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Antimicrobial Use Guidelines for Treatment of Respiratory Guideline and Recommendation J Vet Intern Med 2017;31:279–294 Antimicrobial use Guidelines for Treatment of Respiratory Tract Disease in Dogs and Cats: Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases M.R. Lappin, J. Blondeau, D. Boothe, E.B. Breitschwerdt, L. Guardabassi, D.H. Lloyd, M.G. Papich, S.C. Rankin, J.E. Sykes, J. Turnidge, and J.S. Weese Respiratory tract disease can be associated with primary or secondary bacterial infections in dogs and cats and is a com- mon reason for use and potential misuse, improper use, and overuse of antimicrobials. There is a lack of comprehensive treatment guidelines such as those that are available for human medicine. Accordingly, the International Society for Compan- ion Animal Infectious Diseases convened a Working Group of clinical microbiologists, pharmacologists, and internists to share experiences, examine scientific data, review clinical trials, and develop these guidelines to assist veterinarians in making antimicrobial treatment choices for use in the management of bacterial respiratory diseases in dogs and cats. Key words: Bronchitis; Pneumonia; Pyothorax; Rhinitis. his document contains guidelines for the treatment Tof bacterial causes of feline upper respiratory tract Abbreviations: disease (URTD), canine infectious respiratory disease CIRDC canine infectious respiratory disease complex complex (CIRDC; previously known as canine infec- FCV feline calicivirus tious tracheobronchitis or kennel cough complex), FHV-1 feline herpesvirus 1 bronchitis, pneumonia, and pyothorax that were final- PCR polymerase chain reaction ized in 2016 by the Antimicrobial Guidelines Working URI upper respiratory infection Group of the International Society for Companion URTD feline upper respiratory tract disease Animal Infectious Diseases (www.iscaid.org). During the development of the guidelines, other veterinary rec- ommendations on antimicrobial treatment1–4 and corre- reviewed the literature and met in person to develop the sponding guidelines for human medicine were initial draft of the guidelines. This was followed by a evaluated, with consideration of the differences among number of revisions completed electronically in an species.5,6 attempt to build consensus with the wording of each The committee unanimously believes that there are recommendation within the Working Group. The limitations in objective, published information relevant Working Group recommendations were then provided to the treatment of bacterial respiratory diseases in dogs to all guidelines committee members who were asked to and cats. Thus, the Working Group used a modification independently select whether they agreed, were neutral, of the Delhi method for consensus building in the devel- or disagreed with a recommendation. A updated draft opment of these guidelines.7 The Working Group of the document was then completed and provided to 6 experts in the field that were not members of the Work- ing Group who were asked to rate each recommenda- From the Colorado State University, Fort Collins, CO (Lappin); tion by means of the same system. For those University of Saskatoon, Saskatoon, SK (Blondeau); Auburn recommendations that received any “disagree” votes University, Auburn, AL (Boothe); North Carolina State University, Raleigh, NC (Breitschwerdt, Papich); University of Copenhagen, from the 17 total reviewers (Working Group and out- Copenhagen, Denmark (Guardabassi); Royal Veterinary College, side reviewers), the percentage distribution of all review- London, UK (Lloyd); University of Pennsylvania, Philadelphia, PA ers and appropriate comments are presented. (Rankin); University of California, Davis, CA (Sykes); Ontario As with all guidelines, the antimicrobial use guideli- Veterinary College, Guelph, ON (Weese); and the The Women’s nes for the treatment of bacterial respiratory tract infec- and Children Hospital, Adelaide, SA, Australia (Turnidge). tions in dogs and cats should be interpreted as general An overview of the guidelines was presented at the 2016 American recommendations that are reasonable and appropriate College of Veterinary Internal Medicine Forum, Denver, Colorado. Corresponding author: M.R. Lappin, Colorado State University, for the majority of cases. The Working Group acknowl- 300 West Drake Road, Fort Collins, CO 80523; e-mail: mlappin@ edges the variability among cases and these guidelines colostate.edu. should not be considered standards of care that must be Submitted May 22, 2016; Revised September 5, 2016; followed in all circumstances. Rather, they should be Accepted November 7, 2016. considered the basis of decision-making, with the poten- © Copyright 2017 The Authors. Journal of Veterinary Internal tial that different or additional approaches might be Medicine published by Wiley Periodicals, Inc. on behalf of the Ameri- required in some cases. Further, although these guideli- can College of Veterinary Internal Medicine. This is an open access article under the terms of the Creative nes are designed as international guidelines that are Commons Attribution-NonCommercial License, which permits use, appropriate for all regions of the world, the Working distribution and reproduction in any medium, provided the original Group realizes that regional differences in antimicrobial work is properly cited and is not used for commercial purposes. resistance rates, antimicrobial availability, prescribing DOI: 10.1111/jvim.14627 280 Lappin et al patterns, and restrictions on use of some agents exist. disease. The Working Group recommends that all cats The user of this document is obligated to be familiar with suspected bacterial URI be evaluated for the pres- with local and regional regulations that might restrict ence of feline leukemia virus antigen and feline immun- use of certain antimicrobials listed in this document. odeficiency virus antibodies in serum in accordance Diagnostic and treatment recommendations contained with the American Association of Feline Practitioners in these guidelines are largely limited to those relating Retrovirus Panel Report.23 Although these retroviruses to bacterial infection. do not cause respiratory disease directly, both have been associated with lymphoma (which could cause Feline Upper Respiratory Tract Disease URTD) and both can cause immunosuppression that could predispose to severe viral and bacterial URIs. Definitions and Causes Many diagnostic tests could be performed to assess for evidence of primary or secondary bacterial URI (See the Feline upper respiratory tract disease is a syndrome Diagnosis of Chronic Bacterial Upper Respiratory Infec- consisting of clinical signs that can include serous to tion (>10 Days of Duration) section). It is the opinion mucopurulent ocular and nasal discharges, epistaxis, – of the Working Group that there is limited benefit to per- sneezing, and conjunctivitis.8 11 Clinical signs can be forming cytology of nasal discharges to diagnose bacte- acute (≤10 days) or chronic (>10 days). The term “up- rial infection and guide the antimicrobial choice. per respiratory infection (URI)” is reserved for cats If nasal discharges are serous and lack a mucopuru- with clinical signs of URTD that are directly associated lent or purulent component, the Working Group with one or more of the known pathogenic viral, bacte- believes that antimicrobial treatment is not recom- rial, or fungal organisms. mended because of the likelihood of uncomplicated It is believed that the majority of cats with acute clin- viral infection. ical signs of URTD have feline herpesvirus 1 (FHV-1)- If acute bacterial URI is suspected based on purulent or calicivirus (FCV)-associated URI. Some of the cats or mucopurulent discharge, in the absence of evidence of with viral infections can develop secondary bacterial – the cause of URTD based on history and physical exami- infections.12 15 Staphylococcus spp., Streptococcus spp., nation findings, the Working Group recommends a per- Pasteurella multocida, Escherichia coli, and anaerobes iod of observation without immediate use of an are organisms that are commonly cultured from the sur- antimicrobial drug. This might vary in duration based on face of the upper respiratory mucous membranes from other clinical findings (See the Treatment of Suspected healthy cats.16,17 However, several bacterial species, Acute Bacterial Upper Respiratory Infection section). In including Chlamydia felis, Bordetella bronchiseptica, humans, antimicrobial treatment is recommended only if Streptococcus canis, Streptococcus equi subspp. zooepi- clinical signs have not improved after 10 days or have demicus, and Mycoplasma spp., have been isolated or worsened after 5–7 days.24 A more extensive workup for detected by molecular techniques such as the poly- an underlying cause can be postponed until after the per- merase chain reaction (PCR) from cats with URTD iod of observation, up to 10 days after the onset of clini- without the presence of pathogenic viruses, suggesting a – cal signs if the cat develops chronic URTD. primary role in some cats.16,18 22 The presence of puru- Aerobic bacterial culture and antimicrobial suscepti- lent or mucopurulent nasal or ocular discharges might bility test results from nasal discharges are difficult to increase the suspicion that primary or secondary bacte- interpret because (1) some pathogenic organisms (eg, rial infection is present, but there is no definite proof of Chlamydia and Mycoplasma) cannot be cultured on this association because viral or fungal agents can
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