Foreword

The term “evidence-based medicine” (EBM) was coined in the 1980s by the McMasters University School of Medicine in Canada to define a process of integrating new information and emerging technology into practice. Articles on evidence-based veterinary medicine (EBVM) started to be published at the beginning of the 21st century, along with the Handbook of Evidence-Based Veterinary Medicine, which was published in 2003[1]. Textbooks, journals, veterinary conferences, and websites provide nearly unlimited information about EBVM for the practicing veterinarian to help with the transition to EBVM use in daily practice[2]. By summarising information and analysing the results of different clinical trials relating to a specific topic by expert commissions, concise EBVM allows advanced conclusions to be formulated. Continuous publication of these EBVM conclusions can support the practitioner or clinician in the decision-making process for an optimal treatment. Furthermore, the implementation of state-of-the-art intervention strategy is assured[3]. Ideally, over time, EBVM becomes an integral part of normal clinical practice.

During the preparation process of the work presented in this book, informal interviews with field veterinarians revealed that although they had the background to understand the need for Peer Reviewed Evidence Based data, field veterinarians actually favour standard behaviour without questioning it and still rely much on “Expert Opinions” even if coming from self-proclaimed experts or regardless of the methodology that supports this opinion. Those findings are in line with previously published observations that field veterinarians have difficulty applying the theory of EBVM to their actual medical practice and that veterinary researchers often choose smaller, alternative research methodologies for financial, ethical, and other reasons rather than double-blinded, randomized clinical trials or systematic reviews[4]. It has been long recognized that among companion animal practitioners, colleagues, association meetings, and pharmaceutical representatives are common sources of information. Colleagues are also the preferred information source in critical-care situations. To stay up-to-date with current advances in veterinary medicine, again other practitioners are preferred[5]. In all cases, books, continuing education, journals and the like are cited but are less convenient than oral advice from colleagues.

It is thus rather paradoxical that field veterinarians, having access to the highest quality of EBVM thanks to the Internet, are actually satisfied with the poorest quality available (Figure 1). One reason may be that veterinarians consider themselves as isolated from easy access to information in medical or hospital libraries, which would be the gold standard source.

Another reason may be that field veterinarians taking care of companion animals seek immediate benefits such as reliable decisions to ensure the best clinical outcome to fulfil pet owners’ expectations. From their immediate perception, experts’ opinions seem to meet their needs, although, from the REQUEST Group’s perspective, the equation is rather more complex with more variables (Figure 2).

This preparation work also highlighted that current EBVM lacked practical Standard Operational Procedures and Consensus Guidelines dedicated solely to companion animals, specifically in the antibiotherapy area.

REQUEST is the acronym of REassessing fluoroQUinolone European STandards.

Fluoroquinolones represent a group of potent antimicrobials with excellent activity, especially against Enterobacteriaceae like E. coli. Compared with nalidixic acid, which was the first unfluorinated quinolone introduced in human medicine in the 1960s, modern fluoroquinolones have much better pharmacokinetic properties, an increased spectrum of activity and a broader safety margin[7]. Examples of fluoroquinolones, which are used in veterinary medicine, are enrofloxacin, marbofloxacin, ibafloxacin, danofloxacin, difloxacin, orbifloxacin and pradofloxacin (Figure 3).

Field veterinarians should bear in mind that, although the clinical efficacy of this class of antibacterials is generally acknowledged[8], the most recent are not necessarily breakthrough products in terms of clinical efficacy. As an example, the overall response rates for pradofloxacin at low dose (5mg/kg, q24 h for seven days) or at high dose (10mg/kg, q24 h for seven days) are not statistically different from the response rate of amoxycillin (22 mg/kg, q12 h for seven days) when treating either Mycoplasma species, Bordetella species, Staphylococcus species or Streptococcus species isolated from cats[9]. In fact, pradofloxacin has anti-M hemofelis effects similar to those of doxycycline[10]. Therefore, the therapeutic use of fluoroquinolones has to be carefully reviewed, considering the potential development of bacterial resistance[11]. Therefore, a responsible use of fluoroquinolones is recommended to minimise the risk of the development of bacterial resistance. An increasing degree of bacterial resistance would reduce the therapeutic impact of the drugs dramatically.

For that purpose, REQUEST is assessing whether companion animals should benefit from the human “fluoroquinolone rules” (because they share the same environment and therefore are exposed to the same strains) or from the “agricultural fluoroquinolone rules” (because they should be regarded as an environmental reservoir) or from a dedicated “companion animal fluoroquinolones rule” due to their specific evidence-based medicine available data regarding this population.

In other words, the goal of REQUEST is to define guidelines for the responsible and appropriate prescription of fluoroquinolones among companion animals, and to publish these guidelines, which will help the veterinary practitioner in everyday situations.

In order to achieve this task, eight veterinarians, specialists in pharmacology, surgery, dermatology, bacteriology, feline medicine, internal medicine specialised in fluoroquinolones who have already published papers in their respective field of expertise joined together to form the REQUEST Group.

Thus REQUEST members act in a position of trust for the veterinary community and are responsible for the quality of the guidelines issued by the Group. Members serve for a two-year term. Members may renew their membership for two additional terms.

A third party was entrusted with the mission of organizing the REQUEST Group and providing any scientific and methodological support required to achieve its goals. It secured funding, proposed participants to be invited, identified specific issues related to the responsible use of fluoroquinolones in companion animals, contributed to the review of the literature, and organized every REQUEST consensus meeting in collaboration with the Chairman (agenda, identification of the topics to be discussed, organization of presentations, methods of consensus and editorial reviewing of any REQUEST publications whenever REQUEST members found this relevant).

REQUEST Group members met for the first time at the Veterinary School of Lyon because it was the first School ever created, and elected Pr Jean-Pierre Cotard as the first Chairman. The present book highlights the methodological output from REQUEST elaborated between the foundation meeting that took place in Lyon on the 17th October 2008, the second meeting in Vienna on the 20th March 2009, the third meeting in Edinburgh on the 19th – 20th November 2009, the fourth in Torino on the 11th – 12th May 2010, the fifth in Maisons-Alfort on the 29th – 30th November 2010, the sixth in Liege on the 28th – 20th March 2011, the seventh in Warsaw on the 7th – 8th March 2012, covering more than 42 months of collaborative work.

The present book exposes in detail the REQUEST proprietary methodology that enabled it to elaborate its guidelines. It also presents the results of a critical review of fluoroquinolone susceptibility, pharmacokinetics and a special focus on retinal toxicity among cats and a more general toxicity review among dogs. Then it proposed two clinical situations chosen for the following reasons: the first benefits from numerous publications; the second doesn’t. Both demonstrate the interest of the REQUEST proprietary methodology because it allows drawing sound guidelines on the responsible use of fluororoquinolones for those indications. Then the book presents all available REQUEST Guidelines in order to help field veterinarians in...