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EQUINE VETERINARY EDUCATION

Equine vet. Educ. (2009) 21 (4) 216-224
doi: 10.2746/095777308X321107

Tutorial Article
Current controversies in equine antimicrobial therapy
A. R. Hollis and P. A. Wilkins*
Sections of Medicine and Emergency, Critical Care and Anesthesia, Department of Clinical Studies,
New Bolton Center, University of Pennsylvania School of Veterinary Medicine, 382 West Street Road,
Kennett Square, Pennsylvania 19348, USA.
Keywords: horse; antibiotic; infection; antimicrobial resistance; nosocomial

Summary

Antimicrobial selection

Controversies exist regarding the use, misuse and potential

overuse of antimicrobial treatments in foals and adults.
When antimicrobials are required for treatment of
infectious diseases, veterinarians should follow a logical
approach and not simply reach for the newest drug.
Targeted, single drug therapy is probably best, and culture
and sensitivity testing should be undertaken. The most
likely infectious agent, potential drug toxicities, and ageappropriate dose and route should be considered. The
development of an increasing number of different multiple
drug resistant pathogens requires that veterinarians use
antimicrobial drugs responsibly to protect veterinary
patients and the public at large.

There is little information available regarding appropriate

antimicrobial selection in the horse. First line antimicrobial
agents for suspected or proven infection should generally
be broad spectrum and have known efficacy against the
most likely pathogens. First line antimicrobials are those
that are appropriate for use in the absence of, or pending,
culture and sensitivity results (Table 1). There are instances
in which a first line antimicrobial does not need to be
broad-spectrum, for example simple penicillin is an
appropriate choice for treatment of suspected
Streptococcus equi ssp. equi infections, where treatment is
deemed necessary (Fig 1). Where possible, cultures should
be obtained prior to antimicrobial administration, allowing
selection of further antimicrobial agents on the basis of the

Introduction
Appropriate antimicrobial use in the equine patient poses
many specific challenges. Considerations prior to
antimicrobial selection include poor oral absorption of
many drugs, large total dosage (and therefore high cost)
often required, and risk of adverse side-effects, the most
common of which is antimicrobial-associated enterocolitis.
In addition, drug disposition in the foal may be very
different from that in the adult, with differences in oral
absorption, volume of distribution, metabolism and
clearance of many drugs. Knowledge and understanding
of basic pharmacokinetics and pharmacodynamics in
different age groups is, therefore, essential to appropriate
use of antimicrobial agents. In addition, there is the
question of development of antimicrobial resistance,
which has important implications for both human and
veterinary medicine. Many controversies exist regarding
the current use of antimicrobials, including appropriate
antimicrobial selection, and use of antimicrobials in certain
clinical situations.

*Author to whom correspondence should be addressed.

Fig 1: Horse with nasal discharge (apparent in left nostril) due to

infection with Streptococcus equi var. equi or 'strangles'. While this
disease seldom requires antimicrobials, horses with severe
systemic illness may require treatment.

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A. R. Hollis and P. A. Wilkins

specific sensitivity pattern of the organism in question,

should initial therapy be unsuccessful.
The American College of Veterinary Internal Medicine
(ACVIM) has published a consensus statement on
antimicrobial drug use in veterinary medicine (Morley et al.
2005) recommending that veterinarians categorise
antimicrobials used in their practice into primary,
secondary, and tertiary use categories. Drugs assigned to
TABLE 1: Example antimicrobial use policy
Class 1: First choice antimicrobials in the absence of, or pending
culture and sensitivity results:
Primary use
Penicillins (sodium penicillin, potassium penicillin, ampicillin)
Trimethoprim-sulphonamide
First and second generation cephalosporins
Gentamicin (reserve for serious infections)
Tetracyclines
Metronidazole
Erythromycin
Rifampin (Never use as sole agent)

Class 2: First choice antimicrobial ONLY in emergent situations

Primary use (special circumstances)
Amikacin

Class 3: Antimicrobials to be used only when justified by culture

and sensitivity results AND lack of response to Class 1 or 2 drugs,
contraindication to Class 1 or 2 drugs, or adverse response to
Class 1 or 2 drugs:
Secondary use
Cefotaxime and other 3rd generation cephalosporins
Enrofloxacin
Ticarcillin + clavulanic acid
Chloramphenicol
Azithromycin
Doxycycline

Class 4: Last choice antimicrobials to be used only in very rare

situations with documented resistance to all applicable Class 1, 2
and 3 drugs, and disease. These drugs should only be used when
local therapy, or other alternatives are not an option, and where
there is a chance of survival
Tertiary use
Imipenem
4th generation cephalosporins
Other drugs used for the treatment of resistant bacteria, e.g.
newer flouroquinolones

Class 5: Drugs prohibited for use without approval of designated

members of the Infection Control Committee

217

the primary use category should include older drugs and

those with a narrower spectrum of activity, e.g. simple
penicillins, and these drugs should be used in the majority
of infections. Drugs assigned to the secondary use
category include newer drugs with an extended spectrum
of activity, and those with added importance in the
treatment of serious or frequently resistant infections in
man. Drugs for which antimicrobial resistance appears to
develop relatively easily, e.g. rifampin, should also be
assigned to this class. Secondary use drugs should be
reserved for cases where culture and sensitivity results
indicate primary use drugs are not appropriate. Tertiary
use drugs are those particularly important for human and
animal health care, especially those most recently
developed and those with extended spectra of coverage
that are useful against the most resistant bacteria (for
example methicillin resistant Staphylococcus aureus
[MRSA]), with use limited to animals with clinically
important infections caused by bacteria demonstrated
resistant to all reasonable primary and secondary use
drugs (Morley et al. 2005). It is important that secondary
and tertiary category antimicrobial drugs are not used
when a primary category drug could be just as effective.
Decisions to advance from a primary to a secondary or
tertiary category drug should be based on either culture
and sensitivity information, where available, or inadequate
response to a lower category drug, after allowing sufficient
time to evaluate the response. In general, the authors
recommend a period of at least 48 h with no clinical or
clinicopathological improvement prior to deeming an
antimicrobial agent ineffective. In addition, the use of
tertiary antimicrobials should be restricted to animals with a
reasonable chance of survival. This consensus statement
(Morley et al. 2005) should be studied in detail and used to
develop prescribing guidelines for each individual
practice. Guidelines for antimicrobial use in the authors
hospital are included in Table 1. In addition to these
guidelines, directed antimicrobial therapy should be used
whenever possible, using culture and sensitivity techniques
to target specific organisms. Further considerations for
antimicrobial selection should include the availability of the
drugs and whether the antimicrobial is licensed for use in
the horse, or even any veterinary species. In addition,
consideration should be given to the pharmacokinetic and
pharmacodynamic profile of the drug, where known, as
absorption and distribution varies significantly both within
and between species. The authors are refraining from
comment regarding the use of compounding pharmacies,
as the controls and regulations of such pharmacies are
disparate between regulating agencies on various
continents and between countries on the same continent.

Association of antimicrobial drugs with

enterocolitis and nephrotoxicity

Tertiary use
Vancomycin

There are many adverse drug reactions associated with

antimicrobials, the most common of which is antimicrobial-

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associated enterocolitis. Many clinicians hold very strong

opinions on the association of certain antimicrobials with
enterocolitis, but the fact remains that any antimicrobial
drug has the potential to cause enterocolitis. Horses are
especially prone to the development of antimicrobialassociated enterocolitis because of their poor oral
absorption of many drugs, leading to large concentrations
of active drug in the intestinal lumen (Papich 2003).
However, drugs that are absorbed well orally or
administered i.v., have also been associated with
diarrhoea because of biliary excretion or enterohepatic
recycling, exposing the intestinal lumen to large
concentration of the drug (Papich 2003). A decrease in
anaerobic bacteria in the intestine leads to altered
carbohydrate metabolism and the overgrowth of some
potentially pathogenic bacteria, both of which may lead
to diarrhoea (Papich 2003). The most commonly implicated
antimicrobials are presented in Table 2; it is important to
note that, anecdotally, there appear to be geographical
differences in the antimicrobial drugs most likely to cause
enterocolitis. Local knowledge of antimicrobials commonly
associated with enterocolitis in a specific region is,
therefore, helpful for antimicrobial selection.
The administration of potentially nephrotoxic drugs to
azotaemic animals is another controversial topic. Many of
these animals will have prerenal azotaemia secondary to
hypovolaemia, rather than intrinsic renal disease, although
occult renal parenchymal disease may exist secondary to
that hypovolaemia. In most cases, administration of
nephrotoxic antimicrobial drugs (such as gentamicin and
amikacin) can be avoided and other antimicrobial agents
used in preference; there are, however, clinical situations
in which complete nephrotoxic drug avoidance is not
possible. The prescribing veterinarian should consider the
cost-benefit analysis of using such drugs in these animals;
if the relative risk appears small, and the potential benefit
great, potentially nephrotoxic drugs should be used with
caution and frequent monitoring of renal function
(including urinalyses and serial, daily if necessary,
creatinine concentration determinations) performed. If
aminoglycosides are used in the azotaemic patient,
therapeutic drug monitoring, with particular attention paid
to the trough concentrations, should be carried out.
TABLE 2: Commonly implicated antimicrobials in antimicrobialassociated enterocolitis
Enrofloxacin
Trimethoprim-sulphonamide combinations
Oxytetracycline
Penicillin
Ceftiofur
Doxycycline
Erythromycin
Neomycin
Lincomycin
Clindamycin
Moxifloxacin
Florfenicol
Tylosin

Current controversies in equine antimicrobial therapy

Guidelines for therapeutic drug monitoring are outside the

scope of this article, and the reader is referred to other
texts (e.g. Dowling 2004).
One example of potential benefit outweighing an
apparently small risk is administration of polymyxin B to
endotoxaemic animals. Polymyxin B is an antimicrobial
agent used at subantimicrobial doses for treatment of
endotoxaemia, and has proven to be efficacious, even
when given after administration of endotoxin (Barton et al.
2004). Polymyxin B has potential nephrotoxic and
neurotoxic effects (Raisbeck et al. 1989; MacKay et al.
1999). Interestingly, despite its commonly stated
nephrotoxicity, this has not been demonstrated in the horse
even when very large doses have been experimentally
administered (up to 36,000 iu/kg bwt) (Raisbeck et al. 1989;
Durando et al. 1994; MacKay et al. 1999; Parviainen et al.
2001; Morresey and MacKay 2006), and there are no
reports of nephrotoxicity following polymyxin B
administration in the equine veterinary literature. In spite of
this, it is commonly recommended that polymyxin B should
be used with care in azotaemic or hypovolaemic animals
(Barton et al. 2004). Large doses have been associated
with neurological side-effects, including ataxia,
hypermetria and spasmodic coughing, seen at doses of
18,000 iu/kg bwt and above (Raisbeck et al. 1989), but not
at 10,000 iu/kg bwt or less (Durando et al. 1994; Barton et al.
2004). Fortunately, polymyxin B binding of endotoxin occurs
at much lower doses, and the recommended dose range
is 50006000 iu/kg bwt q. 812 h i.v. (Durando et al. 1994;
Parviainen et al. 2001; Barton et al. 2004). In light of the
current evidence, and lack of reported cases of
nephrotoxicity secondary to administration of polymyxin B,
the authors consider its use appropriate for the treatment
of endotoxaemia, even in those animals with prerenal
azotaemia, alongside other supportive treatments.

Antimicrobial use in neonates

In general, critically ill neonatal foals are considered
immunocompromised patients with presumed sepsis until
proven otherwise, and broad-spectrum antimicrobial
therapy should therefore be provided (Paradis 1994). There
is compelling evidence from human medicine that early
provision of appropriate antimicrobial therapy increases
survival (Ibrahim et al. 2000; Raghavan 2006), and the same
is likely to be true of the septic equine neonate. In spite of
this, clinicians need to avoid the knee-jerk reaction to
provide the best possible antimicrobial coverage, which
may lead to the selection of extended spectrum drugs that
should be reserved for more serious infections that do not
respond to first-line drugs. Antimicrobials selected for these
animals should be primary use drugs, preferably selected
with an evidence-based approach with directed
antimicrobial therapy, following years of information on
blood culture isolates and sensitivity patterns in the local
geographic area. If this is not possible, data should be
extrapolated and guidelines taken from the many

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A. R. Hollis and P. A. Wilkins

published studies available treatment of the equine

neonate is one of the few areas of equine medicine where
much information is available regarding common isolates
and potentially appropriate therapies (Platt 1973; Koterba
et al. 1984; Wilson and Madigan 1989; Brewer and Koterba
1990; Paradis 1994; Raisis et al. 1996; Henson and Barton
2001; McKenzie and Furr 2001; Marsh and Palmer 2001;
Stewart et al. 2002; Furr 2003; Sanchez 2005; Pusterla et al.
2006; Corley et al. 2007).

Antimicrobial use in enterocolitis

Many clinicians have very strong opinions on the use of
antimicrobial agents in horses with enterocolitis. There are
some conditions for which specific antimicrobial therapy is
definitely indicated in enterocolitis; i.v. oxytetracycline for
Potomac horse fever (Neorickettsia risticii) infection, and
orally administered erythromycin (or clarithromycin/
azithromycin) and rifampin for diarrhoea secondary to
infection with Rhodococcus equi.
Oral metronidazole has a specific indication in horses
with enterocolitis for the treatment of clostridial diarrhoea.
Clostridium difficile and Clostridium perfringens infections
are commonly implicated in enterocolitis, especially with
antimicrobial associated enterocolitis (Bverud et al. 1997;
Donaldson and Palmer 1999; Weese and Stmpfli 2001). In
the neonatal foal, clostridial toxins are commonly
detected. Of 93 foals aged <30 days presenting to a
referral hospital with diarrhoea, 34.6% had Clostridium
perfringens and/or Clostridium difficile toxins present in their
faeces (Hollis et al. 2008). Alongside this specific indication,
metronidazole has been shown useful in acute, idiopathic
colitis that developed in a veterinary hospital, where
8 horses treated with metronidazole survived, and
5 of 7 horses that received other treatments, but did not
receive metronidazole, died or had to be subjected to
euthanasia (McGorum et al. 1998). Use of metronidazole
therefore appears rational in all horses with enterocolitis,
with attention paid to potential development of
neurological adverse effects when larger dosages are
used. Although vancomycin is also an effective drug for
treatment of clostridial infections, the authors do not
recommend its use in the equine patient, especially when
other options are available, as it is considered a tertiary use
drug that should be reserved for the most severe infections
and special circumstances, as detailed previously (Table 1).
Most clinicians would agree that, with a few notable
exceptions, that the use of oral antimicrobials in animals
with enterocolitis is generally contraindicated; however,
the use of i.v. antimicrobials remains highly controversial. In
neonatal foals with diarrhoea, the authors recommend
initial blood culture followed by provision of broadspectrum antimicrobial therapy. In foals aged <30 days
presenting to a referral hospital with diarrhoea from
19902007, 50% were bacteraemic at presentation (Hollis
et al. 2008). This percentage is higher than the reported
incidence of bacteraemia in the overall population of

219

foals presenting to referral hospitals (2936%) (Marsh and

Palmer 2001; Corley et al. 2005). It seems that foals with
diarrhoea are at increased risk for bacteraemia,
presumably due to bacterial translocation from a
compromised gastrointestinal tract or as a primary cause
of diarrhoea. The most common isolates from the study of
neonatal foals with diarrhoea were Enterococcus spp.,
Pantoea agglomerans, Escherichia coli and Salmonella
spp. (Hollis et al. 2008), which is different to the most
commonly isolated bacteria in the general population of
critically ill neonatal foals (Marsh and Palmer 2001; Corley
et al. 2005). This information may aid appropriate
antimicrobial selection in these animals. It is generally
accepted that bacteraemic foals should be treated with
appropriate antimicrobials as soon as sepsis is suspected
(Paradis 1994), as previously discussed.
The indications for broad-spectrum i.v. antimicrobial
administration in mature horses with colitis are less clear.
Sepsis, defined as the presence of infection and a
systemic inflammatory response (Levy et al. 2001), is
commonly present in mature horses with colitis, but,
conversely, the combination of sepsis and bacteraemia is
uncommonly reported in mature horses. The prevalence of
bacteraemia in horses with colitis is unknown at this time,
although Gram-negative bacteraemia in horses with
endotoxaemia and altered gastrointestinal mucosal
integrity appears to be uncommon (Moore and Morris
1992). Ten percent of normal human adults with
uncomplicated enteric salmonellosis develop transient
bacteraemia that is cleared by the bodys own defence
mechanisms without the need for specific antimicrobial
therapy (Pitout and Church 2004); the clinical importance
of bacteraemia in the mature horse, where detected, is
unclear. Clinically important bacteraemia responsive to
specific antimicrobial therapy has been reported in a
horse with enteric salmonellosis, and should be considered
in horses with colitis that are unresponsive to typical
supportive therapy (Johns et al. 2006). The authors
recommend collection of multiple blood cultures from all
mature horses with diarrhoea that are not responsive to
general supportive care, and consideration of specific
treatment in those that are bacteraemic with potentially
pathogenic organisms. In addition, i.v. antimicrobial
treatment has been recommended in severely
neutropenic patients with diarrhoea as these animals may
be immunocompromised due to the peripheral
neutropenia (Feary and Hassel 2006; Oliver and Stmpfli
2006); however, the association between administration of
antimicrobials and faecal shedding of Salmonella spp.
(Hird et al. 1986; House et al. 1999; Dargatz and TraubDargatz 2004) may make administration of antimicrobials
inadvisable in certain hospital situations.
Some clinicians advocate treatment of animals with
documented Salmonella spp. infection, as treatment may
kill existing organisms and prevent systemic infection; others
argue that treatment is often unsuccessful, and may lead
to release of more endotoxin secondary to bacterial killing,

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Current controversies in equine antimicrobial therapy

contribute to antimicrobial resistance, and further disturb

colonic flora (Oliver and Stmpfli 2006). It has been shown
that antimicrobial treatment does not reduce faecal
shedding of Salmonella spp, even if the strain is sensitive to
the antimicrobial agent used (van Duijkeren et al. 1995),
and there is no evidence that antimicrobial therapy is
beneficial in altering the course of salmonellosis in adult
horses (Divers and Ball 1996). The decision to begin
antimicrobial treatment on the basis of neutropenia,
pyrexia and other signs of the systemic inflammatory
response syndrome (SIRS) is further complicated by the fact
that these signs also occur in response to endotoxaemia,
extremely common in horses with diarrhoea. Horses are
exquisitely sensitive to the effects of endotoxaemia and
often appear to be endotoxaemic without evidence of
bacteraemia, perhaps due to decreased blood culture
sampling in the cases when compared to neonates. Based
on the current evidence, the authors do not advocate the
use of broad-spectrum antimicrobial agents for horses with
salmonellosis or other causes of enterocolitis unless
persistent bacteraemia is documented, or the animal is
persistently and severely neutropenic (<109 cells/l). In
addition, the authors do not recommend use of
antimicrobial agents other than oral metronidazole even in
the face of an epidemic of diarrhoea or on a property with
a history of salmonellosis. Adult horses documented to be
blood culture positive may benefit from directed
antimicrobial treatment (Pellegrini-Masini et al. 2004; Johns
2008). Further work in this area is indicated. The
antimicrobial agent should be based on the sensitivity of
the isolated organism, where known.
TABLE 3: Post operative infection (POI) risk categories with
common isolates and suggested antimicrobial approaches
Common
pathogens

Suitable
antimicrobials

Low

Staphylococcus
Streptococcus

Penicillin

Medium

Staphylococcus
Streptococcus
Gram-negative
Staphylococcus
Streptococcus
Gram-negative
Nosocomial

Risk of POI

High

Administration

Prior to first
incision only
(<3 h i.m., <1 h i.v.)
i.v., start <1 h
Penicillin and
prior to
gentamicin
first incision,
end within 24 h
Penicillin and
gentamicin

i.v., start <1 h

prior to
first incision,
end within 72 h

Low post operative infection (POI) risk elective procedures

without implants (arthroscopy, upper airway surgery, superficial
urogenital procedures). Medium POI risk nonarthroscopic
elective orthopaedic procedures, urogenital procedures
involving the peritoneum, procedures with minor implants
(laryngoplasty, <3 lag screws) and emergency procedures
without gross contamination or traumatic tissue damage. High
POI risk procedures requiring substantial implant materials
(dynamic compression plate, mesh), procedures with gross
contamination with infectious materials, procedures with
persisting compromised tissue, immunocompromised patients
(e.g. neonates). Adapted from Santschi (2006).

Perioperative antimicrobials
There is much information available on the use of
perioperative antimicrobials in human surgical patients,
and it is well documented that post operative infection
leads to prolonged hospital stay, and increased
morbidity, mortality, and cost of treatment in surgical
patients (Southwood 2006). Aseptic and atraumatic
surgical techniques remain the mainstay of successful
outcome and prevention of infection, but the benefits of
appropriate antimicrobial therapy in prevention of
surgical site and distant infections cannot be disputed
(Southwood 2006). For maximum efficacy, peak
antimicrobial concentration should be present during the
surgical procedure, and the surgical site infection rate in
patients administered preoperative antimicrobials is
significantly lower than in those administered
antimicrobials following the surgical procedure (Classen
et al. 1992; Esposito 1999). In horses, it has been
recommended that prophylactic antimicrobials be
administered 30 min prior to the start of the skin incision,
and no more than 60 min prior to the start of the
procedure (Dallap Schaer 2007). In addition, it is
recommended that the dose be repeated if the length of
the procedure is longer than 2 half-lives of the chosen
antimicrobial (Dallap Schaer 2007). In human surgical
patients, it is generally recommended that antimicrobial
use be restricted to patients where the risk of infection is
greater than 5% without prophylactic antimicrobial use
(Esposito 1999), i.e. those surgeries that are cleancontaminated, contaminated or dirty, and when
implants are used. In man, it has been recommended
that empiric broad-spectrum antimicrobials should be
used for 2448 h with dirty or infected wounds, followed
by a change to narrow-spectrum therapy based on
culture and sensitivity of any isolated organisms, if
available (Imahara and Nathens 2003). The optimal
length of antimicrobial administration in other situations is
less clear, but single dose prophylactic antimicrobial
regimens appear to be as effective as a multiple-dose
regimens (Esposito 1999). Within 24 h of surgery, the
surgical site is considered sealed and resistant to the
entry of microorganisms (Altemeier et al. 1968). Although
the optimum duration of antimicrobial administration in
veterinary patients undergoing clean-contaminated and
contaminated surgical procedures, e.g. gastrointestinal
surgery, is unknown, greater than 24 h of antimicrobial
treatment is probably unnecessary in the majority of
patients (Southwood 2006). Indeed, in human patients,
prolonged use of antimicrobials does not reduce the
prevalence of post operative infections, alters the skin
and gastrointestinal flora, and encourages the
development of antimicrobial resistance (Archer 1991;
Harbarth et al. 2000; Takesue et al. 2002; Hoth et al. 2003).
Guidelines for antimicrobial prophylaxis in the horse have
been published (Santschi 2006) and are presented in
Table 3.

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A. R. Hollis and P. A. Wilkins

Antimicrobial prophylaxis in travelling

animals
There is recognised controversy as to the utility of
administration of prophylactic antimicrobial agents to
animals prior to long distance shipping as an attempt to
prevent pleuropneumonia. There is a paucity of
information on efficacy of prophylaxis with which to make
evidence-based decisions. It is documented that the most
important predisposing factor to lower respiratory disease
is the lack of physical clearance of material when horses
are restrained and unable to lower their heads, with the
accumulation of bacteria and/or inflammatory exudate in
the trachea being documented within 24 h of such
restraint (Racklyeft and Love 1990). It has been shown that
such situations reduce tracheal mucocilliary clearance
(Raidal et al. 1997), and that horses that are transported
for 12 h without restraint showed no changes in the
cytology or bacteriology of broncho-alveolar lavage fluid
(Traub-Dargatz et al. 1988). The authors therefore feel that
the emphasis should be placed on environmental
modifications rather than antimicrobial prophylaxis.

Antimicrobials in Streptococcus equi ssp.

equi infection (strangles)
Veterinary opinion remains divided as to the utility of
antimicrobial therapy in strangles infections. Potential
indications for the use of antimicrobial agents in strangles
include treatment of peracutely affected animals during
an outbreak (those with <24 h pyrexia and no palpable
lymphadenopathy), prophylactic treatment of unaffected
in-contact animals, critical cases with life-threatening
airway obstruction, cases with secondary purpura
haemorrhagica, cases of metastatic infection (bastard
strangles), as adjunctive therapy for guttural pouch
empyema, and for the treatment of chronic carrier animals

221

(Brazil 2005). It is the opinion of the authors that the

guidelines in the recent ACVIM consensus statement on
the treatment of strangles (Sweeney et al. 2005) should be
followed. Although the majority of strangles cases require
no more than supportive care, immediate antimicrobial
therapy of new cases in the early acute phase, with fever
and signs of depression, may be curative, prevent focal
abscessation, and effective in controlling outbreaks
(Sweeney et al. 2005). However, antimicrobial therapy
inhibits synthesis of protective antigens and the
development of protective immunity (Piche 1984) thereby
rendering horses highly susceptible to reinfection if they
remain exposed to infected animals (Sweeney et al. 2005).
There is much debate as to whether the administration
of antimicrobials to animals with strangles infections
predispose to the development of metastatic, or
bastard, strangles. A recent review of this topic
concluded that there is no clinical or experimental
evidence to suggest that antimicrobial therapy in acute S.
equi ssp. equi infection is associated with metastatic
strangles (Ramey 2007). There appears to be less
controversy regarding treatment during the later stages of
clinical disease, or in cases with secondary complications.
Once
external
lymphadenopathy
is
detected,
antimicrobial therapy is probably contraindicated, as it
prolongs the enlargement and eventual rupture of lymph
node abscesses (Sweeney et al. 2005). Horses that
develop complications from strangles infections should be
treated symptomatically, with metastatic abscessation
treated with appropriate antimicrobial therapy. The
antimicrobial agent of choice is penicillin, to which S. equi
is consistently sensitive, with laboratories noting no
emerging antimicrobial resistance (Sweeney et al. 2005).
Identified carrier animals, with clinically silent S. equi
infection of the guttural pouches, should be treated with
both topical and systemic penicillin to aid elimination of
the infection (Sweeney et al. 2005).

TABLE 4: Control measures for MRSA colonisation and infection in horses

Control principal

Control measure

Prevent introduction of infection

Screen all incoming cases

Consider barrier nursing until negative status established

Prevent transmission: Animal to man/man to animal

Hand hygiene and related measures

Hand washing
Alcohol-based hand sanitisers
Staff screening and treatment?
Barrier nursing/isolation of all confirmed cases

Prevent transmission: Animal to animal

Isolation of all MRSA suspects and confirmed cases

Prevent transmission: Indirect

High standards of cleaning and disinfection

Hand touch surfaces
Stables and bedding
Dedicated equipment (headcollars, lead ropes,
thermometers thoroughly disinfected between cases).

Adapted from Leonard and Markey (2008).

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Methicillin resistant Staphylococcus aureus

Methicillin resistant Staphylococcus aureus (MRSA) is a
significant, international problem in human medicine, and
appears to be an emerging problem in equine medicine.
MRSA infections have been reported in horses in many
countries, and transmission between horses and man has
been identified (OMahoney et al. 2005; Weese et al.
2005a,b, 2006a; Cuny et al. 2006). At present, the
epidemiology of infection and colonisation of horses is
poorly understood (Weese and Lefebvre 2007). In a recent
study, MRSA was isolated from 5.3% of 2283 horses
admitted to a tertiary referral hospital; 50.8% were isolated
at admission. Clinical infections attributable to MRSA
occurred in 11.7% of these horses, with horses colonised at
admission were more likely to develop clinical MRSA
infection than those not colonised at admission. Clinical
infections included septic arthritis, jugular catheter site
infection, wound infection, pneumonia, mastitis, rhinitis
and body wall abscess (Weese et al. 2006b). In addition,
risk factors for community-associated MRSA colonisation of
horses presenting to an equine hospital have been
identified, including: previous colonisation of the horse,
previous identification of colonised horses on the same
farm, antimicrobial administration within 30 days,
admission to the neonatal intensive care unit, and
admission to services other than the surgery service. As
more epidemiological information becomes available
and high risk patients are identified, appropriate control
measures will be possible to reduce animal to man and
animal to animal transmission.
It is the impression of the authors that MRSA infections
in horses cause significant morbidity, but rarely cause
mortality. Whilst the majority of identified cases of clinical
disease caused by MRSA in the authors hospital appear
to be catheter site infections that do not require systemic
treatment, wound and post operative infections seem to
be the most commonly reported manifestations of MRSA
infections in horses (Leonard and Markey 2008). Prior to
treatment of clinical infections, it should be determined
whether local treatment may be adequate, as local
treatment with chlorhexidine and 1% acetic acid have
been successfully used to treat incisional and wound
infections (Weese 2004). If specific treatment is required,
directed antimicrobial therapy selected according to the
sensitivity pattern of the isolated organism is preferred.
It is the opinion of the authors that particular attention
should be paid to controlling MRSA in horses, guidelines for
which are presented in Table 4. Surveillance methods
should be considered in any equine hospital, in order to
identify community acquired strains and document
nosocomial infections. In horses, the nasal passage appears
to be the most common site of colonisation (Weese 2004),
therefore any screening programme should involve cultures
of nasal swabs. The question then arises as to whether to
attempt eradication of colonisation to reduce the risk of
further transmission and the development of clinical

Current controversies in equine antimicrobial therapy

disease. The manner by which this should be undertaken is

unclear, and colonisation is transient in most adult horses
(Weese 2004) so treatment of colonised but clinically
unaffected animals is often regarded as unnecessary. In
addition, antimicrobial therapy of colonised horses may be
inadvisable, as MRSA isolates rapidly develop resistance,
and there are only limited antimicrobial options available
for use (Weese 2004). Intranasal antimicrobials are most
commonly used for eradication in man; however, the
difficulty of applying topical antimicrobials to the entire
nasal passage of the horse makes this a questionable
treatment in this species (Weese 2004). Nebulisation of
antimicrobials may be a viable alternative where
eradication is desirable (Weese 2004). Eradication of MRSA
colonisation has been successfully performed on a horse
farm with a policy of segregation, infection control
precautions and repeated testing (Weese and Rosseau
2005), suggesting that these measures would be sufficient in
a hospital situation. At present the authors consider it
appropriate to use barrier nursing techniques on identified
carrier animals in order to limit spread of MRSA, but do not
advise specific treatment unless clinically important
infections have been identified.
Regardless of the approach to screening for and
treatment of MRSA infections, there is little doubt that early
institution of appropriate surveillance and other infection
control measures should be used to attempt to limit the
impact of MRSA in veterinary medicine (Weese 2004), and
it is the responsibility of each individual institution to ensure
that these measures are taken.

Conclusions
There are many controversial topics in the field of
antimicrobial use in equine patients, and as evidencebased medicine becomes more commonplace in
veterinary medicine, the answers to many of the
aforementioned problems may become available. In the
meantime, veterinarians should use antimicrobials
prudently and select appropriate drugs for maximum
efficacy, in order to slow the development of potentially
devastating multidrug resistant bacteria.

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