April 2023

By Deborah Thomson, DVM

Everyday One Health in Small Animal Clinics: More than just ringworm and rabies

In this VETgirl online veterinary continuing education blog sponsored by Blue Buffalo, Dr. Deborah Thomson talks about what veterinary practitioners and veterinary staff need to know about One Health and public health!

Today is your outpatient day. You look at your schedule and see the 14 prebooked appointments with two open slots, reserved for same-day emergencies. You take a deep breath, reach for your coffee, and review the list of client callbacks sitting prominently on the center of your desk. Flipping through the callbacks, your eyes land on Zoomie’s results. Zoomie is a 10-year-old spayed female Golden Retriever Mix that presented yesterday for urinary incontinence in the house, hematuria and pollakiuria. She recently moved to your area and is a new patient. When reviewing her medical history at the time of yesterday’s visit, you saw that she has a murmur and has had a fair number of reported urinary tract infections, but you could not find any urine culture results in the forty pages of faxed-over hand-written notes. You wonder if the most recent urinalysis sample that noted “suspect rods” was collected via free catch or with a cystocentesis. It appeared that no radiographs were done and sometimes the patient received broad-spectrum antibiotics without any urine sampling. On Zoomie’s physical exam, the only two notable findings were that she had a left-sided II/VI holosystolic murmur and a moderately recessed vulva. She left the hospital yesterday without any antibiotics since the urinalysis results were to come back within 24 hours (there is currently no helpful UTI identification equipment like Lexagene at the clinic) and the client did not want to worry about intestinal upset, associated with antibiotic use, in addition to dealing with the hematuria and pollakiuria. Now, you start to look at Zoomie’s labwork in more detail.

The CBC, chemistry and electrolytes are all within normal ranges. The urinalysis shows some isothenuria with a low count of rods and a mildly increased leukocyte count, moderate crystalluria and trace proteinuria. You know that you have only 5 minutes to make one call before you start the madness of your outpatient appointments. Zoomie’s owner answers the phone on the third ring. You start the conversation by saying that the bloodwork looks good overall and there are no obvious issues with Zoomie’s kidneys, but the urine sample is concerning and a urine culture is needed. Since you performed a cystocentesis yesterday, all you need to do is call the lab to add on the urine culture. The owner is upset because he never had to do this before. Why now?? he asks in an irritated manner. You then explain that there is risk of a urinary tract infection but you can’t tell if you would be choosing the correct antibiotic to treat this particular infection; essentially, you’d be “shooting in the dark” and there is a large concern over antibiotic resistance too. What’s that?, he interjects. You explain that when antibiotics are given inappropriately – either in too low a dose, too high a dose, too short a duration or too long a duration, or given when there is no bacterial infection – then future bacterial infections may be harder to treat with the antibiotic. Since Zoomie has had so many doses of antibiotics, there is a high chance that we are dealing with such a resistant infection. That is not only a concern for Zoomie but it also is a concern for the people in the house. How and why would it affect me? he asks indignantly. You explain that when there are bacteria that is extra hard to treat with antibiotics in a shared environment, this may affect people if the bacteria gets into or onto a person. You recall that Zoomie lives with twin toddlers who are actively crawling, you mention that it is best to avoid increasing the risk of having more difficult-to-treat bacteria in the house by giving an antibiotic inappropriately today to help protect the twins. The owner thanks you for the thorough explanation and agrees to have the add-on urine culture and is okay bringing Zoomie back in for further evaluation of abdominal radiographs to check for uroliths as well.

You hang up, write your summary notes under the “client communication” section and then walk over to the appointment area. You see the assistant who has just finished taking a brief medical history and tells you about Finn. Finn is an anxious 8-year-old indoor-outdoor neutered male Domestic Shorthair that is currently hiding in the exam room’s sink and is due for an annual exam including rabies and feline leukemia vaccines. He is brought to you by a couple who is expecting their first child in three months. Fortunately, Finn’s owners remembered to bring in a fresh stool sample and the vet assistant will soon start processing it out to the lab for ova, parasite and giardia testing. You ask if you need cat gloves while your hand is on the doorknob to enter the room and the assistant said you should be fine.

Finn is jet black with green eyes and stands like a statue on the exam table when you perform the physical exam. Everything looks, feels, and sounds good. You review possible vaccine side effects and risk of fibrosarcoma with Finn’s owners and discuss flea and tick prevention. With a new baby expected at home soon, you review ways to create a safe environment for everybody by recommending an oral flea and tick prevention rather than a topical option. Even though it feels like a long way off, eventually the baby will be crawling and it is best to minimize the risk of chemical exposure from a topical ectoparasite medication to a young child. However, you express concern with giving an oral medication to Finn since he is nervous. The clients explain that he has been very easy to give pills to in the past at home and agree to the oral preventative.

You continue to review other new parent topics and explain that stressed cats can sometimes develop signs of Feline Idiopathic Cystitis (FIC) and then you review its signs and possible complications. The now concerned couple ask what can be done to help lower the risk, since Finn had been treated multiple times for FIC over the last few years, and they admit to not having thought about the effect the baby might have on him. You explain a few options that include playing baby sounds from online videos at random hours of the day and night and by building the crib and preparing the baby space slowly over the next few months. You also review that pheromone diffusers exist to alleviate mild anxiety and may be helpful, but if the clients want something stronger, there are also oral anxiolytics. You go on to review that if they wanted an oral anxiolytic, it should be started soon because it can take months to take full effect. Lastly, you cover that some patients may have increased aggression with these types of medications; even though it is rare, it is best to know if this would occur in the patient prior to the baby’s arrival.

The owners are grateful for this unexpected but useful conversation and said they had only thought of Toxoplasma as a possible concern. They agreed to do additional labwork in preparation for starting the anxiolytic medication. You explain that you will call them tomorrow with the labwork and fecal test results. They thank you and head up front to check out. You bring Finn to the back to administer the vaccines and collect his blood and urine while the couple is given the ectoparasite preventative tablets to start at home.

Image by Michal Jarmoluk from Pixabay

Your next appointment is Luna, a 2-year-old spayed female Beagle with first-time itchy ears. She jumps on you immediately when you walk in the exam room and her tail is moving a mile a minute. Her owner does not have any other two- or four-legged children at home – Luna is “an only child and is dearly loved and spoiled” as the client explains. You perform an ear cytology and only find Malassezia. You are looking at your in-house pharmacy stock and are relieved to find that the compounded leave-in antifungal and steroid combination medication has not yet expired. You return to the room to review the cytological findings and offer a few treatment options. There is a three-in-one medication that contains an antifungal, steroid and antibiotic and a flush that can both be given daily until the recheck visit or a leave-in treatment that only contains an antifungal and steroid. You prefer the second option because the daily medication has an unnecessary antibiotic, and then you review antibiotic resistance as you had 35 minutes before with Zoomie’s owner, but there is a downside to the leave-in treatment. You explain that the leave-in medication is like wearing ear plugs so Luna should not be off-leash while outdoors until her recheck. Also, she should not be given the leave-in medication if there are people at home who can startle her when she is sleeping or unaware. The owner says that her 90-year-old mother with dementia occasionally visits but Luna is often placed in a separate room because she has previously inadvertently scratched the older woman’s fragile skin when jumping. The client elects the leave-in treatment. You then explain the other possible side effects of the leave-in medication, and direct the owner to schedule the recheck appointment while you take Luna in the back to clean her ears and apply the compounded leave-in medication.

Image by Zigmars Berzins from Pixabay

The day continues like this, with back-to-back appointments; it is busy but fulfilling. At each appointment, you build trust with the client when asking about the family and home in addition to the patient. Simultaneously, you gain insightful information to help you serve as a thorough practitioner by understanding what is not obvious in the exam room – the environment that is shared between your patient and its family at home. By seeing and considering more than just the patient in front of you, you are practicing with a One Health mindset.

Deborah Thomson, DVM is a relief veterinarian in Virginia, serves as the World Veterinary Association’s Chair of its One Health Education Subgroup, and is the author of The Art of Science Communication: Sharing Knowledge with Students, the Public, and Policymakers.

This VETgirl online veterinary continuing education blog is sponsored by Blue Buffalo. Please note the opinions in this blog are the expressed opinion of the author(s), and not directly endorsed by VETgirl.

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