From Habit to Evidence: The Shift in Antibiotic Use for Canine Acute Diarrhea

Metronidazole has been the reflex prescription for canine acute diarrhea for years and that habit is hard to break. We sit down with Dr. Erin Fry to unpack what the data actually says about outcomes in mild to moderate acute diarrhea, including cases with bloody stool, and why supportive care often matches antibiotics for speed of recovery. Along the way, we get honest about the real reasons “we know better” doesn’t always translate into “we do it” when a worried client is sitting in front of us. 

We walk through what uncomplicated acute diarrhea looks like in practice and what supportive care really means: hydration plans, a highly digestible diet, smart fiber use, and when probiotics may fit. Erin also explains why the gut microbiome is now central to the conversation, and how antibiotic-associated dysbiosis can linger for weeks to months, with special concern for puppies and kittens. If you’ve ever prescribed “just in case” because you feared missing something, this conversation gives you a clearer risk-benefit frame grounded in randomized controlled trials and day-to-day clinical reality. 

Then we zoom out to the culture of prescribing. Peer expectations inside a hospital, mixed standards between clinics, client demand for instant gratification, and the challenges faced by newer grads or relief doctors all shape decisions. Erin shares practical tools for behavior change, including practice-wide talking points, team alignment from front desk to exam room, and a concrete starting point using the AVMA antimicrobial stewardship checklist. 

If you want a clearer, evidence-based approach to treating canine acute diarrhea without unnecessary antibiotics, listen now, share this with a colleague, and leave us a rating and review on Apple Podcasts or wherever you listen.

JAVMA article: https://doi.org/10.2460/javma.25.10.0686

AVMA veterinary checklist for antimicrobial stewardship: Veterinary-Checklist-Antimicrobial-Stewardship.pdf

INTERESTED IN SUBMITTING YOUR MANUSCRIPT TO JAVMA ®  OR AJVR ® ?

JAVMA ® : https://avma.org/JAVMAAuthors

AJVR ® : https://avma.org/AJVRAuthors

FOLLOW US:

JAVMA ® :

Facebook: Journal of the American Veterinary Medical Association - JAVMA | Facebook

Instagram: JAVMA (@avma_javma) • Instagram photos and videos

Twitter: JAVMA (@AVMAJAVMA) / Twitter

AJVR ® : 

Facebook: American Journal of Veterinary Research - AJVR | Facebook

Instagram: AJVR (@ajvroa) • Instagram photos and videos

Twitter: AJVR (@AJVROA) / Twitter

JAVMA ®  and AJVR ®  LinkedIn: https://linkedin.com/company/avma-journals

Transcript

Sponsor Message

SPEAKER_02 0:00

Looking to protect your fan stations against parasites, look no further than some paracetrios. Teroliner black detections by rental doable tablets. The first doable to offer crippled protection from heartwork disease, fixed deflects, and real forms of hook farms. It's also FDA approved to block infections that make up line disease by killing deer death. Visit the parapetrio dpm.com for full prescribing information.

Lisa Fortier 0:31

Welcome to Epic Award-winning Veterinary Vertex, the AVMA Journal's podcast where we delve into behind-the-scenes look with manuscript authors. I'm editor-in-chief Lisa Forti8, joined by Associate Editor Sarah Wright. Today we're discussing veterinarian's intention to use metronidazole for treatment of canine acute diarrhea with Erin Fry. Erin, thanks so much for taking time out of your busy spring schedule to be with us here today. Thanks for joining us, Erin.

SPEAKER_03 0:57

Yes, thank you so much for inviting me. This is a topic I'm really passionate about, so I'm excited to chat today.

What Counts As Acute Diarrhea

Lisa Fortier 1:04

I'm glad somebody else is uh canine diarrhea is one of the reasons I went into equine medicine. Uh so for the listeners, Erin, can you can you set the stage by explaining uh canine acute diarrhea and how it's typically managed in practice today?

Why Metronidazole Still Gets Prescribed

SPEAKER_03 1:22

Sure. So um we use the term canine acute diarrhea as a term to define diarrhea of less than seven days. And this includes both diarrhea with blood and without blood in the stool. Um and overall, we'd say about 90% of cases of canine acute diarrhea are mild. And what we mean by that is the dogs are generally bright, alert, and responsive. They don't have a fever, they don't have clinical signs of dehydration or hypovolemia. And so in the past, historically, um, metronidazole uh was a common drug that vet that's reached for to treat this condition. Um but in the past 10 years, there's been a shift. We've had a tremendous amount of research actually in this area for veterinary medicine that has shown us that the new emphasis really is on supportive care. So rehydrating our patients, providing them a highly digestible diet, adding fiber, um, adding probiotic supplements. And these changes really put the emphasis away from using antibiotics and switching that more to a diet change with all of the new recognition, not just in this field, but the research on the G the gut microbiome and the importance of preserving that healthy bacteria in our pets' guts.

Sarah Wright 2:39

Yeah, I'm happy to report that I was taught that in vet school, which is great. So I was able to implement that in practice. Now, this next question, in my opinion, is going to be the golden question of this podcast. So veterinarians support antimicrobial stewardship, but they still prescribe metronidazole. What's driving a disconnect?

SPEAKER_03 2:54

Yeah, so um as we mentioned, the the typical treatment and the treatment I the that I actually learned when I was in vet school was to use metronidazole, and that was pretty has been pretty widespread. Um, and so anything big and very much the norm within our practice is hard to sometimes overcome. And there's lots of barriers to that. So even as our knowledge has grown, um, some of the barriers that vets face, um, and in our study, they told us things like, I don't have a lot of time, and so it takes me time to explain to clients where there's a you know a new way of treating things. Um, they sometimes get pressure from other doctors in the practice. So if some doctors have adopted the um, you know, using diet, probiotics, other things, but there are others that that do not, it's hard when not all the doc that's agree in your practice. Um, same thing with clients. So if clients have received um these drugs, um antibiotics for diarrhea for other conditions, and now we know more and we're pointing people away from them. It's hard for a client to come in with an expectation. If this is going on with my dog or my cat, I expect to get antibiotics. And when they don't, there's confusion there. So sometimes we get pushback. Um, vets report they get pushback from clients. So uh all of these things can create this situation where uh people know and they've learned and they really want to do the right thing with stewardship. But you know, in the day-to-day, there's a lot of pressure that happened. And so um, when it comes to decision making, sometimes people um have to make choices that may not be what they would want to do in an ideal situation.

Lisa Fortier 4:31

Yeah, lots of factors.

SPEAKER_03 4:32

Yes, yes, it is, it's complicated.

Lisa Fortier 4:35

Yeah, it's hard to change a culture. Uh, you you touched on this a little bit, Erin, but your study very much suggests that peer expectations play a role. And you touched on that as I said, but what does that really look like in clinical practice in that culture?

Client Expectations And The Diarrhea Pack

SPEAKER_03 4:49

Yeah, so um, and we so we did this study and we surveyed people, and the follow-in study that we're we're um analyzing the data right now is our focus groups. So people provided in the survey, open-ended feedback to us, and as well as in focus groups. And what they're telling us is it's more challenging to avoid prescribing metronidazole when there isn't consensus. So if some doctors in the practice do and others do not, that makes it challenging. Particularly, we had um people tell us if they perceive themselves to be lower on the power structure within the practice. Um, and so you're a new graduate, maybe you're part-time, maybe you're a relief doctor. Um, all of those people feel less comfortable with pushing change and promoting change within the practice. And that's not just true about um this particular subject of diarrhea, but uh their perception is I don't really have the power to change big decisions of the practice, so that makes it more complicated. Um, and it could also be the other thing we've heard from vets is that um they, so for example, if if our practice is fully on board and we use diet, we use fiber, we use hydration, all of those things, but the doctor down the street, or perhaps I'm an ER doctor that knows that the referring vets, the primary care vets in my area, do use it and I don't as an ER doctor, this sets up a really complicated dynamic where clients are hearing different things between different doctors. That can be within the practice or also between practices. So if you're junior in the practice and you feel like you can't push change, then you're pushed, um, you know, you feel this expectation. Um, if you're part-time, if you're ER, then again, you know that other people are doing something different and that can create some confusion or controversy um either between yourself and clients or between veterinarians.

Sarah Wright 6:44

Hopefully it's very validating for our listeners to hear. Yes. When I hear you talk about the client side of things, what I hear is people want instant gratification. They want to come home with the medication. They go to the doctor, they're sick, they want to come home with the med to fix them. You send them home with the diet recommendations and probiotics, they're like, well, what is what is this gonna do? I don't want to wait. So it's gonna be hard to change that.

Risk Fear And Microbiome Harm

SPEAKER_03 7:03

Yeah, it is. And I think um we talk about um the the sort of the drive for vets to find it. We're we're taught to find it and fix it. Um, and so we want to provide clients with things. Um, some tactics that other places have used is to create um what they I didn't create this term, but uh that the diarrhea pack. So some places will have already pre-prepared um samples or small servings of the of the appropriate diet, um of the fiber supplements and of the material. So the things that clients can be empowered to do. So there are ways. And um I will I do want to emphasize that a lot of the individuals in our survey and in our focus groups have implemented this. Um, they've they've said things like, we've retrained our clients, we've taught our clients. So I think the the barrier is in that time of making a transition from always using a vetronodazole to going to alternatives to that. Um, and you can get over that. Clients can, you know, doctors and and support staff can get on board, clients can get on board, but it does, it does take some effort. Um, and we have to be patient with clients that have this expectation. It is a change and it could be uncomfortable. The thing that we've learned from um many, again, the body of research in the last 10 years, even 15 years about this is that the use of metronazole does not stop diarrhea any faster than placebo. We've had randomized controlled trials. Um, it's showing multiple in multiple ways that changing the diet, um, adding fiber, um, and potentially the use of some probiotics can resolve things in the same amount of time. And so there's hope. And uh yeah, so we can give something to our clients and we have a lot of research behind it that supports those alternatives.

Sarah Wright 8:51

And how do risk perception and fear of missing something shape antibiotic use?

SPEAKER_03 8:56

Yeah, so I think it feeds into um well, a couple things. One is we want to send our clients away with something. They came to us for our um our guidance, and we want to be able to give them something. Um there is some uncertainty and diagnostic uncertainty. There are many, many causes of diarrhea, and then we don't always know what caused this particular dog or cat to have diarrhea. We also can't, we don't have a uh any way of knowing for sure how the clinical progression is going to happen. So people are concerned, as I mentioned, they want to help their clients, they want to help their patients. Um, and so the idea that what's going to happen if it gets worse is is concerning to people. Um, and and so I think where we have been in the past or what we know from the past is there's a perception that if I don't use people are going to be angry, if they're dogs, if it doesn't resolve or if it gets worse. Uh, and then the other thing is that there's been a perception that, well, there's no risk to it. So if I use metronidazole or if I use antibiotic, I'm not causing any harm. So it's safer for me to just go ahead and use it than to not. And what we're learning more and more again, this kind of this research kind of goes hand in hand is that the use of metronidazole and other antibiotics for the treatment of diarrhea, really anything, can upset that gut microbiome that we were talking about. Um, so there it's not without risk. And I think when we come to that question of um risk versus benefit, then if we can look more um uh cautiously about what effect am I going to have, is this antibiotic going to have, um, then I the you know the thought process there is I don't know, I don't want to cause my animal harm. If I'm not convinced that this is going to make them better, if I have evidence that other treatments work, then I can feel more confident about it. And this for the listener, the um the the the most important thing about um the the disruption of the gut microbiome. So people may have heard of like dysbiosis and other terms, is we really worry about that about our young animals. So our puppies and kittens using these drugs can that there's evidence that the use of metronidazol in young animals can disrupt the microbiome for weeks or even months uh after the use. So it is not without risk, and we really should take that into account when when trying to make decisions about what's best for our patients.

Lisa Fortier 11:22

Yeah, really well said. And you've talked on the veterinarian and the client side on what perpetuates the use of antimicrobials and specifically Metro for acute diarrhea. And there's tons of knowledge to support what you're saying, not just your article, as you said, the dysbiosis. So if knowledge isn't enough, uh what things I I love the idea of like, here's a buy a three-day package of food. Like, what else can help actually change behavior and practice?

One Practical Step To Start Tomorrow

SPEAKER_03 11:53

Yeah, so I think um kind of going back to the the idea of um uh consensus amongst the practice. So I think what what Vets have told us um and what we've learned from other research is when uh when the practice agrees or is part of the practice culture, then it's easier to do that thing. So if as I mentioned in our focus groups, we had veterinarians say five years ago, we transitioned from everybody got metronidazole to using diets, to using fiber. Um, and now our we've I will use their words, we trained our clients. So, and how you do that is if if you can get the whole practice to agree. And that's not just the vets. Um, it's it's very powerful and very important to get the support staff involved. So veterinary technicians, veterinary assistants, our front um, you know, the receptionists and front desk staff are all part of that messaging. So we can get everybody on the same page about what um what's uh the the care, what care we provide, then it makes it easier for everyone to go along with it. So if a client calls or emails or texts in, they're gonna get the same message from start to finish from everyone. So, how do we achieve consensus? Um, and that's what these educational resources that we created. We're not the only ones to create them, but when we looked at them, we said, what can we provide for vets for education? And then um what what can then be shared amongst the practice? So a very succinct group of talking points that can be used amongst the practice, particularly we, um, as I mentioned earlier, those that maybe don't feel they have as much um decision-making power in a practice. These are resources that have citations from all this research. They can be brought to team meetings, discussions, and then um we're having a group discussion, not a my opinion versus your opinion. We're using these trusted sources of information to help move things forward and adjust what is our practice culture. So um I will refer people back to um the AVMA's veterinary checklist for antimicrobial stewardship is on the AVMA website. And so if you're trying to turn things in from theory to what can I do, that checklist is a really good place to start. You and your team can look at that and say, what can we really do? What what where are we in our practice and what one thing can we change today? What do we want to change next? Um I find that if we can have a concrete step, that's more helpful than just thinking, like, yes, I agree with stewardship. Because I think many people do. Like in theory, it's it's a good idea. But as we're mentioning, what do you do in practice? What do you do when that dog shows up with diarrhea and you have a client in front of you that you really want to help?

Sarah Wright 14:40

So, in addition to practice consensus, what's one practical step veterinary teams can take tomorrow to reduce unnecessary antibiotic use and canine acute diarrhea?

SPEAKER_03 14:50

That's a great question. And I um from again from other research, and I would say human medicine is a little ahead of us on this. And we're the realization is really this is about behavior change. And so we're moving beyond just guidelines to thinking about behavior. Uh and other research that's been done shows that veterinarians that um have been in practice longer and are more comfortable with um, we talk about difficult conversations. So this can be a difficult conversation, especially if this is the first time you're having this conversation with a client. Um, but the good news is the more that you practice, the better you you will feel about it and the more and the uh the better you will be at getting your message across and conveying that to clients. You really care about their dog, you're trying to do the best thing. So, what I would do is challenge people to pick one dog in the next week, pick a dog with diarrhea, a dog that's you know fairly healthy, that's bright and alert, doesn't have a fever. And for that dog, have a conversation about using dietary fiber, digestive change, hydration with this client. Try it out. And what you will see is the more that you have the conversation, the more comfortable and confident you will feel. And the subsequent conversations do they do get easier. Um, I've I've been in VetMed long enough to have gone through this transition. I feel the the concern, but also know the more that you have it, more confident you will be.

Lisa Fortier 16:19

Yeah, good old communication.

SPEAKER_03 16:21

Yep.

Lisa Fortier 16:23

All right, Aaron. Lots and lots of good tidbits in here. And here's your wrap-up chance. What is one key takeaway that you want our listeners to remember?

SPEAKER_03 16:33

Um, I would say that we have a mountain of evidence over the past 15 years plus that antibiotics, including metronidazole, do not improve clinical outcomes for dogs with mild to moderate diarrhea. And that includes dogs with bloody diarrhea. So the concern with metronidazole is that that can cause upsets to the GI microbiome that can last weeks to months, especially in our puppies and kittens. And we have excellent evidence that supportive care, including hydration, um high fiber, and highly digestible diets, can help those pets return to normal stool in a short period of time.

Sarah Wright 17:14

Well, Erin, this was excellent information. Thank you for sharing it with us. I've learned so much today. So thank you again for joining us. Thank you so much for having me. And for our listeners and viewers, you can read Erin's article in Javma. I'm Sarah Wright here at Lisa Fortier. Be sure to tune in next week for another episode of Veterinary Vertex. And don't forget to leave us a rating and review on Apple Podcasts or wherever you listen.