with 20 mg/kg oral metronidazole (Alpharma) once daily in addition to enrofloxacin, as previously. The stifle and the drainage system was managed with sterile dressings and, using sedation, the stifle was flushed with sterile saline once daily for five days. After an additional 10 days, there was minimal clinical improvement and repeat joint fluid analysis revealed a cell count of 144 X 109/litre (90 per cent neutrophils). Bacterial culture and sensitivity identified a multidrug-resistant S aureus (Table 1).

Further sensitivity testing of the isolate at the Public Health Laboratory, Bristol, identified methicillin resistance (Table 1). In order to deliver high levels  antimicrobial agent to the joint, intra-articular antibacterial delivery was administered using a GICS (2 mg gentamicin) (Collatamp G; Schering-Plough).Joint fluid aspiration from the infected stifle revealed a large volume of turbid joint fluid. The joint was debrided and lavaged with saline prior to sponge placement. Postoperatively, systemic antimicrobial therapy was switched to 5 mg/kg gentamicin (Pangram; Bimeda), administered intravenously once daily for five days (Brown and Bennett 1988), while giving maintenance intravenous fluids and 10 mg/kg clindamycin (Antirobe; Pfizer), orally twice daily for four weeks.

For two days postoperatively, opioid analgesia was administered as needed, in addition to meloxicam for analgesia. Following institution of this treatment regimen, there was a progressive improvement in limb function. Systemic gentamicin therapy was discontinued after five days in order to reduce the chance of iatrogenic renal damage. Serum urea (6.3 mmol/litre) and creatinine (124 mmol/litre) indicated no evidence of drug-induced renal damage.

Barrier nursing methods (Bennett and others 1992) were used during the hospitalisation period in order to minimise risk to personnel and to other hospitalised patients. Four weeks later, the lameness was markedly improved and signs of stifle discomfort were completely resolved. Repeat joint fluid analysis revealed a cell count of 0.8>(109/litre consisting predominantly of mononuclear cells and lymphocytes). Bacterial culture was negative. Twelve months later, there had been no recurrence of clinical signs.

DISCUSSION
Infection is a potential complication of any surgical procedure and infection rates of 2.5 (Vasseur and others 1988) to 15.6 per cent for orthopaedic procedures (Whittem and others 1999) have been reported in veterinary teaching hospitals. Surgery is a risk factor for the development of septic arthritis, but larger breeds of dogs appear to be particularly predisposed to joint sepsis after arthrotomy (Bennett and Taylor 1988).

MRSA infection is a rarely reported cause of infection in companion animals (Hartmann and others 1997, Tomlin and others 1999). In humans, MRSA infections are a cause for concern because of increasing prevalence, the morbidity of infection and the costs associated with efficacious treatments (Wenzel and others 1991).

Furthermore, the treatment options available are decreasing as further resistance traits develop. Human clinical MRSA infections are usually preceded by colonisation that occurs without adverse effects (Bonten and Weinstein 1996). MRSA infections in pet owners have been associated with MRSA colonisation in their pets (Scott and others 1988, Cefai and others 1994, Manian 2003) and, consequently, an MRSA-infected pet may potentially pose health risks to its owners.

The dog described in this case was hospitalised and barrier nursing methods were used to prevent transmission of MRSA (Bennett and others 1992) in order to reduce the risk of zoonotic spread of the disease to hospital staff or to the dog’s owners. The source of this single case of MRSA infection at the University of Bristol Small Animal Clinic is unknown but chronically colonised hospital personnel can transmit MRSA (Mulligan and others 1993).

As this is the only MRSA infection identified in this clinic to date, it is probable that this infection was from a human source. In a study of 19 cases of septic arthritis, Marchevsky and Read (1999) identified the stifle as the joint most commonly affected in dogs. All 14 of the dogs in this study with stifle sepsis had undergone previous stifle surgery. It was proposed that the stifle joint may be predisposed to infection due to a combination of the large surgical incision frequently used, the long duration of surgery and the related potential for bacterial contamination, and the use of non-absorbable periarticular sutures.

The prognosis for resolution of joint infection is generally good if appropriate antimicrobials, based on bacterial culture and sensitivity, are used (Bennett and Taylor 1988) and if previously placed non-absorbable suture material is removed (Marchevsky and Read 1999). In the case described in this report, indolent bacterial infections occurred despite surgical joint lavage and debridement. In order to improve the chances of eliminating the MRSA infection once it had been identified, intra-articular local antimicrobial delivery was used in addition to appropriate systemic antibacterial therapy, based on culture and sensitivity testing.

Local antimicrobial delivery using PMMA beads achieves higher drug concentrations in the tissue at the site of infection than those achieved using systemic therapy alone and, despite high target tissue concentrations, serum levels do not reach toxic levels (Walenkamp and others 1986). Successful outcomes have been reported using antibiotic-impregnated PMMA beads in indolent joint infections in horses (Holcombe and others 1997), cattle (Butson and others 1996) and in a single dog (Brown and Bennett 1988), but in most cases a second surgery is necessary to retrieve the PMMA beads.

In contrast to PMMA beads, GIGS are absorbed and, in humans, absorption occurs between nine days and three months after implantation (Stemberger and others 1989). Because the gentamicin is neither mechanically nor chemically bound in the Collatamp preparation, its release depends on the rate of collagen breakdown. The relatively rapid rate of gentamicin release which therefore occurs prevents subinhibitory local antibiotic concentrations, which can occur using PMMA beads, and which contribute to bacterial resistance problems (von Hasselbach 1989).

Hence, the GIGS results in prolonged antimicrobial release without the need for future implant retrieval (Steiner and others 1999). Furthermore, the sponge is simple to insert and does not interfere with joint motion. The efficacy of using GIGS alone in the management of joint sepsis is yet to be evaluated and it is currently normal clinical practice to give systemic antibacterial therapy in addition to local antimicrobial delivery (Brown and Bennett 1988, Holcombe and others 1997, Dernell and others 1998, Steiner and others 1999).

Clindamycin was used systemically in the case described here because sensitivity tests indicated susceptibility to macrolides, such as erythromycin and lincomycin. The dog had previously suffered adverse gastro intestinal responses to erythromycin and lincomycin but not to clindamycin. Because the dog in the present report was client-owned and because the bacteria responsible for the infection were sensitive to drugs that could be safely administered systemically, it was not possible to evaluate the efficacy of the GIGS used alone. Further studies of GIGS for the management of indolent joint sepsis in dogs are justified.

Acknowledgements
The authors thank Geoff Werrett for microbiological assistance and Tracey Dewey and John Gonibear of reprographics, University of Bristol, Langford, for illustrative assistance.

References
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DERNELL, W. S., WITHROW, S. J., STRAW, R. C., POWERS, B. E., WEMBER, E. W., JAMESON. V. J.1 WILKINS, R. M. & ALLEN, R. F. (1998) Clinical response to antibiotic impregnated polymethyl methacrylate bead implantation of dogs with severe infections after limb sparing and allograft replacement — 18 cases (1994-1996). Veterinary and Comparative Orthopaedics and Traumatology 11, 94-99

HARTMANN, F. A., TReSTLE, S. S. & KLOHNEN, A. A. 0. (1997) Isolation of methicillin-resistant Staphylococcus aureus from a postoperative wound infection in a horse. Journal of the American Veterinary Medical Association 2±1, 590-592

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HIRSBRIJNNER, G. & STEINER, A. (1998) Treatment of infectious arthritis of the radiocarpal joint of cattle with gentamicin-impregnated collagen sponges. Veterinary Record ±42, 399-402

HOLCOMRE, S. J., SCHNEIDER, R. K., BRAMLHGE, L. R. & EMBERTSON, R. M. (1997) Use of antibiotic impregnated polymethyl methacrylate in horses with open or infected fractures or joints: 19 cases (1987- 1995). Journal of the American Veterinary Medical Association 2±1, 889-893

MANIAN, F. A. (2003) Asymptomatic nasal carriage of mupirocin-resistant, methicillin-resistant Staphylococcus aureus (MRSA) in a pet dog associated with MRSA infection in household contacts. Clinical Infectious Diseases 36, E26-E28

MARCHEVSKY, A. M. & READ, R. A. (1999) Bacterial septic arthritis in 19 dogs. Australian Veterinary Journal 77, 233-237

MOORE. R. M., SCHNEIDER, R. K., KOWALSKI, J., BRAMLAGE, L. R., MECKLENBURG, L. M. & KOHN, C. W. (1992) Horses with musculoskeletal infection during 1979- 1989. Equine Veterinary Journal 24, 450-456

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SCOTT, G. M., THOMSON, R., MALONELEE, J. & RIDGWAY, G. I. (1988) Cross-infection between animals and man — possible feline transmission of Staphylococcus aureus infection in humans. Journal of Hospital In faction 12, 29-34

STEINER, A., HIRSBRUNNER, G., MISEREZ. R. & TSCHUDI, P. (1999) Arthroscopic lavage and implantation of gentamicin-impregnated collagen sponges for treatment of chronic septic arthritis in cattle —14 cases (1995- 1997). Veterinary and Comparative Orthopaedics and Traumatology ±2, 64-69

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WEI, G. X., KOTOURA, Y., OHS, M., YAMAMURO, T., WADA, R., HYON, S. H. & IKRDA, Y. A. (1991) Bioabsorbable delivery system for antibiotic-treatment of osteomyelitis —the use of lactic-acid oligomer as a carrier. Journal of Bone and Joint Surgery — British Volume 73, 246- 252

WENZEL, R. P., NETTLEMAN, M. 0., Josis, R. N. & PFALLER, M. A. (1991) Methicillin-resistaflt Staphylococcus aureus — implications for the 1990s and effective control measures. American Journal of Medicine 91 (Supplement 3b), 5221-5227

WHITTEM, T. L., JOHNSON, A. L., SMITH, C. W., SCHAEFFER, 0. J., COOLMAN, B. R., AVERILL, S. M., COOPER, T. K. & MERKIN, G. R. (1999) Effect of perioperative prophylactic antimicrobial treatment in dogs undergoing elective orthopedic surgery. Journal of the American Veterinary Medical Association 215, 212-216

Methicillin-Resistant Staphylococcus aureus Outbreak in a Veterinary Teaching Hospital

Link: Journal of Clinical Microbiology.

Methicillin-Resistant Staphylococcus aureus Outbreak in a Veterinary Teaching Hospital: Potential Human-to-Animal Transmission Jennifer C. Seguin,1 Robert D. Walker,1,* John P. Caron,1 Wesley E. Kloos,2 Carol G. George,2 Richard J. Hollis,3 Ronald N. Jones,3 and Michael A. Pfaller3

Michigan State University College of Veterinary Medicine, East Lansing, Michigan1; North Carolina State University, Raleigh, North Carolina2; and University of Iowa, Iowa City, Iowa3

Received 22 July 1998/Returned for modification 16 October 1998/Accepted 8 February 1999

    ABSTRACT
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References

During a 13-month period, 11 equine patients visiting a veterinary teaching hospital for various diagnostic and surgical procedures developed postprocedural infections from which methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA) strains were isolated. The S. aureus isolates were identified by conventional methods that included Gram staining, tests for colonial morphology, tests for clumping factor, and tests for coagulase and urease activities and were also tested with the API STAPH IDENT system. Antimicrobial susceptibility tests were performed by the disk diffusion method. The biochemical profile and antibiogram of each isolate suggested that the isolates may have come from a common source. Because MRSA strains are very uncommon animal isolates but are rather common human isolates, a nasal swab specimen for culture was collected voluntarily from five persons associated with equine surgery and recovery in an attempt to identify a possible source of the organisms. MRSA strains were isolated from three of the five people, with one person found to be colonized with two biotypes of MRSA. The MRSA isolates from the people appeared to be identical to the isolates from horses. Further study of the isolates included SmaI and EagI macrorestriction analysis by pulsed-field gel electrophoresis conducted in two different laboratories. The results indicated that both the equine and human isolates were members of a very closely related group which appear to have originated from a common source. On the basis of the pattern associated with the infection, it is speculated that the members of the Veterinary Teaching Hospital staff were the primary source of the infection, although the specific mode of transmission is unclear.

Human-to-Dog Transmission of MRSA | CDC EID

Link: Human-to-Dog Transmission of MRSA | CDC EID.

Human-to-Dog Transmission of Methicillin-Resistant Staphylococcus aureus

Engeline van Duijkeren,*Comments Maurice J.H.M. Wolfhagen,† Adrienne T.A. Box,‡ Max E.O.C. Heck,� Wim J.B. Wannet,� and Ad C. Fluit‡
*Faculty of Veterinary Medicine, Utrecht, the Netherlands; †Isala Clinics, Zwolle, the Netherlands; ‡University Medical Center Utrecht, Utrecht; the Netherlands; and �National Institute of Public Health and the Environment, Bilthoven, the Netherlands

Suggested citation for this article

    Methicillin-resistant Staphylococcus aureus (MRSA) was cultured from the nose of a healthy dog whose owner was colonized with MRSA while she worked in a Dutch nursing home. Pulsed-field gel electrophoresis and typing of the staphylococcal chromosome cassette mec (SCCmec) region showed that both MRSA strains were identical.

The Case

In 2000, a methicillin-resistant Staphylococcal aureus (MRSA) strain was isolated from a patient admitted to a multisite 1,100-bed tertiary-care teaching hospital in the Netherlands. This strain recurred during several outbreaks and spread to a 190-bed nursing home, which is part of the hospital. During a large outbreak in 2003 in the nursing home, 48 patients and 15 nurses were identified as carriers of MRSA, either in their nares, throat, perineum, or a combination of these sites. All MRSA isolates from the outbreaks were sent to the National Institute of Public Health and the Environment (RIVM) for identification and genotyping by pulsed-field gel electrophoresis (PFGE). Most MRSA had the same PFGE pattern, RIVM cluster 35.

In 2003, a 31-year-old female nurse who had psoriasis was identified as an MRSA carrier during the above-mentioned MRSA outbreak. The nurse was treated to eliminate MRSA carriage by applying mupirocin ointment in her nares and washing with a chlorhexidine in ethanol solution for 7 days. Initially she became MRSA-negative but later converted to a carrier state again: samples from her nose, throat, perineum, and skin lesions were taken, and MRSA could be isolated from all sites. She was treated for her psoriasis with topical application of triamcinolonacetonide/tetracycline to minimize the skin lesions and thereafter with oral doxycycline and rifampin to eliminate MRSA. However, after some weeks, she became colonized again at all previously mentioned sites. Screening her home environment showed that her 1-year-old daughter, who also had psoriasis, was colonized in the nose, throat, and skin lesions. The nares, but not the perineum, of their healthy pet dog were also colonized. The dog had not been treated with antimicrobial drugs in the past. Samples from nose, throat, and perineum from the patient's husband were MRSA negative, as were samples from nose, throat, perineum, and skin lesions of the baby's grandmother, who also had psoriasis and took care of the baby when the mother worked.

MRSA in Horses

Link: Entrez PubMed.

J Am Vet Med Assoc. 1997 Sep 1;211(5):590-2

Related Articles, Links

Isolation of methicillin-resistant Staphylococcus aureus from a postoperative wound infection in a horse.

    Hartmann FA, Trostle SS, Klohnen AA.

    Department of Clinical Pathology, School of Veterinary Medicine, University of Wisconsin, Madison 53706-1102, USA.

Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from a postoperative wound infection in a horse. Methicillin-resistant S aureus infections in animals have been reported. In human beings, MRSA is an important cause of hospital-acquired (nosocomial) infections. Infections caused by MRSA respond poorly to beta-lactam treatment, and resistance of MRSA to multiple antimicrobials, including aminoglycosides, macrolides, clindamycin, and tetracyclines, is common. Identification of MRSA by routine susceptibility testing may be difficult; therefore, techniques for MRSA detection should be incorporated by clinicopathology laboratories. Because the number of hospital and community-acquired MRSA infections in human beings is increasing, it seems likely that MRSA infections in animals will also become more frequent.

Pets, Infections & MRSA

Questions re bacterial dermatitis (also called pyoderma)(For info on hot spots see Q3)

Dr. Tim Nuttall BSc BVSc PhD CertVD CBiol MIBiol MRCVS, Senior Lecturer in Veterinary Dermatology

1. How significant is infected dermatitis to the overall health of a dog?
Superficial bacterial skin infections or pyoderma rarely cause significant illness. The clinical signs include itching, pustules, scaling and crusting but affected dogs are usually quite well in themselves. Deep pyodermas, in contrast, can cause fever, malaise and potentially life threatening septicaemia. These are fortunately much less common than superficial infections. Superficial and deep pyodermas, however, are often secondary to an underlying skin disease or immunosuppressive condition that may have a significant impact on the dog’s health.

2. Should infected dermatitis be routinely swabbed for cultures?
More than 95% of superficial pyodermas are associated with Staphylococcus intermedius, which have a fairly predictable antibiotic sensitivity pattern. It is therefore not necessary to perform routine culture and antibiotic sensitivity testing on most cases as they will respond to a sensible choice of antibiotic. Those that should be cultured, however, include: cases that do not respond to an empirical antibiotic as expected; cases that have had multiple antibiotic courses; cases where there is cytological or other evidence that non-staphylococcal bacteria are involved; and any cases that are potentially life-threatening.

3. How can an owner tell when dermatitis is infected?
Surface infections are characterised by itching, hair loss and moist erosions (often called ‘hot-spots’ or ‘pyo-traumatic dermatitis’). Clinical signs of superficial infections include itching, red papules, pustules, scaling (often in a circular ring called an ‘epidermal collarette’), crusting and hair loss. Deep infections cause swelling, ‘boils’ or ‘furuncles’, ulcers, draining sinuses and abscesses (see figures below).

Pyotraumatic dermatitis or hot spot in a dog with itchy ears. The infections is caused by the dog scratching at the affected skin.

Superficial folliculitis with red papules and pustules in a dog with flea allergic dermatitis.

Epidermal collarettes in a dog with a superficial infection on the ventral abdomen.

Deep pyoderma around the muzzle in a mastiff cross.

None of these signs are 100% specific for infections, however, and suspected cases should be examined by a vet.

4. What Is the main treatment for infected dermatitis?
The mainstay of treatment is antibiotics to control the infection. These are usually given systemically but topical antibiotics can be used in localised infections,  e.g. ears, chin, eyes etc. Topical antibacterial shampoos, washes, lotions and creams can be used to augment antibiotics and reduce bacterial populations once the infection is controlled. Pus and other debris should be flushed and cleaned out of ears, wounds, abscesses etc. Foreign bodies or implants should be removed. Most infections, however, will recur unless the underlying cause is diagnosed and treated.

5. Are there alternative treatments to antibiotics?
See Q4 above. There are a number of highly effective shampoos, gels, washes and ear cleaners etc. Autogenous vaccines, made from cultures taken from the affected animal, are sometimes used in idiopathic recurrent pyodermas (i.e. without a known cause). A veterinary surgeon will be able to advise which products would be most suitable for individual cases.

6. Should antibiotics be started before cultures have been analysed?
See Q2 above. Many cases won’t require cultures. In those that do the decision to treat will de-pend on the consequences of any delay.

7. What general rules should owners know about the use of antibiotics in infected dermatitis?
It is difficult to apply rules as every case is different. Generally the antibiotic should be effective against the bacteria involved (although this doesn’t always require culture), be given at the appropriate dose (it is always better to slightly overdose rather than underdose) and be given for long enough (superficial infections usually require three weeks treatment; deep infections may require 6-8 weeks or longer).

8. What questions should an owner as the vet about the dermatitis affecting their pet? The most important to know with recurrent infections is what the underlying cause is, what steps are being taken to diagnose this and what other treatments can be used.

9. How significant is the difference between dermatitis that is also infected and that which is not? Many other skin diseases can trigger bacterial infections. The infections will usually make the underlying condition worse and require treatment but it is most important to diagnose and manage the primary disease.

10. What happens if dermatitis is left untreated? This entirely depends on the disease. Most will get progressively worse and the inflammation, itching etc. can become very distressing for the dog. Some conditions can be eventually fatal.

11. Are there any particular things an owner should make sure to point out to the vet? Owners should make sure that they present their pets promptly, give a full and accurate history including whether the pet (or any close contacts), have been abroad, any contagion to other pets or owners and whether any family members have conditions that leave them vulnerable to infections (e.g. chemotherapy etc.).

12. What precautions (if any) should an owner expect a vet to take when operating on a pet either with infected dermatitis or with a history of that? Surgery may need to be delayed until the infection has been treatment although this may not be possible. Antibiotics and antibacterial shampoos can be used to reduce bacterial contamination of the skin or ears if necessary. Full sterile precautions (including preparation of the surgical site, sterile operating theatre and instruments, hand washing and wearing of sterile gown, gloves, hat and mask) and good post-operative care will minimise the risk of wound contamination.

13. What other infections should pet owners be aware of?
There are a great many of other bacterial, fungal and viral infections ranging from the trivial to serious, but it is beyond the scope of this piece to discuss them all.

14. What other infections have developed resistance to antibiotics?
Any bacteria (and potentially fungal infection, although this is less common) can develop antibiotic resistance. Some resistance patterns are stable and well recognised (e.g. amoxicillin is largely ineffective against staphylococci) and other patterns will be picked up by sensitivity testing. Multiple antibiotic resistance as seen in MRSA and other species such as Pseudomonas is the most worrying problem.

15. How quickly can bacteria develop resistance to antibiotics? It depends on the species of bacteria, the individual situation and the selection pressure they are exposed to. Resistance can occur very quickly, especially in species like Pseudomonas that readily acquire DNA.

16. What lessons should the veterinary world take from the history of MRSA
The main lessons are: don’t rely on antibiotics alone; use antibiotics appropriately; perform cultures and antibiotic sensitivity testing when necessary; and pay attention to hygiene, infectious disease control and sterile surgery. The BVA and BSAVA are taking the issue very seriously but it is also important not to panic: MRSA infections remain rare in animals and is not dangerous to healthy people and pets.

MRSA is carried by less than 1% of healthy humans (although this figure is higher in healthcare workers. The oft-quoted 30% figure refers to methicillin sensitive Staphylococcus aureus. We don’t know the carriage rate in animals. Small scale studies show that it is uncommon but the strains recovered from dogs and cats appear to be the same as those in people. Funding is being sought for large scale epidemiological studies to determine the carriage rate in healthy pets.

MISSION STATEMENT

This website is dedicated to the memory of Bella Louise Moss. Its aims are to:

• Tell the story of Bella’s life, her unnecessary death and the inhumane suffering to which she was subjected
• Develop a source of information that pet owners can access to improve their knowledge of MRSA and other issues concerning the care and treatment of companion animals
• Enable pet owners to have the confidence to challenge poor or negligent care without fear or intimidation
• Campaign to develop enforceable standards of infection control in veterinary premises, and
• Generate understanding within the veterinary profession of the effect of their actions upon owners of companion animals.

We believe that companion animals are as deserving of proper care and treatment from vets as their owners are from the medical profession, and we believe that this can only be achieved through a fundamental change in the institutional culture of the veterinary profession.

Dogs Today on Vet Malpractice

 Vets In Malpractice: Feature by Claire Horton-Bussey

 This is part of an article that appeared in DOGS TODAY, February, 2005

 If a builder rips you off, or his work is shoddy, you can take your case to the appropriate trade federation or the trading standards authority. If you feel that your doctor is incompetent, and your complaint is not being handled adequately, you have recourse to the General Medical Council. If a vet bungles an operation, misdiagnoses a condition, or is otherwise incompetent, you can go to the Royal College of Veterinary Surgeons and get him struck off - right? 

Wrong! The disciplinary system at the RCVS is woefully limited - by its own admission - and has sparked a 42-strong group of disgruntled pet owners to form an action group calling for a complete overhaul to how complaints are handled. Jan Mahoney and Felicity Norton founded the group in 2002. Frustrated at how their own misconduct allegations were handled, they felt helpless, so decided to campaign for a change to the system.

 

Jan, from Bristol, and Felicity, from Cardiff, organised a demonstration of around a dozen disgruntled pet owners outside the RCVS London office, and made history in doing so - it was the first time that placards had been waved outside the College. The number of supporters increased as the campaign grew. A 6,000-signature petition calling for an overhaul to the veterinary disciplinary procedure was handed over to Elliot Morley MP, the then Parliamentary Undersecretary for the Department for the Environment, Food and Rural Affairs, in May 2003. 

When Jan and Felicity realised it was just sitting on a shelf at DEFRA, they asked for it back and arranged for the Queen's secretary to receive it. Now, they are spearheading a new petition, which they hope to present to the Prime Minister. 

Setting up the action group has brought Felicity and Jan into contact with many terrible cases - a vet who performed surgery in his kitchen, with inadequate anesthesia and unqualified support; a vet who kept a dog with a life-threatening pyometra (womb infection) in a cage for more than 18 hours (delegating the surgery, for the next morning, to a junior vet, who didn't feel confident to perform the spay, and who waited until the boss returned - the dog died soon after); a vet who gave a cow wormer to a tiny Yorkie pup, causing it to hemorrhage and die; the list goes on and on. 

Animal Aid, the non-profit making national campaign group, has also been approached by pet owners who do not feel supported by the RCVS. Director Andrew Tyier says, 'The veterinary profession should not be self-regulated by a body whose first concern is not to protect animals but to protect the reputation of vets. It's a closed shop.Cases that have been brought to our attention have been horrifying; stories of callousness and incompetence have been convincing." 

So what is wrong with the current system? Why have so many pet owners lost faith in the RCVS? First, some background information to understand how a complaint is currently managed... If you are not happy with how your complaint has been handled by the vet or practice in question, you should contact the Professional Conduct Department at the RCVS. You are sent a complaint form to fill in, which is then forwarded to the vet in question for a response (you can later comment on the vet's response). Both sides are then put before the Preliminary Investigation Committee, which has the simple job of deciding whether to refer the matter to the Disciplinary Committee.

Your complaint could be deemed unsuitable for referral, in which case, that's formally the end of the matter. The vet could be given advice, asked to give certain undertakings, and/or the complaint could be held open for two years, but the case does not reach the Disciplinary Committee.

The Preliminary Investigation Committee is required to give its reasons for not pursuing a complaint, and these reasons can be subject to review by the courts - however, this can be a potentially costly, time-consuming and emotionally stressful venture. If the Preliminary Investigation Committee decides to refer the case on to the Disciplinary Committee, then it is made public. Before this point, everything is kept confidential, and is in line with the policy of the Crown Prosecution Service, for instance, meaning unfounded accusations cannot ruin a person's reputation or professional standing. 

Once the complaint is in the hands of the Disciplinary Committee, it can decide to strike off, or suspend, a vet. A third option is to postpone judgement, given certain undertakings, as in the case of Dr Ronald Porter, discussed later. Postponement is not technically covered in the current legislation, but the Disciplinary Committee sometimes uses it nevertheless, where the vet concerned is in agreement.

Although there are exceptions, negligence generally falls outside the remit of the Disciplinary Committee - a pet owner has to sue a vet personally in court, but it is a costly procedure. People don't want the price of their dog, or guinea pig, or cat reimbursed, they want to know that other people's pets will be in safe, capable hands.

There are two reasons only why a vet would be struck off by the Disciplinary Committee. The first ground for striking off or suspension is when the vet has been convicted of a criminal offence that, in the opinion of the Disciplinary Committee, renders him unfit to practice veterinary surgery. Being convicted is not a reason per se; the Committee has to take a view on whether the conviction implies unfitness to practice or not. The second reason is if a vet is seen to engage in 'disgraceful conduct'. If a vet is incompetent and a patient dies, it is not necessarily considered 'disgraceful conduct' and he can continue practicing. If a vet is incompetent, a patient dies, and the vet tries to cover up the facts, then that is seen as disgraceful and would be grounds for dismissal.

If the Disciplinary Committee finds the charges against the respondent proven, it may order that person's name to be removed from the Register of Veterinary Surgeons or his registration to be suspended for a specified period. Alternatively, judgment may be postponed for a period of up to two years, or the Committee may make no order but warn the respondent as to future conduct. 

Sometimes judgment may be postponed subject to specified undertakings given by the vet to the Committee. For example, in the case of a Dr Ronald Porter in 2001, who performed major surgery on his kitchen table (as well as failing to provide adequate anesthesia), judgment from the Disciplinary Committee was postponed on the basis that, among other conditions, he didn't perform surgical or anesthetic procedures unsupervised, but should refer them to another veterinary surgeon, and that he take a course of continuing professional development.

Any respondent against whom an order has been made has a right of appeal to the Judicial Committee of the Privy Council. The appeal must be lodged within 28 days after receiving notification of the Committee's order. The order itself does not take effect until after the 28-day period or until any appeal has been heard and determined. During the lengthy review that follows an appeal, the vet can continue practicing. 

When a vet's name is removed from the Register (striking off), they may not practise veterinary surgery. They may apply to have their name restored to the Register after 10 months have elapsed, in which case they must reappear before the Committee to satisfy it that they are fit to return to practice. In the case of a suspension, the vet is similarly debarred from any direct form of veterinary activity until the period of suspension has expired, at which time their name will be automatically restored and they may resume practice.

Need for change

In 2002, the RCVS drew up a consultation document, disseminated to all vets, which reviewed how the Veterinary Surgeons Act 1966 could be updated. It addressed, among other points, how professional conduct can be supervised and how complaints can be addressed. In the document, the RCVS admits the system needs an overhaul: "Most of the powers and duties of the Royal College of Veterinary Surgeons are derived from the Veterinary Surgeons Act 1966. The Act is out of date in many respects." It later goes on to say, 'The Preliminary Investigation and Disciplinary Committees need greater independence and more flexible powers to supervise professional conduct."

This need is great. At the moment, it can strike off, or suspend, a vet. But, as Jeff Gill, from the RCVS external affairs department, points out, "It's quite nuclear. There's nothing in between dropping a bomb or saying nothing can be done. When we update our legislation, we would like a wider range of possibilities, such as the Preliminary Investigation Committee sending someone away with a formal warning or advice. Or conditions could be imposed, so a vet could continue practicing, but subject to certain conditions, such as brushing up on certain skills or having supervision for certain procedures."

Apology and closure

With a broader arsenal at its disposal, the Disciplinary Committee could be far more effective. Given that most disgruntled pet owners currently see no redress for their complaints, a more varied spectrum of penalties would be welcomed. Where, at the moment, a vet is likely to have no action taken against him (as most cases do not reach the Disciplinary Committee stage), in the future he could receive a fine, be ordered to make an apology, be formally admonished, ordered to pay costs or compensation, or to waive, reduce or repay his professional fees, as well as being required to retrain or be supervised for certain procedures. 

Another option under discussion is for there to be a tribunal independent of the College, which would either include veterinary members (necessary, as they have the specialist subject knowledge to investigate cases) or non-veterinary members but with veterinary expert witnesses that can be called for advice where appropriate. Other professions have made significant changes to their ' complaints departments in recent years. For example, the General Dentistry Council has opened up its disciplinary committee to include more lay people. 

In many cases, these proposals/in the consultation document would appease the complainants and would prevent the anger that can swell when they feel that nothing is being done, or that the vet has 'got away with it', without even a rap over the knuckles. However, one crucial area will not be changed - in the current proposals for the new Veterinary Surgeons Act, the RCVS is unlikely to be given powers to adjudicate on allegations of negligence. As is currently the case, the only recourse on these grounds would be personally suing a vet in the courts system, which is prohibitively expensive for most.

Where a vet is suspended, currently 10 months must pass before he can apply to be re-registered with the RCVS, to begin practising again. The consultation document considers a lengthening of the suspension - perhaps up to five years. 

DEFRA consulted on its own proposals to modernise the Act at the end of 2003 and is currently analysing the response. A summary of the comments is available on its website (www.defra.gov.uk/corporate/consult/ vetsurgeons/index.htm). It is too early to say what the new Act will contain, as DEFRA is in continuous discussion with the RCVS still, as well as other key stakeholders, but it is certainly reviewing the current disciplinary procedures, the composition of the statutory committees and disciplinary powers, including the need for greater lay representation on the committees. 

Those waiting for change shouldn't hold their breath, though. DEFRA has bid for a slot in the 2005/6 parliamentary legislative programme, but it is more than likely that there will not be a slot until 2006/7.

The action group is cynical of the proposed changes. Jan has little faith in self-regulation of any sort and believes that an independent ombudsman is the only way forward. Felicity agrees, and would like also to see the establishment of a mediation bureau, where aggrieved pet owners can meet with the vet, together with a trained third party, to sort out any disputes around a table.

Jan and Felicity do not want to appear as 'vet-bashers'. They recognise that the vast majority of vets are competent, professional people - indeed some members of the action group are vets themselves. But they want to protect us all from the minority - those who shouldn't own an animal, let alone operate on one. 

"People make mistakes in every job - it's only human," says Felicity. "But where a vet shows incompetence again and again and again, there has to be action." •

 

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