a for apoquel
TRANSCRIPT
![Page 1: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/1.jpg)
What’s New in Vet Dermatology?
Small Animal Specialist Hospital
Linda Vogelnest BVSc (Hons) MANZCVSc (Feline Medicine)
FANZCVSc (Veterinary Dermatology)Specialist Veterinary Dermatologist
![Page 2: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/2.jpg)
What’s new?
• New Meds– Apoquel® – when and why?, compared to Atopica®– Bravecto® & Nexgard®- demodicosis
• Update on tricky infections– MRSP dermatitis/otitis – diagnosis & treatment options– Malassezia dermatitis/otitis – treatments
![Page 3: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/3.jpg)
Apoquel• Oclacitinib
– New drug and class• Janus Kinase inhibitor
– Enzymes vital to signaling & cell activation– Found in many cell types
» Suppressing activation (i.e. immunosuppressant!)» Lymphocytes (cell-mediated immunity)
• “allergy” cytokines e.g. IL-2/4/7/9/21• “itch” cytokine – IL-31• “anti-viral/anti-tumour” cytokines e.g. IL-10, IFN-γ
» Innate immunity – macrophages, neutrophils etc – IL-12/23
![Page 4: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/4.jpg)
Apoquel• Oclacitinib
– Immunosuppressant• No metabolic effects• No drug interactions
– Indications• Control of pruritus from allergic dermatitis• Control of atopic dermatitis • In dogs ≥ 12 months old
![Page 5: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/5.jpg)
IL-31• Injected into 11 dogs (expt AD) pruritus (lasted 4-24 hours)*
– 2 dogs – placebo; 10 dogs - itch increased 2-10 fold; 1 dog – no itch • Detected in serum*
– in 57% of dogs with ‘natural’ AD(127/223)– in 0% of dogs with expt AD (no itch; 0/24), normal dogs (no itch; 0/87)– in 0% of dogs with flea allergy (itchy; 0/30)
• Detected in human AD; levels correlate with severity of AD
Gonzales et al(2013)* Interleukin-31: its role in canine pruritus and naturally occurring canine atopic dermatitis." Vet Dermatol 24(1): 48-53
![Page 6: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/6.jpg)
• 299 dogs client-owned dogs with AD• Enrolled at 19 Dermatology Specialty Practices in USA
![Page 7: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/7.jpg)
0 1 2 7 14 28 56 84 1120
1
2
3
4
5
6
7
8
9
10OWNER VAS SCORE
Placebo (P) Oclacitinib (O) Open Label (OL)
Day of Study
Ow
ner V
AS S
core
(cm
)
0 14 28 56 84 1120
10
20
30
40
50
60
70
80
90
100DERMATOLOGIST CADESI-02 SCORE
Placebo (P) Oclacitinib (O) Open Label (OL)
Day of Study
Mea
n CA
DESI
-02
Scor
e
After time 0 Oclacitinib is significantly different from PlaceboAs much as (p < 0.0001)
![Page 8: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/8.jpg)
More Controlled Studies - AUS• Gadeyne C, Little PR, King VL, et al (2014)
– Efficacy of oclacitinib (Apoquel®) compared with prednisolone for the control of pruritus and clinical signs associated with allergic dermatitis in client-owned dogs in Australia. Vet Dermatol 25(6), 512-e586
• single-masked, randomized controlled clinical trial • 123 client-owned dogs with allergic dermatitis in GP
0.0 0.2 1.0 6.0 14.0 28.00
102030405060708090
100Delta-Cortef (prednisolone)
APOQUEL (oclacitinib)
Day of Study
Mea
n VA
S Sc
ore
(mm
)
DOSE:Pred – 0.5-1mg/kg SID up to Day 6, then EOD to Day 28Apoquel – 0.4-0.6mg/kg BID up to Day 14, then SID
![Page 9: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/9.jpg)
More Controlled Studies - AUS• Little PR, King VL, Davis KR, et al (2015)
– A blinded, randomized clinical trial comparing the efficacy and safety of oclacitinib and ciclosporin for the control of atopic dermatitis in client-owned dogs. Vet Dermatol, 26(1), 23-e28
• blinded, randomized clinical trial, non-inferiority test at day 28• 226 client-owned dogs with AD from eight specialty derm practices
DOSE:Atopica – 5mg/kg SID Apoquel – 0.4-0.6mg/kg BID up to Day 14, then SID
0 1 2 7 14 28 56 840
10
20
30
40
50
60
70
80
90
100Owner VAS Pruritus Score
Atopica Apoquel
Day of Study
Mea
n VA
S Sc
ore
(mm
)
Extremely severe itch-ing
Severe itching
Moderate itching
Mild itching
Very mild itching
Normal dog
**
*
*
![Page 10: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/10.jpg)
Apoquel in Sydney
• Compassionate use – 5 dogs severe AD – 1-2 years
• Not readily controlled variety other tx
– 4 dogs x 2 years (JRT, Staffie, Sharpei X, Lab)• Owners extremely happy• Mild intermittent dermatitis – erythema, alopecia• Minimal pruritus• Worsening when daily dose due/if dose late (1 dog)• Weight gain (mild, 2 dogs)
– 1 dog (Lab) – moved to Canberra (AD signs resolved)
![Page 11: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/11.jpg)
Apoquel in Sydney
• Compassionate use– 1 dog (choc lab)– severe AD
• Partially controlled - pred 0.5mg/kg EOD, azathioprine, shampoo– Couldn’t afford cyclosporin
• Responded brilliantly in trial on Apoquel (within one day)• Severe secondary infections – yeast, bacterial• Poor response 1yr later restarting under compassionate use
– severe infections, continued pruritus, ultimately euthenasia
![Page 12: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/12.jpg)
When To Use Apoquel?• Indicated for Atopic dermatitis • Also FAD, Food allergy, Contact (?)
![Page 13: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/13.jpg)
13
1. Atopic DermatitisMulti-modal treatment plans1. Acute flare plan2. Long-term management plan
Strategies:1. Minimise allergen &/or irritant exposure2. Immunotherapy3. Symptomatic therapy
OLIVRY, DE BOER (2010). Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. Veterinary Dermatology 21: 3; 233-248.
![Page 14: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/14.jpg)
14
1. Atopic DermatitisMultimodal Treatment• Allergen-specific Immunotherapy (“allergy vaccines”)
– May reduce need for life-long symptomatic therapy• Safe symptomatic options
– Antihistamines, Fatty acids– Topicals – cleansing, soothing, potent steroids– Manage secondary infections
• More potent options– Glucocorticoids– Cyclosporin– Oclacitinib
![Page 15: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/15.jpg)
15
1. Atopic DermatitisMultimodal Treatment• Allergen-specific Immunotherapy (“allergy vaccines”)• Safe symptomatic options• More potent options
– Glucocorticoids – flares & long-term (low regular dose e.g. 1-2X wkly)– Cyclosporin – slow onset: long-term (2-6wks; wean gradually)– Oclacitinib – quick onset: flares & long-term (daily for life)
• ADVANTAGES– small, easily divided tablets– rare, mild side effects – GIT– quick response– no interference with allergy testing
• DISADVANTAGES– Flare secondary infections/otitis?– Cost
![Page 16: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/16.jpg)
16
2. Food Allergy?
• Diagnosis– Elimination diet x 6-8 weeks
• Novel protein – fresh (ideal) or commercial• Hydrolysed commercial
– Rechallenge phase x 2wks (smorgasbord)• Role for Apoquel?
– During diagnostic trial - initial relief– Discontinue last week of diet
• Stabilise if flare before progress to rechallenge
![Page 17: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/17.jpg)
17
3. Flea Allergy?
• Diagnosis– Flea treatment trial x 4wks
• Adulticidal: quick flea kill• Consider environment: consider IGR
• Role for Apoquel?– During diagnostic trial - initial relief– Discontinue last week of trial
![Page 18: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/18.jpg)
When Not To Use Apoquel• For pruritus due to infectious causes
– Bacterial pyoderma– Malassezia dermatitis– Bacterial &/or malassezia otitis– Sarcoptes, Demodicosis, Dermatophytosis etc.
![Page 19: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/19.jpg)
When Not To Use Apoquel• For pruritus due to infectious causes• For AD with effective, safe, affordable control plans
– Allergen-specific immunotherapy– Safer symptomatic treatment plans– Cyclosporin (EOD or less)
• For FAD, Food allergy in long-term– Diagnose and avoid allergens
• In dogs under one year age• In dogs with history of demodicosis?
![Page 20: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/20.jpg)
Using ApoquelDose:• 0.4-0.6mg/kg BID x 2wks, then SID long term
• Poor response – reconsider infections/diagnosis
![Page 21: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/21.jpg)
Expectations:• Quick response• Pruritus flares common when reduce to SID
– Not severe– Usually settle over next ~2-4 weeks
• What if SID not sufficiently effective?– Consider timing of administration – AM vs PM– Can dose be raised?
– Remember the dose range– Consider off-label BID dosing (low dose)
Using Apoquel
![Page 22: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/22.jpg)
22
Vet Dermatol 2015; 26: 235–e52
5/12 Cats - AD
![Page 23: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/23.jpg)
What’s new?
• New Meds– Apoquel® – when and why?, compared to Atopica®
– Bravecto® & Nexgard®- demodicosis
• Update on tricky infections– MRSP dermatitis/otitis – diagnosis & treatment options– Malassezia dermatitis/otitis – treatments
![Page 24: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/24.jpg)
Squeeze Tape Impressionfor Demodicosis
![Page 25: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/25.jpg)
30 dogs – demodicosis 21 generalised; 9 localised 27 positive deep scrape (single) 30 positive tape squeeze (one squeeze)
Advantages Simple, less invasive Sensitivity comparable
(greater?) than deep scraping
![Page 26: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/26.jpg)
26
40 dogs – demodicosis 23 generalised; 17 localised 40 positive deep scrape 30 positive tape squeeze (one
squeeze per site) 29 positive trichogram
Advantage Simple, less invasive first test
Disadvantage Deep skin scraping more sensitive
![Page 27: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/27.jpg)
16 dogs Demodicosis15 dogs – normal skin15 dogs – inflamed skin- Multiple squeezes per site 100% specificity – no mites in normal/inflamed skin (120 samples)
100% sensitivity – mites in each lesional sample 16 dogs (16 samples)
Deep skin scraping – 90% sensitivityMites in 14/16 samples
![Page 28: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/28.jpg)
![Page 29: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/29.jpg)
Squeeze Tape Impression• Simple, minimally invasive test
– Less patient discomfort– No skin trauma– Readily sample multiple sites
• High specificity• Apparent high sensitivity
![Page 30: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/30.jpg)
Isoxazolines• Bravecto® - fluralaner
– 8 dogs generalised demodicosis
– No mites Days 56, 84
![Page 31: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/31.jpg)
Isoxazolines• Nexgard® - afoxolaner
– Twice monthly– 8 dogs generalised
demodicosis; no mites day 84– Anecdotal: monthly very
effective
![Page 32: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/32.jpg)
Isoxazolines• Simparica® - sarolaner
– Zoetis– Monthly flea/tick control
![Page 33: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/33.jpg)
What’s new?
• New Meds– Apoquel® – when and why?, compared to Atopica®– Bravecto® & Nexgard®- demodicosis
• Update on tricky infections– MRSP dermatitis/otitis – diagnosis & treatment options– Malassezia dermatitis/otitis – treatments
![Page 34: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/34.jpg)
• Superficial - pyoderma, folliculitis, impetigo, mucocutaneous pyoderma
• Deep• 2° to
– 1° Skin disease/defects– Systemic immune suppression
34
Bacterial Pyoderma
![Page 35: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/35.jpg)
35
Bacterial Pyoderma
• Causal Bacteria– Staphylococcus pseudintermedius
• Normal flora – esp. moist sites: nares, mouth, perianal• Virulence factors
– Staphylococcus aureus– Staphylococcus schleiferi schleiferi
• Other normal flora – many – Gram +ve - coagulase negative Staph, α-haem.
Streptococci, Propionibacterium acnes– Gram –ve - Clostridium spp., Acinetobacter spp.
• Transients – many– Proteus mirabilis, Pseudomonas spp., Corynebacterium
spp.
![Page 36: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/36.jpg)
• Historically – predictable antibiotic sensitivity– ~98% isolates sensitive to β-lactams
• cephalexin, amoxyclav
• Methicillin-resistance (MRSP, MRSA)– Small mobile gene (mecA), transferred amongst Staph spp.;
alters PBP
– MRSP - first report France – mid 1980’s; first dz USA – 1999
– Alarming MRSP since 2006 – clonal spread of small number isolates
• ST71 (Europe, Japan), ST68 (USA)
• ST45 (Israel, Thailand) 36
Staphylococcus pseudintermedius
![Page 37: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/37.jpg)
• Colonisation/transient carriage (dogs, cats)
– 0-10% worldwide; 30% in Japan (2006)
• Pyoderma (dogs)
– 15-17% (USA 2001-4); 0.8% (Germany 2007); 10% (Spain 2009)
– ~30% (USA 2008); 55-67% (Japan 2007-9)
– Australia – Sydney, Brisbane, Melbourne, Adelaide, Perth
• Perth - 12 isolates/19 dogs 2011/12: some potentially related ST45 (Thailand); some new lineage Canada
• Sydney – 1/29 dogs 2010/12
– 55 dogs 2013 - ~ 20% 37
MRSP
Siak M, Burrows AK, Coombs GW et al. Journal of Medical Microbiology 2014; 63 (9): 1228-1233
Ravens PA, Vogelnest LJ, Ewen E et al. AVJ 2014; 92(5): 149-155.
![Page 38: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/38.jpg)
• Concurrent transfer of resistance to multiple antibiotics: MDR
• Resistance to– Β-lactams: cephalexin, amoxyclav, cefovecin– Macrolides: clindamycin– Fluoroquinolones: enro, marbo– Tetracyclines: doxy– TMS– Chloramphenicol (European isolates)
• Sensitive to– Rifampicin, amikacin– Topicals: fusicid acid, mupirocin– Restricted: vancomycin, linezolid, teicoplanin
38
MRSP Challenges
![Page 39: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/39.jpg)
• Dissemination– risk MRSP infections – hospitalisation, prior antibiotic
therapy
– Positive cultures hospital environment/staff
– Hospital outbreaks
• Zoonosis– Rare
– concern – hospital staff, pet owners
• Survival 6mnth (environ)
• Ready transmission household pets39
MRSP Challenges
![Page 40: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/40.jpg)
• Dogs, Cats, (Horses)• Skin/ears
– Pyoderma – superficial, deep– Otitis– Surgical wound infections
• Urinary tract infections
• Septicaemia
40
MRSP Infections
![Page 41: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/41.jpg)
• Clinical clues?– None – looks like ‘normal’ pyoderma
• Historical clues?– Poorly responsive to antibiotics
• Inadequate antibiotics dose/duration/poor owner compliance
• Concurrent GC therapy
• Active underlying disease (rare)
• MRSP
41
MRSP Pyoderma
![Page 42: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/42.jpg)
• Diagnosis?– Cytology
• Neutrophils, i/c bacterial cocci
– Exclude other causes for poor response to empirical ab’s
– Bacterial C&S (cytologically confirmed pyoderma sites)• Pustule - puncture sterile 25g needle, culture swab
• Other lesions - dry swab rubbed vigorously 5 sec
• Avoid moist sites/cytology confirms mixed microbes
42
MRSP Pyoderma
![Page 43: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/43.jpg)
• Skin cytology– Adhesive tape impression (all lesions)
• Diff-Quik stain (no fixative)
43
Diagnosis
![Page 44: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/44.jpg)
• Skin cytology– Adhesive tape impression (all lesions)– Glass slide impression/FNA (moist/nodular
lesions)
44
Diagnosis
![Page 45: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/45.jpg)
45
Tape Impression - Normal skin - 4X lens (40x magnification)Keratinocytes dominate; normal flora very sparse
![Page 46: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/46.jpg)
46
Tape Impression – Pyoderma 4X lens (40x magnification)Clumped keratinocytes; Neutrophil rims/clusters
![Page 47: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/47.jpg)
47
4X lens (40x magnification)
![Page 48: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/48.jpg)
48
Neutrophils with intracellular & colonising cocci
1000X (oil)
200X (20X lens)
![Page 49: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/49.jpg)
49
Degenerate neutrophils with intracellular cocci – oif (1000x)
![Page 50: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/50.jpg)
50
Neutrophils with intracellular & colonising cocci – oif (1000x)
![Page 51: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/51.jpg)
51
Neutrophils with intracellular & colonising cocci
1000X (oil)
40X (4X lens)
![Page 52: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/52.jpg)
52
Neutrophils, colonising bacterial rods – oif (1000x)
Yeast, and colonising cocci, rods – oif (1000x)
![Page 53: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/53.jpg)
53
Deep Pyoderma: neutrophils with intracellular cocci (often sparse)
1000X (oil)
![Page 54: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/54.jpg)
1. Address 1° disease/cause – Reduce immunosuppression
– Atopic Dermatitis – cyclosporin
2. Antibiotic susceptibility unpredictable– Susceptibility testing important, in light of cytology
findings!– Methicillin (oxacillin) resistance = resistant to all β
lactams
54
MRSP Pyoderma - Treatment
![Page 55: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/55.jpg)
1. Systemic Options– Possibly doxycycline – 10mg/kg SID
– Possibly TMS – 30mg/kg BID
– Rifampicin – 5-10mg/kg SID• Hepatotoxicity (25% dogs)
• Drug interactions – many
• Orange discolouration body fluids
• Combine with 2nd antibiotic?
55
MRSP Pyoderma - Treatment
![Page 56: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/56.jpg)
1. Systemic Options – doxy?, enro?, TMS? – based on C/S2. Topical Options
– Antibiotics - resistance documented; colonisation MRSA (people)
• Mupirocin oint/cream (Bactroban®)• Fusidic acid oint (Conoptal®, Fucidin® - tablet also)
– Antiseptics - act rapidly at bacterial cell walls; less susceptible to resistance?
• Chlorhexidine (more effective; less irritating/staining vs iodine)– Effective as sole tx MRSP in dogs; daily chlorhex baths reduce MRSA
(people)– 3-4% faster antibacterial effect; leave-on solution/cream;
shampoos/scrubs– Resistance documented
• Other: acetic/boric acid; benzoyl peroxide• Low irritant: silver sulfadiazine (Flamazine®); medical honey• Sodium hypochlorite (household bleach) ~ 1ml per litre water
56
MRSP Pyoderma - Treatment
![Page 57: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/57.jpg)
• Aggressive individual patient treatment plan
1. Minimum 3-wk treatment course• Topicals - chlorhexidine; bleach +/- antibiotics
• Cleaning - frequent swimming (salt water), gentle shampooing
2. NO CONCURRENT GLUCOCORTICOIDS!• Incomplete/delayed resolution of infections
• Encourages antimicrobial resistance
• Pruritus markedly reduced in 24-48 hours without steroids in most cases
57
MRSP Pyoderma – Tx Summary
![Page 58: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/58.jpg)
• Aggressive individual patient treatment plan
1. Minimum 3-wk treatment course• Topicals - chlorhexidine; bleach +/- antibiotics
• Cleaning - frequent swimming (salt water), gentle shampooing
2. NO CONCURRENT GLUCOCORTICOIDS!
3. Address underlying disease• Atopic Dermatitis/On-going immunosuppression – active
prevention plan
1. Topical antiseptics/cleaning
58
MRSP Pyoderma – Tx Summary
![Page 59: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/59.jpg)
59
Diagnosis uncertain?• Options
1. Antibiotic (or antifungal) treatment trial (3wks; no steroids) • Pruritic: pruritus & lesions should improve by 5-7d• Non-pruritic: lesions should resolve by 2-3wks
2. Steroid-treatment trial (2-7 days; no antibiotics/antifungals)• Pruritic: pruritus and lesions should improve notably by 7d• Non-pruritic: not indicated!
3. Referral?DON’T use pred & 5-10 days antibiotics !!
Pyoderma (& MD) - Treatment
![Page 60: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/60.jpg)
1. Prudent Antibiotic Use1. Pruritic presentations
1. DO NOT USE pred/dex + 5-10d course cephalexin/cefovecin inj
2. Identify pyoderma (cytology or tx trial)– 3wk cephalexin/amoxyclav AND NO concurrent GC
– Only use 2nd line drugs e.g. fluoroquinolones, clindamycin, cefovecin IF supported by C&S
60
MRSP – Limiting Spread
![Page 61: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/61.jpg)
1. Sensitivity testing SP isolates Sydney
– 27 dogs; 227 isolates - dry swab, saline-moistened swab, skin scraping
– Cephalexin, amoxyclav, TMS (96%)
– Enrofloxacin, chloramphenicol (96%)
– Less to cefovecin (90%) , clindamycin (88%), doxycycline (78%)
61
Staph Pseudintermedius - Sydney
Ravens PA, Vogelnest LJ, Ewen E et al. Canine superficial bacterial pyoderma: evaluation of skin surface sampling methods and antimicrobial susceptibility of casual Staphylococcus isolates. AVJ 2014; 92(5): 149-155.
![Page 62: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/62.jpg)
1. Prudent Antibiotic Use– When clearly indicated, wise choices, complete courses (3wks), no
GC2. Adequate staff and patient hygiene
– Strict hand hygiene• Remove gross contamination – soap/water• Alcohol hand gel
– Patient barrier nursing – if MRSP infection confirmed3. Hospital disinfection/maintenance
– Regular decontamination – two-step process• Remove organic debris• Disinfection
– Alcohol (70-90% ethanol, isopropanol) – fastest action– Bleach 0.5% (1:10 dilution) – 10-min contact time– Chlorhexidine 0.15% - 10-min contact time– Quarternary ammonium compounds e.g. Trigene® – less
effective62
MRSP – Limiting Spread
![Page 63: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/63.jpg)
1. Treat the infection first Topicals essential
Fusidic Acid - Canaural®
Miconazole/Polymixin B - Surolan®/Dermotic®
2. Reduce any chronic inflammatory changes
3. Treat the underlying disease
63
Treatment – MRSP Otitis
![Page 64: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/64.jpg)
What’s new?
• New Meds– Apoquel® – when and why?, compared to Atopica®– Bravecto® & Nexgard®- demodicosis
• Update on tricky infections– MRSP dermatitis/otitis – diagnosis & treatment options– Malassezia dermatitis/otitis – treatments
![Page 65: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/65.jpg)
• 2° to– Allergies – AD (can markedly pruritus)– Systemic immune suppression
• Immuno-suppressive therapies (e.g. pred)• Disease (e.g. neoplasia, FIV)
– Hormonal – hypoT, hyperA (can cause pruritus)– Keratinisation defects - primary seborrhoea, sebaceous
adenitis
65
Malassezia dermatitis
![Page 66: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/66.jpg)
• Skin cytology– Adhesive tape impression (all lesions)
• Diff-Quik stain (no fixative)
66
Diagnosis
![Page 67: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/67.jpg)
67
MD – oil lens (1000X)Dx = >1 yeast per oif
![Page 68: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/68.jpg)
• Surface cytology– Most important– Not 100% sensitive (esp. pyoderma)
• Clinical appearance– Rarely reliable– Odour – variable
• Consider treatment trial– Antifungals alone (3wks min - superficial)
68
Diagnosis
![Page 69: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/69.jpg)
1. Treat the infection first (underlying dz 2nd) Systemic most reliable (min. 3wk course)
Itraconazole 5-10mg/kg SID
Pulse tx: 2 consecutive days/wk?
69
Treatment – Malassezia Dermatitis
![Page 70: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/70.jpg)
1. Treat the infection first (underlying dz 2nd) Systemic most reliable (min. 3wk course)
Topicals can be useful
Enilconazole rinse (twice wkly), miconazole cream (BID)
Chlorhexidine solution (2-3%) sid-bid
Shampoos – adjunctive only (limited residual effect)
Chlorhexidine, miconazole
Piroctone olamine, econazole
70
Treatment – Malassezia Dermatitis
![Page 71: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/71.jpg)
1. Treat the infection first (underlying dz 2nd) Topicals essential
‘azoles’ - BID seems most effective
Miconazole - Surolan®/Dermotic®
Clotrimazone - Otomax®
Nystatin – BID
Canaural®, Topigen®
Systemics – may be helpful, especially if otitis media?
71
Treatment - Otitis
![Page 72: A for Apoquel](https://reader031.vdocuments.us/reader031/viewer/2022030207/58ac08e11a28abb6718b6ee3/html5/thumbnails/72.jpg)
72
Questions?