Between January 2014 and July 2021, cephalexin represented more than a third of all the units sold in veterinary prescriptions, followed by amoxicillin. Furthermore, the sales of all antimicrobials have remarkably increased during this period, especially azithromycin (212.9%) and metronidazole (137.6%).
The average monthly sales of commercial units of azithromycin in pharmacies in Brazil, prescribed by veterinarians, increased from March 2020. This was when the first cases of COVID-19 appeared in Brazil and the search for treatments that could treat or lessen the effects of the new disease was sought after, which included the use of azithromycin. Regression analysis showed that the sale of azithromycin grew by 0.67% per month since May 2014. This growth trend remained stable until March 2020, when it began to grow at 12.64% per month.
Another fact that draws attention to the rapid growth in the sales of azithromycin in the treatment of animals is the share of this drug in the total number of antibiotics sold in veterinary medicine during the study period. The sales of azithromycin between 2014 and 2019 represented, on average, 4.6% of the sales of all antibiotics prescribed by veterinarians, this percentage being 6.72% and 8.2%, in the years 2020 and 2021, respectively.
An assessment of the use of antibiotics in cats in Switzerland showed that together, azithromycin, lincosamides, amphenicols, and nitroimidazoles accounted for less than 2% of all prescriptions for cats in the country between 2016 and 2018 (Hubbuch, Schmitt et al. 2020). Similarly, another study in Switzerland evaluated the prescription profile of antibiotics intended for animals. In that study, the entire macrolide group represented only 1.5% of the prescriptions for dogs and 0.1% for cats (Regula, Torriani et al. 2009). In the present study, azithromycin represented 8.2% of the prescriptions in 2021, which is five times greater than that in the aforementioned study. (Regula, Torriani et al. 2009).
A working group formed by professors from American universities, and supported by the International Society for Companion Animal Infectious Diseases, published important guidelines on the use of antibiotics in animals. The guidelines note that, for the treatment of feline ocular chlamydiosis, azithromycin should only be used if other treatments with tetracyclines or penicillin are not effective. Likewise, the guidelines state a lack of evidence to guide the use of azithromycin in the treatment of suspected bacterial pneumonia (Lappin, Blondeau et al. 2017). Allerton et al. (2021) stated that macrolides should be of restricted use in veterinary practice and not of the first choice, and their prescription should be conditioned to the results of sensitivity or antibiogram tests (Allerton, Prior et al. 2021).
Azithromycin is an antimicrobial agent with important effect on exclusive organelles of protozoa, such as Babesia spp. and Toxoplasma gondii, which are important and common parasites in veterinary routine. The efficacy of treating babesiosis with azithromycin alone or in combination has already been demonstrated in dogs infected with different Babesia species (Jefferies, Ryan et al. 2007, Baneth 2018). However, the drug is not the main indication for the treatment of the disease caused by Babesia vogeli detected in Brazil (Checa, Montoya et al. 2017). Animals are usually asymptomatic to T. gondii infection, and dogs in particular, rarely suffer from toxoplasmosis as a primary disease. In these cases, they do not require treatment with antiprotozoal drugs such as azithromycin (Calero-Bernal and Gennari 2019). Therefore, the indication for the use of azithromycin in the treatment of animal diseases is limited, and there is no public knowledge of any outbreak of infectious diseases that require the use of azithromycin in animals during the pandemic which justifies the sudden and abrupt increase in the number of antibiotics sold.
The increase in azithromycin consumption during the pandemic is not an event that only occurred in the veterinary field. In the field of human medicine, other studies have also found increased consumption of antibiotics during the pandemic. In some cases, consumption has increased by up to two-fold (Castro-Lopes and Correia 2021, Grau and Hernández 2021, Sulis and Batomen 2021). Sulis and Batomen (2021) (Sulis and Batomen 2021) reported the increase in azithromycin use in India during the pandemic, jumping from 26.4 million to 49.2 million doses, an increase of 53%, justifying its use as a possible treatment for COVID-19. In March 2021, data from the American Veterinary Medical Association showed that only 115 cats and 81 dogs worldwide were infected by SARS-CoV-2 (AVMA 2022). However, Manzini et al. (2021) (Manzini, Rodrigues et al. 2021) pointed out that most domestic animals that tested positive for COVID-19, manifesting mild clinical signs or remaining asymptomatic, do not play a role in the transmission of the disease; therefore, antibiotic therapy is of questionable indication.
A point worth mentioning is the prescription of antibiotics by veterinarians, which indicates commercial preparations intended for humans. Options in the veterinary drug market are restricted and expensive compared to human drugs, whose preparations, in most of the cases, are also suitable for the treatment of pets.
The use of drugs by humans prescribed for animals is not a new problem, as well as the administration of human drugs to animals without veterinary guidance. In 2002, in the United States, 1,077 veterinarians answered a questionnaire about their perceptions of the use of medicines intended for animals but used in humans. The question was, “What percent of your clients, whose animals you treat, do you suspect misuse of veterinary medications in themselves, their children, or friends?” Responses showed that, on average, 23% could use prescription drugs in humans and 39% could be using over-the-counter veterinary medications. This study also showed that the most used classes by humans were anti-inflammatory and analgesics, followed by antibiotics (Erramouspe, Adamcik et al. 2002).
The exaggerated and extensive use of certain antibiotics, such as azithromycin, will, as is already known, exert great selective pressure on the local microbiome, favoring the emergence of multi-resistant microbial specimens such as non-typhoidal Salmonella strains (Hooda, Tanmoy et al. 2020) and Enterobacteriaceae (Babu, Kumar et al. 2016). This excessive and unnecessary use must be discouraged to fight and prevent the emergence of antibiotic-resistant bacteria.