Two Professions, One Drug Cabinet: The Antimicrobial Accountability Gap

In 2023, most over-the-counter medically important antibiotics for animals — including many injectables — became prescription-only, closing the latest loophole in a three-decade regulatory chain that binds food animal veterinarians. Small animal practitioners, by contrast, still prescribe the same drug classes multiple times a day with no records audit, no oversight, and, one veterinarian argues, an economic incentive to over-prescribe.

Patty Khuly, VMD, MBA, sold her small animal practice in Miami and now splits her time between companion animal work in Miami, Fla., relief work in Charlottesville, Va., and Crossroads Farm, a commercial goat dairy and beef cattle operation in North Garden, Va. Writing from both sides of the divide, she describes the contrast as "a professional wake-up call."

What shaped food animal accountability?

Khuly traces four regulatory milestones that made antimicrobial stewardship part of the business of livestock production:

• 1994: Congress passed AMDUCA, the Animal Medicinal Use Clarification Act, legalizing certain extra-label drug uses while imposing safeguards for food animals. Veterinarians gained prescribing flexibility but assumed responsibility for preventing illegal residues through withdrawal intervals and treatment records.
• 1997: The FDA prohibited extra-label use of fluoroquinolones in food animals, citing the threat resistant bacteria posed to human health.
• 2017: Medically important antibiotics could no longer be used for growth promotion; administration in feed or water required intensive veterinary oversight under the Veterinary Feed Directive.
• 2023: Most over-the-counter medically important antibiotics, including many injectables, moved to prescription-only status.

The practical consequences, she writes, included more veterinary involvement, more paperwork, fewer unrestricted drug choices, and serious economic penalties when treated animals' milk had to be discarded, slaughter delayed, or carcasses condemned. Stewardship, in short, became a major source of liability for food animal veterinarians and reshaped the culture of an entire generation of practitioners.

What happens at the small animal clinic instead?

Back in companion animal practice, Khuly catalogues the reflexes: diarrhea gets metronidazole, clean surgical incisions leave with cephalexin, a cat with urinary signs may receive Convenia "just in case," and kennel cough receives its familiar prescription — despite, she notes, evidence that does not support these medications in the uncomplicated cases practitioners routinely encounter.

The drivers she identifies are concrete:

• Direct or indirect client pressure
• Fear of treatment failure or poor outcome
• The antibiotics' perceived anti-inflammatory or immunomodulating effect
• Therapeutic reflex — "I've always prescribed X antimicrobial because it works"

She adds an economic dimension. If a practitioner wants to make production, an extra $50 to $200 on the bill means an additional 18-22 percent of income, and she writes that most practice owners tacitly encourage over-prescription. Client cost concerns and expectations, she argues, influence antibiotic selection more than antimicrobial resistance does.

What does the evidence say about prescribing behavior?

A recent study on metronidazole use in small animal medicine backs her assessment. The research, published by Frey, Hatcher, Snavely and colleagues in the Journal of the American Veterinary Medical Association (2026;264(5):1-9; doi:10.2460/javma.25.10.0594), found that awareness of stewardship guidelines does not translate into lower metronidazole prescribing frequency. Newer graduates and academic veterinarians followed guidelines more closely, but the authors concluded that attitudes toward clinical risk and perceived social pressure carried more weight than guideline knowledge alone.

Khuly puts the finding bluntly: practitioners prescribe the drug even when they know they should not, conforming to the standards of the practices they work at and to clients' assumptions that antibiotics offer a universal solution.

Why does the divide persist?

Khuly is explicit that the gap is not a matter of character. Livestock veterinarians are not inherently more conscientious about antimicrobial resistance; their prescribing decisions are shaped by an external system that imposes serious consequences for misuse. Small animal veterinarians face none.

That asymmetry raises what she calls an uncomfortable question: how did the profession arrive at a place where veterinarians treating animals destined for the dinner table are held to one standard of antibiotic accountability, while those treating animals that sleep in clients' beds operate under another? No one checks small animal records, and she acknowledges the profession is incentivized to over-prescribe — a dynamic she says applied to a culture-pending UTI case in her own clinic 15 minutes before she wrote the piece.

Her proposed direction is regulatory rather than exhortative. She asks whether small animal antibiotic use should be controlled alongside scheduled drugs, whether records should be examined, and whether companion animal practitioners would resist such rules the way many food animal veterinarians once did. Livestock veterinarians adjusted to accountability, she writes, and companion animal practitioners would too — because One Health, in her framing, should carry real-world consequences rather than serve as an invoked buzzword.

Whether regulators, corporate practice owners — whom she expects would oppose new restrictions — or the profession itself move first remains the open question the article leaves for the exam table.