AIDAP Prescribing Guidelines

ANTIBIOTIC
PRESCRIBING
DETAILED GUIDELINES
AUSTRALASIAN INFECTIOUS
DISEASES ADVISORY PANEL AIDAP
Dr Steve Holloway
BVSc (Syd), MVS, PhD (Melb), DACVIM, MACVSc
Steve graduated from the University of Sydney in 1983 and after several years in practice, journeyed along the pathway
to becoming a specialist in internal medicine. In 1991 Steve became a Diplomate of the American College of Internal
Medicine. In 1994 Steven commenced his PhD studying herpesviruses of horses at the University of Melbourne,
completing in early 1998. Between 1999 and 2009 Steve lectured in infectious diseases of small animals at the Faculty
of Veterinary Science at the University of Melbourne. Steven is currently a specialist in internal medicine in private
practice and regularly consults on infectious disease problems in small animal patients.
Dr Darren Trott
BSc (Hon), BVMS (Hon), PhD
Dr Trott is a veterinarian with 20 years experience in bacterial disease research focused on zoonotic infections, enteric
diseases, gastrointestinal microbial ecology and antibiotic resistance. In 2010, Darren accepted a position in the new
School of Animal and Veterinary Sciences at The University of Adelaide and aims to establish a new Research Centre
focused on Comparative Gastrointestinal Health in animals and humans.
Dr Mike Shipstone
BVSc, FACVSC, DACVD
Dr Shipstone graduated from Queensland University in 1984 and has worked in a number of different private practice
and industry positions. In 1995 he started a residency at the Animal Skin and Allergy Clinic in Melbourne, with additional
periods of study at the University of California, Davis and Louisiana State University, Baton Rouge. Mike is principal and
director of a specialist dermatology referral practice and adjunct Associate Professor at the University of Queensland.
Mike is a Fellow of the Australian College of Veterinary Scientists (Veterinary Dermatology) and a Diplomate of the
American College of Veterinary Dermatology, the only dual boarded veterinary dermatologist in Australia. Mike has
published in Australia and overseas and has presented in Australia, South East Asia and North America.
Associate Professor Vanessa Barrs
BVSc (hons), MVetClinStud, FACVSc (Feline Medicine), GradCertEd (Higher Ed)
Associate Professor Vanessa Barrs is the Director of the University Veterinary Teaching Hospital and Head of Small
Animal Medicine at the University of Sydney. She is a registered Specialist in Feline Medicine and has worked in
University and Private Referral Practices in London and Sydney. She has represented the profession in many roles
including as President of the Feline Chapter of the Australian College of Veterinary Scientists, Specialist representative
of the NSW Board of Veterinary Practitioners and trustee of the Australian Feline Health Research Fund. She
enjoys teaching and was awarded the Australian Veterinary Association Excellence in Teaching Award in 2007. Her
research interests include lymphoma and infectious diseases, especially fungal diseases, for which she was awarded
Distinguished Scientifc Award in 2009 by the Australian Small Animal Veterinary Association. She has over 70 refereed
publications and book chapters. Most of all A/Professor Barrs loves cats and feline medicine.
Dr Richard Malik
DVSc, DipVetAn, MVetClinStud, PhD, FACVSc, FASM
Richard Malik graduated from the University of Sydney, trained in Anaesthesia and Intensive Care, and then moved to
ANU where he completed a PhD in pharmacology at the John Curtin School of Medical Research. He then completed a
Postdoctoral fellowship at the Neurobiology Research Centre before returning to his alma mater where he remained
there for 16 years in a variety of positions (1995 to 2002). Since 2003 Richard has worked as a consultant for the
Centre of Veterinary Education and he fnds time also to see cases in a number of practices in the Eastern suburbs of
Sydney. Richard has varied research interests, most notably infectious diseases, genetic diseases and diseases of cats
in general. He is a Fellow of the Australian Society of Microbiology, a member of the Australian Society of Infectious
Diseases and an Adjunct Professor of Veterinary Medicine at Charles Sturt University.
Dr Mandy Burrows
BSc, BVMS Murd, MACVSc, FACVSc (Dermatology)
Mandy is a Fellow of the Australian College of Veterinary Scientists in Veterinary Dermatology and a registered specialist
in veterinary dermatology. She is a consultant in veterinary dermatology and has two dermatology practices in Perth,
Western Australia that provide secondary and tertiary referral advice for skin, ear and allergy problems in dogs, cats
and horses. She lectures in dermatology at Murdoch University Veterinary Hospital and she teaches undergraduate
veterinary students and the dermatology unit of the Masters in Veterinary Medicine at both Murdoch and Massey
University, New Zealand. She is currently the Chief Examiner and serves on the Council and the Board of Examiners
of the Australian and New Zealand College of Veterinary Scientists and is a member of the Advisory Committee for the
Registration of Veterinary Specialists. She is a member of the Australian Advisory Board for Infectious Diseases in
companion animals and is the current Australian and New Zealand representative and the Secretary of the World
Association for Veterinary Dermatology. She has extensive experience with clinical dermatology in companion animals
and she enjoys teaching dermatology to veterinary undergraduate and postgraduate students.
DISEASES ADVISORY PANEL
Antimicrobial resistance is a critical problem in human medicine around the world, both in
hospitals and in the wider community. It is emerging as a problem in veterinary medicine,
especially in the USA. Although the situation in Australia is currently much better than in
North America, multi-resistant E. coli and some methicillin-resistant Staphs have appeared
in Australian small animal practices over the last 10 years. Although detailed discussion and
analysis of this problem is currently beyond the scope of AIDAP, the group thought some
pertinent practical tips would be a good step towards improved antimicrobial stewardship,
which is the best way to prevent the emergence of a more widespread resistance problem.
1. Choose antimicrobials based on the most likely pathogen(s) that are associated with
particular infectious disease settings (e.g. E. coli from a lower urinary tract infections or
S. pseudintermedius from canine pyoderma). Published susceptibility proles for any given
pathogen should be used to make an informed decision as to the antibiotic to be selected.
In situations where it is not possible to accurately predict the likely pathogens and/or their
likely antibiograms, then culture and susceptibility testing should be performed as soon as
practical. Where nances preclude this, an in-practice Gram stain can sometimes be very
informative.
2. If empiric antibiotic therapy is instituted but has failed, then ideally perform culture and
susceptibility testing. For example, urinary tract infections or staphylococcal pyoderma
cases that fail to respond to empiric antimicrobial therapy justify culture. If nances
preclude this, choose another class of agent likely to be effective against the putative
pathogen.
3. Avoid empiric use of uoroquinolones for treating chronic Staph spp. infections in dogs
or uncomplicated UTI. Amoxicillin clavulanate is a superior choice to uoroquinolones for
empiric therapy of UTIs in the opinion of this panel.
4. Avoid using combination therapy unless there is clearly a life-threatening infection present
and/or an unpredictable antibiotic susceptibility of the pathogen(s) involved. For example,
life-threatening sepsis in a dog that has peritonitis from a ruptured bowel is an indication
for 4-quadrant antibiotic therapy until the results of culture are known.
6. Ensure the length of treatment with antibiotics is appropriate. Serious infections generally
justify at least two-weeks of therapy. Identify where owner or patient compliance is likely to
be an issue and take appropriate measures to achieve compliance.
7. In the hospital setting, be vigilant for the occurrence of infections attributable to an
unusual organism (e.g. Serratia spp.) or common pathogens (e.g. E. coli) with a consistent
antibiograms, often with a multi-resistant prole. Such organisms should ideally be
forwarded to a suitable reference laboratory (e.g. Darren Trotts laboratory, the University of
Adelaide or VPDS at the University of Sydney) for archiving and possibly additional molecular
testing. If such case clustering occurs, consider consultation with an infectious disease
expert to try to track down potential sources of infection e.g. foam bedding, a staff member
who is a chronic carrier of Staph. aureus.
8. Develop in-house infection control guidelines for every veterinary hospital. These should
include signs and policies that encourage regular hand washing with alcohol-based hand
preparations.
AIDAP
RESISTANCE TIPS
AIDAP: ANTIBIOTIC PRESCRIBING DETAILED GUIDELINES
DOGS

SUBCUTANEOUS ABSCESS/CELLULITIS p1

PERIODONTAL DISEASE p5

ACUTE URT DISEASE/INFECTIOUS TRACHEOBRONCHITIS p9
CHRONIC RHINOSINUSITIS p13

ACUTE LRT INFECTION p16
PYOTHORAX p20

ACUTE LOWER UTI/CYSTITIS (FIRST OCCURRENCE) p24
COMPLICATED UTIs: RECURRENT LOWER UTI/CYSTITIS AND CKD WITH PYURIA p28

ACUTE FEBRILE ILLNESS p33
ACUTE ABDOMINAL PAIN AND PYREXIA/ABDOMINAL INFECTION AND LEUKOPENIA p36

ANTIBIOTIC USE AFTER ROUTINE DESEXING p39

USE OF ANTIBIOTICS IN DENTAL PROPHYLAXIS p41

SURFACE BACTERIAL INFECTIONS: (i.e. INTERTRIGO e.g. LIP FOLD, TAIL FOLD) p44
SUPERFICIAL BACTERIAL INFECTIONS: (i.e. MUCOCUTANEOUS PYODERMA,
BACTERIAL FOLLICULITIS, BACTERIAL OVERGROWTH) p47
DEEP BACTERIAL INFECTIONS: (i.e. FURUNCULOSIS WITH DRAINING TRACTS p52
MYCOBACTERIA AND NOCARDIA AS CAUSES OF DEEP DRAINING SINUS TRACTS p58
DERMATOPHYTE INFECTIONS (e.g. MICROSPORUM OR TRICHOPHYTON) p62
SUPERFICIAL YEAST (MALASSEZIA) INFECTIONS OF THE SKIN (NOT INCLUDING EARS) p71

OTITIS EXTERNA (UNCOMPLICATED, FIRST EPISODE AND COMPLICATED, RECURRENT) p77
SOFT TISSUE
ORAL
UPPER RESPIRATORY TRACT
LOWER RESPIRATORY TRACT
URINARY TRACT
PYREXIA
ABDOMINAL
DESEXING
DENTAL
SKIN/SOFT TISSUE
AURAL
CATS

SUBCUTANEOUS ABSCESS/CELLULITIS p83

CHRONIC GINGIVOSTOMATITIS/FAUCITIS p87

ACUTE URT DISEASE p91
CHRONIC RHINOSINUSITIS p95

ACUTE LRT INFECTION p99
PYOTHORAX p103

ACUTE LOWER UTI/CYSTITIS (FIRST OCCURRENCE) p107
COMPLICATED UTIs: RECURRENT LOWER UTI/CYSTITIS AND CKD WITH PYURIA p112

ACUTE FEBRILE ILLNESS p116
ACUTE ABDOMINAL PAIN AND PYREXIA/ABDOMINAL INFECTION AND LEUKOPENIA p120

ANTIBIOTIC USE AFTER ROUTINE DESEXING p123

USE OF ANTIBIOTICS IN DENTAL PROPHYLAXIS p125

MYCOBACTERIA AND NOCARDIA AS CAUSES OF DEEP DRAINING SINUS TRACTS p128
DERMATOPHYTE INFECTIONS (e.g. MICROSPORUM OR TRICHOPHYTON) p132

OTITIS EXTERNA (UNCOMPLICATED, FIRST EPISODE AND COMPLICATED, RECURRENT) p141
SOFT TISSUE
ORAL
UPPER RESPIRATORY TRACT
LOWER RESPIRATORY TRACT
URINARY TRACT
PYREXIA
ABDOMINAL
DESEXING
DENTAL
SKIN/SOFT TISSUE
AURAL
GLOSSARY
abx = antibiotics
BAL = bronchioalveolar lavage
C+S = culture and susceptibility
CKD = chronic kidney disease
E. coli = Escherichia coli
FB = foreign body
FC = feline calicivirus
FHV-1 = feline herpes virus-type 1
FQ = uoroquinolone
GA = general anaesthetic
hrs = hours
IM = intramuscular
IV = intravenous
KCS = keratoconjunctivitis sicca
LRT = lower respiratory tract
LRTI = lower respiratory tract infection
MDR = multi-drug resistant
N/A = not applicable
NSAID = non-steroidal anti-inammatory drug
PCR = polymerase chain reaction
Rx = treatment
SC = subcutaneous
spp. = species
TMS = Trimethoprim-sulfonamide
TTW = transtracheal wash
UA = urinalysis
URT = upper respiratory tract
URTI = upper respiratory tract infection
UTI = urinary tract infection
= off label
= not registered for animal use

For easy access to the AIDAP guidelines, download
the Vets Australia iPhone and iPad application.
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
SPECIES: DOG
SPECIES: DOG 1 SECTION: SOFT TISSUE
CONDITION: SUBCUTANEOUS ABSCESS/CELLULITIS
For this reason, dog bite wounds
are typically presented for
attention early, often when the
wound is contaminated with
bacteria, rather than actually
being infected. The aim of therapy
is prophylactic. Some abscesses
in dogs result from migration of
grass awns, with translocation
of bacteria either from the oral
cavity or the environment.
Fight wounds are likely to be
contaminated by a variety of
obligate and facultative anaerobic
organisms from the oral cavity
and gingival cleft.
Other bacteria from the skin
surface and mucous membranes,
such as Staphylococcus
pseudintermedius and
Streptococcus spp. (which may
potentially cause necrotising
fasciitis [NF] and toxic shock
syndromes [TSS]), can become
important pathogens, and
occasionally soil saprophytes
which enter the wounds as
contaminants (such as Nocardia
spp., Pseudomonas aeruginosa,
rapidly growing mycobacteria and
fungi) can give rise to chronic
infections that fail to respond to
standard therapy.
Bite wounds inficted
by dogs generally
have greater lateral
shearing forces. This
results in extensive
tearing and disruption
of tissues.
BACKGROUND/NATURE OF INFECTION/
ORGANISMS INVOLVED
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
SPECIES: DOG
It can be helpful to make smears of purulent exudate,
when present. Subsequent Gram or DiffQuik staining
may demonstrate pathogenic bacteria. C+S testing
may be helpful, especially in cases that have failed
to respond to empiric therapy.
Radiology (with contrast i.e. stulogram),
ultrasonography and occasionally advanced
cross-sectional imaging may be useful to detect
inciting foreign bodies such as grass seeds,
wood splinters, teeth or metallic fragments.
KEY ISSUES
01
Dog ght wounds involve lateral
shearing forces, major disruption of
tissues and an open draining wound.
02
There is variable contamination with
a variety of different bacteria.
03
Streptococcus species can
sometimes be important pathogens
in this setting.
04
Occasionally, subcutaneous
infections occur due to migrating
plant foreign bodies such as grass
seeds and awns.
TESTS FOR DIAGNOSIS
Latex drain placed to allow ongoing gravitational drainage.
Photo courtesy of Dr Anne Fawcett.
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
SPECIES: DOG
TREATMENT
Debridement, drainage and wound reconstruction
are critical to prevent infections developing. One
should be very wary of using monotherapy with
currently registered veterinary uoroquinolones
as this may induce superantigen expression and
potentially, NF/TSS in otherwise uncomplicated
Streptococcus canis infections in some patients.
Thorough exploration of dog ght wounds is
important as the iceberg effect is often present,
with greater disruption to subcutaneous tissues
being present than suggested by the appearance
of the surface wound. Thus, opening up pockets
of devitalised tissues, wound debridement and the
strategic placement of drains are just as critical
as careful selection of antimicrobial agents.
Placing latex (Penrose) or Jackson Pratt drains
to facilitate removal of exudate while minimising
wound dead space is often helpful.
Greater emphasis should be placed on selecting agents active against Gram-positive cocci.
Amoxicillin-clavulanate, initially by injection (SC and IM), and subsequently orally offers the best antimicrobial
spectrum of activity. Alternatives include an IV combination (ampicillin/amoxicillin plus gentamicin; ticarcillin
clavulanate; 1st generation cephalosporin plus gentamicin), perhaps in more severe cases when rapidly obtaining
high blood levels is desirable. However, uoroquinolones should not be used unless indicated by C+S testing
(e.g. Pseudomonas aeruginosa superinfection).
First line:
Amoxicillin-clavulanate (12.5 mg/kg q12h).
Second line:
Based on C+S.
Cefovecin is suitable for any case where there are
concerns of compliance, or there are difculties
with oral dosing.
ANTIBIOTICS USED
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
SPECIES: DOG

AIDAP TOP TIPS
USAGE RECOMMENDATION
There is no evidence-base to guide recommendations regarding
treatment duration.
From experience AIDAP recommend at least 4 days and ideally 7-14 days.
Avoid empiric use of
fuoroquinolones in
dogs with fght wounds,
as they may predispose
to the development
of life-threatening
streptococcal infections.
Key references:
1. Hall M. J Am Vet Med Assoc 2010; 236(6): 620
2. Brook I. Curr Infect Dis Rep 2009; 11(5): 389-395
3. Six R, Cherni J, Chesebrough R, et al. J Am Vet Med Assoc 2008; 233(3): 433-439
4. Csiszer AB, Towle HA, Daly CM. J Am Anim Hosp Assoc 2010; 46(6): 433-438
5. Weese JS, Poma R, James F, et al. Can Vet J 2009; 50(6): 655-656
6. Dendle C and Looke D. Aust Fam Physician. 2009; 38(11): 868-874
SPECIES: DOG
SPECIES: DOG 5 SECTION: ORAL
CONDITION: PERIODONTAL DISEASE
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
It usually is a result of feeding
soft food or highly rened
carbohydrate (that is readily
fermented by gingival anaerobes)
that leads to a shift in the
host: bacteria relationship with
overgrowth of pathogenic
organisms specically
Porphyromonas spp. closely
related to P. gingivalis.
At some level, this is a
natural disease condition, in
which dietary factors, host
factors (including crowding of
teeth, retention of deciduous
teeth, malocclusion due to
abnormal head conformation
[brachycephalic dogs]) and
microbial factors interplay in a
complex manner. The bacteria
involved are normal constituents
of the normal microbiota of the
gingival cleft, although they can
behave as true pathogens in this
scenario.
In this entity, the amount of
inammation in the gum is
usually commensurate with the
extent of the build-up of plaque
and tartar, although irreversible
changes in local anatomy
(gingival recession with exposure
of dentine) contribute.
Typically, the extent of the
inammation is usually
proportionate to the extent of
plaque and tartar accumulation,
although in certain breeds
(e.g. Maltese) there seems to be
an exaggerated host response.
This suggests that genetic
factors in this and certain other
breeds may play a role in this
multi-factorial disease complex.
Faucitis the entity which occurs
in cats has no equivalent entity
in the dog, presumably because
calicivirus infection does not
occur in the dog.
Periodontal disease
when it occurs as a
single entity in the
older dog in association
with a build-up of
plaque (a bioflm of
obligate anaerobes and
salivary mucoproteins),
tartar (mineralised
plaque) and gingival
recession.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
1. Examination of the oral cavity under general
anaesthesia is very helpful, with probing of the
periodontal pockets.
2. Dental radiography can be very helpful.
3. Biopsy of gums is of very limited value other than
to exclude other diseases such as neoplasia.
KEY ISSUES
01
Chronic gingivostomatitis can be
due to severe periodontal disease.
02
In some breeds, e.g. Maltese, there
may be an additional host immune
deciency state or bacterial dysbiosis
that results in inammation of the
gums and adjacent tissues that is
disproportionate to the extent of
plaque and tartar accumulation.
03
The cornerstone of therapy is re-
establishment of normal structure
and function, and changing the diet
to encourage more chewing and
natural cleansing of the dentition.
TESTS FOR DIAGNOSIS
Canine patient with tartar and mild to moderate periodontal disease, especially in the
vicinity of the canine and carnassial teeth of the upper dental arcade.
Photo courtesy of Dr Richard Malik.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
Remove tartar and plaque, scale and polish
enamel and exposed dentine, remove
unsalvageable teeth, and administer (perhaps) a
2-week course of antimicrobials highly effective
against obligate anaerobes likely to be involved.
Clindamycin, metronidazole (with or without
spiramycin) and doxycycline are preferred over
amoxicillin-clavulanate because they reach more
effective levels within the biolm in the vicinity of
the periodontal space.
First line:
Doxycycline monohydrate (5 mg/kg q12h
)
or clindamycin (5-11 mg/kg q12h).
Second line:
Metronidazole (10 mg/kg q12h).
Cefovecin is suitable for any case where there
are concerns of compliance, or there are difculties
with oral dosing.
ANTIBIOTICS USED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T

AIDAP TOP TIPS
Ideally, start therapy a few days prior to anaesthesia for dental radiography, extractions,
scaling, polishing, and continue for 2 weeks following the procedure or until there is good
healing of the periodontal tissues. Ensure doxycycline given with food or water bowl provided.
Key references:
1. Lyon KF. Vet Clin North Am Small Anim Pract 2005; 35(4): 891-911
2. Johnston TP, Mondal P, Pal D, et al. J Vet Dent 2011; 28(4): 224-229
3. Radice M, Martino PA, Reiter AM. J Vet Dent 2006; 23(4): 219-224
4. Stegemann MR, Passmore CA, Sherington J, et al. Antimicrob Agents Chemother 2006; 50(7): 2286-2292
5. Zetner K and Rothmueller G. Vet Ther 2002; 3(4): 441-452
6. Zetner K, Pum G, Rausch WD, et al. Vet Ther 2002; 3(2): 177-188
7. Nielsen D, Walser C, Kodan G, et al. Vet Ther. 2000; 1(3): 150-158
8. Warrick JM, Inskeep GA, Yonkers TD, et al. Vet Ther 2000; 1(1): 5-16
9. Harvey CE, Thornsberry C, Miller BR, et al. J Vet Dent 1995; 12(4): 151-155
10. Jones RL, Godinho KS, Palmer GH. Br Vet J 1994; 150(4): 385-388
11. Sarkiala E, Harvey C. Semin Vet Med Surg (Small Anim) 1993; 8(3): 197-203
12. Giboin H, Becskei C, Civil J, et al. Open J Vet Med 2012; 2: 89-97
Chewing encourages a scissors action of the carnassials on fresh meat and
ossing by stripping muscle from periosteum and bone, use of specially
formulated kibble that minimises tartar accumulation and using adjunctive
products and procedures such as dental chews, brushing, chlorhexidine etc.
Further therapy is
directed at changing
the diet to include
more chewing.
SPECIES: DOG
SPECIES: DOG 9 SECTION: URT
CONDITION: ACUTE URT DISEASE/INFECTIOUS
TRACHEOBRONCHITIS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
The term acute URT disease
in dogs, may be associated with
primary viral URT disease (with
secondary bacterial involvement)
or disease due to Bordetella
bronchiseptica, which can
cause tracheobronchitis and
pneumonia, and sometimes nasal
discharge. Viruses that can cause
primary URT disease include
distemper, canine adenovirus,
parainuenza, true inuenza.
These are very rare indeed in
contemporary suburban practice
in Australian cities. Bordetella
can be a primary pathogen
or a secondary invader after
primary viral disease. There is
some new information on canine
herpesvirus type 1 as a cause of
ocular and also URT disease, but
there is no consensus on this or
any research data from Australia.
So the question comes down to
treatment of canine cough or
kennel cough. Nasal foreign
bodies e.g. twigs, grass awns,
can cause peracute onset of
URT signs. Acute cryptococcal
rhinosinusitis does occur in
dogs, and it is therefore worth
examining nasal discharge
cytologically or using special
fungal media like bird seed agar.
Nasal aspergillosis is usually
subacute to chronic disease,
but should be considered also
as a diagnostic possibility.
Primary bacterial
rhinitis in dogs does
probably not exist as
a clinical entity.
ORGANISMS INVOLVED
SPECIES: DOG
TRACHEOBRONCHITIS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
The new range of multiplex PCR panels may have a
use in the clinical evaluation of such cases, although
we do not yet have sufcient experience to comment,
and they are expensive and slow to give a result.
If cough was the main problem and the owner and/
or clinician was interested in further diagnostics,
thoracic radiographs and airway (BAL) cytology,
Gram stain and bacterial C+S testing might be helpful
if you wanted to rule in or rule out Bordetella and
other bacteria, or further characterise the nature of
the infectious respiratory disease.
C+S of nasal discharge is unlikely to be helpful,
although is some cases one might observe a heavy
pure growth of Bordetella which might be clinically
signicant. Cytology of nasal discharge is useful for
assessment of cryptococcal rhinosinusitis, a rare
diagnostic possibility.
KEY ISSUES
01
Consider nasal foreign bodies
in peracute cases of sneezing
and/or nasal discharge. Consider
anterior and posterior rhinoscopy
in this setting.
02
Consider using a multiplex PCR
panel to rule in or rule out
potential viral pathogens and
Bordetella using pharyngeal swabs.
The problem is such tests are
expensive, especially in comparison
with the cost of empiric treatment.
03
Consider thoracic radiography and
unguided BAL and C+S in dogs with
severe cough, especially when fever
or dyspnoea is present.
04
Consider empiric treatment with
doxycycline monohydrate especially
if there is a history of potential
contagion from dogs with canine
cough e.g. from a shelter or pound.
05
Consider a full investigation
(radiology, rhinoscopy, bronchoscopy
and CT) for cases that fail to respond
to empiric therapy. This is more likely
to be useful than the selection of a
second antimicrobial agent.
Consider that acute cryptococcal rhinosinusitis
does occur in dogs, and also consider nasal
aspergillosis as a diagnostic possibility.
TESTS FOR DIAGNOSIS
SPECIES: DOG
TRACHEOBRONCHITIS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
A thorough history (access to kennels, pounds,
other dogs at show), a vaccination history, perhaps
thoracic radiography (in certain circumstances)
and then trial empiric therapy using doxycycline
monohydrate. This drug is arguably the most
effective and reliable agent against Bordetella
because of its high penetration of respiratory
mucous. It also has good efcacy for Pasteurella
species and obligate anaerobes involved as
secondary respiratory pathogens.
Cough suppressants (e.g. opioids) may be
appropriate under some circumstances
(persistent dry cough). Nebulisation therapy
(using saline with or without gentamicin) may
also be helpful. Amoxicillin-clavulanate is a less
satisfactory choice because, being charged and
water soluble, it tends not to reach sufciently
high levels in respiratory mucous. In young
animals, uoroquinolones should not be used
because of their effects on growing cartilage.
First line:
).
Second line:
Based on C+S of material collected carefully
from the airways (TTW, unguided BAL etc.).
ANTIBIOTICS USED
SPECIES: DOG
TRACHEOBRONCHITIS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T

Empiric treatment with doxycycline monohydrate plus nebulisation with saline [with or without
gentamicin 1% (10 mg/mL) solution
] for 1-2 weeks, or longer, depending on response to therapy.

Ensure doxycycline given with food or water bowl provided.
Key references:
1. Van Pelt DR and McKiernan BC. Vet Clin North Am Small Anim Pract 1994; 24(5): 789-806
2. Marretta SM. Vet Clin North Am Small Anim Pract 1992; 22(5): 1101-1117
3. Williams M, Olver C, Thrall MA. Vet Clin Pathol 2006; 35(4): 471-473
4. Schwarz S, Alesk E, Grobbel M, et al. Berl Munch Tierarztl Wochenschr. 2007; 120(9-10): 423-430
5. Datz C. Compend Contin Educ Pract Vet 2003; 25(12): 902-914
6. Speakmana AJ, Dawsonb S, Corkillc JE, et al. Vet Microbiol 2000; 71(3-4): 193-200
Profuse nasal discharge, crusting and depigmentation of the nasal
planum in a dog with sinonasal aspergillosis.
Photos courtesy of Dr Vanessa Barrs.
Close-up of the dog in previous photo after removal of nasal
discharge, illustrating crusting and depigmentation of the nasal
planum, which are common fndings in dogs with sinonasal
aspergillosis an important differential diagnosis for rhinitis
in dogs.
SPECIES: DOG
CONDITION: CHRONIC RHINOSINUSITIS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Causes of chronic nasal
disease include lymphocytic-
plasmacytic rhinitis, foreign
bodies (fragmented grass awns,
twigs, grass blades etc.), fungal
infections (cryptococcosis, low
grade aspergillosis), neoplasia
and tooth root infections.
Primary viral rhinitis in the dog
appears rarely. Nasal cavity
disease in the dog is often not
primarily due to an infectious
agent, apart from mycotic
rhinosinusitis.
Chronic rhinosinusitis
is rare as a primary
entity in the dog.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
1. Diagnostic imaging of the sinus and nose
(radiographs, CT, MRI).
2. Rhinoscopy (anterior and posterior).
3. Biopsy of nasal turbinates.
4. Culture of suspected fungal plaques.
5. Bacterial and fungal culture (interpret in
light of normal nasal ora).
6 Cytology of nasal discharge or latex agglutination
testing to rule in or rule out cryptococcosis.
7. Examination of fresh biopsy material using
light microscopy for ciliary activity.
KEY ISSUES
01
Primary chronic bacterial
rhinosinusitis is uncommon.
02
Nasal aspergillosis may occur in
canine patients, but is important to
rule in or rule out. Depigmentation
of the nasal planum in association
with chronic nasal discharge is
strongly suggestive of this aetiology.
Secondary bacterial infection may
occur in cases of nasal aspergillosis
and foreign bodies.
03
Nasal foreign bodies normally cause
a peracute onset of sneezing in dogs,
but chronic signs can develop if the
material is not cleared naturally or by
veterinary intervention.
TESTS FOR DIAGNOSIS
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
Do not routinely prescribe antimicrobials when confronted with a dog with nasal cavity signs, unless
there is some known event e.g. vomition into the nasal cavity, inhalation of small foreign bodies.
First line:
None empirically.
Second line:
May be appropriate after investigation and C+S
e.g. nasal aspergillosis may need antimicrobial
therapy for secondary bacterial infection.
ANTIBIOTICS USED
AIDAP TOP TIPS
Nasal discharge should make the clinician pursue diagnostic
investigations rather than trialing empiric antimicrobial therapy.
Primary rhinitis is not a
clinical entity in the dog.
Key references:
1. Edwards DF, Patton CS, Kennedy JR. Probl Vet Med 1992; 4(2): 291-319
2. Sharman M, Paul A, Davies D, et al. J Small Anim Pract 2010; 51(8): 423-427
3. Nelson HS. J Allergy Clin Immunol 2007; 119(4): 872-880.
4. Malik R, Dill-Macky E, Martin P, et al. J Med Vet Mycol 1995; 33(5): 291-297
SPECIES: DOG
SPECIES: DOG 16 SECTION: LRT
CONDITION: ACUTE LRT INFECTION
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
In animals presenting with
dyspnoea and coughing,
alternative diagnoses must
be also considered including
pulmonary oedema, aspiration
pneumonia, allergic or
hypersensitivity disease,
haemorrhage and neoplasia.
The remarkable number of
non-infectious causes of acute
respiratory disease makes
denitive diagnosis of acute LRT
disease difcult. Furthermore,
secondary pneumonia may
occur in the setting of prior LRT
disease due to a non-infectious
cause. Clinical signs suggesting
infection might include a moist
cough, harsh breath sounds,
fever, purulent appearing
expectorant and sometimes
purulent nasal discharge.
Radiographs are strongly
recommended to investigate
all cases presenting with such
clinical signs. Haematologic
ndings suggesting infection
include neutrophilia and perhaps
left shifting to band neutrophils.
In severe acute infection,
neutropenia might be seen due to
overwhelming demand.
For initial treatment of life-
threatening acute infectious LRT
disease, consideration of the
route of delivery should be made.
For hospitalised patients,
parenteral therapy to obtain
adequate blood levels of
antibiotics immediately should
be considered. In such cases,
therapy with IV antibiotics with a
high likelihood of efcacy against
Gram-positive and Gram-negative
bacteria/aerobic and anaerobic
(four-quadrant therapy) should
be given. This includes the use
of IV amoxicillin or ampicillin
combined with either gentamicin
or an injectable uoroquinolone.
Many clinicians in Australia
use ticarcillin-clavulanate in
this setting, however it should
be remembered this drug is
more effective against Gram-
negative enteric bacteria, but
has less intrinsic activity against
Gram-positive organisms and
anaerobes than amoxicillin.
Identication of bacteria in
trans-tracheal wash (TTW) or
BAL samples may be inuenced
by prior antibiotic therapy
and ongoing therapy with oral
antibiotics. In such cases, where
successful emergency therapy
has been given, treatment with
amoxicillin-clavulanic acid can
be used with close monitoring
of patient responses.
Infammation of the LRT
in the dog is a common
fnding in small animal
practice. The presenting
complaints and clinical
signs in cases involving
the LRT may be acute
and severe in nature.
Signs include coughing,
dyspnoea, tachypnoea,
fever and lethargy.
Additionally, auscultation
may demonstrate
crackles, wheezes and
harsh breath sounds.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
In animals with suspected infectious pneumonia,
sampling of the cellular and uid content of the
lower bronchi and alveolar space is strongly
recommended. This may be accomplished by guided
or unguided BAL methods.
Alternately, in larger dogs a suitable sample can
be obtained by TTW. TTW is technically more
challenging but is suitable in dogs that are compliant
and has the added advantages of not requiring
anaesthesia and having less risk of oropharyngeal
contamination. Sampling will assist in conrmation
of the presence of infectious agents and allow for
the culture of bacteria and the identication of
antibiograms.
KEY ISSUES
01
Careful clinical examination
to rule out non-infectious
respiratory diseases.
02
Thoracic imaging (radiography rst,
then possibly CT where available).
03
TTW and BAL samples for
C+S testing.
04
Bronchoscopy, where indicated.
TESTS FOR DIAGNOSIS
Radiograph of a 12 year-old dog with bronchopneumonia. Air bronchograms
are evident. Previous metal sutures are from surgery for PDA as a puppy.
This dog had a TTW with a heavy growth of Klebsiella pneumoniae isolated.
Photo courtesy of Dr Steve Holloway.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
It is recognised that in some cases due to nancial
considerations or owner compliance that sampling
of the LRT will not be feasible. In severely affected
dogs institution of appropriate broad-spectrum
four quadrant antibiotic therapy (i.e. effective
coverage of both Gram-positive and Gram-negative
causes, as well as both aerobes and anaerobes)
will be required. The rational choice of antibiotics
in such cases is best made with knowledge of the
likely bacteria that may be present and their likely
antibiograms. In this setting, the clinician and pet
owner need to be aware that there is a possibility
of treatment failure and that close observation of
the response to therapy is required.
It is recognised that due to the nature and severity
of acute LRT disease that some animals may be
at risk from anaesthesia and TTW/BAL. In such
cases, empiric antibiotic therapy is often instituted
and may be lifesaving. Correct identication of
the most appropriate antibiotic(s) for severe life
threatening primary pneumonia is challenging.
Multiple bacterial species have been identied
as potential pathogens. These bacterial species
show a wide variety of antibiotic susceptibilities
making a single antibiotic choice problematic.
For this reason, many authorities recommend
combinations of two or three agents. In severe life
threatening primary pneumonia it is important
to consider the use of antibiotics with activity
against Gram-positive pathogens such as
Staphylococcus spp., Streptococcus spp., and
Gram-negative pathogens such as Pasteurella
multocida, Bordetella bronchiseptica, E. coli and
Klebsiella pneumoniae. In many cases, obligate
anaerobes are also involved, especially following
aspiration. In particular, infections with E. coli
and K. pneumoniae can be associated with severe
pneumonia associated with unpredictable (and
often resistant) susceptibility patterns. In such
cases data provided by C+S testing is essential.
Small animals with LRT infections greatly benet
by nebulisation with saline followed by appropriate
physiotherapy, viz. exercise (in dogs), percussion,
coupage and elevating the hindquarters to
facilitate expectoration of inammatory exudate
from the airways. Some clinicians advocate the
addition of gentamicin (1% solution or
10 mg/mL) to the nebulisation chamber.
Gentamicin is not absorbed systemically when
delivered via a nebuliser. Nebulisation of
gentamicin may have efcacy against bacteria
located on the surface of the ciliary epithelium
that may not be exposed to sufcient levels of
antibiotics delivered systemically. However it is
not suitable for monotherapy in cases of bacterial
pneumonia and adequate coverage with systemic
antibiotic therapy is essential.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
AIDAP TOP TIPS ANTIBIOTICS USED
In non-life-threatening infections:
First line: Doxycycline (5 mg/kg q12h
).
Second line: Amoxicillin-clavulanate (12.5 mg/kg q12h).
In severe infections:
Four quadrant parenteral coverage with amoxicillin
clavulanate, [enrooxacin (5 mg/kg q24h) or gentamicin
(6 mg/kg q24h IV/SC in a well hydrated patient)] and
metronidazole (10 mg/kg q12hrs).
Oral for non-life-threatening infections.
Parenteral IV if life threatening.
There are only a few
published studies or reviews
on the treatment of dogs
with broncho-pneumonia,
the bacteria isolated and
their common antibiotic
susceptibilities.
This emphasises the need
for C+S to be performed in
all severe or chronic cases.
Key references:
1. Jameson PH, King LA, Lappin MR, et al. J Am Vet Med Assoc 1995; 206(2): 206-209
2. Chandler JC, Lappin MR. J Am Anim Hosp Assoc 2002; 38(2): 111-119
3. Tart KM, Babski DM, Lee JA. J Vet Emerg Crit Care (San Antonio) 2010; 20(3): 319-329
SPECIES: DOG
CONDITION: PYOTHORAX
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Critically, there are some key
differences compared with cats
where the disease is observed
more commonly most notably,
grass awn inhalation is a
common cause of the disease
in many dogs (especially where
Actinomyces spp. and related
bacteria are cultured).
For this reason, surgical
exploration may be warranted
fairly early in therapy, unless
there is a prompt response
to medical therapy. Also,
Enterobacteriaceae are more
commonly implicated in
infections, (E. coli in up to 54%
of cases compared with 0-7%
of cats), and Nocardia spp.
infections are more common
(up to 22%, compared with 0-7%
in cats). Therefore, empiric
four quadrant antimicrobial
therapy is warranted until results
of antimicrobial susceptibility
testing become available.
Because of the wide range of
organisms that may be isolated
from canine pyothorax cases,
C+S testing is mandatory and
cost effective, as it permits
targeted therapy of the specic
pathogen involved.
Pyothorax is an
uncommon disease
in dogs.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
1. Cytology (both DiffQuik and Gram staining)
and C+S of the uid (aerobic and anaerobic).
2. Thoracic radiographs, or if available thoracic
CT scans after uid removal. These tests may
help identify, focal/lobar pneumonia, foreign
bodies, lung abscesses etc. Thoracic CT scans
are especially useful in identifying foreign bodies.
3. Bronchoscopy in cases of a suspected foreign
body may assist in removal of the instigating
cause, although typically the offending awn has
already migrated into the pleural space by the
time of diagnosis.
KEY ISSUES
01
Aspiration of pleural uid to provide
adequate lung expansion and
alleviate dyspnoea. This may be
accomplished initially via needle
aspiration (a 19-gauge buttery is
convenient in many patients) followed
by placement of indwelling thoracic
drains, as deemed necessary, to
facilitate daily drainage and lavage
with warm crystalloid solutions.
Unlike most cats, thoracic drains
can often be inserted in larger dogs
under local anaesthesia without a
requirement for general anaesthesia.
02
Severe compartmentalisation of
infection in the thorax and lung
abscessation may require surgical
intervention.
TESTS FOR DIAGNOSIS
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
Initial antimicrobial therapy is empiric and based on cytology and Gram staining of the pleural uid. Gram
positive lamentous rods are suggestive of Actinomyces, Nocardia and occasionally some obligate anaerobes.
Therapy should be modied, if necessary, in the light of C+S data which can take up to 3 days to become
available. Factors to consider when choosing an antibiotic regimen for initial treatment are whether to
use a bactericidal or bacteriostatic antimicrobial, spectrum of activity, combination therapy, dose, route,
frequency and duration of administration. A recent study by Boothe et al (2010) would suggest a wide variety
of bacterial species may be isolated from dogs with pyothorax. Furthermore, polymicrobial infections with
facultative anaerobic and obligate anaerobic bacteria were common. The use of antibiotics with efcacy
against obligate anaerobes is strongly advocated for all cases. Many people also like to choose agents that
adequately penetrate into devitalised tissues that might be poorly perfused, such as metronidazole. Adding
antimicrobials, such as penicillin, to thoracic lavage solution is controversial and would appear to offer no
advantage because comparable tissue levels are attained with IV administration. Some people add small
quantities of heparin to the lavage uid, although this too is controversial.
DiffQuik stained smear of purulent exudates from a dog which
presented with tension pneumothorax and purulent pleurisy
attributable to migration of grass awn(s).
Photo courtesy of Dr Shane Raidal.
Tension pnuemothorax and lobar pneumonia in a pig dog following
migration of a grass awn.
Photo courtesy of Dr Peter Young.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
ANTIBIOTICS USED
First line empiric therapy with three agents:
(i) Cefazolin (20 mg/kg q8h
) or amoxicillin (10-20 mg/kg q6h
),
(ii) Aminoglycoside (gentamicin 6 mg/kg q24h IV to a well hydrated patient)
or uoroquinolone (enrooxacin, 5 mg/kg q24h SC),
(iii) Metronidazole (10 mg/kg q12h) four quadrant therapy.
If branching lamentous rods are observed on staining of specimens of pleural uid,
trimethoprim-sulfonamide may also be effective but a C+S is recommended.
IV initially then based on C+S and clinical response. Change to oral antibiotics after a few days, after the animal
is responding and has commenced eating. Prolonged therapy after discharge from hospital may be required if
signicant lobar pneumonia is present.
Key references:
1. Boothe HW, Howe LM, Boothe DM, et al. J Am Vet Med Assoc 2010; 236(6): 657-663
SPECIES: DOG
SPECIES: DOG 24 SECTION: URINARY TRACT
CONDITION: ACUTE LOWER UTI/CYSTITIS
(FIRST OCCURRENCE)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Infections occur most commonly
in older female dogs, but in
contrast to cats uncomplicated
UTIs are common in dogs and a
low urine specic gravity has not
been identied as a risk factor for
UTI in dogs. The median age of
diagnosis for UTI in dogs is
7 to 8 years.
Dogs may also present with LUT
signs due to urolithiasis, bladder
neoplasia or prostatic disease
(prostatitis, prostatic neoplasia,
benign prostatic hypertrophy).
E. coli is the most common
pathogen and most common
Gram-negative isolate in canine
UTIs accounting for 33-55% of
isolates, while Streptococcus/
Enterococcus are the most
common Gram-positive isolates
in canine UTIs. Most UTIs are
thought to result from ascending
infections of colonic microbiota
as opposed to infections from
haematogenous/lymphatic
spread.
Urease-positive mycoplasmas
that are adapted for life in the
urogenital tract (Ureaplasma
spp.) can be uncommon but
important causes of UTI in dogs,
and may be clinically relevant as
they are resistant to -lactams.
Mycoplasma infection should
be considered in dogs with high
urine pH crystalluria and a high
white cell count that returns a
diagnostic microbiology report
yielding no signicant growth.
Whilst research has been
undertaken on a small number
of highly resistant Gram-negative
organisms causing canine UTIs
in Australia, apart from focused
studies often involving a single
class of antimicrobial, there is
an absence of data on both the
prevalence of specic pathogens
causing UTI and the susceptibility
proles of the isolates obtained.
In one Australian study involving
162 E. coli isolates obtained
mainly from the urogenital
system of dogs, resistance
prevalence was as follows:
amoxicillin (44%); cephalothin
(22%); amoxicillin-clavulanate
(20%); tetracycline (17%);
trimethoprim-sulphonamide
(14%); enrooxacin (10%); third
generation cephalosporin (9%);
gentamicin (3%). A total of 20% of
isolates were classied as MDR
i.e. resistant to four or more of
nine tested antimicrobial agents.
However, it must be remembered
that the majority of the cases were
presented to specialist rather
than primary accession veterinary
practices and thus may be more
likely to have been obtained from
dogs with complicated rather than
uncomplicated UTI.
Similar to cats, simple
uncomplicated UTI is
a sporadic bacterial
infection of the bladder
in an otherwise healthy
individual with normal
urinary tract anatomy
and function.
ORGANISMS INVOLVED
SPECIES: DOG
(FIRST OCCURRENCE)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
1. Rectal examination is important in male dogs to
assess for presence of prostatic disease while
vulval examination is important in female dogs.
2. A full urinalysis is recommended for all dogs
presenting with LUT signs, using a urine sample
collected by cystocentesis or using a sterile
urinary catheter.
3. Diagnosis of an uncomplicated UTI should be
made on the basis of presence of LUT signs
with supporting evidence of UTI (epithelial cells,
RBC, WBC and bacteria) on a full urinalysis
including examination of Gram or DiffQuik stained
urine sediment. Urine collected for urinalysis
should also be submitted for C+S testing since
false positive diagnoses can be made on urine
sediments, usually due to the presence of stain
precipitates mimicking bacteria.
4. Free-catch urine samples are inferior and should
generally be avoided.
KEY ISSUES
01
Increasing age and female gender
are risk factors for uncomplicated
UTIs in dogs.
02
Where subclinical bacteriuria is
identied (positive urine culture
in the absence of clinical and
cytological evidence of UTI)
treatment is generally not
recommended in otherwise healthy
patients with normal urinary tract
anatomy and function.
03
In dogs with rst occurrence
of cystitis look for markers of
underlying disease or of bladder
dysfunction/abnormalities (e.g.
prostatic enlargement or PU/
PD and cutaneous abnormalities
suggestive of hyperadrenocortism)
so an assessment can be made as
to whether the UTI is most likely
uncomplicated or complicated.
TESTS FOR DIAGNOSIS
SPECIES: DOG
(FIRST OCCURRENCE)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
1. Empiric antimicrobial therapy is appropriate
pending urine culture results.
2. Recommended rst-line choices for empiric
therapy are amoxicillin or trimethoprim-
sulfonamide (for Gram-positive infections)
and trimethoprim-sulfonamide or amoxicillin-
clavulanate (for Gram-negative infections).
Adverse side effects associated with trimethoprim-
sulfonamide in dogs include keratoconjunctivitis
sicca, gastrointestinal side effects, fever,
haemolytic anaemia, urticaria, polyarthropathy,
facial swelling, PUPD and cholestasis. Also,
hypothyroidism can occur after chronic treatment
with potentiated sulfonamides. Consideration
should be given to using another antimicrobial in
large-breed dogs including Doberman Pinschers
due to increased risk of hypersensitivity reactions
such as idiosyncratic hepatopathy.
3. The recommended treatment duration is
7 to 14 days, although shorter treatment times
may be effective.
4. For prostatitis, trimethoprim-sulfonamide
and uoroquinolones reach adequate tissue
concentrations in the prostate gland.
5. Be aware of administration of trimethoprim-
sulfonamide to large-breed dogs such as
Rottweilers and Dobermans as they are prone to
idiosyncratic reactions including hypersensitivity
and keratoconjunctivitis sicca.
SPECIES: DOG
(FIRST OCCURRENCE)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
First line:
Amoxicillin (11-15 mg/kg q8h PO
);
Amoxicillin-clavulanate (12.5-20 mg/kg q8-12h PO
give with food to minimise vomiting).
Second line:
Consider a uoroquinolone (enrooxacin 5 mg/kg q24h,
marbooxacin 2.75-5.5 mg/kg q24hrs) on the basis of
C+S if the bacteria are resistant to rst-line therapy or
if the infection is serious; or trimethoprim-sulfonamide
(15 mg/kg q12h PO
) be aware of hypersensitivity
reactions in Rottweilers and Dobermans and
keratoconjunctivitis sicca.
Cefovecin should only be used where compliance is an
issue, or there are difculties with medicating orally.
Recommended duration of therapy for uncomplicated UTIs is 7 to 14 days.
For treating frst time
UTIs in dogs, consider
administering
amoxicillin-clavulanate
towards the upper dose limit
of 20 mg/kg q12h
(give with
food to minimise vomiting).
Amoxicillin-clavulanate
reaches high concentrations
in the urine and increasing
the dose rate is one of
the best ways to prevent
resistance emergence and
will exceed the MIC for most
UTI pathogens.
Key references:
1. Thompson MF, Litster AL, Platell JL et al. Vet J 2011; 190: 22-27
2. Weese JS, Blondeau JM, Boothe D, et al. Vet Med Int 2011; 2011: 263768
3. Gottlieb S, Wigney DI, Martin PA, et al. Aust Vet J 2008; 86(4): 147-152
SPECIES: DOG
CONDITION: COMPLICATED UTIs: RECURRENT LOWER UTI
/CYSTITIS AND CKD WITH PYURIA
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Complicated UTIs occur where
there is an underlying anatomic
or functional abnormality or
where there is a concurrent
disease that predisposes to UTI,
for example CKD. Recurrent UTIs,
occurring within six months after
successful treatment of the rst
infection, can be re-infections
caused by a different bacterial
species to the original isolate or
relapses caused by the same
bacterial species as the original
isolate. Relapses are common
in persistent or recurrent
canine UTIs, and similar with
complicated infections in cats
are often asymptomatic.
Pseudomonas aeruginosa and
Enterococcus spp., are isolated
more frequently in complicated
canine UTIs as compared
to uncomplicated UTIs. The
six most prevalent bacterial
isolates in complicated canine
UTIs are E. coli, Klebsiella
spp., Staphylococcus spp.,
Enterococcus spp., Proteus spp.
and Pseudomonas aeruginosa.
In addition, multiple isolates are
common in complicated canine
UTIs.
Since MDR faecal E. coli are
increasingly prevalent, accurate
identication of uropathogens
is important and urine
collection by cystocentesis
should be performed to prevent
contamination with faecal
bacteria and a false-positive
diagnosis of a MDR E. coli UTI.
Causes of complicated UTIs in
dogs include malformations of
the genitourinary tract including
ectopic ureter, urethral sphincter
mechanism incompetence,
diverticuli or stulas, struvite
urolithiasis and prostatitis,
as well as underlying disease
including hyperadrenocorticism,
diabetes mellitus and CKD.
Although indwelling urinary
catheters predispose to UTI,
asymptomatic bacteriuria in
the absence of cytological and
clinical signs of UTI does not
warrant treatment in
catheterised dogs.
In several studies involving large
datasets, E. coli, Klebsiella
spp.,Staphylococcus spp.,
Enterococcus spp., Proteus
spp. and Pseudomonas spp.
As for cats, recurrent
UTIs in dogs are a
subset of complicated
UTIs.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
were identied as the most
common bacterial pathogens
encountered in cases of chronic
or recurrent cystitis in dogs.
In a case study of 37 dogs with
MDR E. coli or Enterobacter
infections, the majority of which
were urogenital, most dogs had
underlying diseases predisposing
them to complicated infections.
Whilst a small number of dogs
were successfully treated with
carbepenems, the majority
also responded to 25 mg/kg of
amoxicillin-clavulanate even
though disc diffusion tests
indicated in vitro resistance to
this combination.
The global emergence and
spread of E. coli serotype O25b
sequence type (ST) 131 as a
cause of urosepsis in humans
is of grave medical concern.
These strains are highly virulent,
MDR and often show combined
resistance to uoroquinolones
and third generation
cephalosporins. E. coli ST131
UTI has recently been identied
in dogs internationally as well
as in Australia and the strains
are often indistinguishable from
human strains. Over 50% of
FQ-resistant E. coli isolates from
humans in Australia belong to
ST131 compared to <10% from
dogs. These extraintestinal
pathogenic E. coli should
therefore be considered to
be zooanthroponotic.
E. coli strain 83972 achieves
persistent asymptomatic
bacteriuria when administered
by urinary catheter in humans
with spinal injuries who are
prone to chronic, recurrent
UTI and may be an alternative
method of prevention in dogs
prone to similar UTI infections.
The organism has been shown to
temporarily colonise the normal
canine bladder and clinical
trials are currently underway in
Australian dogs with complicated
cystitis.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
1. Clinical signs alone should not be used for
diagnosis.
2. Diagnosis should not be based on examination
of urine sediment alone.
3. C+S testing (aerobic) should be performed in
all cases.
4. Cystocentesis should be used for urine collection
where possible.
5. Investigation for underlying disease (comorbidity)
should include determination of owner compliance
with previous antimicrobial therapy, rectal/vulval
exam, CBC/biochemistry, urinalysis, imaging,
endocrine testing.
6. Where concurrent disease or an underlying
bladder abnormality is not identied, consideration
should be given to referral for further
investigations, e.g. cystoscopy.
7. Where subclinical bacteriuria is identied (positive
urine culture in the absence of clinical and
cytological evidence of UTI) treatment is based on
the risk of ascending or systemic infection.
8. In dogs with indwelling urinary tract catheters
that develop cytological or clinical signs of UTI the
urinary catheter should be removed permanently.
If this is not possible the catheter should be
replaced. Urine for urinalysis and C+S testing
should ideally be collected by cystocentesis in
these patients when the bladder has relled after
catheter removal. Culture of urine from urine
collection bags is contraindicated and culture of
urinary catheter tips is not recommended since
results do not predict catheter-associated UTI.
KEY ISSUES
01
In dogs with recurrent cystitis,
careful consideration must be
given to detection of an underlying
bladder abnormality (e.g. urolithiasis,
neoplasia), prostatic disease
(prostatitis) or concurrent disease
that predisposes to recurrent UTIs
e.g. hyperadrenocorticism, diabetes
mellitus, CKD.
02
Recurrent UTIs in young dogs should
arouse suspicion of an underlying
abnormality or dysfunction of the
LUT, e.g. ectopic ureter.
03
Because MDR pathogens such as
ST131 are becoming increasingly
recognised globally and have
been identied in dogs, careful
consideration must be given to
selection of antimicrobials used for
treatment of UTI.
04
Prophylactic antimicrobials should
not be administered to dogs with
indwelling urinary catheters or after
catheter removal in dogs without
clinical or cytological evidence of UTI.
TESTS FOR DIAGNOSIS
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
1. Empiric antimicrobial therapy is not recommended
unless clinical signs necessitate it. Recommended
antimicrobials for empiric therapy are as for
uncomplicated UTIs but may often involve
treatment with a uoroquinolone if indicated
by C+S. Where possible the drug class selected
should be different from that used to treat the
original UTI. If the bacterial isolate is resistant
to the antimicrobial chosen for empiric therapy,
treatment should be changed to an antimicrobial
to which the isolate is susceptible and if possible
is excreted in its active form primarily in urine.
Adverse side effects associated with trimethoprim-
sulfonamide in dogs include keratoconjunctivitis
sicca, gastrointestinal side-effects, fever,
haemolytic anaemia, urticaria, polyarthropathy,
facial swelling, PUPD and cholestasis. Also,
hypothyroidism can occur after chronic treatment
with potentiated sulfonamides. Consideration
should be given to using another antimicrobial in
large-breed dogs including Doberman Pinschers
due to increased risk of hypersensitivity reactions
such as idiosyncratic hepatopathy.
2. In dogs with asymptomatic bacteriuria and
underlying disease (e.g. CKD) wait until C+S test
results are available to initiate treatment using an
appropriate antimicrobial.
3. For mixed infections consisting of Enterococcus
spp. and another bacterial isolate infection by
the former will often resolve when the other
organism is successfully treated. Ideally a single
antimicrobial or antimicrobial combination
effective against both organisms should be
selected, however if this is not possible due to
resistance antimicrobial therapy should be based
on efcacy against the organism perceived to be
most clinically relevant.
4. Where MDR organisms are identied, consultation
with colleagues with expertise in infectious
diseases is recommended. Antimicrobials
including carbapenems, vancomycin and linezolid
should never be used for treatment of subclinical
bacteriuria and are reserved for treatment of
complicated UTI diagnosed by C+S testing of a
urine sample obtained by cystocentesis in patients
with treatable diseases in which all other possible
antimicrobials have been considered.
5. Obtaining an antimicrobial minimum inhibitory
concentration for the isolated pathogen (or a disc
diffusion zone diameter size) from the diagnostic
laboratory may indicate that a drug that shows
in vitro resistance but effectively concentrates in
the urine, such as amoxicillin-clavulanate may be
used at the maximum dose rate of 25 mg/kg to
clear the infection.
(Note that some dogs may vomit after receiving
high oral doses of amoxicillin-clavulanate).
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
First line:
Guided by C+S testing,
but consider amoxicillin
(11-15 mg/kg q8h PO
);
amoxicillin-clavulanate
(12.5-20 mg/kg q8-12h PO);
or trimethoprim-sulfonamide
(15 mg/kg q12h PO
).
Cefovecin should only be
used where compliance is an
issue, or there are difculties
with medicating orally.
Second line:
Consider a uoroquinolone
(marbooxacin
2.75-5.5 mg/kg q24hrs,
enrooxacin 5 mg/kg q24hrs)
on the basis of C+S if the
bacteria are resistant to rst-
line therapy or if the infection
is serious; or trimethoprim-
sulfonamide (15 mg/kg
q12h PO) be aware of
hypersensitivity reactions in
Rottweilers and Dobermans
and keratoconjunctivitis sicca.
The recommended treatment duration is four weeks although shorter treatment times may be effective.
For recurrent infections, consider urine culture 5 to 7 days after starting therapy and 7 days after stopping
oral therapy.
In cases of
complicated cystitis
in dogs where a
fuoroquinolone is
indicated on the basis
of C+S, administer at
the higher end of the
registered dose rate.
Key references:
1. Gibson JS, Morton JM, Cobbold RN, et al. J Vet Intern Med 2008; 22(4): 844-850
2. Platell JL, Trott DJ, Wetzstein HG, et al. J Vet Sci Technol 2008; S6: 1
3. Thompson MF, Schembri MA, Mills PC, et al. Vet Microbiol 2012; 158(3-4): 446-450
4. Thompson MD, LItster AL, Platell JL et al. vet J 2011; 190: 22-27
5. Platell JL, Cobbold RN, Johnson JR, et al. J Antimicrob Chemother 2010; 65(9): 1936-1938
6. Platell JL, Cobbold RN, Johnson JR et al Antimicro Agents Chemother 2011; 55(8): 3782-3787
SPECIES: DOG
SPECIES: DOG 33 SECTION: PYREXIA
CONDITION: ACUTE FEBRILE ILLNESS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
On average, fever is less
commonly due to infectious
agents than in the cat, where
occult ght injuries and other
bacterial and viral infections are
quite common. Cats may respond
to empiric antimicrobial therapy
when presented with fever and
no localising signs, whereas dogs
less commonly do so.
In the dog, bacterial infections
causing fever include
endocarditis, peritonitis,
pneumonia, prostatitis,
pyothorax, pyometra, abscesses
(which may be in body cavities).
In certain breeds (e.g. German
Shepherds), disseminated fungal
disease should be considered
also in the differential diagnosis.
Thus, although infections should
always be considered as the
potential cause of acute febrile
illness, immune-mediated and
neoplastic diseases may also
cause fever. Immune-mediated
diseases have been noted to
represent up to 36% of febrile
diseases of the dog in one study.
Diseases such as corticosteroid-
responsive meningitis (also
known as aseptic suppurative
meningitis), immune-mediated
polyarthritis, metaphyseal
osteopathy (also known as
hypertrophic osteodystrophy),
panosteitis etc. should also
be considered. Pancreatitis
is another common cause
of fever in the dog. In some
dogs, unexplained neutropenia
may occur due to immune-
mediated mechanisms, further
complicating the diagnosis.
Therefore, a thorough search
for an infectious cause should
be undertaken, but with the
knowledge that some dogs may
have immune-mediated disease
as the primary cause of fever.
In young dogs, acute febrile
diseases may be infectious and
in such instances viral diseases
such as parvovirus may be
responsible. However, acute
bacterial enteritis (Salmonella,
Campylobacter, some E. coli)
may also occur. In these
scenarios, antibiotic selection
and efcacy is problematic.
Acute febrile
illness in the dog
may be infectious,
immune-mediated
or attributable to
malignancy.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Ideally samples for bacterial culture should
be collected prior to empiric antibiotic use.
Blood and joint uid culture may require
enrichment culture bottles to facilitate bacterial
growth. Many laboratories will give culture
bottles to veterinarians, so they are immediately
on hand when such cases are presented.
KEY ISSUES
01
A thorough physical examination is
mandatory. Pay particular attention
to identifying regions of pain such as
neck pain or joint pain. New cardiac
murmurs may signal development of
bacterial endocarditis. It is important
to look at the eye for uveitis, and
retinal examination can occasionally
be rewarding.
02
Haematology, biochemistry,
urinalysis and urine culture are
required, unless physical ndings
point to a specic anatomical region
as a potential cause of the infection.
03
Diagnostic imaging of the
thorax/abdomen radiographs,
ultrasonography and cross-sectional
imaging all have their place.
04
Blood and urine cultures may
be appropriate.
05
If considered appropriate, specic
searches for infectious agents/immune
diseases may be required such as
cardiac ultrasound for endocarditis,
CSF analysis, joint uid analysis.
Culture or PCR may be used for the
detection of Bartonella species and
other tick-borne agents in some cases,
especially in areas where such diseases
are endemic (e.g. far north Queensland
and the Northern Territory).
06
In young dogs with febrile disease
and lameness, radiographs of long
bones are required to investigate for
metaphyseal osteopathy, panosteitis
and fungal osteomyelitis.
TESTS FOR DIAGNOSIS
TREATMENT
If a high index of suspicion is present for
infection then antibiotic selection should
be based on likely pathogenic bacteria and
a bactericidal, broad-spectrum antibiotic
should be selected. If overwhelming sepsis
is suspected, four-quadrant therapy may
be instituted after collection of appropriate
samples for testing.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
First line:
Amoxicillin clavulanic acid
12.5 mg/kg SC or PO q12h.
Second line:
If overwhelming
sepsis is suspected then
four-quadrant therapy with
IV antibiotics is suggested.
E.g. IV amoxicillin (20 mg/kg
q6-8h
), metronidazole
10 mg/kg q12h and
gentamicin (6 mg/kg q24h
in a well hydrated patient) /
injectable uoroquinolone
(enrooxacin 5 mg/kg q24h).
Antibiotic use may interfere with subsequent diagnostics and should be reserved for severe cases with a high
index of suspicion for an infectious cause.
Acute abdominal
infammation is a special
subcategory of these
where multiple species of
bacteria may be identifed.
Therefore, if there is danger
of intestinal perforation
or translocation of enteric
organisms, then the
use of four quadrant
therapy may be required
until appropriate testing
and surgical therapy is
undertaken.
Key references:
1. Dunn KJ and Dunn JK. J Small Anim Pract 1998; 39(12): 574-580
2. Battersby IA, Murphy KF, Tasker S, et al. J Small Anim Pract 2006; 47(7): 370-376
SPECIES: DOG
SPECIES: DOG 36 SECTION: ABDOMINAL
CONDITION: ACUTE ABDOMINAL PAIN AND PYREXIA
/ABDOMINAL INFECTION AND LEUKOPENIA
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
The source of the infection is
often bowel leakage, but can
be from pyometra, prostatitis,
pyothorax, hepatic or kidney
abscess rupture. Migrating grass
awns and metallic foreign bodies
(needles) may also instigate
peritonitis. A ruptured gall
bladder may occur in animals
with infectious cholecystitis.
Penetrating bite wounds may
also cause peritonitis. In cats and
dogs primary bacterial peritonitis
is also reported where no
predisposing cause is identied.
Mortality rate is high and delayed
treatment and diagnosis may
result in a poor outcome.
This situation is clearly
a severe life or death
scenario with no time
for C+S data prior to
initiation of therapy.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
1. Abdominal uid should be obtained for cytology
and for C+S. Immediate treatment should then be
started. Aerobic and anaerobic cultures need to be
performed.
2. Surgical exploration of the abdomen is usually
required for diagnostic and treatment purposes.
3. Surgical drainage of the abdomen may be required
using Jackson Pratt drains; alternately, in some
cases an open abdomen method for drainage is
applied.
KEY ISSUES
01
Immediate antibiotics given
parenterally, preferably IV
at maximal safe doses.
02
Coverage of Gram-negatives,
Gram-positives, obligate anaerobes
with a high possibility of antibiotic
resistant bacteria being involved.
03
Immediate uid support and
probably surgery for correction
of underlying issue.
TESTS FOR DIAGNOSIS
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
1. Four-quadrant IV antibiotic therapy.
2. Surgical drainage.
3. Management of sepsis syndrome with uids,
plasma or colloids, sometimes a whole blood
transfusion and inotropic support, as needed.
1. Amoxicillin 20 mg/kg IV q6h
or ampicillin
(20 mg/kg IV q6-8h
) or cefazolin (22 mg/kg IV q8h
)
/cefoxitin (30 mg/kg IV q8h
).
2. Enrooxacin 5 mg/kg IV or SQ q24h or use an
aminoglycoside (e.g. gentamicin 6 mg/kg IV q24h.
3. Metronidazole 10 mg/kg IV q8h.
ANTIBIOTICS USED
Key references:
1. Ruthrauff CM, Smith J, Glerum L. J Am Anim Hosp Assoc 2009; 45(6): 268-276
2. Culp WT, Zeldis TE, Reese MS, Drobatz KJ. J Am Vet Med Assoc 2009; 234(7): 906-913
3. Mueller MG, Ludwig LL, Barton LJ. J Am Vet Med Assoc. 2001; 219(6):789-794
2 weeks post-recovery
The upper limit of the recommended dose range should be given.
Note that beta-lactams (penicillins and cephalosporins) and aminoglycosides
(gentamicin, amikacin) need to be given separately as they precipitate in the
uid line if given simultaneously. These agents should be given by slow IV
push over several minutes, separated by a ush with saline.
SPECIES: DOG
SPECIES: DOG 39 SECTION: DESEXING
CONDITION: ANTIBIOTIC USE AFTER ROUTINE DESEXING
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
As a general rule desexing
operations conducted using
sterile technique and not taking
longer than average for an
experienced veterinarian to
complete would not be given
antibiotics prophylactically.
In one study, peri operative
antimicrobial prophylaxis
decreased postoperative infection
rate in dogs undergoing elective
orthopaedic surgery, compared
with the infection rate in control
dogs. Cefazolin was not more
efcacious than potassium
penicillin G in these dogs.
This would suggest that
prolonged surgery times
for routine desexing might
be considered an increased
risk of infection, as might a
breach in aseptic technique.
Denitive studies of what time
limits are associated with
increased infection in desexing
operations are lacking. However,
antibiotics with higher efcacy
for Staphylococcus spp. would
be considered in the event of a
prolonged desexing operation.
Several studies have
shown that length of
time of surgery and
the more people in the
room at the time of
surgery, the greater
the risk of infections.
ORGANISMS INVOLVED
SPECIES: DOG
SPECIES: DOG 40 SECTION: DESEXING
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
KEY ISSUES
01
There is no need for prophylactic
antimicrobials for routine desexing.
02
If the procedure is unduly prolonged,
or there is a breach in asepsis, then
a single injection of amoxicillin-
clavulanate or a 1st generation
cephalosporin might be appropriate.
TREATMENT
Antibiotics are considered unnecessary in
routine short surgery conducted under sterile
conditions. Given the use of gloves and sterile
conditions, the routine use of prophylactic
antibiotics for spays is not required. Also given
that most potential contaminants arise from the
skin of the dog or the veterinary staff, a single
shot of procaine penicillin offers insufcient
coverage for Staphylococcus pseudintermedius
or Staphylococcus aureus infection.
Routine use of antibiotics not suggested.
ANTIBIOTICS USED

N/A.
SPECIES: DOG
SPECIES: DOG 41 SECTION: DENTAL
CONDITION: USE OF ANTIBIOTICS IN DENTAL PROPHYLAXIS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Pasteurella multocida, and
anaerobic Gram-negative rods
including Capnocytophaga are
frequently involved and these
are all sensitive to penicillins,
including benzyl penicillin and
amoxicillin-clavulanate.
There is a very small risk that
bacteraemia associated with
the use of ultrasonic scaling
devices and extractions could
produce infections elsewhere,
such as bacterial endocarditis.
This is most unlikely in normal
patients, but the risk is increased
with structural heart disease,
especially subaortic stenosis
which has been associated
with increased risk for the
development of bacterial
endocarditis.
For this reason, it may be prudent
to administer prophylactic
bactericidal antibiotics so that
high blood levels are obtained
during and immediately after the
dental procedures.
Most bacteria found
in the mouths of dogs
(and cats) are similar
to what is recovered
in bite wounds.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Histopathology and culture of infected tissue is
suggested if initial prophylaxis fails to cure an
ulcerated mouth lesion.
KEY ISSUES
01
Prophylactic antibiotics are
best administered prior to the
procedure e.g. procaine penicillin or
amoxicillin-clavulanate administered
SC or IM after premedication or
immediately after anaesthetic
induction.
TESTS FOR DIAGNOSIS
TREATMENT
N/A.
Amoxicillin or amoxicillin-clavulanate would cover the great majority of potential pathogens in this setting.
First line:
Amoxicillin 10 mg/kg q12h/amoxicillin-clavulanate
(12.5 mg/kg q12h).
Second line:
Clindamycin (5-11 mg/kg q12h) or
doxycycline monohydrate (5 mg/kg q12h
).
Cefovecin is suitable for any case where there
are concerns of compliance, or there are
difculties with oral dosing.
ANTIBIOTICS USED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
If there are extractions or bleeding, which occurs in most cases, then a 7-10 day course of antibiotics is required
depending on the healing period. Ensure doxycycline given with food or water bowl provided.
Key references:
1. Love D 1990 et al (isolated lots of anaerobes but possibly no data on their sensitivities)
2. Bowersock TL, Wu CC, Inskeep GA, Thoracicer ST. J Vet Dent 2000; 17(1): 11-16
4. Nielsen D, Walser C, Kodan G, et al. Vet Ther 2000; 1(3): 150-158
6. Sarkiala E and Harvey C. Semin Vet Med Surg (Small Anim) 1993; 8(3): 197-203
7. Zetner K and Thiemann G. J Vet Dent 1993; 10(2): 6-9
8. Wilcke JR. Probl Vet Med 1990; 2(2): 298-311
SPECIES: DOG
SPECIES: DOG 44 SECTION: SKIN/SOFT TISSUE
CONDITION: SURFACE BACTERIAL INFECTIONS:
(i.e. INTERTRIGO e.g. LIP FOLD, TAIL FOLD)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Surface pyodermas involve the
epidermis. As infection does not
cross the basement membrane
the dermis remains intact. The
great majority of bacterial skin
infections involve Gram-positive
organisms and particularly
the coagulase positive
staphylococci. The most common
of these is Staphylococcus
pseudintermedius which
represents over 90% of
infections in dogs.
The new species, Staphylococcus
pseudintermedius, was rst
described in 2005 and was
formed by the division of
isolates previously known as
S. intermedius into two species.
The name S. intermedius is
now applied to isolates that are
principally found in pigeons.
Infections with S. aureus are
relatively uncommon (around
5% or less). S. schleiferi
coagulans and S. schleiferi
schleiferi (coagulase negative)
are less often recognised as
causes of infection, but are found
particularly in otitis externa and
in certain geographic regions.
Other coagulase-negative
staphylococci are rarely involved
and normally only if immunity is
greatly reduced or when implants
are used. Gram-negative
bacteria are sometimes found
in pyoderma, particularly when
lesions are moist. Organisms
such as Proteus spp. And
coliforms may be secondary
invaders that fail to persist when
more signicant pathogens
are removed. Pseudomonas
aeruginosa is more serious and
requires specic therapy.
The most common surface
pyodermas are skin fold-
pyoderma (intertrigo) and
pyotraumatic dermatitis.
These clinical entities are only
reported in dogs. These are
types of surface pyoderma with
secondary bacterial involvement.
These infections typically respond
favourably to topical therapy,
but recurrence is frequent if a
primary disease process cannot
be identied and controlled.
The more recent
literature classifes
bacterial skin
infections based on
lesion depth and
distribution pattern
and this relies heavily
on clinical features
in combination with
histopathological data
on depth of infection.
It can be used to give a
prognosis and suggest
possible therapy.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
We would recommend that practitioners perform
an impression smear for cytological evaluation.
Examine under the microscope using immersion
oil (x100) and evaluate for the presence of healthy
or degenerate neutrophils (swollen and pale nuclei)
and extracellular cocci and bacilli and intracellular
phagocytosed bacteria. If there are abundant
bacilli, and if there is no response to empirical
antibacterial therapy then we would recommend
that practitioners submit a swab of the exudate for
C+S. Collecting a skin biopsy to rule out immune
mediated disease may be indicated if the lesions
fail to respond to appropriate topical and systemic
antimicrobial therapy, however these diseases are rare.
KEY STEPS
01
Identify bacterial overgrowth and/or
infection via surface cytology.
02
Commence trial treatment with
appropriate topical and/or systemic
antibiotic.
03
Consider bacterial C+S testing if
failure to respond to therapy.
04
Correct underlying anatomical
abnormality.
TESTS FOR DIAGNOSIS
Facial fold pyoderma.
Photos courtesy of Dr Mandy Burrows & Dr Mike Shipstone.
Tail fold pyoderma.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
There is very little evidence based data concerning the treatment of surface pyoderma in dogs.
For uncomplicated surface bacterial pyoderma, we recommend the use of topical antimicrobial therapy
in lieu of systemic antimicrobial therapy.
2% mupirocin (Bactroban
) is bactericidal within 48 hours for most Gram-positive cocci.

Fusidic acid (Fucidin
) is bacteriostatic and active against all Staphylococcus spp. including those that
are penicillin resistant, and its lipophilic nature allows good tissue penetration.
Hydrocortisone (topical corticosteroid) in combination with neomycin is not favoured by dermatologists
due to the high rates of contact sensitisation associated with neomycin.
First line:
Cephalexin
(22 mg/kg q12h or
30 mg/kg q24h)
vomiting may occur
at higher doses;
Cefovecin 8 mg/kg q14d
for 21-28 days.
Second line:
Clindamycin 11 mg/kg q12h.
Fluoroquinolones should be
avoided for Staphylococcal
pyodermas unless bacterial
resistance has been
demonstrated.
Application rate of topical agents is 1-2 times daily until cure and then twice a week as maintenance.
These lesions often respond
well to a combination
of gentle wiping with a
chlorhexidine impregnated
plagette or wipe and
application of topical therapy;
if bacilli are detected on
cytologic evaluation, then
Tris EDTA can be a useful
intervention followed by
topical silver sulfadiazine.
Key references:
1. Fitzgerald JR. Vet Dermatol 2009; 20(5-6): 490-495
SPECIES: DOG
CONDITION: SUPERFICIAL BACTERIAL INFECTIONS:
(i.e. MUCOCUTANEOUS PYODERMA, BACTERIAL
FOLLICULITIS, BACTERIAL OVERGROWTH)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Supercial bacterial folliculitis:
is a bacterial skin infection
affecting the hair follicle.
Staphylococcus pseudintermedius
is the primary pathogen. Most
bacterial folliculitis is seen
secondary to coexistent disease
or other predisposing factors.
Triggering diseases or syndromes
include atopic dermatitis, ea
allergy dermatitis, food allergy,
hypothyroidism, spontaneous and
iatrogenic hyperglucocorticoidism,
primary keratinisation disorders
and genodermatosis such as
colour dilution alopecia. Other
predisposing factors include
pruritus of any origin, defects
in the immune system and
poor grooming.
Distribution: axillae, inguinal
region, dorsal trunk, interdigital
Skin lesions: follicular pustules
with a central protruding hair
(unless the hair has been
shed). Pustules are fragile and
transient and rupture forming
crusted papules. After pustules
rupture, collarettes may form
with peripheral scaling and post
inammatory hyperpigmentation.
Alopecia is variable but common
and distinct, circular patches
of transient alopecia may form
around previously affected hair
follicles and give the coat a
moth-eaten appearance,
particularly in short coated dogs.
Mucocutaneous pyoderma:
affects mucocutaneous junctions
of dogs, most commonly the
lips and perioral skin. German
Shepherds are predisposed. The
pathogenesis is unknown but
the response to antimicrobial
therapy supports the role
of bacterial infection in the
aetiology, however the response
is variable and relapses are
common. The predisposing or
initiating factors are not known
and mucocutaneous pyoderma
may have a more complex
immunologic pathogenesis.
Distribution: lips and perioral
skin, and less commonly nasal
planum, nares, eyelids, vulva,
prepuce and anus.
Clinical features: erythema and
swelling of the lips; erosion and
ulceration with adherent crusting
may occur in more severe cases.
Depigmentation of the lips can
occur. The adjacent philtrum may
also be affected. The lesions are
sometimes painful and the dogs
rub areas and resent examination
and palpation.
Superfcial bacterial
infections are common
and include supercial
bacterial folliculitis,
bacterial overgrowth
and mucocutaneous
pyoderma.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
The diagnosis of supercial bacterial folliculitis
and bacterial overgrowth is usually straightforward
based on history, clinical signs, cytology and
response to antimicrobial therapy. A direct smear
of the pustular contents or an impression smear
of greasy skin should be performed for cytological
evaluation. If the lesion fails to respond to therapy,
or coccoid organisms persist after apparently
appropriate antimicrobial therapy or there are
abundant bacilli, then a swab of the exudate
should be submitted for C+S. Histopathology is
of little to no value in the diagnosis of supercial
bacterial infection but may be useful to differentiate
between discoid lupus erythematosus (nasal lupoid
dermatosis) and MCP, but antibiotic trial therapy
should be instituted before sample collection.
KEY STEPS
01
Identify bacterial overgrowth and/or
02
Commence trial treatment
with appropriate topical and/or
systemic antibiotic.
03
Consider bacterial C+S testing
if failing to respond to therapy.
04
Correct underlying predisposing
factors.
TESTS FOR DIAGNOSIS
TREATMENT
The majority of canine skin infections are caused by the coagulase positive S. pseudintermedius, and therefore
antibiotics that affect these bacteria and concentrate in the skin are of primary interest. Empirical antibiotic
selection is justied for supercial bacterial pyoderma. Selecting an antibiotic that penetrates to the site of
infection given at the correct dosage and frequency and for an adequate length of treatment is important.
In supercial bacterial infections, therapy should be instituted for at least 3-4 weeks.
Shampoo therapy is usually the most suitable topical agent for the treatment of pyoderma and benets
most dogs by removing tissue debris, hydrating the skin and reducing or eliminating the surface bacterial
population. Chlorhexidine is usually the active ingredient of choice for supercial bacterial infections.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
First line:
Cephalexin (22 mg/kg q12h).
Second line:
Clindamycin (11 mg/kg q12h).
Cefovecin is suitable for any case where
there are concerns of compliance, or
there are difculties with oral dosing.
Full therapeutic dose of antibiotics for 3 weeks, or 10 days beyond complete clinical resolution.
1. It is important to remember that
amoxicillin or doxycycline monohydrate
will not be generally effective for the
treatment of superfcial pyoderma.
2. Antibiotics must be given for a suffcient
duration and a minimum of three weeks
is recommended for superfcial bacterial
infections in dogs and cat.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Pustule.
Target lesion indicative of resolving epidermal collarette.
Epidermal collarette.
Multiple epidermal collarettes with annular alopecia.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Key references:
1. Loefer A. Cobb MA, Bond R. Vet Rec 2011; 169(10): 249
2. Summers, J. F., Brodbelt, D. C., Forsythe, P. J., Loefer et al. Vet Derm 2012; 23: 305
3. Kadlec, K. and Schwarz, S. Vet Derm 2012; 23: 276
4. Frank, L. A. and Loefer, A. Vet Derm 2012; 23: 283
Lip fold pyoderma. Ulcerative lip fold pyoderma.
Impression smear demonstrating intracellular cocci.
SPECIES: DOG
CONDITION: DEEP BACTERIAL INFECTIONS:
(i.e. FURUNCULOSIS WITH DRAINING TRACTS)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Deep pyoderma may be seen
without evidence of prior
supercial pyoderma or as a
sequelae to supercial bacterial
folliculitis. Deep follicular
inammation leads to follicular
rupture releasing hair shaft
keratin, bacteria and bacterial
products into the dermis resulting
in a furunculosis or infection
of the dermis and subcutis.
Bacteria present are usually S.
pseudintermedius, but Proteus,
Pseudomonas and E. coli are
seen more frequently in deeper
infections. Pseudomonas
aeruginosa has also been isolated
from dorsal furunculosis following
shampoo therapy.
Generalised furunculosis:
Underlying triggers commonly
initiate deep pyoderma.
Generalised demodicosis
is the most common cause
of deep pyoderma. Other
predisposing causes include
hyperadrenocorticism,
the injudicious use of
glucocorticoids (iatrogenic
hyperglucocorticoidism), actinic
disease and immunologic
defects. Comedonal diseases
such as calluses, actinic
comedones and Schnauzer
comedone syndrome also
predispose to deep pyoderma via
rupture of the abnormal follicle.
Triggers are not always
identied in deep pyoderma.
Distribution: Glabrous skin of
axillae, inguinal region.
Skin lesions: Papules, pustules
that rupture forming stulous
tracts discharging seropurulent
or haemorrhagic exudate with
necrotic, friable tissue and
haemorrhagic crusts; erosions
and ulcers develop secondary to
inammation, necrosis and self-
trauma. Haemorrhagic bullae
are a distinctive clinical feature
of canine deep pyoderma. Well
circumscribed, rm nodules
exhibit a deep dark red to blue
hue. Lethargy, depression and
fever; pain and pruritus are
common with accompanied
regional and generalised
lymphadenopathy.
Localised syndromes:
Deep bacterial folliculitis and
furunculosis may be manifest in
skin diseases with a traumatic
component, and may be termed
traumatic furunculosis in this
context. Diseases featuring
traumatic furunculosis include
post grooming furunculosis,
canine acne, callus pyoderma
and interdigital furunculosis.
Deep bacterial
folliculitis and
furunculosis is a
common, somewhat
heterogeneous group
of bacterial skin
diseases.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Interdigital furunculosis:
is a common presentation.
Lesions occur predominantly
in the interdigital webs but
may affect the digits as well.
Although interdigital furunculosis
is multifactorial, trauma to hair
follicles is probably a common
precipitating cause.
Licking/trauma of the interdigital
skin leads to penetration of hair
shaft into dermis or follicular
rupture resulting in a foreign
body reaction to the hair shaft
keratin with pyogranulomatous
inammation and secondary
bacterial infection. Thus allergic
skin disease such as canine
atopic dermatitis and adverse
food reactions may initiate this
syndrome.
Interdigital pyoderma may also
present as a sequelae to rupture
of obstructed, keratin-lled
follicles that result from chronic
friction or other trauma.
Large/giant breeds and dogs
with abnormal foot conformation
are predisposed and most
commonly the front feet are
involved due to increased weight
bearing. Follicular dilation and
comedone formation result
forming follicular cysts. Follicular
cysts rupture and the release of
the keratin protein results in a
foreign body reaction.
Skin lesions: Nodules,
haemorrhagic bullae, stulae
discharging serosanguinous to
seropurulent exudate; alopecia
from constant licking leading to
maceration, chronic moistness
and surface secondary bacterial
and Malassezia overgrowth;
varying degrees of pain and
lameness, pruritus and
paronychia may be present.
Distribution: Dorsal interdigital
webs; the front feet are most
commonly and usually most
severely affected.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Perform a direct smear of the contents of the
pustule, nodule or bulla by puncturing or squeezing
the lesion; transfer and spread the contents
directly onto a microscope slide for cytological
evaluation and stain the sample with DiffQuik.
If there are no intact lesions then sample the
exudate draining from a stulous tract and make
an impression smear of the uid contents although
microorganisms are usually less evident than
in surface and supercial bacterial infections. If
there are abundant bacilli, then tissue should be
submitted for culture and sensitivity. In all deep
pyodermas, it is important to rule out underlying
demodicosis by collecting multiple deep skin
scrapings and or trichograms.
Histological evaluation is often useful in the
diagnostic work-up of deep bacterial pyoderma
because the biopsy sample can be divided, with half
submitted fresh, for bacterial and fungal culture
and the rest submitted in formalin for histological
examination to rule out pododemodicosis. It is
routine for us to skin biopsy all other cases of
localised and generalised deep bacterial folliculitis
and furunculosis.
Further diagnostic workup involves evaluation of
spontaneous or iatrogenic hyperglucocorticoidism
(CBC, biochemistry, urinalysis, ACTH stimulation
testing), hypothyroidism (free T4 with TSH) and for
interdigital furunculosis, evaluation of underlying
allergic skin disease (elimination diet trials and
intradermal/serological allergy testing) as well as
mechanical and traumatic factors.
KEY STEPS
01
Collect surface/exudative cytology
from draining or intact lesions.
02
Multiple deep skin scrapings
or trichograms to evaluate for
demodicosis.
03
Biopsy for deep tissue bacterial and
fungal culture for recurrent/non-
responsive cases.
04
Treat for adequate length of time
(4-6 weeks minimum) with systemic
antimicrobial therapy.
05
Evaluate for underlying cause/s.
TESTS FOR DIAGNOSIS
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
Systemic antibiotics, namely cephalosporin, -lactam and uoroquinolone antimicrobial agents should be used
for the treatment of deep bacterial infections.
Interdigital furunculosis is usually managed with systemic antimicrobial agents using either cephalosporin
or beta-lactams. If Gram-negative organisms are implicated then either trimethoprim-sulphonamide or
enrooxacin is used for an extended treatment period of 8-12 weeks. Metronidazole may be used as an adjunct
treatment. Most affected animals are allergic and so diagnostic investigation of the underlying allergic skin
disease and the use of cyclosporin and other drug modalities to control the underlying allergic symptoms may be
indicated once the secondary infection is resolved. Laser ablation of the interdigital follicular cysts and surgical
fusion podoplasty have also been described for these cases, particularly the large or giant breeds that present
with comedone formation.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
First line:
Cephalexin 22 mg/kg q 12h;
Cefovecin 8 mg/kg q 14d SC for
3 administrations (off-label).
Second line:
Higher doses of uoroquinolones e.g.
enrooxacin 10-15 mg/kg q 24h (off-label)
or marbooxacin 5.5 mg/kg q 24h.
Topical therapy:
3% benzoyl peroxide or 3% chlorhexidine
shampoo/lotion/gel.
Full therapeutic dose for 6 weeks, or 10 days beyond complete clinical resolution.
Always look for Demodex canis as an
underlying cause of recurrent deep
bacterial pyoderma in dogs.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Key references:
1. Duclos DD, Hargis AM, Hanley PW. Vet Derm 2008; 19(3): 134-141
2. Summers, J. F., Brodbelt, D. C., Forsythe P.J. et al. Vet Derm 2012; 23: 30
3. Kovacs MS, McKiernan S, Potter DM et al. Contemp Top Lab Anim Sci 2005; 44(4): 17-21
Deep bacterial infection on lateral thigh with multiple
discharging sinuses.
Deep bacterial infection of callus.
Interdigital cyst formation.
Interdigital cyst formation.
SPECIES: DOG
CONDITION: MYCOBACTERIA AND NOCARDIA AS CAUSES OF
DEEP DRAINING SINUS TRACTS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
(i) Infections of the subcutaneous
panniculus generally with
rapidly growing mycobacteria
and;
(ii) granulomatous or
pyogranulomatous masses
of the skin and subcutis
(generally due to non-
cultivable mycobacteria
e.g. leproid granulomas
etc. and sometimes
mycobacterium avium
complex infections).
The taxonomy of these organisms
is evolving, and currently they are
divided into complexes:
a. M. smegmatis complex
(including M. goodii)
drugs of choice doxycycline,
moxioxacin, gentamicin.
b. M. fortuitum complex
drugs of choice
clarithromycin, moxioxacin,
gentamicin.
c. M. chelonae/abscesses
complex drug of choice
clarithromycin, rest depends
on susceptibility testing.
Generally speaking they are all
resistant to rifampicin, and all
susceptible to clofazamine.
Mycobacteria cause
two major types of
disease affecting the
skin and subcutis.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
1. The cornerstone of therapy is obtaining a
positive culture.
2. This is obtained by aspirating purulent exudate
present in the subcutis through intact skin,
after preparation of the skin with 70% ethanol
(and allowing time for drying).
3. Primary isolation can be done in a veterinary
laboratory, although it important to keep the
plates for the 4-5 days it takes for the colonies
to appear.
4. Positive cultures should be forwarded to a
human mycobacteria reference laboratory for
species identication and C+S testing.
Infections of the skin and subcutis with
rapidly growing mycobacteria.
Reference laboratories managing culture
and PCR of Mycobacteria and Nocardia:
VICTORIA
Dr Janet Fyfe
Email: [email protected]
Victorian Infectious Diseases
Reference Laboratory
10 Wreckyn Street, North Melbourne VIC 3051
Ph: (03) 9342 2600
WESTERN AUSTRALIA
Dr Ian Arthur
PathWest Laboratory Medicine WA
QEII Medical Centre, Nedlands WA 6009
KEY STEPS
KEY ISSUES
01
Draining sinus tracts should alert
the practitioner to the presence
of saprophytic pathogens such
as mycobacteria, Nocardia spp.
and fungi.
02
Involvement of the inguinal
panniculus is suggestive of
mycobacterial and nocardial disease.
03
Preliminary cytology stained with
DiffQuik can be very helpful in
cases where Nocardia and fungi
are involved, whereas culture on
routine media is far more expedient
a way to diagnose mycobacterial
infections caused by rapidly growing
saprophytic mycobacteria.
a. Rapidly growing mycobacteria, Nocardia spp.
and fungi can all give rise to deep draining
tracts that discharge to the skin surface.
b. Rapidly growing mycobacteria (and to a lesser
extent Nocardia nova) have a predilection for
the fatty subcuatenous panniculuis, especially
in the inguinal region.
TESTS FOR DIAGNOSIS
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
These infections require months to years of
antimicrobial therapy, and in some cases surgery
is required to debulk lesions to enable a clinical
cure to be achieved.
Generally speaking, topical therapy is not useful in
the management of these infections as the disease
process is situated in the subcutis and involves the
skin secondarily.
C+S is strongly advised in these cases.
Mycobacteria
First line:
Doxycycline (5 mg/kg q12h
) and moxioxacin (5 mg/kg q12h
(compounded) for M. smegmatis

complex infections; clarithromycin (5-15 mg/kg q12h
) for other rapidly

growing mycobacteria.
Second line:
Clofazimine (4-10 mg/kg q24h
compounded), amikacin (10-15 mg/kg q24h
IV/IM/SC).
Nocardia
First line:
Trimethoprim/sulphonamide combinations at a dose of 12.5 to 30 mg/kg q12h (do not split or otherwise divide
the coated tablet) combined with a second drug depending on C+S testing; beware ketatoconjunctivitis sicca
during therapy.
Second line:
Amoxicillin 20 mg/kg twice a day for N. nova (but not amoxicillin clavulanate).
Clarithromycin (5-15 mg/kg q12h) or moxioxacin (10 mg/kg once a day).
ANTIBIOTICS USED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T

See current textbooks for detailed guidelines.
Key references:
1. Reppas G, Nosworthy P, Hansen T, et al. Aust Vet J 2010; 88(5): 197-200
2. Escalonilla P, Esteban J, Soriano ML, et al. Clin Exp Dermatol 1998; 23(5): 214-221
3. Malik R, Krockenberger MB, OBrien CR, et al. Aust Vet J 2006; 84(7): 235-245
4. Malik R, Love DN, Wigney DI, et al. Aust Vet J 1998; 76(6): 403-407
5. Charles J, Martin P, Wigney DI, et al. Aust Vet J 1999; 77(12): 799-803
6. Fyfe JA, McCowan C, OBrien CR, et al. J Clin Microbiol 2008; 46(2): 618-626
7. Malik R, Shaw SE, Grifn C, et al. J Small Anim Pract 2004; 45(10): 485-494
8. Malik R, Hughes MS, James G, et al. J Feline Med Surg 2002; 4(1): 43-59
9. Govendir M, Norris JM, Hansen T, et al. Vet Microbiol 2011; 153(3-4): 240-245
10. Malik R, Wigney DI, Dawson D, et al. J Feline Med Surg 2000; 2(1) 35-48
SPECIES: DOG
CONDITION: DERMATOPHYTE INFECTIONS
(e.g. MICROSPORUM OR TRICHOPHYTON)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Microsporum canis is
responsible for 70 to 95%
of canine infections.
Microsporum gypseum and
Trichophyton mentagrophytes
account for most of the remaining
cases. Infections with unusual
species such as Microsporum
persicolor have been reported; it
is uncertain how common these
infections occur, but prevalence
maybe related to local climate
and environmental factors.
Skin lesions: Dermatophyte
infections are not common in
dogs. They are most common
in young dogs, dogs from
animal shelters or dogs that
are debilitated. Circular patches
of alopecia with scale, crust,
central hyperpigmentation
and follicular papules on the
periphery affecting the face,
pinnae, paws and tail is the most
frequent presentation in the dog.
Less commonly dermatophytosis
can present with folliculitis
that may be localised, regional
(facial) or generalised; often with
furunculosis. Nodular (kerion)
lesions on face and legs are
exudative, circumscribed type
of furunculosis with multiple
draining tracts usually associated
with M. gypseum or
T. mentagrophytes.
Onychomycosis is a rare, chronic
subungual fold inammation with
or without footpad involvement,
paronychia, claw deformity and
fragility in the dog.
Dermatophytoses
are superfcial fungal
infections that involve
the skin, hair and
claws.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Surface cytology: via acetate preparations may
identify fungal hyphae in the stratum corneum.
Trichograms: examine the follicular debris of
anagen follicles for the presence of ectothrix fungal
elements. This may be aided by the use of clearing
agents, with KOH or chlorphenolac.
Fungal culture: collection of scale and hair from the
edge of a lesion or the use of a sterile toothbrush
to comb through the entire coat to maximise the
sensitivity. Sample lesional areas last.
KEY STEPS
01
Perform a trichogram to evaluate
for ectothrix arthrospores.
02
Woods lamp examination for
Microsporum canis infections only.
03
Collect hair and scale for fungal
culture using haemostat (dogs).
04
Avoid spot therapy with topical
antifungal ointments.
05
Implement topical/systemic/
environmental treatment.
TESTS FOR DIAGNOSIS
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
In most healthy animals, dermatophytosis is a self-curing disease, with full resolution of disease
in 10-16 weeks without therapy. The best treatment protocol is a combination of three modalities:
1. Topical treatment: to kill infective material and prevent its dissemination into the environment.
2. Systemic treatment: to shorten the time of infection in the individual animal.
3. Environmental treatment: to help prevent recurrence of infection or spread to other
animals or people in the household.
A. Clipping the hair coat: should you clip?
Clipping of the hair coat will mechanically remove
fragile hairs that will fracture and release spores into
the environment. Clipping of the entire hair coat is
optimal but not always possible or practical. Clipping
is time consuming and often requires sedation and is
irritating to cats. Owners are often unwilling to commit
to clipping their pets. Short-haired dogs with fewer
than ve focal lesions do not need to be clipped.
When dogs have more than ve lesions, long hair and
there are multiple pets in the environment and the
affected pet cannot be segregated, clipping the entire
pet is optimal. Clip the hair short and gently to avoid
spreading the infection due to the microtrauma and
mechanical spread of the spores.
The owner should be warned that a temporary
exacerbation of lesions may occur after clipping.
Note: If the animal is to be clipped in the clinic all
debris produced must be considered to be infectious
with zoonotic potential and so rigorous infection
control measures should be observed.
i.e. cover table surface with disposable drape,
gown and glove, collect all material and double bag,
thoroughly disinfect the room and all equipment
used with an appropriate antifungal agent.
B. Topical therapy: which one is best?
i. Localised (treating only the spots) or
whole body topical therapy
In animals, not all the lesions may be visible due to
the long hair coat. It is almost certain that there are
infective spores in non-lesional areas. Therefore spot
treatment with topical drugs is not recommended even
for focal lesions because infection beyond the margin
of visible lesions is likely. There is no clinical data to
support that the use of spot treatment clear lesions
any more rapidly than whole-body treatment alone. If
the owner insists, the best products are probably 1%
terbinane solution, lotion, cream or spray (Lamisil
)
and 2% clotrimazole cream (Canesten
).
ii. Total body treatment
Topical therapy inactivates fungal spores and mycelia
on and within hair shafts reducing environmental
contagion and results in a faster cure than systemic
therapy alone. Shampoo therapy, dipping or rinsing
with topical antifungal agents is preferred. The choice
of topical antifungal agent is important because studies
have shown that many topical antifungal agents are
ineffective. In vitro and in vivo studies have shown
that the most consistently effective topical treatments
are lime sulphur, enilconazole, and miconazole; the
latter with or without chlorhexidine. Miconazole and
chlorhexidine (Malaseb
) shampoo has been studied in

cats as an adjunct treatment to oral griseofulvin.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Systemic therapy
The role of systemic therapy in treating
dermatophytosis is to accelerate the resolution of
infection in the individual animal. Several effective
drugs are available, and the appropriate choice should
be made depending on cost, fungal species, patient
species and potential for toxicity. Systemic therapy
is the treatment of choice for dermatophytosis. It
is important to remember that systemic antifungal
therapy does not rapidly reduce contagion and should
be used in conjunction with clipping and topical
antifungal agents.
Griseofulvin
Griseofulvin is administered at 25 mg/kg q12h.
The absorption is enhanced when administered as a
divided dose and with a fatty meal. The most common
side-effects anorexia, vomiting and diarrhoea can
be avoided by dividing or lowering the dose. The drug
is highly teratogenic and therefore contraindicated in
pregnant animals.
Do not administer to dogs less than 6 weeks of age.
Griseofulvin is a good systemic drug for
dermatophytosis in dogs, where myelotoxicity is not
a concern. Nearly all patients with Microsporum
infections, and many with Trichophyton infections
will be cured with this drug,
Ketoconazole (KTZ)
Ketoconazole 10 mg/kg q12h
(Nizoral
) is an
alternative but perhaps best reserved for resistant
Trichophyton infections in dogs. Some strains of
Microsporum canis appear resistant to ketoconazole.
Therefore ketoconazole has no real advantage over
other drugs for routine cases of dermatophytosis.
Itraconazole (ITZ)
Itraconazole (Sporanox
) is a fungicidal triazole
drug that is extremely useful for dermatophytosis.
The recommended dose is 5-10 mg/kg/day PO.
Itraconazole persists in the skin and nails for weeks
to months after dosing, and intermittent or pulse
therapy is frequently prescribed for skin infections
or onychomycosis.
Itraconazole is generally well tolerated; reported
side-effects include vomiting and/or anorexia and
an idiosyncratic cutaneous vasculitis has been
reported in dogs. Itraconazole is reportedly not
teratogenic when used at a dose of 5 mg/kg.
Fluconazole
Fluconazole (Diucan
) is receiving some recent

attention as an alternative drug because it has now
become inexpensive through some compounding
pharmacies. Several recent in vitro studies have shown
that the MICs of uconazole against dermatophytes
are much higher that the MICs of itraconazole
suggesting that itraconazole may be the superior
drug. Current evidence and clinical anecdotes would
suggest that there is no advantage of this drug over
itraconazole and currently we do not recommend it for
the treatment of dermatophytosis.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Environmental treatment
The critical role of environmental disinfection in
eradication of M. canis from a household cannot be
overemphasised. Environmental contamination with
M. canis spores is widespread, difcult to eliminate
and routinely transported by the fur of uninfected dogs.
Such contamination is a major reservoir for recurrence
of infection. M. canis spores remain viable in the
environment for up to 18 months.
Studies using isolated infected hairs or spores or
eld studies using dermatophyte-contaminated
environments have shown that the following
disinfectant products are consistently effective: lime
sulphur (1:33), enilconazole (0.2%), and 1:10 to 1:100
household bleach (10 mL/L). In addition, a study
has also shown that strain variation of M. canis with
respect to susceptibility to disinfectants is not present.
For treatment of routine infections with one or a few
animals in the household, extensive environmental
decontamination is generally impractical and
unnecessary. Thorough vacuuming and mechanical
cleaning will remove infective material. All hard
surfaces should be mopped with 1:100 bleach solution.
During treatment these few animals should be
conned to a small easily cleaned room without
carpeting until they have received systemic
antifungal therapy for at least two weeks and
have been dipped at least four times with topical
preparations. All bedding, brushes, combs, rugs,
cages, carriers can be washed daily in hot water,
detergent and a 1:10 dilution of household bleach.
Carpeted areas are problematic because of the lack
of effective disinfectant that preserves carpeting.
Frequent vacuuming on a daily basis or steam cleaning
mechanically removes many but not all spores. Steam
cleaning may not be a reliable method of killing
M. canis unless an antifungal disinfectant such as
chlorhexidine or sodium hypochlorite is added to
the water. Draperies should be dry cleaned and not
replaced until the infection is eradicated.
Length of treatment
Dogs with dermatophytosis should be treated until
complete resolution of clinical signs (clinical cure) and
then continued until the fungus cannot be cultured
from the hair coat on at least two sequential cultures a
week or more apart (mycologic cure)
Weekly fungal cultures should be started after the
dog has received 4-6 weeks of therapy and thereafter
on a 2 week schedule. Once the culture results are
negative, monitoring can be done on a once weekly
basis. Dogs appear healthy before their skin and hair
are cleared of fungal organisms.
It is not always possible or practical however to
re-culture every patient. In otherwise healthy dogs,
systemic and topical treatments should generally be
continued for 6-10 weeks, preferably until 2 weeks
after clinical resolution.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T

Signicant duration: 6-10 weeks; treat until two successive negative fungal cultures obtained one week apart or
14 days beyond a clinical cure.
AIDAP TOP TIPS
Our treatment recommendations for dermatophytosis for dogs:
2% miconazole, 2% chlorhexidine shampoo baths twice a week
0.2% enilconazole (Imaverol
) rinse twice a week (not registered for use in cats)

Itraconazole 5 mg/kg q24h 7d, 7d break and repeat pulse for 3 treatment cycles OR
Griseofulvin 25 mg/kg q12h
Environmental decontamination.
ANTIFUNGAL AGENTS USED
First line:
Itraconazole 5 mg/kg q24h
7d, 7d break and repeat

pulse for 3 treatment cycles.
Second line:
Griseofulvin 25 mg/kg q12h.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Characteristic presentation of
T. mentagrophytes (before)
Same dog after treatment for
T. mentagrophytes
Characteristic presentation of
T. mentagrophytes
Photos courtesy of Dr Mike Shipstone.
Severe dermatophytosis causing soft tissue swelling.
Multifocal alopecia dt Trichophyton infection.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Onychomycosis causing nail deformation. Fungal hyphae on surface cytology.
Fungal hyphae surrounding the hair shaft.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Key references:
Positive colour change on DTM agar.
NB: A positive test is the characteristic red colour change that enlarges progressively in line with colony growth.
Dermatophyte lesions dt M. canis affecting a child. Photo courtesy of Dr Richard Malik.
SPECIES: DOG
CONDITION: SUPERFICIAL YEAST (MALASSEZIA) INFECTIONS
OF THE SKIN (NOT INCLUDING EARS)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
In healthy animals it exists at
higher population densities at
the lips and interdigital skin than
in the ears. The anus seems to
be the most frequently colonised
mucosal site. M. pachydermatis
acts as an opportunistic
pathogen and factors promoting
its pathogenicity may include
increased temperature and
humidity, excessive lipid secretion
and pruritic inammatory
diseases (allergic and parasitic),
endocrinopathies and some
metabolic (hepatocutaneous
syndrome, zinc-responsive
dermatoses) and occasionally
cutaneous or internal neoplasia.
(Malassezia dermatitis is
typically secondary to allergy,
endocrinopathy, or neoplasia
(reported with thymoma-induced
exfoliative dermatitis and
pancreatic and/or hepatobiliary
paraneoplastic alopecia) in
cats and may play a primary
role in feline acne. Malassezia
dermatitis is rare in cats when
compared to dogs).
Breed-related factors are
important in Malassezia
dermatitis; Basset hounds
and West Highland white terriers
are particularly predisposed.
Since S. pseudintermedius and
M. pachydermatisare inhabitants
of the mucosae, including the
oral cavity, they will continually
be transferred to the skin,
particularly in areas which
require cleaning or grooming,
and which are pruritic. Thus there
is potential for the establishment
of microbial overgrowth whenever
the skin is damaged or there is
underlying disease impairing
cutaneous function.
Distribution: Lips, between the
pads and digits, groin, perivulvar
and perianal areas, ventral
abdomen, axillae, pinnae, and in
skin folds; clawbeds.
Lesion: Erythema, greasiness or
exudation, scaling, pruritus and
saliva staining; reddish-brown
staining of the proximal claw
or a waxy exudate in the claw
fold, with inammation of the
surrounding soft tissue. Pruritus
may be quite marked. In chronic
or severe lesions there may be
excoriation and lichenication.
There is commonly odour.
Malassezia
pachydermatis
is present as a
commensal of the
skin and mucosae
of most dogs.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Diagnosis is conrmed by cytology using tape
strip samples, slide impressions or swab smears
stained with DiffQuik showing elevated populations
of Malassezia.
Tape strips are preferred because the organisms
are sometimes not located at the surface of the
lesions and repeated application of the tape to
the same site will reveal deeper populations.
The technique is quick and easy to perform and,
with experience, tapes can be examined quickly
under the microscope permitting a diagnosis to
be made rapidly.
The presence of numbers of Malassezia above
2 per high power x1000 oil immersion eld is
suggestive of microbial overgrowth. Common
populations are very much higher but the
organisms may be found in clusters so at least
20 high power elds should be examined. For
diagnosis of Malassezia paronychia, the broken end
of a wooden cotton-tip swab is used to scrape the
claw fold, and exudate is pressed and rolled onto a
glass slide. For examination of ear exudate in dogs
with ceruminous or exudative otitis externa, rolling
of exudate in a thin layer on glass slides with a
cotton-tip swab is the preferred method.
KEY ISSUES
01
Identify yeast overgrowth or
02
Response to trial treatment
with appropriate topical and
systemic antimicrobial therapy.
TESTS FOR DIAGNOSIS
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
The condition normally
responds to topical
therapy with lotions,
cream and ointments or
antimicrobial shampoos
that are active against
staphylococci and
Malassezia.
Benzoyl peroxide shampoo can also be used. In severe or extensive
cases of microbial overgrowth or when washing/spraying of the
affected areas is not practical, systemic therapy with imidazoles
(e.g. ketoconazole or itraconazole) or terbinane can be utilised.
Ketoconazole is the drug of choice for the treatment of Malassezia
dermatitis in the dog.
Itraconazole is the drug of choice in the cat. Itraconazole persists in
the stratum corneum and therefore pulse therapy can be employed.
Anecdotal evidence suggests that uconazole is not as clinically
effective as the other azoles.
Topical agents containing miconazole (Daktarin
) or clotrimazole (Canesten
) spray, lotion, cream for spot

therapy. Shampoos containing chlorhexidine, or chlorhexidine and miconazole (active against staphylococci and
Malassezia). Systemic therapy with ketoconazole (5-10 mg/kg q12h
; dog only) or itraconazole (5 mg/kg q24h
;
dog [and cat]) or terbinane (30 mg/kg q12h
; dog [and cat]).

First line:
Topical chlorhexidine/miconazole shampoo with or without ketoconazole (5-10 mg/kg q12h
; dog only).
Second line:
Oral itraconazole.
ANTIMICROBIALS USED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
AIDAP TOP TIPS
Ketoconazole: Nizoral
5-10 mg/kg q12h PO for 21-28 days.

A low-dose regimen of ketoconazole 5 mg/kg every 24 hours PO for 10 days, followed by 5 mg/kg every 48 hours
PO for 10 doses has been reported to be successful in the majority of cases, and lessens the expense of therapy.
Itraconazole: Sporanox
5 mg/kg q12h PO or 10 mg/kg q24h PO for 2128 days.

Itraconazole persists in the stratum corneum and therefore pulse therapy can be employed.
One study found that dogs treated with 5 mg/kg q24h for 2 days followed by 5 days without treatment for 3 cycles
(3 weeks) responded as well as dogs who had received the medication at 5 mg/kg/day for 21 days.
Prophylaxis for chronic/relapsing Malassezia dermatitis
Regular shampoo therapy (weekly or biweekly).
Pulse oral ketoconazole or itraconazole (5-10 mg/kg given 2 consecutive days per week).
Monitor for hepatotoxicity with CBC and biochemistry every 6 months.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Mild interdigital erythema. Surface cytology showing heavy Malassezia infection collected from
the foot (on the left).
Erythema, brown waxy otitis commonly seen in Malassezia otitis. Alopecia, lichenifcation, greasiness, scale formation characteristic
of yeast infection.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Key references:
1. Bond R, Saijonmaa-Koulumies LE, Lloyd DH. J Small Anim Pract 1995; 36(4): 147-150
2. Nardoni S, Manciani F, Corazza M, et al. Mycopathologica 2004; 157(4): 383-388
3. Negre A, Bensignor E, Guillot J. Vet Dermatol 2009; 20(1): 1-12
4. Ahman S, Perrins N, Bond R. Vet Dermatol 2007; 18(3): 171-176
5. Pinchbeck LR, Hillier A, Kowalski JJ, et al. J Am Vet Med Assoc 2002; 220(12): 1807-1812
Discolouration of base of nail commonly seen in association
with paronychia.
SPECIES: DOG
SPECIES: DOG 77 SECTION: AURAL
CONDITION: OTITIS EXTERNA (UNCOMPLICATED,
FIRST EPISODE AND COMPLICATED, RECURRENT)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
The normal ora is generally
Gram-positive, with higher
bacterial counts retrieved from
the vertical external ear canal
than the horizontal ear canal.
Commensal and pathogenic
bacteria rapidly colonise the
external ear canal where changes
in the microclimate subsequent
to inammation modify the
environment. The microbial
proliferation exacerbates and
perpetuates the inammatory
response within the ear canal.
Once inamed, there is a shift
towards increased bacterial
numbers, initially coagulase
positive staphylococci and with
more chronic inammation,
Gram-negative bacteria.
Because potential pathogens
can be recovered in the absence
of disease (as they can from the
skin surface), it is assumed that
they are unable to initiate disease
in the ear.
However, once the ear becomes
inamed or macerated,
proliferation may occur and it is
for this reason that bacteria are
considered perpetuating rather
than primary or predisposing
factors in otitis externa.
In dogs, coagulase positive
Staphylococcus spp. are
most commonly isolated in
acute otitis and as a single
organism. Streptococcus spp.,
Pseudomonas aeruginosa,
Proteus mirabilis, E. coli,
Corynebacterium spp., Klebsiella
spp. are also frequently identied.
Pseudomonas organisms are
frequently identied in chronic
recurrent cases or those
cases that have had long-term
antimicrobial treatment.
The external ear
canal of most normal
dogs harbours low
numbers of a variety
of commensal and
potentially pathogenic
bacteria with between
2 and 52% of healthy
ears having bacteria
identifed on culture.
ORGANISMS INVOLVED
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
In many cases of otitis, a single organism can be
isolated on bacterial culture of exudate, but in
others, multiple potentially pathogenic organisms are
identied. Thus it is of critical importance to combine
cytological examination of the otic discharge when
a C+S test is performed. This allows determination
of the dominant population of bacteria evident,
the presence of leukocytes, and the presence of
phagocytosed bacteria.
Cytology is the rst step. It is mandatory in ALL cases
of otitis externa and should be repeated at each visit.
A number of studies have shown that cytology is more
sensitive than C+S testing in identifying the presence
of bacteria or yeast (e.g. sensitivity of cytology for
detection of Gram-positive cocci, Gram-negative rods,
and yeasts was 84%, 100% and 100% respectively).
The sensitivity of culture for detection of these
organisms was 59%, 69% and 50% respectively.
Normal cerumen does not have high stain uptake
because of the high lipid content. Outlines of occasional
squames may be seen. Inammation leads to increased
numbers of squames (some of which may be nucleated
indicting faster epithelial turnover with incomplete
keratinisation before desquamation). As the severity of
inammation increases inammatory cells may be seen
along with increasing numbers of organisms. Higher
cellular content of cerumen may also be appreciated
by increasing stain uptake on the stained slide (before
microscopic examination is even started).
The number of organisms and inammation should
be assessed on a 1-4+ scale. Normal ears may have
a few yeast and Gram-positive cocci per oil eld
but not rods. The nding of yeast or cocci should
be correlated with the ndings of the otoscopic
examination. Some animals may have few organisms
yet show marked inammation and exudation,
whilst others seem to be able to tolerate quite
large numbers without any pathologic changes.
Repeating the cytology at each revisit allows accurate
assessment of response to therapy. Medical treatment
should continue until otoscopic and cytologic
examinations demonstrate no pathologic change.
KEY STEPS
Otic examination alone is not sufcient and
the following minimum database is necessary
in order to identify both the nature and type of
the otitis as well as any underlying primary or
predisposing factors.
01
Thorough dermatological history.
02
Complete physical examination
of all areas of integument.
03
Thorough otic examination
(may require sedation/anaesthesia).
04
Collect otic cytology.
05
Implement topical antimicrobial
therapy on the basis of
cytological ndings.
06
Systemic antibiotic therapy is
not indicated for otitis externa.
TESTS FOR DIAGNOSIS
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
TREATMENT
Topical therapy is the key to successful resolution
of the majority of cases of otitis externa which is
essentially a surface infection. Essential to this
therapy though is the successful removal of exudate.
If the medication cannot penetrate the full length
of the ear canal, then treatment is likely to fail. The
choice of appropriate active ingredients and vehicles
for treatment of otitis externa is usually made
empirically based on cytological examination of ear
canal exudates and otoscopic examination of the
inamed ear canals.
Most commercially produced topical products contain
one or more active antibacterial, antifungal and anti-
inammatory agents in various combinations as well
as vehicle and various solubilisers, stabilisers and
surfactants.
Clients may need to be shown how to administer
medications correctly. Failure to do this is a
signicant cause for treatment failure. An adequate
volume of medication must be delivered to line the
entire canal. Getting clients to count drops increases
the time for administration and fundamentally means
that the nozzle of the bottle is not in the canal,
reducing penetration of the medication. Putting
the nozzle of the bottle in the canal and telling
clients to use a squeeze means that both under
and overdosing are risked because the amount to
medication is not measured out. We use the Terumo
brand of syringe to most accurately measure ear
medications and dispense them into the ear canal.
A broad guideline depending on the length
and diameter of the ear canal would be:
0.3 mL for a Shih tzu.
0.6 mL for a Labrador.
1 mL for a German Shepherd or very large dog.
Twice daily dosing may require slightly
smaller volumes to avoid overdosing.
Duration of therapy
For acute disease a minimum of 5 to 14 days therapy
depending on the degree of inammatory change
(oedema, hyperplasia, and erosion, ulceration) is to
be expected. Rechecks every one to two weeks are
necessary to ensure that ears are cytologically and
otoscopically resolved prior to cessation of therapy.
It is not uncommon to have a dog clinically resolved
with otoscopically normal ears because of anti-
inammatory medications, where cytology is still
not normal.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
Antimicrobial therapy for ears with mainly
cocci on cytology
Coccoid organisms will be Staphylococcus spp. or
Streptococcus spp. The challenge for empirical
therapy for cocci is the relative resistance of
streptococci to some of the routine antibiotics,
which otherwise tend to have reasonable activity for
most Staphylococci spp. For this reason products
containing antibiotics with good efcacy against both
bacteria are desirable. For this reason, Canaural
is
useful if the TM is intact because of the framycetin
and fusidic acid. Other reasonable choices would be
Otomax
or Mometamax
where both the gentamicin

and clotrimazole have anti-coccal activity. Remember
that gentamicin is degraded by organic debris and
purulent exudate so the ear must be clean and
inammation well controlled for best effect and that
gentamicin is not middle ear safe, at least not in
commercial preparations.
When the TM is ruptured, enrooxacin is the only
real choice although its activity against streptococcal
infections is not always reliable. If this inadequate,
then options include the use of systemic antibiotics
based on culture and sensitivity and also ear wicks
impregnated with more effective (but not middle ear
safe) ointments.
Systemic antibiotics are used if there is signicant
involvement of the pinna, if a methicillin resistant
Staphylococcal infection is identied on culture
and sensitivity or if otitis media is evident.
They are unreliable in our experience used as
a sole therapy of otitis externa.
rods on cytology
Rods are rarely found in healthy ears. In Australia,
the majority of rods identied on culture are
Pseudomonas aeruginosa with Proteus and E. coli
both identied at about 11% to 20% of the otitis ears.
Other less common rods include Corynebacterium
spp. and Klebsiella. While Corynebacterium is not
uncommonly found on culture from ears with otitis
it is usually found as part of a mixed culture and is
probably of minimal signicance unless isolated in
pure growth.
Tris-EDTA acts as a chelating agent and enhances
activity of topical antibiotics against otic pathogens
by decreasing stability and increasing permeability of
the cell wall. The ear canal should be lled with the
solution 15 to 30 min before the topical antibiotic is
applied every 12 hours. First line antibiotic therapy
includes enrooxacin (compounded enrooxacin
1.5% with dexamethasone and once the tympanic
membrane is intact and the inammation controlled
then products containing gentamicin Otomax
q
12hrs and Mometamax
q 24hrs as long as the ear

is clean. Culture and sensitivity testing is indicated if
the infection fails to respond. Timentin
6% q 12hrs
or ciprooxacin can be used topically as a second-
line antibiotic. Systemic antibiotics are only used
if there is signicant involvement of the pinna or if
otitis media is evident. They are unreliable in our
experience used as a sole therapy of otitis externa.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
yeast on cytology
Malassezia can be retrieved from up to 80% of otitis
ears. Dogs with atopy can produce IgE to Malassezia
which means that the degree of inammation
depends on the host response rather than the
number of yeast.
Disinfectants are useful as sole therapy where there
are low numbers of yeast and minimal inammation
or occasionally in cases apparently resistant to
other antifungal ear medications. The only two with
any proven efcacy against Malassezia are Epiotic

and Malacetic Otic
. Neither are particularly good

ceruminolytics so penetration is an issue where
there is signicant exudate. Alpha Ear Cleaner

(Troy) has good activity against yeast and is a good
ceruminolytic. None of these products is middle
ear safe.
Most of the major commercial combination ear
products (except Baytril Otic
) are reliable in the

therapy of an uncomplicated yeast otitis. Surolan

q 12hrs, Otomax
q 12hrs, Mometamax
q 24hrs
containing miconazole and clotrimazole are both
useful rst line treatment. In cases of product
failure, both clotrimazole and miconazole resistance
has been reported and in these instances nystatin
(Canaural
) has proven useful. None of these

products are middle ear safe.
Systemic use of antifungal medication is a
consideration where there is a fungal otitis media
and for sole or adjunctive therapy where topical
medications are not possible or there are severe
proliferative changes in the ear canal.
Secondary changes are sequelae that occur due to
acute and chronic inammation of the external ear
canal that when present will increase the likelihood
of relapse of otitis externa irrespective of whether
the trigger factor has been controlled. Sequelae
secondary to otitis externa include epidermal or
glandular hyperplasia, inammatory polyps, brosis,
stenosis, calcication, ceruminoliths, otitis media and
complete occlusion of the external ear canals.
SPECIES: DOG
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
C
A
T

C
O
N
T
E
N
T
AIDAP TOP TIPS
Bacterial C+S testing
The commonly accepted practice is that a
bacterial C+S testing should be performed if:
rods are seen on cytology
ulceration of the epithelium is present
the condition is recurrent
there is no response to appropriate treatment
otitis media is present.
However there have been several recent studies
raising doubts as to the usefulness and accuracy of
culture results (Graham-Minze and Rosser 2004).
It has been suggested that the culture may identify
organisms from the external ear canal that are low in
number and possibly irrelevant in the pathogenesis
of the disease state. As such the initial cytology may
be a better indicator of the relative importance of the
different organisms present.
Robson (2008) has proposed the following:
That bacterial C+S testing should be performed when
cytology shows a uniform or near uniform pattern of
bacteria AND when appropriate empirical therapy has
failed AND all other causes of failure of therapy have
been ruled out as well as causes of otitis media.
Sample on right showing marked stain uptake due to
presence of neutrophils.
Photo courtesy of Dr Mandy Burrows & Dr Mike Shipstone.
Key references:
1. Sharma VD and Rhodes HE. J. Sm An Pract 1975; 156: 241-247
2. McCarthy G and Kelly WR. Irish V J 1983; 36: 53-56
3. Colombini S, Merchant SR, Hosgood G. Vet Dermatol 2000; 196: 84-90
4. Graham-Minze CA and Rosser EJ J. Am An Hosp Assoc 2004; 40(2): 102108
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
SPECIES: CAT
SPECIES: CAT 83 SECTION: SOFT TISSUE
The subcutaneous tissues and
underlying muscle are damaged
by the crushing action of the
long canine teeth of the feline
perpetrator. The teeth of the
perpetrator cut deep and crush
muscles, releasing myoglobin
and hence iron, but leave no
connection with the atmosphere
(because there is no ripping
action). The reduced oxygen
environment sets the scene for
the evolution of an anaerobic
infection, initially a cellulitis.
This starts as a cellulitis, and
will usually evolve into a full
blown abscess that eventually
will 'point' and burst, discharging
pus to the skin surface. Once
this occurs, the infection will
often heal spontaneously due to
oxygenation of the wound and
drainage of pus and necrotic
debris, especially if the location
of the abscess is amenable to
licking and the debriding action
of the victim's tongue.
The anaerobic nature of
the infection results in a
characteristic foetid odour
(due to volatile fatty acids
and other fermentation products
of the anaerobic bacteria).
Infections are typically
polymicrobial, involving
variable combinations of a
variety of obligate anaerobic
organisms (Bacteriodes
spp., Porphyromonas spp.,
Fusobacterium spp.,
Prevotella spp.). Some
facultative anaerobic
organisms, such as
Pasteurella multocida
and streptococci, are also
often present.
Rare: Nocardia spp. (especially
N. nova), Corynebacterium spp.,
Rhodococcus equi.
Cat fght abscesses
are polymicrobial
anaerobic infections
that result from
inoculation of the
microbial bioflm from
the gingival cleft deep
into a bite wound.
ORGANISMS INVOLVED
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
SPECIES: CAT
Smears of the purulent exudate
Gram/DiffQuik stained. C+S is not necessary.
Readily conrmed by making smears of the
purulent exudate. Subsequent Gram or DiffQuik
staining shows multiple bacterial morphotypes
particularly Gram-negative, fusiform rods, and
Gram-positive cocci, lamentous forms etc.
C+S testing although theoretically of great interest
requires anaerobic collection and processing of
specimens. This is rarely done except in research
settings. The susceptibility pattern of key bacteria
is predictable and has not appeared to change
over the last 30 years.
KEY ISSUES
01
Deep puncture wounds.
02
Crushing results in haemorrhage
and myonecrosis.
03
Absence of exposure to air permits
an anaerobic environment to develop.
04
Toxin elaborated by organisms cause
further tissue necrosis and signs
of sepsis (fever, malaise, etc.).
05
Variable brosis occurs in an attempt
to localise the infection.
06
Death of overlying skin results in the
abscess discharging pus, which can
lead to spontaneous resolution.
Dermal necrosis associated with a cat fght abscess.
TESTS FOR DIAGNOSIS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
SPECIES: CAT
TREATMENT
For an uncomplicated cat ght abscess, aeration
of the wound, surgical debridement and drainage
(sometimes using a latex drain) is recommended
in combination with antimicrobial therapy.
IV (during anaesthesia) and/or subcutaneous
uid therapy to re-establish and
maintain hydration.
On day 1, opioid analgesia may be indicated in
selected cases.
The practitioner should be wary of using any NSAID
in a potentially dehydrated cat, subjected to sepsis
and general anaesthesia. These drugs are much
more safely given from day 2 onwards, once the cat
has resumed eating and drinking normally.
Based on the human literature where there is more of an evidence-base to draw upon, an injection of
amoxicillin-clavulanate (or amoxicillin) will produce high and predictable blood levels, and is easily given
under anaesthesia, and can be followed up by the same drug given orally.
Doxycycline monohydrate is often preferred because it has excellent anaerobic activity, is good at diffusing
into marginally perfused tissues, available in tablets and paste which are both easy to administer (which
greatly facilitates compliance); the anti-inammatory action of the drug is helpful also.
Cases that fail to respond to standard therapy should be sampled appropriately (from deep within the lesion)
to permit cytology (DiffQuik), Gram staining, and C+S.
First line:
Amoxicillin-clavulanate (12.5 mg/kg q12h) or
doxycycline monohydrate (5 mg/kg q12h
);
clindamycin (5-11 mg/kg q12h) and metronidazole
(10 mg/kg q12h) are also suitable, but perhaps less so
than the recommended agents; some clinicians may
combine amoxicillin-clavulanate and metronidazole
or clindamycin for an especially severe or extensive
anaerobic infection.
Second line:
Based on C+S.
Cefovecin is suitable for any case where
there are concerns of compliance, or
there are difculties with oral dosing.
Note: Currently registered veterinary
uoroquinolones are completely
INAPPROPRIATE in this setting as they
have virtually no activity against anaerobes.
RECOMMENDED ANTIBIOTICS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
SPECIES: CAT
How long to treat?
AIDAP TOP TIPS
Adequate drainage,
debridement, copious lavage
with saline and the resulting
aeration of the wound is actually
the cornerstone of therapy,
although AIDAP recommends
adjunctive antimicrobial therapy,
especially in instances where
the cat is systemically unwell
(fever, lack of appetite, etc.)
or where the infection has a
substantial cellulitis component
extending to involve contiguous
tissues.
Example of a fulminant cat fght abscess.
There is no evidence-base, regarding treatment length but the panel
recommends at least 4 days, and ideally 7-14 days.
In simple uncomplicated cases 4-7 days of therapy is probably adequate.
Where there is concern
that owners may have
diffculty medicating
the cat reliably, a
long-acting injection
of procaine and
benethamine penicillin
or cefovecin are
reasonable choices.
Key references:
1. Love DN, Malik R, Norris JM. Vet Microbiol 2000; 74: 179-193
2. Norris JM and Love DN. Vet Microbiol 1999; 65: 115-122
3. Dendle C and Looke D. Aust Fam Physician 2009; 38(11): 868-874
SPECIES: CAT
SPECIES: CAT 87 SECTION: ORAL
CONDITION: CHRONIC GINGIVOSTOMATITIS/FAUCITIS
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
It is thought that this occurs
as a result of feeding soft food
or highly rened carbohydrate
(readily fermentable by
gingival anaerobes), without
the natural ossing action
of stripping meat and sinew
from prey tissues. This leads
to a shift in the host: bacteria
relationship with overgrowth of
pathogenic organisms specically
Porphyromonas spp. closely
related to the human periodontal
disease pathogen Porphyromonas
gingivalis. At some level, this is a
physiological disease condition,
in which dietary factors, host
factors and microbial factors
interplay in a complex manner.
The bacteria involved are normal
constituents of the microbial
ora of the gingival cleft,
although they can behave as true
pathogens in this scenario. The
amount of inammation in the
gum is usually commensurate
with the extent of the build-up
of plaque and tartar, although
irreversible changes in local
anatomy (gingival recession
with exposure of dentine,
odontoclastic resorptive lesions)
contribute. Abnormal dentition,
e.g. crowding and misalignment
of teeth in brachycephalic cats,
can also contribute to disease
occurrence and progression.
Critically, there is no concurrent
inammation of the palatoglossal
arches (fauces) or contiguous
pharyngeal or palatine mucosa.
Chronic gingivostomatitis/
faucitis signies a different
syndrome in which the amount
of inammation in the gums
and contiguous tissues is vastly
disproportionate to the extent
of plaque and tartar build up.
Indeed, the disease can occur
in young cats with hardly any
traditional periodontal disease,
and this condition is often termed
juvenile gingivitis. This syndrome
is a manifestation of chronic
low grade calicivirus infection.
Because of (perhaps) the specic
strain of FCV, the immune status
of the cat, or (most likely) a
combination of the two some
cats can develop a latent infection
associated with chronic shedding
of virus, in the presence of a
orid antibody-mediated immune
response that causes pain,
erythema and dysfunction, but
fails to clear virus from the gums
possibly due to insufcient cell
mediated immunity.
Periodontal disease
can occur as a discrete
entity, in the older cat,
in association with
a build-up of plaque
(a bioflm of obligate
anaerobes and salivary
mucoproteins), tartar
(mineralised plaque)
and gingival recession.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
1. Examination of the oral cavity under general
anaesthesia is very helpful, with probing of
the periodontal pockets.
2. Dental radiography can be very helpful.
3. Biopsy of gums is of limited value, although
immunohistology (available through Assoc Prof.
Jacqui Norris, The University of Sydney) can
conrm the presence of FCV antigen.
KEY ISSUES
01
Chronic gingivostomatitis can be
due to severe periodontal disease.
02
More often it is due to chronic,
persistence of FCV in the gums,
palatoglossal arches and adjacent
mucosa.
03
There is abundant antibody mediated
inammation directed at FCV
deep within the host tissues, but
insufcient or ineffective cellular
immunity to eliminate the chronic
persistent carrier state.
Severe gingivostomatitis and faucitis.
Photos courtesy of Dr Richard Malik.
TESTS FOR DIAGNOSIS
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
1. Remove tartar and plaque, scale and polish
enamel and exposed dentine, remove
unsalvageable teeth and administer (perhaps)
a 2-week course of antimicrobials highly
effective against obligate anaerobes involved
in periodontal disease.
2. Further treatment options for affected cats are
controversial. The following comments apply to
cats with chronic FCV-associated disease:
i. The best evidence based medicine suggests
radical dentistry has the highest chance to
affect a cure or substantial benet. This involves
removal of all the cats teeth or at least all of
the cheek teeth. This somehow alters the host:
virus relationship leading to eradication of the
chronic calicivirus carrier state. Unfortunately,
this is only successful in perhaps 50-70%
of cases (some are cured, some are greatly
improved, some are somewhat improved).
ii. Other antiviral strategies are the use of
omega interferon topically, intra-lesionally
or subcutaneously; and topical antiviral
agents such as lactoferrin.
iii. An alternate approach is to give up trying
to clear the virus, but instead dampen
down the inammatory response using
immunomodulatory drugs including
corticosteroids, cyclosporine, megestrol,
thalidomide, chlorambucil and NSAIDs
(meloxicam, Bonjella). In the USA, laser
therapies of varying intensities are also
commonly used, although the evidence-base
for the success rate of these therapies is
impossible to nd.
Clindamycin, metronidazole (alone or with spiramycin) and doxycycline monohydrate (5 mg/kg q12h
) are
preferred over amoxicillin-clavulanate because they have been shown to be clinically superior. This may be
because these agents attain more effective levels within the biolm in the vicinity of the periodontal ligament.
First line:
),
Clindamycin (5-11 mg/kg q12h) or
Metronidazole (10 mg/kg q12h).
Second line:
Amoxicillin-clavulanate (12.5 mg/kg q12h).
ANTIBIOTICS USED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T

AIDAP TOP TIPS
Chewing encourages a scissors action of the carnassials on fresh meat
and ossing by stripping muscle from periosteum and bone, reducing
fermentable carbohydrates in the diet and using adjunctive products such
as chews, brushing, chlorhexidine, T/D diets etc.
C+S testing is worthless in this disease. The bacteria involved are fastidious
obligate anaerobes and it is very difcult to collect a meaningful specimen
and transport it to the laboratory in a timely manner that would permit the
causal organisms to be cultured. Susceptibility testing for anaerobes is not
available routinely in any private or institutional vet laboratories in Australia
currently. Other techniques e.g. immunohistology for FCV, in situ PCR and
uorescent in situ hybridisation (FISH) have not become routinely available
to be useful in a general practice setting.
Typically for 1-2 weeks, but longer in certain circumstances.
Ensure doxycycline given with a small bolus of water, or a small dab of margarine.
Consider topical treatment with lactoferrin from a compounding pharmacist.
Consider topical or intra-lesional interferon.
Consider radical dentistry with extraction of the cheek teeth in
refractory cases.
Further therapy is
directed at changing
the diet to include
more chewing.
Key references:
1. Norris JM and Love DN. Aust Vet J 2000; 78(8): 533-537
2. Harley R, Gruffydd-Jones TJ, Day MJ. J Comp Pathol 2011; 144(4): 239-250
3. Hennet PR, Camy GA, McGahie DM, et al. J Feline Med Surg 2011; 13: 577-587
4. Southerden P and Gorrel C. J Small Anim Pract 2007 48(2): 104-6
SPECIES: CAT
SPECIES: CAT 91 SECTION: URT
CONDITION: ACUTE URT DISEASE
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Dual infections also occur.
In some instances Chlamydophila
felis, Mycoplasma felis
and possibly Bordetella
bronchiseptica can also be
primary pathogens, but all
except the rst three organisms
tend to be ocular pathogens
primarily, rather than naso-
ocular pathogens. Although
cryptococcal rhinitis can occur as
a primary disease entity, it is very
unusual for this to be detected
until the disease has entered a
more chronic stage. Primary viral
disease is frequently complicated
by secondary bacterial
involvement, and typically it is
the normal anaerobic ora of
the sino-nasal cavity that is
involved although mycoplasmas,
Pasteurella and Bordetella can
also be signicant pathogens.
Acute URT disease
in cats is in the great
majority of instances
a primary viral disease,
with FHV-1 the most
important primary
pathogen, and FCV
implicated in a smaller
proportion of cases.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
1. Multiplex PCR panels for feline respiratory
pathogens can be informative if taken carefully
and early in the course of the disease, although
they are expensive.
2. C+S of nasal discharge is completely unhelpful
in most instances, as the material that appears
in the nares is not representative of the deeper
underlying infective process and is contaminated
by commensal microbiota. Deep nasal ushes
are not commonly performed in cases with acute
disease, and most labs do not handle specimens
in such a way that fastidious organisms such as
obligate anaerobes and mycoplasmas can be
detected. Isolating Bordetella bronchiseptica in
pure culture may implicate its role as a primary
pathogen or secondary invader, and permits
susceptibility testing.
3. In the exceedingly rare case of acute
cryptococcosis, budding capsulated yeasts are
easy to see on cytology and can be cultured
on appropriate media e.g. bird seed agar (plus
antibiotics). However, Cryptococcus is rarely
cultured from the nasal cavities of normal cats
(but you do not see them cytologically it is likely
that it is inhaled spores that germinate).
4. Radiography, endoscopy or advanced cross
sectional imaging (CT or MRI) has usually little
to offer in acute disease unless a foreign body is
suspected (peracute onset of sneezing and nasal
discomfort, possibly with stertor).
KEY ISSUES
01
Most URT disease in cats is viral.
02
FHV-1 (particularly) and FCV are
the most common causes.
03
Secondary bacterial involvement
is common, with mixed anaerobes,
Mycoplasma felis and Bordetella
bronchiseptica all being potential
pathogens.
04
Acute disease may represent
recurrence of latent FHV-1 disease,
rather than primary infection.
This is common in cats that are
stressed (e.g. boarding) or given
corticosteroids.
TESTS FOR DIAGNOSIS
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
1. The treatment of acute viral URT disease should
be based on the fact that most cases are due to
FHV-1/FCV, with variable secondary invaders.
2. It should also be remembered that the cost of
a diagnostic PCR panel may exceed the cost of
denitive therapy. So the cornerstone of therapy
should be appropriate doses of famciclovir, the
only safe and effective anti-herpesvirus agent
available in feline practice.
3. To treat the other potential naso-ocular pathogens
(primary and secondary), such as Bordetella,
Pasteurella, Chlamydia and obligate anaerobes,
an antibiotic should be given concurrently in most
cases. Doxycycline monohydrate and clindamycin
probably are the most cogent choices. Although
many papers have been written on this subject,
most are low down on the evidence based
pyramid, for a variety of reasons.
4. Additional measures can be very helpful, such as
subcutaneous uid therapy, nutritional support,
nebulisation with saline etc. Omega-interferon
may be helpful for acute FCV infections.
5. In the shelter or pet shop setting, timely
administration of famciclovir early in the
disease course can have dramatic effects.
Anecdotal reports from CPS/RSPCA and shelter
veterinarians support the successful use of
famciclovir in acute feline URT disease. Recent
work, utilising experimental infections provides a
solid evidence base for these recommendations,
although more studies under eld conditions
would be helpful.
2
First line:
Famciclovir (30-40 mg/kg q8-12h
) plus
).
Second line:
Clindamycin (5-11 mg/kg q12h).
ANTIMICROBIALS USED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T

FHV-1 infection in a kitten.
Secondary bacterial infections are common.
Chronic feline herpes keratitis.
Famciclovir in concert with doxycycline monohydrate; treat for at least 2 weeks, up to several months [in certain
cases], depending on the response to therapy. Ensure doxycycline given with a small bolus of water, or a small
dab of margarine.
Key references:
1. Malik R, Lessel NS, Webb S, et al. J Feline Med Surg 2009; 11(1): 40-48
2. Thomasy SM, Lim CC, Reilly CM, et al. Am J Vet Res 2011; 72(1): 85-95
3. Egberink H, Addie D, Belk S, et al. J Feline Med Surg 2009; 11(7): 610-614
4. Litster AL, Wu CC, Constable PD. J Am Vet Med Assoc 2012; 241(2): 218-226
5. Thomasy SM, Whittem T, Bales JL, et al. Am J Vet Res. 2012 Jul; 73(7): 1092-1099
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
It is seen commonly in general
practice, although perhaps less
commonly than in the 1970s
and 1980s. Although there is
no universal agreement, many
authorities consider this to be
sequel of viral rhinitis, and in
the vast majority of cases it is
thought to be caused by FHV-1.
Most cases occur in younger cats,
however occasionally it is seen as
a rst presentation in older cats.
FHV-1 is an epitheliotropic virus,
causing necrosis, neutrophilic
and sometimes eosinophilic
inammation. This results in
destruction of normal turbinate
architecture, with loss of bone
and cartilage. Subsequent failure
of normal drainage pathways can
lead to abnormal accumulation
of mucus and inammatory
exudate. Anatomic pockets not
cleared by normal mucociliary
clearance mechanisms develop
and there can be scarring
and web formation within the
nasal cavity and also in the
nasophaynyx (nasopharyngeal
stenosis). Distortion of normal
anatomy interferes with defence
against commensal bacteria,
including mycoplasmas, obligate
anaerobes, Pasteurella spp.,
Bordetella and sometimes other
infectious agents including fungi
(Cryptococcus spp. complex,
Aspergillus spp., Neosartorya
spp.) and also lamentous
bacteria (Actinomyces,
Streptomyces).
This syndrome is hard to
diagnose denitively. Indeed,
it is essentially diagnosed by
exclusion, in the presence of
supportive historical, physical
and imaging ndings. Perhaps
in the future immunohistology or
uorescent in situ hybridisation
(FISH) will provide more denitive
evidence of the underlying
patho-mechanisms. Despite
its commonness, there is no
universally acceptable approach
to the management of these
cases, and various different
authorities recommend different
approaches.
Chronic rhinosinusitis
syndrome is known by
a variety of different
colloquial terms
chronic snuffer
syndrome, chronic
snorter syndrome,
chronic post-viral
rhinitis, lymphocytic
plasmacytic
rhinosinusitis etc.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Full investigation of these cases requires
cross section imaging, anterior and posterior
rhinoscopy, pathological studies from nasal
washing and biopsy material (for cytology,
routine culture, fungal culture, FISH, PCR
and immunohistochemical studies). Such
investigations are beyond the nancial limitation of
many owners, and so empiric therapy after limited
investigations is commonly done in practice. It is
prudent to rule out cryptococcosis and invasive
diseases that cause bone lysis, but even this is not
always possible. In the older cat, the possibility of
neoplasia should be explored as the most common
nasal malignancy is lymphoma, and this often
responds to sequential multi-agent chemotherapy.
KEY ISSUES
01
Most cats with chronic rhinosinusitis
develop it as a consequence of
long standing FHV-1 infection with
distortion of local anatomy and
secondary bacterial invasion.
02
Most chronic snufer cats have
negative or non-specic ndings on
radiography, CT, biopsy and culture.
03
It is important to rule out some
specic aetiologies such as
cryptococcosis, lamentous fungal
infections and neoplasia. This is best
achieved by biopsy of representative
material obtained using cupped
alligator forceps, ideally guided by
imaging ndings.
TESTS FOR DIAGNOSIS
Bilateral nasal discharge in a cat with a nasopharyngeal polyp
a differential diagnosis for chronic rhinonsinusitis in cats.
Photo courtesy of Dr Vanessa Barrs.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
Antimicrobial therapy is considered a critical
component of therapy to control secondary
opportunistic infection. Some clinicians
recommend surgical interventions. Some
clinicians utilise judicious use of NSAIDs such
as meloxicam, while others sometimes utilise
other strategies such as nebulisation, instillation
of saline nose drops, and even low dose
corticosteroid therapy.
There is anecdotal evidence that use of famciclovir
is helpful as an adjunct to antibacterial therapy in
a subset of cases, especially where bony erosion
within or adjacent to the nasal cavity is present,
or where FHV-1 associated ocular disease or
dermatitis is present concurrently.
Most commonly recommended agents are doxycycline, and clindamycin. Anti-Pseudomonas drugs (such as
enrooxacin, marbooxacin and pradooxacin) are usually reserved for cases where there is a pure heavy growth
of P. aeruginosa from deep nasal washing or nasal biopsy specimens.
First line:
).
Second line:
Clindamycin (11 mg/kg q12h).
Consider using concurrent anti-herpes therapy
with Famciclovir (30-40 mg/kg q8-12h
) if cost
permits, or if there is denitive evidence of the
involvement of FHV-1.
ANTIBIOTICS USED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T

AIDAP TOP TIPS
The nature of the underlying pathological process is deep-seated neutrophilic and lymphoplasmacytic
inammation, with bone and cartilage atrophy and necrosis i.e. bacterial chondritis and osteomyelitis.
In cases where there is initially a favourable response to therapy, it is imperative that treatment be run out
for many months, typically 2-3 months past clinical remission. Ensure doxycycline given with a small bolus
of water, or a small dab of margarine.
Key references:
1. Quimby J and Lappin M. Compend Contin Educ Vet 2010; 32(1): E1-E10
2. Quimby J and Lappin M. Compend Contin Educ Vet 2009; 31(12): 554-564
3. Reed N and Gunn-Moore D. J Feline Med Surg 2012; 14(5): 317-326
4. Malik R, Lessels NS, Webb S, et al. J Feline Med Surg 2009; 11(1): 40-48
5. Kuehn NF. Clin Tech Small Anim Pract 2006; 21(2): 69-75
6. Johnson LR, Foley JE, De Cock HE, et al. J Am Vet Med Assoc 2005; 227(4): 579-585
Deep nasal washings or
biopsy specimens procured with
small cutting alligator forceps
(or endoscopy biopsy forceps)
are more useful for cytology
and culture.
Nasal discharge is
an inferior sample,
although it can be
useful for diagnosing
cryptococcosis.
SPECIES: CAT
SPECIES: CAT 99 SECTION: LRT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Pasteurella spp. and obligate
anaerobes are commensals of
the oropharynx and aspiration of
these bacteria is the most likely
route of infection, for example
after viral URT infection or other
disease resulting in impairment
of mucociliary clearance.
Infection with these bacteria
often results in pleuropneumonia
and pyothorax (see pyothorax).
Bordetella bronchiseptica is a
primary respiratory pathogen
that can cause acute or chronic
LRT disease. Risk factors for
infection include high population
density (eg catteries or shelters),
poor hygiene, young age/
immunosuppression and exposure
to dogs with respiratory disease.
B. bronchiseptica is a rare
zoonosis of humans, particularly
if immunosuppressed. Clinical
disease is most likely in kittens
less than 10 weeks of age and
signs range from sneezing, ocular
discharge and mild cough to
severe dyspnoea and respiratory
distress, which can be fatal.
Mycoplasmas are also an
important cause of LRT infection
in cats. Whether they act as
primary or secondary pathogens
in this location is less clear.
Some investigators consider
that mycoplasmas can only
colonise inamed/infected lower
airways (e.g. secondary to chronic
bronchitis/asthma) while others
consider they can act as primary
LRT pathogens. Mycoplasmas (M.
felis, M. gateae, M. feliminutum)
have been detected by culture
or PCR in 15 to 22% of cats with
LRT disease in the USA, UK and
Australia. (Foster et al 2004,
Randolph et al 1993, Reed et al
2012). They have been reported
to cause bronchopneumonia,
focal pulmonary abscessation
and pyothorax spontaneously
in owned cats and pneumonia
after experimental inoculation in
kittens. Evidence is mounting for
a pathogenic role of mycoplasmas
(M. pneumoniae) in triggering
acute exacerbations in humans
with chronic asthma.
Non-bacterial LRT pathogens
of cats include lungworm,
heartworm, toxoplasmosis,
viral infection and fungi. These
aetiologies should be considered
in the diagnostic investigation of
cats with acute LRT signs.
The most common
bacteria to cause lower
respiratory tract (LRT)
infections in cats are
B. bronchiseptica,
Pasteurella spp.,
Mycoplasma spp.,
Streptococcus spp.
and E. coli. Other less
common bacterial
pathogens include
mycobacteria,
Salmonella
typhimurium,
Pseudomonas spp. and
obligate anaerobes.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
1. Careful clinical examination to rule out
non-infectious respiratory disease.
2. Thoracic imaging (radiography rst,
then possibly CT where available).
3. BAL samples for cytology and C+S.
4. Bronchoscopy, where indicated.
5. PCR of BAL uid for specic pathogens
such as Mycoplasma spp. and
Bordetella bronchiseptica in some
settings. Bordetella bronchiseptica
can also be detected by PCR of
oropharyngeal swabs.
KEY ISSUES
01
Although infectious LRTI occurs
in cats, allergic lower airway disease
is more common, and at some level
is a diagnosis of exclusion.
02
Mycoplasma species may cause
primary LRTI, or occur as a
complication of feline asthma.
03
Bordetella bronchiseptica is a
primary respiratory pathogen
and clinical disease is most
common in kittens.
04
Because of the difculty of
determining whether bacterial
involvement is primary or secondary
in cases with feline bronchial
disease, antimicrobials are often
used as a component of therapy,
even when the primary aetiology
is thought to be allergic.
TESTS FOR DIAGNOSIS
DiffQuik-stained smear of bronchial lavage fuid from a cat with
a Bordetella bronchiseptica lower respiratory tract infection.
Clusters of rods are attached to ciliated respiratory epithelial cells.
Photo courtesy of Dr Patricia Martin.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
Therapy should be based on antimicrobial
susceptibility testing of bacteria cultured
from BAL uid or lung FNAs where available.
Mycoplasma spp. are generally susceptible to
doxycycline, macrolides and uoroquinolones.
B. bronchiseptica is usually susceptible to
doxycycline and uoroquinolones. Resistance
has often been detected to ampicillin and
trimethoprim. Amoxicillin-clavulanate is
not recommended, even if susceptibility is
documented, due to poor distribution into
respiratory secretions. Early treatment of
URT infections caused by B. bronchiseptica is
recommended to prevent LRT involvement.
For empirical therapy of feline LRTI where the
aetiological agent has not been cultured but
is suspected to be bacterial, doxycycline is the
recommended rst-choice antimicrobial and has
good efcacy for treatment of infections caused by
B. bronchiseptica, mycoplasmas, Pasteurella spp.
and anaerobes.
Acute life-threatening bronchopneumonia: Empiric therapy with ampicillin (20 mg/kg IV every 8 hours
)
and gentamicin (5-6 mg/kg IV once daily) while receiving IV uid therapy, plus nebulisation with saline and
thoracic percussion and coupage. Change agents on the basis of C+S from BAL specimens.
Chronic LRTI: Empiric treatment with doxycycline monohydrate (5 mg/kg q12h
).
Change therapy on the basis of C+S data if available.
Re-assess drug choices in the light of the response to therapy.
Note: As mycoplasmas lack a peptidoglycan cell they are resistant to all -lactam drugs.
ANTIBIOTICS USED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
AIDAP TOP TIPS
1. As well as systemic antimicrobials, nebulisation with oxygen and saline, combined with thoracic
physiotherapy can be helpful in cats with severe LRTI.
2. Maintain a high index of suspicion for pulmonary toxoplasmosis in cats receiving combination
therapy using prednisolone and either cyclosporine or cytotoxic drug therapy.
Minimum treatment durations for effective treatment of LRTI caused by mycoplasmas or B. bronchiseptica have
not been established, but extrapolating from URT infections and because of virulence factors of B. bronchiseptica
which favour persistence six weeks therapy is recommended. For other bacterial LRT infections three weeks may
be adequate. Ensure doxycycline given with a small bolus of water, or a small dab of margarine.
Key references:
1. Foster SF and Martin P. J Feline Med Surg 2011; 13(5): 313-332
2. Bart M, Guscetti F, Zurbriggen A, et al. Vet J 2000; 159(3): 220-230
3. Macdonald ES and Norris CR. J Am Vet Med Assoc 2003; 223(8): 1142-1150
4. Foster SF, Martin P, Allan GS, et al. J Feline Med Surg 2004; 6(3): 167-180
5. Barrs VR, Martin PM and Beatty JA. Aust Vet J 2006; 84: 30-35
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Isolates include Bacteroidaceae
(Bacteroides spp.,
Porphyromonas spp., Prevotella
spp.), Fusobacterium spp.,
Peptostreptococcus spp.,
Actinomyces spp., Eubacterium
spp., Propionibacterium spp.,
Filifactor villosus, Pasteurella
multocida, Streptococcus spp.
and Mycoplasma spp.
Less than 20% of cases of
feline pyothorax are caused by
infectious agents other than
oropharyngeal microbiota
such as Staphylococcus spp.,
Rhodococcus equi, Nocardia spp.,
enteric Gram-negative organisms
(E. coli, Salmonella spp.,
Klebsiella spp., Proteus spp.) non-
enteric Gram-negative organisms
(Pseudomonas spp.) and protozoa
(Toxoplasma gondii).
Fungal causes of feline pyothorax
are rare and include Cryptococcus
spp. and Candida albicans. In
contrast with dogs, infection with
Enterobacteriaceae is uncommon,
with E. coli being isolated in 0-7%
of cases.
Pyothorax is mostly a disease of
young cats (4-6 years), although
cats of any age can be affected.
There is no breed or gender
predisposition.
Possible routes of infection
include extension from
an adjacent structure
(bronchopneumonia, para-
pneumonic spread, oesophageal
rupture, mediastinitis or
sub-phrenic infection), direct
inoculation (penetrating
trauma, migrating foreign body,
thoracocentesis or thoracic
surgery) or haematogenous
or lymphatic spread from a
distant site (systemic sepsis).
Oropharyngeal microbiota
could gain access to the pleural
space by aspiration, direct
penetration from a bite wound
or by haematogenous spread
from a distant wound. The
evidence suggests that aspiration
of oropharyngeal microbiota,
subsequent colonisation of the
LRT and direct extension of
infection from the bronchi and
lungs is the most common cause
of feline pyothorax, as it is also
in cases of human pyothorax
and equine pleuropneumonia
that also often involve obligate
anaerobes. Viral URT infection
can impair mucociliary clearance
of respiratory secretions and
predispose to accumulation
of aspirated oropharyngeal
secretions, resulting in
colonisation of the LRT then
pleuropneumonia.
Similar to cat bite
abscesses, the majority
of cases of pyothorax in
cats are polymicrobial
infections caused by
obligate and facultative
anaerobic bacteria
derived from the feline
oral cavity.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
1. Ultrasonography (U/S) of the chest, followed by
thoracocentesis using a 23 gauge buttery needle,
ideally using U/S guidance. Note the odour of the
discharge, which is usually foetid in anaerobic or
mixed infections with an anaerobic component.
2. Where U/S guidance is not available,
thoracocentesis can be performed safely at the
ventral third of the 6th, 7th or 8th intercostal space
with the cat standing or in ventral recumbency.
Avoid the intercostal vessels and nerves located
near the caudal rib margin.
3. Inoculate aerobic and anaerobic culture bottles at
the cage side if anaerobic culture is contemplated.
Do NOT permit air into the syringe after aspiration
of purulent uid from the pleural space.
4. If U/S is not available, judiciously take thoracic
radiographs to conrm uid is present in the
pleural space and to identify a prudent site for
attempted thoracocentesis. Examine pleural
uid specimen by making smears, stained with
DiffQuik and Burkes modication of the Gram
stain (if available).
5. Submit purulent exudates collected whilst
maintaining anaerobic conditions to the
laboratory for C+S.
KEY ISSUES
01
Most cats with pyothorax have
polymicrobial infections dominated
by obligate anaerobes.
02
These infections typically begin in the
lung after aspiration of orpharyngeal
microbiota and spread secondarily to
the pleura and pleural space. Thus,
pyothorax is often a complication
some weeks after acute viral URT
infection in cats. Rarely, infection
occurs after penetrating cat bite
injuries to the thoracic wall.
03
Unlike dogs, grass seeds are rarely
the cause of pyothorax in cats,
although they can cause signs as
tracheal foreign bodies.
TESTS FOR DIAGNOSIS
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
Indwelling thoracostomy vs. needle
thoracocentesis: Although there are reports
of successful management of feline pyothorax
using single or repeated needle thoracocentesis
combined with antimicrobial therapy, mortality
rates are much higher in cats treated with daily
thoracocentesis compared with indwelling chest
tubes.
The accepted standard-of-care treatment
includes drainage via closed thoracostomy
tubes and antimicrobial treatment for a
minimum of four weeks.
Antimicrobials suitable for empiric treatment of polymicrobial feline pyothorax include penicillin G
(e.g. benzylpenicillin potassium or sodium, 20,000-40,000 IU/kg q6h IV
) or an aminopenicillin (e.g. ampicillin

20-40 mg/kg q6-8h IV
) or amoxicillin (10-20 mg/kg IV q12hrs
) either alone or in combination with

metronidazole (10 mg/kg q12h IV). Another alternative is parenteral monotherapy with potentiated penicillin,
e.g. amoxicillin-clavulanate. These agents are effective against both -lactamase producing anaerobes and
Pasteurella spp. Adjunctive, targeted antimicrobial therapy can be administered if indicated by the results
of antimicrobial susceptibility testing, or if Gram-negative rods only are seen in smears of pleural uid.
ANTIBIOTICS USED
Cat with pyothorax at necropsy.
Photos courtesy of Dr Vanessa Barrs.
Placement of bilateral chest tubes is recommended where
effusions are bilateral.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
AIDAP TOP TIPS
1. Pyothorax in cats occurs as a sequel to URT
infection, and is due to spread of aspirated bacteria
from the lung to the pleural space.
2. Although cats may present acutely, they have
actually been sick for quite some time.
3. Ultrasound scans for pleural effusion is often the
most cost effective test in cats with dyspnoea and
cats with fever of unknown origin.
4. Of all the causes of pleural effusion in the cat,
bacterial pyothorax has the best long-term
prognosis.
5. The presence of volatile fatty acids and other
fermentation products in the expired air of
affected cats cause halitosis, which can be a
tip off to the presence of pyothorax if the cats
have good oral hygiene.
Successful treatment of feline pyothorax
requires pleural drainage and lavage plus
antimicrobial therapy.
Indwelling thoracostomy tubes (chest tubes)
are the gold-standard for pleural space drainage,
and bilateral tubes should be placed where
effusions are bilateral.
Before anaesthesia for chest tube placement, the
pleural effusion should be drained as completely
as possible using needle thoracocentesis.
Treatment of anaerobic infections associated
with devitalised tissue requires high doses of
antimicrobials administered for extended periods.
There may be risk of relapse if therapy
is discontinued prematurely. For ongoing treatment
once clinical improvement is seen and the patient
is eating well, oral antibiotics may be substituted
for IV agents. Antimicrobial therapy for treatment
of feline pyothorax should be administered for
4-6 weeks.
Key references:
1. Love DN, Vekselstein R, Collings S. Vet Microbiol 1990; 22(23): 267-275
2. Love DN, Johnson JL, Moore LV. Vet Microbiol 1989; 19(3): 275-281
3. Love DN, Jones RF, Bailey M, et al. Vet Microbiol 1982; 7(5): 455-461
4. Barrs VR and Beatty JA. Vet J 2009; 179: 163-170
5. Barrs VR and Beatty JA. Vet J 2009; 179: 171-178
6. Walker AL, Jang SS, Hirsh DC. J Am Vet Med Assoc 2000; 216(3): 359-363
7. Waddell LS, Brady CA, Drobatz KJ. J Am Vet Med Assoc 2002; 221(6): 819-824
8. Barrs VR, Allan GS, Martin P, et al. J Feline Med Surg 2005; 7(4): 211-222
9. Demetriou JL, Foale RD, Ladlow J, et al. J Small Anim Pract 2002; 43(9): 388-394
SPECIES: CAT
SPECIES: CAT 107 SECTION: URINARY TRACT
(FIRST OCCURRENCE)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Although presentation for
lower urinary tract (LUT) signs
including dysuria, haematuria,
stranguria, pollakiuria and
periuria (inappropriate urination)
is common in feline practice,
the prevalence of bacterial UTI
overall in cats with LUT signs
is less than 3%, though the
prevalence may be higher in
older cats. The major differential
diagnosis for cats presenting
with LUT signs, in up to 55% of
cats, is idiopathic cystitis (also
known as interstitial cystitis
or feline urological syndrome).
Urethral obstruction in male cats
(mostly due to struvite plugs or
calcium oxalate uroliths) is the
next most common cause of LUT
signs while less common causes
include urolithiasis, anxiety
disorder (where inappropriate
urination is the presenting sign)
and neoplasia. Age ( 10 years) is
a risk factor for UTI in cats which
may be related to lower urine
osmolarity in older cats with
renal disease.
E. coli is the most common
Gram-negative bacterium and
Enterococcus spp. and S. felis
are the most common Gram-
positive bacteria to cause UTI
in Australian cats. This was
demonstrated in a study of LUT
infections in Australian cats
presenting with LUT signs,
where infections were due to
E. coli (37%), Enterococcus
spp. (30%), Staphylococcus
felis (20%), Proteus spp. (5%),
Enterobacter/Klebsiella spp.
(3%), Pseudomonas aeruginosa
(<2%), S. aureus (<2%) and
S. pseudintermedius (<2%).
A total of 94% of E. coli isolates
in that study were susceptible to
amoxicillin-clavulanate, as were
all Enterococcus and S. felis
isolates. Amoxicillin has been
suggested as an appropriate
rst-choice empiric antimicrobial
for uncomplicated UTI in cats by
ISCAID. While all Enterococcus
spp. are likely to be susceptible
to amoxicillin, 12% of S. felis and
32% of E. coli in an Australian
study were resistant.
First occurrence UTI in
an otherwise healthy
cat with normal urinary
tract anatomy and
function is defned as
an uncomplicated UTI.
ORGANISMS INVOLVED
SPECIES: CAT
(FIRST OCCURRENCE)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Also, given that three times
daily dosing is recommended for
amoxicillin, compliance is likely
to be a key issue for cat-owners.
Trimethoprim-sulfonamide has
also been recommended for rst-
line therapy of uncomplicated
UTIs by the International Society
for Companion Animal Infectious
Diseases (ISCAID) 90% of
Australian feline isolates of
E. coli and all Enterococcus spp.
and S. felis were susceptible
to this agent. However, some
formulations of trimethoprim-
sulfonamide such as coated
tablets can induce profound
salivation in cats if the exterior
coating is broken so may not be
appropriate oral therapy unless
available in capsules.
For cats that cannot be orally
medicated with amoxicillin-
clavulanate, empirical treatment
with doxycycline may be an
alternative as 80% of E. coli
isolates from Australia were
susceptible to this agent
and it reaches appropriate
concentrations in urine. It should
be noted, however that some
less prevalent Gram-negative
pathogens (i.e. Proteus spp.)
are intrinsically resistant to
doxycycline.
SPECIES: CAT
(FIRST OCCURRENCE)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
1. A full urinalysis is recommended for all cats
presenting with LUT signs, using a urine
sample collected by cystocentesis.
2. Diagnosis of an uncomplicated UTI should
be made on the basis of presence of LUT
signs with supporting evidence of UTI
(epithelial cells, RBC, WBC and bacteria)
on a full urinalysis including examination of
Gram or DiffQuik stained urine sediment.
It is recommended that urine collected for
urinalysis also be submitted for C+S testing
since false positive diagnoses can be made
on urine sediments, usually due to the
presence of stain precipitates mimicking
bacteria.
3. Free-catch urine samples are inferior and
should generally be avoided.
4. Where subclinical bacteriuria is identied
(positive urine culture in the absence of clinical
and cytological evidence of UTI) treatment
is generally not recommended in otherwise
healthy patients with normal urinary tract
anatomy and function.
KEY ISSUES
01
The majority of acute rst occurrence cystitis
cases in cats are sterile and due to idiopathic
cystitis, also known as feline interstitial
cystitis.
02
UTIs are uncommon in young cats.
03
E. coli is the most common Gram-negative
bacterium while Enterococcus spp., and
Staphylococcus felis are the most common
Gram-positive bacteria to cause UTIs in
Australian cats.
04
Considering both antimicrobial susceptibility
and compliance issues, amoxicillin-
clavulanate and doxycycline are appropriate
empiric choices for treating uncomplicated
UTIs in cats.
05
GIT side-effects, primarily vomiting,
occur in a small minority of cats after
administration of amoxicillin-clavulanate,
in which case a lower-dose or changing to
another antimicrobial, such as doxycycline is
recommended.
06
Collection of urine by cystocentesis for full
urinalysis including sediment examination
can be difcult on an out-patient basis in
some cases due to LUT signs resulting in an
empty bladder at rst presentation. Consider
admitting the cat, if required, to obtain a
urine sample by cystocentesis.
07
For cats with urethral obstruction and
indwelling urinary tract catheters,
prophylactic antimicrobials should never be
given during the period of catheterisation
and culture of urine from urine-collection
bags is contraindicated. Culture of urine-
catheter tips after removal is not necessary.
Post-catheter UTI should be diagnosed on
the basis of presence of clinical signs and
cytological evidence of infection using a
urine-sample collected by cystocentesis.
TESTS FOR DIAGNOSIS
SPECIES: CAT
(FIRST OCCURRENCE)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
1. Empiric antimicrobial therapy is appropriate
while waiting for urine culture results since
LUT signs cause pain and discomfort.
2. Recommended rst-line choice for empiric
therapy in cats include amoxicillin-clavulanate at
12.5 mg/kg q12h PO (using the higher dose will
achieve a concentration in urine that is likely to
exceed the MIC for most pathogens). Doxycycline
5 mg/kg q12h
, then 2.5 mg/kg q24h
can be
considered as an alternative for non-compliant
cats or cats that vomit on amoxicillin-clavulanate.
3. The recommended treatment duration is
7-14 days, although shorter treatment times
may be effective.
First line:
Amoxicillin-clavulanate (12.5 mg/kg q12h)
or doxycycline (5 mg/kg q12h
) are recommended
for empiric treatment.
Cefovecin should only be considered where
compliance is an issue, or there are difculties
with medicating orally.
Second line:
Consider a uoroquinolone (marbooxacin,
2.75-5.5 mg/kg q24h) on the basis of C+S if the
bacteria are resistant to rst line therapy or the
infection is serious.
ANTIBIOTICS USED
SPECIES: CAT
(FIRST OCCURRENCE)
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T

AIDAP TOP TIPS
Cystocentesis should be performed routinely to collect urine for urinalysis in cats
presenting with LUT signs. It is easy to perform with the cat restrained in lateral
recumbency, the bladder gently supported in the left hand while aspirating urine
using a 23 gauge needle and syringe held in the right hand. Cystocentesis is generally
safe in cats providing the bladder is not overly distended. It is also important not to
squeeze the bladder during urine aspiration or transient uroabdomen can result.
Photo courtesy of Dr Vanessa Barrs.
Recommended duration of therapy is 7 to 14 days for uncomplicated UTIs.
Consider bacterial UTI
in cats with underlying
risk factors (e.g. age,
renal impairment,
metabolic disease)
and perform a full
diagnostic workup
including C+S testing.
Key references:
1. Litster A, Thompson M, Moss S, et al. Vet J 2011; 187(1): 18-22
2. Litster AL, Moss SM, Honnery M, et al. Vet Microbiol 2007; 121: 182-188
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T

Complicated UTIs occur where
there is an underlying anatomic
or functional abnormality or
where there is a concurrent
disease that predisposes to UTI,
for example CKD. Recurrent UTIs,
occurring within six months after
successful treatment of the rst
infection, can be re-infections
caused by a different bacterial
species to the original isolate
or relapses caused by the same
bacterial species as the original
isolate.
The most common underlying
anatomic abnormality associated
with complicated UTIs in cats
is perineal urethrostomy in
previously obstructed male cats
with approximately 1 in 5 cats
developing recurrent UTIs.
The most common concurrent
diseases associated with
complicated UTIs in cats are CKD,
hyperthyroidism and diabetes
mellitus. In two retrospective
studies of 224 and 614 cases,
UTIs were identied in 17 and
22% of cats with CKD, in 12 and
22% of cats with hyperthyroidism
and in 12 and 13% of cats with
diabetes mellitus, respectively.
The majority of cats with UTIs
secondary to these diseases did
not present with LUT signs. Risk
factors for complicated UTIs
in cats include female gender,
increasing age and decreasing
body weight. In some studies low
urine specic gravity has also
been identied as a risk factor
for UTI caused by Gram-negative
bacteria.
Recurrent UTIs
are a subset of
complicated UTIs.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
1. To identify diseases that cause recurrent
LUT signs in cats an appropriate minimum
data base should include the following:
(i) a detailed history of previous antimicrobial
therapy used including dose, duration of
therapy and owner compliance.
(ii) a full urinalysis and C+S testing of a
urine sample collected by cystocentesis.
(iii) haematology, serum biochemistry
and a total T4.
(iv) abdominal imaging (sonography and
radiography).
2. For recurrent UTI where concurrent disease
or an underlying bladder abnormality cannot
be detected after the investigations above
consider referral for further investigation,
e.g. cystoscopy.
3. Where subclinical bacteriuria is identied
(positive urine culture in the absence of
clinical and cytological evidence of UTI)
treatment is based on the risk of ascending
or systemic infection.
KEY ISSUES
01
UTIs are most common in older female
cats. Females are predisposed to ascending
infections from the gastrointestinal tract
due to a relatively wide and short urethra
compared to males.
02
Other risk factors for complicated UTIs
in cats are concurrent diseases, most
commonly CKD, hyperthyroidism and
diabetes mellitus.
03
Causes of recurrent sterile cystitis including
urolithiasis and bladder neoplasia need to be
excluded in any diagnostic investigation.
04
Recurrent UTIs in young cats should arouse
suspicion of an underlying abnormality or
dysfunction of the LUT, e.g. ectopic ureter
05
In addition to identication and treatment
of underlying predisposing causes of
recurrent UTIs accurate identication of the
underlying bacterial isolate(s), antimicrobial
susceptibility testing and appropriate
duration treatment are important for
successful management of recurrent UTI.
06
Because MDR pathogens are becoming
increasingly recognised globally, careful
consideration must be given to selection
of antimicrobials used for treatment of
UTI and should be guided by C+S ndings.
TESTS FOR DIAGNOSIS
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
1. Empiric antimicrobial therapy is not
recommended unless clinical signs necessitate it.
Recommended antimicrobials for empiric therapy
are as for uncomplicated UTIs. Fluoroquinolones
are also possible second line choices in cases of
resistance to rst line drugs. Organisms isolated
from complicated UTI cases are more likely
to be resistant to doxycycline. Where possible
the drug class selected should be different
from that used to treat the original UTI. If the
bacterial isolate is resistant to the antimicrobial
chosen for empiric therapy, treatment should be
changed to an antimicrobial to which the isolate
is susceptible and if possible is excreted in its
active form primarily in urine. Consider complete
blood counts during therapy to monitor for
haematological side-effects.
2. In cats with asymptomatic bacteriuria and
underlying disease (e.g. CKD) wait until C+S test
results are available to initiate treatment using an
appropriate antimicrobial.
3. For mixed infections consisting of Enterococcus
spp. and another bacterial isolate infection by
the former will often resolve when the other
organism is successfully treated, though infections
where Enterococcus is the sole pathogen may be
refractory to treatments of short duration. Ideally a
single antimicrobial or antimicrobial combination
effective against both organisms should be
selected, however if this is not possible due to
resistance antimicrobial therapy should be based
on efcacy against the organism perceived to be
most clinically relevant.
4. Where multi-drug resistant (MDR) organisms
are identied, consultation with colleagues with
expertise in infectious diseases is recommended.
Antimicrobials including carbapenems, vancomycin
and linezolid should never be used for treatment
of subclinical bacteriuria and are reserved for
treatment of complicated UTI diagnosed by C+S
testing of a urine sample obtained by cystocentesis
in patients with treatable diseases in which
all other possible antimicrobials have been
considered.
First line:
Amoxicillin-clavulanate (12.5 mg/kg q12h PO;
higher doses may be used off-label but
vomiting may occur).
Second line:
Consider a uoroquinolone* on the basis of
C+S if the bacteria are resistant to rst line
therapy or for serious infections.
Cefovecin is not recommended as a treatment for
cats with complicated or recurrent UTI as the strains
involved could potentially acquire extended spectrum
-lactamases following repeated treatments.
*Enrooxacin should not be used in a cat as it has
been reported to cause retinal toxicity, so other
uoroquinolones are recommended.
ANTIBIOTICS USED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T

AIDAP TOP TIPS
The recommended treatment duration is four weeks although shorter treatment times may be effective.
For recurrent infections, consider urine culture 5 to 7 days after starting therapy and 7 days after stopping
oral therapy.
In cases of complicated
cystitis in cats where a
fuoroquinolone is indicated
on the basis of C+S,
administer at the higher
end of the registered dose
rate. Enrofoxacin has been
reported to be associated
with retinal toxicity in cats.
Key references:
1. Weese JS, Blondeau JM, Boothe D, et al. Vet Met Int 2011; Article ID 263768: 1-9
2. Mayer-Roenne B, Goldstein RE, Erb HN. J Feline Med Surg 2007; 9: 124-132
3. Bailiff NL, Westropp JL, Nelson RW, et al. Vet Clin Pathol 2008; 37: 317-322
4. Litster A, Moss S, Platell J, et al. Vet Microbiol 2009; 136: 130-134
5. Grifn DW and Gregory CR. J Am Vet Med Assoc 1992; 200: 681-684
6. Plumb DC 2011. Plumbs veterinary handbook (7th edition). Wiley-Blackwell
7. Dierikx CM, van Duijkeren E, Schoormans AH, et al. J Antimicrob Chemother 2012; 67(6): 1368-1374
SPECIES: CAT
SPECIES: CAT 116 SECTION: PYREXIA
D
O
G

C
O
N
T
E
N
T
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Common causes may be bacterial
(e.g. cat ght cellulitis) or viral
(feline infectious peritonitis,
FHV-1, FCV). It is uncommon to
have immune-mediated disease
in cats when compared with dogs,
although sterile polyarthropathies
can mimic infection-related fever.
Pasteurella, Staphylococcus
pseudintermedius, obligate
anaerobic spp. and Streptococcus
spp. can be involved.
Many cats with
acute febrile illness
have an underlying
infectious cause.
ORGANISMS INVOLVED
SPECIES: CAT
D
O
G

C
O
N
T
E
N
T
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
1. History and thorough clinical examination remain
the corner stone. Was the cat boarded recently?
Are mouth ulcers present? Is there oculonasal
discharge. Was the cat recently in a ght?
2. Systematic palpation for regions of
hyperaesthesia.
3. Consider thoracic radiographs and ultrasound
examination of the thoracic and abdomen for uid.
4. Consider echocardiography to rule in or rule out
bacterial endocarditis.
5. Consider blood culture if there is an index of
suspicion for sepsis.
6. Where joint effusions are detected, imaging and
cytological analysis/culture of joint effusions are
recommended.
KEY ISSUES
01
A key element of any acute febrile
disease is making a diagnosis as
early as possible. A thorough physical
examination is required, in particular
a search for cat bite cellulitis lesions.
02
A high creatine kinase activity
in a serum biochemistry prole
in a cat with acute fever can
suggest myonecrosis secondary
to undetected cat bite wounds.
03
Acute upper respiratory viral
disease is a common cause of
fever in the cat.
04
Early pyothorax can present for fever
and little else, as there is insufcient
uid to impair ventilation. Thoracic
radiographs or thoracic sonography
may reveal a small amount of septic
pleural exudate in this case.
05
Palpate joints carefully for thickening
joint capsules, effusion and pain.
TESTS FOR DIAGNOSIS
SPECIES: CAT
D
O
G

C
O
N
T
E
N
T
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
Clearly investigating and reaching a diagnosis
is very important, but in the initial situation
antibiotics may be used if there is a strong
suspicion of a bacterial infection.
Given the high likelihood of cat ght wounds or a
non-bacterial infection then if an antibiotic is to
be used, a broad-spectrum antibiotic with good
activity against common bacterial found in CFA
or on skin would be required.
Amoxicillin-clavulanate is a rational rst choice (12.5 mg/kg q12h).
) is a good second choice,

or in situations where the use of paste or a small easy to use pill
will improve compliance.
ANTIBIOTICS USED
SPECIES: CAT
D
O
G

C
O
N
T
E
N
T
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T

AIDAP TOP TIPS
1. Although there is a strong compassionate desire to use a
NSAID to reduce the fever and make the patient feel more
comfortable, this is only recommended when the diagnosis
is known for example detection of cat puncture wounds,
but no abscess. In other situations it is more prudent to
use antibiotics alone and let the response to therapy
(e.g. resolution of fever, resumption of eating) conrm
that there is likely an underlying bacterial aetiology.
2. If there is a favourable response to antimicrobial therapy
consider a longer course, rather than a shorter course,
in case there is undetected signicant disease such as
pneumonia or purulent pleurisy.
An initial injection of amoxicillin-clavulanate subcutaneously
followed by administration of oral therapy as required.
Modications of this pending result of further diagnostic
testing. Ensure doxycycline given with a small bolus of water,
or a small dab of margarine.
Key references:
1. Hause WR. Mod Vet Pract 1984; 65(6): 461-465
SPECIES: CAT
SPECIES: CAT 120 SECTION: ABDOMINAL
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
The source of the infection is
often bowel leakage, but can
be from pyometra, prostatitis,
pyothorax, hepatic or kidney
abscess rupture. Migrating grass
awns and metallic foreign bodies
(needles) may also instigate
peritonitis. A ruptured gall
bladder may occur in animals
with infectious cholecystitis.
Penetrating bite wounds may
also cause peritonitis. In cats
(and dogs) primary bacterial
peritonitis is also reported
where no predisposing cause
is identied. Mortality rate is
high and delayed treatment and
diagnosis may result in a poor
outcome.
For example a retrospective
study of 12 client-owned animals
reviewed clinical ndings,
laboratory and microbial culture
results, radiographic ndings,
diagnosis, treatment and
outcome. The overall mortality
rate of the cats was 31%,
consistent with previous reports
of septic peritonitis in cats. All
cats that were both bradycardic
and hypothermic on presentation
did not survive. Results suggest
that clinico-pathological
ndings and outcomes in cats
with primary septic peritonitis
are similar to those in cats
with septic peritonitis from a
determined cause. A specic
mechanism of inoculation has
yet to be determined, but an oral
source of bacteria is suggested
for cats with primary bacterial
septic peritonitis. There is little
published information on the
bacteria aetiologies and their
sensitivity proles.
This situation is clearly
a severe life or death
scenario with no time
for C+S data prior to
initiation of therapy.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
1. Abdominal uid should be obtained for cytology
and for C+S. Immediate treatment should then be
started. Aerobic and anaerobic cultures need to be
performed.
2. Surgical exploration of the abdomen is usually
required for diagnostic and treatment purposes.
3. Surgical drainage of the abdomen may be required
using Jackson Pratt drains; alternately, in some
cases an open abdomen method for drainage is
applied.
KEY ISSUES
01
Immediate antibiotics given
parenterally, preferably IV
at maximal safe doses.
02
Coverage of Gram-negative and
Gram-positive aerobes and anaerobes,
with a high possibility of antibiotic
resistant bacteria being involved.
03
Immediate uid support and
probably surgery for correction
of underlying issue.
TESTS FOR DIAGNOSIS
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
1. Four-quadrant IV antibiotic therapy.
2. Surgical drainage.
3. Management of sepsis syndrome with uids,
plasma or colloids, sometimes a whole blood
transfusion and inotropic support, as needed.
1. Amoxicillin 20 mg/kg IV q6h
or ampicillin
(20 mg/kg IV q6-8h
) or cefazolin (22 mg/kg IV q8h
)
/cefoxitin (30 mg/kg IV q8h
).
2. Use an aminoglycoside (e.g. gentamicin
6-8 mg/kg IV q24h).
3. Metronidazole 10 mg/kg IV q8h.
ANTIBIOTICS USED
Key references:
1. Ruthrauff CM, Smith J, Glerum L. J Am Anim Hosp Assoc 2009; 45(6): 268-276
2. Culp WT, Zeldis TE, Reese MS, Drobatz KJ. J Am Vet Med Assoc 2009; 234(7): 906-913
3. Mueller MG, Ludwig LL, Barton LJ. J Am Vet Med Assoc. 2001; 219(6):789-794
2 weeks post-recovery
The upper limit of the recommended dose range should be given.
Note that beta-lactams (penicillins and cephalosporins) and aminoglycosides
(gentamicin, amikacin) need to be given separately as they precipitate in the
uid line if given simultaneously. These agents should be given by slow IV
push over several minutes, separated by a ush with saline.
SPECIES: CAT
SPECIES: CAT 123 SECTION: DESEXING
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
As a general rule desexing
operations conducted using
sterile technique and not taking
longer than average for an
experienced veterinarian to
complete would not be given
antibiotics prophylactically.
In one study, peri operative
antimicrobial prophylaxis
decreased postoperative infection
rate in dogs undergoing elective
orthopaedic surgery, compared
with the infection rate in control
dogs. Cefazolin was not more
efcacious than potassium
penicillin G in these dogs.
This would suggest that
prolonged surgery times
for routine desexing might
be considered an increased
risk of infection, as might a
breach in aseptic technique.
Denitive studies of what time
limits are associated with
increased infection in desexing
operations are lacking. However,
antibiotics with higher efcacy
for Staphylococcus spp. would
be considered in the event of a
prolonged desexing operation.
Several studies have
shown that length of
time of surgery and
the more people in the
room at the time of
surgery, the greater
the risk of infections.
ORGANISMS INVOLVED
SPECIES: CAT
SPECIES: CAT 124 SECTION: DESEXING
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
KEY ISSUES
01
There is no need for prophylactic
antimicrobials for routine desexing.
02
If the procedure is unduly prolonged,
or there is a breach in asepsis, then
a single injection of amoxicillin-
clavulanate or a 1st generation
cephalosporin might be appropriate.
TREATMENT
Antibiotics are considered unnecessary in
routine short surgery conducted under sterile
conditions. Given the use of gloves and sterile
conditions, the routine use of prophylactic
antibiotics for spays is not required. Also given
that most potential contaminants arise from the
skin of the dog or the veterinary staff, a single
shot of procaine penicillin offers insufcient
coverage for Staphylococcus pseudintermedius
or Staphylococcus aureus infection.
Routine use of antibiotics not suggested.
ANTIBIOTICS USED

N/A.
SPECIES: CAT
SPECIES: CAT 125 SECTION: DENTAL
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Pasteurella multocida, and
anaerobic Gram-negative rods
including Capnocytophaga are
frequently involved and these
are all sensitive to penicillins,
including benzyl penicillin and
amoxicillin-clavulanate.
There is a very small risk that
bacteraemia associated with
the use of ultrasonic scaling
devices and extractions could
produce infections elsewhere,
such as bacterial endocarditis.
This is most unlikely in normal
patients, but the risk is increased
with structural heart disease,
especially subaortic stenosis
which has been associated
with increased risk for the
development of bacterial
endocarditis.
For this reason, it may be prudent
to administer prophylactic
bactericidal antibiotics so that
high blood levels are obtained
during and immediately after the
dental procedures.
Most bacteria found
in the mouths of cats
(and dogs) are similar
to what is recovered
in bite wounds.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Histopathology and culture of infected tissue is
suggested if initial prophylaxis fails to cure an
ulcerated mouth lesion.
KEY ISSUES
01
Prophylactic antibiotics are
best administered prior to the
procedure e.g. procaine penicillin or
amoxicillin-clavulanate administered
SC or IM after premedication or
immediately after anaesthetic
induction.
TESTS FOR DIAGNOSIS
TREATMENT
N/A.
Amoxicillin or amoxicillin-clavulanate would cover the great majority of potential pathogens in this setting.
First line:
Amoxicillin 10 mg/kg q12h/amoxicillin-clavulanate
(12.5 mg/kg q12h).
Second line:
Clindamycin (5-11 mg/kg q12h) or doxycycline
monohydrate (5 mg/kg q12h
).
ANTIBIOTICS USED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
If there are extractions or bleeding, which occurs in most cases, then a 7-10 day course of antibiotics is
required depending on the healing period. Ensure doxycycline given with a small bolus of water, or a small
dab of margarine.
Key references:
1. Love D 1990 et al (isolated lots of anaerobes but possibly no data on their sensitivities)
2. Bowersock TL, Wu CC, Inskeep GA, Thoracicer ST. J Vet Dent 2000; 17(1): 11-16
4. Nielsen D, Walser C, Kodan G, et al. Vet Ther 2000; 1(3): 150-158
6. Sarkiala E and Harvey C. Semin Vet Med Surg (Small Anim) 1993; 8(3): 197-203
7. Zetner K and Thiemann G. J Vet Dent 1993; 10(2): 6-9
8. Wilcke JR. Probl Vet Med 1990; 2(2): 298-311
SPECIES: CAT
SPECIES: CAT 128 SECTION: SKIN/SOFT TISSUE
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
(i) Infections of the subcutaneous
panniculus generally with
rapidly growing mycobacteria
and;
(ii) granulomatous or
pyogranulomatous masses
of the skin and subcutis
(generally due to non-
cultivable mycobacteria
e.g. feline leprosy-like
syndromes, leproid
granulomas etc. and
sometimes mycobacterium
avium complex infections).
The taxonomy of these organisms
is evolving, and currently they are
divided into complexes:
a. M. smegmatis complex
(including M. goodii)
drugs of choice doxycycline,
moxioxacin, gentamicin.
b. M. fortuitum complex
drugs of choice
clarithromycin, moxioxacin,
gentamicin.
c. M. chelonae/abscesses
complex drug of choice
clarithromycin, rest depends
on susceptibility testing.
Generally speaking they are all
resistant to rifampicin, and all
susceptible to clofazamine.
Mycobacteria cause
two major types of
disease affecting the
skin and subcutis.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
1. The cornerstone of therapy is obtaining a
positive culture.
2. This is obtained by aspirating purulent exudate
present in the subcutis through intact skin,
after preparation of the skin with 70% ethanol
(and allowing time for drying).
3. Primary isolation can be done in a veterinary
laboratory, although it important to keep the
plates for the 4-5 days it takes for the colonies
to appear.
4. Positive cultures should be forwarded to a
human mycobacteria reference laboratory for
species identication and C+S testing.
Infections of the skin and subcutis with
rapidly growing mycobacteria.
Reference laboratories managing culture
and PCR of Mycobacteria and Nocardia:
VICTORIA
Dr Janet Fyfe
Victorian Infectious Diseases
Reference Laboratory
10 Wreckyn Street, North Melbourne VIC 3051
Ph: (03) 9342 2600
WESTERN AUSTRALIA
Dr Ian Arthur
PathWest Laboratory Medicine WA
QEII Medical Centre, Nedlands WA 6009
KEY STEPS
KEY ISSUES
01
Draining sinus tracts should alert
the practitioner to the presence
of saprophytic pathogens such
as mycobacteria, Nocardia spp.
and fungi.
02
Involvement of the inguinal
panniculus is suggestive of
mycobacterial and nocardial disease.
03
Preliminary cytology stained with
DiffQuik can be very helpful in
cases where Nocardia and fungi
are involved, whereas culture on
routine media is far more expedient
a way to diagnose mycobacterial
infections caused by rapidly growing
saprophytic mycobacteria.
a. Rapidly growing mycobacteria, Nocardia spp.
and fungi can all give rise to deep draining
tracts that discharge to the skin surface.
b. Rapidly growing mycobacteria (and to a lesser
extent Nocardia nova) have a predilection for
the fatty subcutaneous panniculus, especially
in the inguinal region.
TESTS FOR DIAGNOSIS
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
These infections require months to years of
antimicrobial therapy, and in some cases surgery
is required to debulk lesions to enable a clinical
cure to be achieved.
Generally speaking, topical therapy is not useful in
the management of these infections as the disease
process is situated in the subcutis and involves the
skin secondarily.
C+S is strongly advised in these cases.
Mycobacteria
First line:
Doxycycline (5 mg/kg q12h
(compounded) for M. smegmatis complex infections;

clarithromycin (5-15 mg/kg q12h
) for other rapidly growing mycobacteria.

Second line:
Clofazimine (4-10 mg/kg q24h
compounded), amikacin (10-15 mg/kg q24h
IV/IM/SC).
Nocardia
First line:
Trimethoprim/sulphonamide combinations at a dose of 125 mg per cat once daily (do not split or otherwise divide
the coated tablet) combined with a second drug depending on C+S testing; note that many cats can tolerate
chronic dosing with trimethorpim/sulphonamide combinations.
Second line:
Amoxicillin 20 mg/kg twice a day for N. nova (not amoxicillin clavulanate).
Clarithromycin (5-15 mg/kg q 12h) or moxioxacin (10 mg/kg once a day).
ANTIBIOTICS USED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T

See current textbooks for detailed guidelines.
Key references:
1. Reppas G, Nosworthy P, Hansen T, et al. Aust Vet J 2010; 88(5): 197-200
2. Escalonilla P, Esteban J, Soriano ML, et al. Clin Exp Dermatol 1998; 23(5): 214-221
3. Malik R, Krockenberger MB, OBrien CR, et al. Aust Vet J 2006; 84(7): 235-245
4. Malik R, Love DN, Wigney DI, et al. Aust Vet J 1998; 76(6): 403-407
5. Charles J, Martin P, Wigney DI, et al. Aust Vet J 1999; 77(12): 799-803
6. Fyfe JA, McCowan C, OBrien CR, et al. J Clin Microbiol 2008; 46(2): 618-626
7. Malik R, Shaw SE, Grifn C, et al. J Small Anim Pract 2004; 45(10): 485-494
8. Malik R, Hughes MS, James G, et al. J Feline Med Surg 2002; 4(1): 43-59
9. Govendir M, Norris JM, Hansen T, et al. Vet Microbiol 2011; 153(3-4): 240-245
10. Malik R, Wigney DI, Dawson D, et al. J Feline Med Surg 2000; 2(1) 35-48
Close-up showing pepper pot draining sinus tracts.
Multiple draining sinus tracts on the lateral thorax of a ginger cat
due to rapidly growing Mycobacteria.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Microsporum canis is
responsible for 94 to 99%
of feline infections.
Microsporum gypseum and
Trichophyton mentagrophytes
account for most of the remaining
cases. Infections with unusual
species such as Microsporum
persicolor have been reported; it
is uncertain how common these
infections occur, but prevalence
maybe related to local climate
and environmental factors.
Skin lesions: There are many
clinical presentations of feline
dermatophytosis. Pruritus is
variable and can range from nil
to severe. In kittens, irregular,
annular to circular patches of
alopecia with scale, crust and
erythema affecting face, ears
and forelegs are common. In
adult cats, focal, multifocal or
generalised patchy alopecia
with or without scale occurs
frequently, especially in long
haired cats.
Dermatophytoses
are superfcial fungal
infections that involve
the skin, hair and
claws.
ORGANISMS INVOLVED
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Surface cytology: via acetate preparations may
identify fungal hyphae in the stratum corneum.
Trichograms: examine the follicular debris of
anagen follicles for the presence of ectothrix fungal
elements. This may be aided by the use of clearing
agents, with KOH or chlorphenolac.
Fungal culture: collection of scale and hair from the
edge of a lesion or the use of a sterile toothbrush
to comb through the entire coat to maximise the
sensitivity. Sample lesional areas last.
KEY STEPS
01
Perform a trichogram to evaluate
for ectothrix arthrospores.
02
Woods lamp examination for
Microsporum canis infections only.
03
Collect hair and scale for fungal
culture using McKenzie toothbrush
culture (cats).
04
Avoid spot therapy with topical
antifungal ointments.
05
Implement topical/systemic/
environmental treatment.
TESTS FOR DIAGNOSIS
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
In most healthy animals, dermatophytosis is a self-curing disease, with full resolution of disease
in 10-16 weeks without therapy. The best treatment protocol is a combination of three modalities:
1. Topical treatment: To kill infective material and prevent its dissemination into the environment.
2. Systemic treatment: To shorten the time of infection in the individual animal.
3. Environmental treatment: To help prevent recurrence of infection or spread to other
animals or people in the household.
A. Clipping the hair coat: should you clip?
Clipping of the hair coat will mechanically remove
fragile hairs that will fracture and release spores into
the environment. Clipping of the entire hair coat is
optimal but not always possible or practical. Clipping
is time consuming and often requires sedation and is
irritating to cats. Owners are often unwilling to commit
to clipping their pets. Short-haired cats with fewer
than ve focal lesions do not need to be clipped.
When cats have more than ve lesions, long hair and
there are multiple pets in the environment and the
affected pet cannot be segregated, clipping the entire
pet is optimal. Clip the hair short and gently to avoid
spreading the infection due to the microtrauma and
mechanical spread of the spores.
The owner should be warned that a temporary
exacerbation of lesions may occur after clipping.
Note: If the animal is to be clipped in the clinic all
debris produced must be considered to be infectious
with zoonotic potential and so rigorous infection
control measures should be observed.
i.e. cover table surface with disposable drape,
gown and glove, collect all material and double bag,
thoroughly disinfect the room and all equipment
used with an appropriate antifungal agent.
B. Topical therapy: which one is best?
i. Localised (treating only the spots) or
whole body topical therapy
In animals, not all the lesions may be visible due to
the long hair coat. It is almost certain that there are
infective spores in non-lesional areas. Therefore spot
treatment with topical drugs is not recommended even
for focal lesions because infection beyond the margin
of visible lesions is likely. There is no clinical data to
support that the use of spot treatment clear lesions
any more rapidly than whole-body treatment alone. If
the owner insists, the best products are probably 1%
terbinane solution, lotion, cream or spray (Lamisil
)
and 2% clotrimazole cream (Canesten
).
ii. Total body treatment
Topical therapy inactivates fungal spores and mycelia
on and within hair shafts reducing environmental
contagion and results in a faster cure than systemic
therapy alone. Shampoo therapy, dipping or rinsing
with topical antifungal agents is preferred. The choice
of topical antifungal agent is important because studies
have shown that many topical antifungal agents are
ineffective. In vitro and in vivo studies have shown
that the most consistently effective topical treatments
are lime sulphur, enilconazole, and miconazole; the
latter with or without chlorhexidine. Miconazole and
chlorhexidine (Malaseb
) shampoo has been studied in

cats as an adjunct treatment to oral griseofulvin.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Systemic therapy
The role of systemic therapy in treating
dermatophytosis is to accelerate the resolution of
infection in the individual animal. Several effective
drugs are available, and the appropriate choice should
be made depending on cost, fungal species, patient
species and potential for toxicity. Systemic therapy
is the treatment of choice for dermatophytosis. It
is important to remember that systemic antifungal
therapy does not rapidly reduce contagion and should
be used in conjunction with clipping and topical
antifungal agents.
Griseofulvin
Griseofulvin is administered at 25 mg/kg q12h.
The absorption is enhanced when administered as a
divided dose and with a fatty meal. The most common
side-effects anorexia, vomiting and diarrhoea can
be avoided by dividing or lowering the dose. The drug
is highly teratogenic and therefore contraindicated in
pregnant animals.
Bone marrow suppression producing anaemia and
leukopenia is a relatively uncommon yet severe
and unpredictable adverse effect of griseofulvin in
cats. These effects can reverse when treatment
is withdrawn but irreversible fatal idiosyncratic
pancytopenia has been reported. Myelosuppression
does not appear to depend on dose, breed or duration
of treatment. Blood counts are recommended
once a month when using this drug in cats. Severe
neutropenic reactions have been reported in cats
with dermatophytosis associated with FIV infection.
Griseofulvin should not be used in cats with FIV.
All cats should be tested for FIV before griseofulvin
is administered. Do not administer cats less than
6 weeks of age.
Nearly all patients with Microsporum infections, and
many with Trichophyton infections will be cured with
this drug,
Ketoconazole (KTZ)
This drug should be avoided in cats due to
hepatotoxicity. Some strains of Microsporum
canis appear resistant to ketoconazole. Therefore
ketoconazole has no real advantage over other drugs
for routine cases of dermatophytosis and should not
be used in cats due to the adverse effects in these
species.
Itraconazole (ITZ)
Itraconazole (Sporanox
) is a fungicidal triazole
drug that is extremely useful for dermatophytosis.
The recommended dose is 5-10 mg/kg/day PO.
Itraconazole persists in the skin and nails for weeks
to months after dosing, and intermittent or pulse
therapy is frequently prescribed for skin infections or
onychomycosis. In cats a regime has been reported
using 5 mg/kg/day every 24 hours for three one week-
on and one week-off cycles and this is recommended
by the authors.
Itraconazole is generally well tolerated; reported side-
effects include vomiting and/or anorexia in cats. Signs
of dose related hepatotoxicosis have been reported
rarely in cats. Itraconazole is reportedly not teratogenic
when used at a dose of 5 mg/kg.
Fluconazole
Fluconazole (Diucan
) is receiving some recent

attention as an alternative drug because it has now
become inexpensive through some compounding
pharmacies. Several recent in vitro studies have shown
that the MICs of uconazole against dermatophytes
are much higher that the MICs of itraconazole
suggesting that itraconazole may be the superior
drug. Current evidence and clinical anecdotes would
suggest that there is no advantage of this drug over
itraconazole and currently we do not recommend it for
the treatment of dermatophytosis.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Terbinane
Terbinane (Lamisil
) is a fungicidal allylamine useful

in the treatment of supercial dermatophytosis and
onychomycosis in humans. There is little data on the
use of terbinane in cats and this drug appears to offer
no advantages over itraconazole. Preliminary studies
indicate that a dose of 30-40 mg/kg/day is the most
efcacious in the cat.
Terbinane is generally well tolerated; reported
adverse effects include vomiting and asymptomatic
elevation in liver enzymes. Idiosyncratic acute
hepatotoxicity has been reported occasionally. No
teratogenicity has been reported. The drug reaches
very high concentrations in sebum and stratum
corneum and fungicidal concentrations persist in the
skin for several weeks after administration in humans.
Environmental treatment
The critical role of environmental disinfection in
eradication of M. canis from an endemic cattery or
household cannot be overemphasised. Environmental
contamination with M. canis spores is widespread,
difcult to eliminate and routinely transported by the
fur of uninfected cats. Such contamination is a major
reservoir for recurrence of infection. M. canis spores
remain viable in the environment for up to 18 months.
Studies using isolated infected hairs or spores or
eld studies using dermatophyte-contaminated
environments have shown that the following
disinfectant products are consistently effective: lime
sulphur (1:33), enilconazole (0.2%), and 1:10 to 1:100
household bleach (10 mL/L). In addition, a study
has also shown that strain variation of M. canis with
respect to susceptibility to disinfectants is not present.
For treatment of routine infections with one or a few
animals in the household, extensive environmental
decontamination is generally impractical and
unnecessary. Thorough vacuuming and mechanical
cleaning will remove infective material. All hard
surfaces should be mopped with 1:100 bleach solution.
During treatment these few animals should be
conned to a small easily cleaned room without
carpeting until they have received systemic
antifungal therapy for at least two weeks and
have been dipped at least four times with topical
preparations. All bedding, brushes, combs, rugs,
cages, carriers can be washed daily in hot water,
detergent and a 1:10 dilution of household bleach.
Carpeted areas are problematic because of the lack
of effective disinfectant that preserves carpeting.
Frequent vacuuming on a daily basis or steam cleaning
mechanically removes many but not all spores. Steam
cleaning may not be a reliable method of killing
M. canis unless an antifungal disinfectant such as
chlorhexidine or sodium hypochlorite is added to
the water. Draperies should be dry cleaned and not
replaced until the infection is eradicated.
Length of treatment
Cats or dogs with dermatophytosis should be treated
until complete resolution of clinical signs (clinical
cure) and then continued until the fungus cannot be
cultured from the hair coat on at least two sequential
cultures a week or more apart (mycologic cure)
Weekly fungal cultures should be started after the
cat has received 4-6 weeks of therapy and thereafter
on a 2 week schedule. Once the culture results are
negative, monitoring can be done on a once weekly
basis. Cats appear healthy before their skin and hair
are cleared of fungal organisms.
It is not always possible or practical however to
re-culture every patient. In otherwise healthy cats,
systemic and topical treatments should generally be
continued for 6-10 weeks, preferably until 2 weeks
after clinical resolution.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T

Signicant duration: 6-10 weeks; treat until two successive negative fungal cultures obtained one week apart or
14 days beyond a clinical cure.
Key references:
1. Moriello KA, Vet Derm 2004; 15(2): 99-110
2. Bond R, Clin Dermatol 2010; 28(2): 226-236
AIDAP TOP TIPS
Our treatment recommendations for dermatophytosis for cats:
2% miconazole, 2% chlorhexidine shampoo baths twice a week
0.2% enilconazole (Imaverol
) rinse twice a week (not registered for use in cats)

Itraconazole 5 mg/kg q24h 7d, 7d break and repeat pulse for 3 treatment cycles OR
Griseofulvin 25 mg/kg q12h
Environmental decontamination.
ANTIFUNGAL AGENTS USED
First line:
Itraconazole 5 mg/kg q24h
7d, 7d break and repeat

pulse for 3 treatment cycles.
Second line:
Griseofulvin 25 mg/kg q12h, but monitor for
BM suppression in cats.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
M. canis infection on preauricular skin showing mild infammation. M. canis infection of pinnal tip producing alopecia with minimal
skin changes.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Fungal hyphae on surface cytology.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
Key references:
Positive colour change on DTM agar.
NB: a positive test is the characteristic red colour change that enlarges progressively in line with colony growth.
Dermatophyte lesions dt M. canis affecting a child. Photo courtesy of Dr Richard Malik.
SPECIES: CAT
SPECIES: CAT 141 SECTION: AURAL
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
The normal ora is generally
Gram-positive, with higher
bacterial counts retrieved from
the vertical external ear canal
than the horizontal ear canal.
Commensal and pathogenic
bacteria rapidly colonise the
external ear canal where changes
in the microclimate subsequent
to inammation modify the
environment. The microbial
proliferation exacerbates and
perpetuates the inammatory
response within the ear canal.
Once inamed, there is a shift
towards increased bacterial
numbers, initially coagulase
positive staphylococci and with
more chronic inammation,
Gram-negative bacteria.
Because potential pathogens
can be recovered in the absence
of disease (as they can from the
skin surface), it is assumed that
they are unable to initiate disease
in the ear.
However, once the ear becomes
inamed or macerated,
proliferation may occur and it is
for this reason that bacteria are
considered secondary rather than
primary or predisposing factors
in otitis externa.
In cats, Staphylococcus
pseudintermedius and
Pasteurella multocida are
commonly isolated from
otitis externa cases.
Malassezia are relatively more
important and have been found
in more than 95% of cases of
otitis externa.
ORGANISMS INVOLVED
Otitis externa is a
relatively common
disease with 2-6.5%
of cats affected.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
In many cases of otitis, a single organism can be
isolated on bacterial culture of exudate, but in
others, multiple potentially pathogenic organisms are
identied. Thus it is of critical importance to combine
cytological examination of the otic discharge when
a C+S test is performed. This allows determination
of the dominant population of bacteria evident,
the presence of leukocytes, and the presence of
phagocytosed bacteria.
Cytology is the rst step. It is mandatory in ALL cases
of otitis externa and should be repeated at each visit.
Normal cerumen does not have high stain uptake
because of the high lipid content. Outlines of occasional
squames may be seen. Inammation leads to increased
numbers of squames (some of which may be nucleated
indicting faster epithelial turnover with incomplete
keratinisation before desquamation). As the severity of
inammation increases inammatory cells may be seen
along with increasing numbers of organisms. Higher
cellular content of cerumen may also be appreciated
by increasing stain uptake on the stained slide (before
microscopic examination is even started).
The number of organisms and inammation should
be assessed on a 1-4+ scale. Normal ears may have
a few yeast and Gram-positive cocci per oil eld
but not rods. The nding of yeast or cocci should
be correlated with the ndings of the otoscopic
examination. Some animals may have few organisms
yet show marked inammation and exudation,
whilst others seem to be able to tolerate quite
large numbers without any pathologic changes.
Repeating the cytology at each revisit allows accurate
assessment of response to therapy. Medical treatment
should continue until otoscopic and cytologic
examinations demonstrate no pathologic change.
KEY STEPS
Otic examination alone is not sufcient and
the following minimum database is necessary
in order to identify both the nature and type of
the otitis as well as any underlying primary or
predisposing factors.
01
Thorough dermatological history.
02
Complete physical examination
of all areas of integument.
03
Thorough otic examination
(cats in particular may require
sedation/anaesthesia).
04
Collect otic cytology.
05
Implement topical antimicrobial
therapy on the basis of
cytological ndings.
06
Systemic antibiotic therapy is
not indicated for otitis externa.
TESTS FOR DIAGNOSIS
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
TREATMENT
Topical therapy is the key to successful resolution
of the majority of cases of otitis externa which is
essentially a surface infection. Essential to this
therapy though is the successful removal of exudate.
If the medication cannot penetrate the full length
of the ear canal, then treatment is likely to fail. The
choice of appropriate active ingredients and vehicles
for treatment of otitis externa is usually made
empirically based on cytological examination of ear
canal exudates and otoscopic examination of the
inamed ear canals.
Most commercially produced topical products contain
one or more active antibacterial, antifungal and anti-
inammatory agents in various combinations as well
as vehicle and various solubilisers, stabilisers and
surfactants.
Clients may need to be shown how to administer
medications correctly. Failure to do this is a
signicant cause for treatment failure. An adequate
volume of medication must be delivered to line the
entire canal. Getting clients to count drops increases
the time for administration and fundamentally means
that the nozzle of the bottle is not in the canal,
reducing penetration of the medication. Putting
the nozzle of the bottle in the canal and telling
clients to use a squeeze means that both under
and overdosing are risked because the amount to
medication is not measured out. We use the Terumo
brand of syringe to most accurately measure ear
medications and dispense them into the ear canal.
A broad guideline depending on the length
and diameter of the ear canal would be:
0.15-0.2 mL for a cat.
Twice daily dosing may require slightly
smaller volumes to avoid overdosing.
It is important to remember that the bulla of cats
it divided by an incomplete bony septum. This
septum is rooved by a sympathetic nerve plexus
that can be easily damaged causing Horners
syndrome. Therefore, products should be used
with caution if the tympanum is ruptured.
Duration of therapy
For acute disease a minimum of 5 to 14 days therapy
depending on the degree of inammatory change
(oedema, hyperplasia, and erosion, ulceration) is to
be expected. Rechecks every one to two weeks are
necessary to ensure that ears are cytologically and
otoscopically resolved prior to cessation of therapy.
It is not uncommon to have a cat clinically resolved
with otoscopically normal ears because of anti-
inammatory medications, where cytology is still
not normal.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
cocci on cytology
Coccoid organisms will be Staphylococcus spp. or
Streptococcus spp. The challenge for empirical
therapy for cocci is the relative resistance of
streptococci to some of the routine antibiotics,
which otherwise tend to have reasonable activity for
most Staphylococci spp. For this reason products
containing antibiotics with good efcacy against both
bacteria are desirable. For this reason, Canaural
is
useful if the TM is intact because of the framycetin
and fusidic acid. Other reasonable choices would be
Otomax
or Mometamax
where both the gentamicin

and clotrimazole have anti-coccal activity. Remember
that gentamicin is degraded by organic debris and
purulent exudate so the ear must be clean and
inammation well controlled for best effect and that
gentamicin is not middle ear safe, at least not in
commercial preparations.
When the TM is ruptured, enrooxacin is the only
real choice although its activity against streptococcal
infections is not always reliable. If this is inadequate,
then consider the use of systemic antibiotics based
on culture and sensitivity.
Systemic antibiotics are used if there is signicant
involvement of the pinna, if a methicillin resistant
Staphylococcal infection is identied on culture
and sensitivity or if otitis media is evident.
They are unreliable in our experience used as
a sole therapy of otitis externa.
rods on cytology
Rods are rarely found in healthy ears. In Australia,
the majority of rods identied on culture are
Pseudomonas aeruginosa with Proteus and E. coli
both identied at about 11% to 20% of the otitis ears.
Other less common rods include Corynebacterium
spp. and Klebsiella. While Corynebacterium is not
uncommonly found on culture from ears with otitis
it is usually found as part of a mixed culture and is
probably of minimal signicance unless isolated in
pure growth.
Tris-EDTA acts as a chelating agent and enhances
activity of topical antibiotics against otic pathogens
by decreasing stability and increasing permeability of
the cell wall. The ear canal should be lled with the
solution 15 to 30 min before the topical antibiotic is
applied every 12 hours. First line antibiotic therapy
includes enrooxacin (compounded enrooxacin
1.5% with dexamethasone and once the tympanic
membrane is intact and the inammation controlled
then products containing gentamicin Otomax
q
12hrs and Mometamax
q 24hrs as long as the ear

is clean. Culture and sensitivity testing is indicated if
the infection fails to respond. Timentin
6% q 12hrs
or ciprooxacin can be used topically as a second-
line antibiotic. Systemic antibiotics are only used
if there is signicant involvement of the pinna or if
otitis media is evident. They are unreliable in our
experience used as a sole therapy of otitis externa.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
yeast on cytology
Malassezia can be retrieved from up to 95% of
otitis ears. In some cases, the inammation seen
is disproportionately large compared with the
number of organisms seen on cytology.
Disinfectants are useful as sole therapy where there
are low numbers of yeast and minimal inammation
or occasionally in cases apparently resistant to
other antifungal ear medications. The only two with
any proven efcacy against Malassezia are Epiotic

and Malacetic Otic
. Neither are particularly good

ceruminolytics so penetration is an issue where
there is signicant exudate. Alpha Ear Cleaner

(Troy) has good activity against yeast and is a good
ceruminolytic. None of these products are middle
ear safe.
Most of the major commercial combination ear
products (except Baytril Otic
) are reliable in the

therapy of an uncomplicated yeast otitis. Surolan

q 12hrs, Otomax
q 12hrs, Mometamax
q 24hrs
containing miconazole and clotrimazole are both
useful rst line treatment. In cases of product
failure, both clotrimazole and miconazole resistance
has been reported and in these instances nystatin
(Canaural
) has proven useful. None of these

products are middle ear safe.
Systemic use of antifungal medication is a
consideration where there is a fungal otitis media
and for sole or adjunctive therapy where topical
medications are not possible or there are severe
proliferative changes in the ear canal.
Secondary changes are sequelae that occur due to
acute and chronic inammation of the external ear
canal that when present will increase the likelihood
of relapse of otitis externa irrespective of whether
the trigger factor has been controlled. Sequelae
secondary to otitis externa include epidermal or
glandular hyperplasia, inammatory polyps, brosis,
stenosis, calcication, ceruminoliths, otitis media and
complete occlusion of the external ear canals.
SPECIES: CAT
S
O
F
T

T
I
S
S
U
E
O
R
A
L
U
R
T
L
R
T
U
R
I
N
A
R
Y

T
R
A
C
T
P
Y
R
E
X
I
A
A
B
D
O
M
I
N
A
L
D
E
S
E
X
I
N
G
D
E
N
T
A
L
S
K
I
N
/
S
O
F
T

T
I
S
S
U
E
A
U
R
A
L
D
O
G

C
O
N
T
E
N
T
AIDAP TOP TIPS
Bacterial C+S testing
The commonly accepted practice is that a
bacterial C+S testing should be performed if:
rods are seen on cytology
ulceration of the epithelium is present
the condition is recurrent
there is no response to appropriate treatment
otitis media is present.
However there have been several recent studies
raising doubts as to the usefulness and accuracy of
culture results (Graham-Minze and Rosser 2004).
It has been suggested that the culture may identify
organisms from the external ear canal that are low in
number and possibly irrelevant in the pathogenesis
of the disease state. As such the initial cytology may
be a better indicator of the relative importance of the
different organisms present.
Robson (2008) has proposed the following:
That bacterial C+S testing should be performed when
cytology shows a uniform or near uniform pattern of
bacteria AND when appropriate empirical therapy has
failed AND all other causes of failure of therapy have
been ruled out as well as causes of otitis media.
Sample on right showing marked stain uptake due to
presence of neutrophils.
Photo courtesy of Dr Mandy Burrows & Dr Mike Shipstone.
Key references:
1. Sharma VD and Rhodes HE. J. Sm An Pract 1975; 156: 241-247
2. McCarthy G and Kelly WR. Irish V J 1983; 36: 53-56
3. Colombini S, Merchant SR, Hosgood G. Vet Dermatol 2000; 196: 84-90
4. Graham-Minze CA and Rosser EJ J. Am An Hosp Assoc 2004; 40(2): 102108
Copyright 2013 Zoetis Inc. All rights reserved.
Zoetis Australia Pty Ltd. ABN 94 156 476 425. 38-42 Wharf Road, West Ryde NSW 2114. www.zoetis.com.au AM56255 JUNE 2013
AI AIDDAP AP
DISEASES ADVISORY PANEL
Zoetis would like to thank the dedicated members of AIDAP for all their hard work and contribution towards
these guidelines. AIDAP, the Australasian Infectious Diseases Advisory Panel, is a committee of Specialists
with fields in Internal Medicine, Feline Medicine, Dermatology and Microbiology. The panel works together
with Zoetis to assist with the ongoing understanding of the nature of infectious diseases; the understanding
of how to treat infectious diseases; and also the current rationale for the appropriate use of antibiotics.
Please note, these recommendations are based entirely on the decisions made by the AIDAP
committee, and some of these recommendations include the "off-label" use of certain medications.
These off-label uses are not endorsed by Zoetis.
For more information please visit www.vetsaustralia.com.au.
ANTIBIOTIC
PRESCRIBING
GUIDELINES
ANTIBIOTIC
PRESCRIBING
DETAILED GUIDELINES

AIDAP Prescribing Guidelines

Uploaded by

Copyright:

Available Formats

AIDAP Prescribing Guidelines

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

AIDAP Prescribing Guidelines

Uploaded by

Copyright:

Available Formats

What are the credentials and backgrounds of the panel members mentioned in the document?

What are the credentials and backgrounds of the panel members mentioned in the document?

What is the purpose of the Australasian Infectious Diseases Advisory Panel (AIDAP)?

What is the purpose of the Australasian Infectious Diseases Advisory Panel (AIDAP)?

ANTIBIOTIC

= not registered for animal use

] for 1-2 weeks, or longer, depending on response to therapy.

) or amoxicillin (10-20 mg/kg q6h

) or cefazolin (22 mg/kg IV q8h

) is bactericidal within 48 hours for most Gram-positive cocci.

) and moxioxacin (5 mg/kg q12h

(compounded) for M. smegmatis

) and moxioxacin (5 mg/kg q12h

) for other rapidly

compounded), amikacin (10-15 mg/kg q24h

) shampoo has been studied in

) is receiving some recent

) rinse twice a week (not registered for use in cats)

7d, 7d break and repeat

) spray, lotion, cream for spot

; dog only) or itraconazole (5 mg/kg q24h

; dog [and cat]).

5-10 mg/kg q12h PO for 21-28 days.

5 mg/kg q12h PO or 10 mg/kg q24h PO for 2128 days.

where both the gentamicin

q 24hrs as long as the ear

. Neither are particularly good

) are reliable in the

) has proven useful. None of these

) or an aminopenicillin (e.g. ampicillin

) or amoxicillin (10-20 mg/kg IV q12hrs

) either alone or in combination with

, then 2.5 mg/kg q24h

) is a good second choice,

) or cefazolin (22 mg/kg IV q8h

) and moxioxacin (5 mg/kg q12h

(compounded) for M. smegmatis complex infections;

) and moxioxacin (5 mg/kg q12h

) for other rapidly growing mycobacteria.

compounded), amikacin (10-15 mg/kg q24h

) shampoo has been studied in

) is receiving some recent

) is a fungicidal allylamine useful

) rinse twice a week (not registered for use in cats)

7d, 7d break and repeat

where both the gentamicin

q 24hrs as long as the ear

. Neither are particularly good

) are reliable in the

) has proven useful. None of these

You might also like