Recording antimicrobial treatments creates comprehensive documentation supporting responsible stewardship, food safety, regulatory compliance, and practice improvement. Every antimicrobial administration (whether to individual animals or groups) should be documented with sufficient detail. This demonstrates responsible use and supports future decisions.

This chapter explains what information to record, how antimicrobial records integrate with existing treatment documentation, and why each element matters.

When to Record Antimicrobial Use

Individual Animal Treatments: Record use when administering antibiotics or related medications to specific animals. Includes injectable antibiotics, oral medications, topical treatments, intramammary infusions for mastitis, other antimicrobial products.

Animal Mob (Group) Treatments: Record use when treating groups through medicated feed, medicated water, mass injections, other group methods. Document number of animals treated, average weight, total quantities used.

Planned Treatment Courses: Record even scheduled treatments that are part of multi-day plans. Document each administration or complete course with planned duration and actual completion tracking.

Supervised Treatments: Community animal health workers, farm staff, or conservation field teams administering under veterinary supervision should record treatments. Include clear attribution to prescribing veterinarian and clinical justification.

Essential Information to Record

Product Identification

Product Name: Commercial name as it appears on packaging. Identifies specific formulation, strength, manufacturer for reviewing treatment history or investigating adverse reactions.

Active Ingredient: Primary antimicrobial compound (e.g., "Penicillin G," "Oxytetracycline," "Enrofloxacin"). Essential for tracking usage patterns, identifying resistance issues, avoiding repeated use of same antimicrobial family.

Manufacturer: Company that produced the product. Supports traceability, batch tracking for adverse reactions, communication with manufacturers.

Additional Active Ingredients: If product contains multiple antimicrobial compounds or combines antimicrobials with other medications, record all active ingredients. Ensures complete understanding of what was administered.

Dosage Information

Dose Amount and Unit: Quantity administered (e.g., "5 mL," "10 mg/kg," "2 tablets"). Precise dosing supports usage verification. Helps identify under-dosing or over-dosing contributing to treatment failure or resistance.

Dose Per Kilogram Body Weight: For weight-based dosing, record dose per kilogram with animal's weight. Allows dosing verification. Supports future dose calculations for similar cases.

Route of Administration: How antimicrobial was given (Oral, Intramuscular, Intravenous, Subcutaneous, Topical, InFeed, InWater, Intramammary, Intrauterine, Inhalation, Other). Route affects medication speed, duration, withdrawal period requirements.

Doses Per Day: How many times daily antimicrobial should be administered (e.g., "twice daily," "every 8 hours"). Critical for treatment completion tracking and ensuring effective blood levels.

Treatment Duration

Planned Duration: Days the antimicrobial should be administered as prescribed by veterinarian or product label. Establishes baseline for measuring completion.

Actual Duration: Days the antimicrobial was actually administered. If stopped early, extended, or modified, record actual duration to track completion rates and identify patterns.

Treatment Start and End Dates: Specific dates when treatment began and ended (or is planned to end). Support withdrawal period calculations, timeline documentation, chronological health history.

Clinical Justification

Clinical Indication: Reason for using antimicrobial. What condition or illness you're treating. Be specific: "Respiratory infection with fever and nasal discharge" is better than "sick animal." Clear indications support responsible use. Distinguish therapeutic treatment from preventive use.

Clinical Signs Observed: Symptoms or physical findings leading to antimicrobial decision (fever, reduced appetite, discharge, swelling, lameness, behavioural changes). Provides context for treatment decisions and outcome assessment.

Diagnosis Code and Description: If formal diagnosis was made by veterinarian, record standardised diagnosis codes (if used in your region) and diagnosis description. Supports integration with veterinary health information systems and regulatory reporting.

Diagnostic Support

Diagnostic Test Performed: Whether tests were conducted before starting treatment (Clinical Examination, Bacteriology, Virology, Parasitology, Serology, PCR, Rapid Test, Imaging, Necropsy, Other). Diagnostic testing supports appropriate antimicrobial selection and is key stewardship indicator.

Culture and Sensitivity Testing: Whether bacterial culture was performed and sensitivity testing conducted. Identifies which antimicrobials the pathogen is susceptible to. Culture-guided therapy ensures chosen antimicrobial will be effective against specific bacteria causing infection.

Identified Pathogen: If diagnostic testing identified specific bacterium, virus, or pathogen, record organism's name (e.g., "Staphylococcus aureus," "Mannheimia haemolytica"). Supports resistance pattern monitoring and protocol refinement.

Sensitivity Profile: For culture and sensitivity testing, record which antimicrobials pathogen was sensitive to, intermediate, or resistant against. Guides treatment selection. Contributes to resistance surveillance.

Diagnostic Test Results: Summary of diagnostic findings including test values, imaging findings, or examination results supporting antimicrobial treatment decision.

Prescription Details

Prescription Type: Purpose of antimicrobial treatment (Therapeutic: treating diagnosed infection in sick animals; Metaphylactic: treating at-risk animals in group where some are sick; Prophylactic: preventing infection before it occurs; Growth Promotion: using antimicrobials to enhance growth, illegal or discouraged in many regions). Most use should be therapeutic. Preventive use requires careful justification and veterinary oversight.

First-Line Choice: Whether this antimicrobial is recommended first treatment option for this condition. First-line antimicrobials are proven effective, have narrower spectrums, less likely to contribute to resistance compared to broad-spectrum or reserve antimicrobials.

Reason for Selection: If not using first-line antimicrobial, document why this medication was chosen. Reasons might include culture sensitivity results, previous treatment failure, product availability, specific clinical factors.

Alternatives Considered: What other antimicrobials were considered before choosing this one. Documenting alternatives shows thoughtful decision-making. Supports stewardship audits.

Veterinary Involvement

Prescribing Veterinarian: Name of licensed veterinarian who prescribed antimicrobial or provided clinical justification. Some antimicrobials require veterinary prescription by law. All use should ideally be veterinary-guided.

Veterinarian Licence Number: Prescribing veterinarian's professional licence number. Supports regulatory compliance and traceability when required by authorities.

Quantity and Metrics

Total Quantity Used: Total amount of antimicrobial product used for treatment or course. For individual animals, total millilitres or tablets. For mob treatments, total quantity administered to entire group.

Animal Weight: For individual animals, body weight at time of treatment. Allows dosing verification. Supports future dose calculations.

Number of Animals Treated: For mob treatments, how many animals received antimicrobial. Essential for calculating per-animal usage metrics and assessing treatment scope.

Average Animal Weight: For mob treatments, average body weight of treated animals. Allows dosage verification when treating groups with varied sizes.

Cost Tracking

Cost Per Unit: Price paid for each unit of antimicrobial product (per millilitre, per tablet, per dose). Supports treatment economics analysis and inventory management.

Total Treatment Cost: Complete cost including product cost, administration costs, associated testing or consultation fees. Understanding economics helps optimise resource allocation.

Currency: Currency used for cost tracking (USD, EUR, KES, AUD, etc.). Supports international operations and multi-currency reporting.

Treatment Outcome

Treatment Outcome: Result of antimicrobial treatment (Successful: animal recovered fully; Partial Response: some improvement but incomplete resolution; Failed: no improvement or worsening; Animal Died; Animal Euthanised; Ongoing; Treatment Discontinued; Unknown). Tracking outcomes identifies resistance patterns, refines protocols, supports evidence-based decisions.

Outcome Assessment Date: When treatment outcome was evaluated. Distinguishes immediate response from longer-term resolution. Supports outcome data quality.

Required Treatment Modification: Whether treatment needed to be changed (switching antimicrobials, adjusting dose, extending duration, adding medications). Frequent modifications might indicate resistance issues or inappropriate initial selection.

Modification Reason: Why treatment was modified (lack of response, adverse reaction, diagnostic findings, cost considerations, product availability, other factors).

Safety and Compliance

Off-Label Use: Whether antimicrobial was used in way not specified on approved product label (different species, indication, dose, route). Off-label use may be medically necessary but requires clear justification and veterinary oversight.

Off-Label Justification: If using off-label, document clinical reasoning. Might include lack of approved alternatives, specific clinical circumstances, established veterinary protocols for this use.

Withdrawal Period: Days required between last antimicrobial dose and when animal products (meat, milk, eggs) can safely enter food chain. Ensures antimicrobial residues are eliminated to safe levels.

Withdrawal End Date: Specific date when withdrawal period ends and products can be safely consumed or sold. Kora calculates this automatically based on treatment end date and withdrawal period.

Adverse Reactions: Whether animal experienced adverse reactions to antimicrobial (allergic reactions, injection site reactions, gastrointestinal upset, neurological symptoms, other unexpected effects).

Adverse Reaction Details: Description of any adverse reactions including severity, timing, duration, interventions required. Supports product safety monitoring. Informs future treatment decisions.

Linking to Existing Treatments

Antimicrobial use records link to existing treatment records in Treatment Administration system (Chapter 10.2). Benefits include:

Unified Medical History: All treatment information (basic details, stewardship data, observations, outcomes) connected in one comprehensive medical record for the animal.

Simplified Workflow: Create both basic treatment record and detailed antimicrobial stewardship record in one workflow. Reduces duplicate data entry.

Cross-Reference: Navigate between basic treatment details and comprehensive antimicrobial documentation. Supports different detail levels for different purposes (daily operations vs. regulatory compliance).

Treatment Plans: Antimicrobial records associate with treatment plans for scheduled medication courses. Ensures all planned administrations are documented and tracked.

Data Quality and Completeness

Kora tracks data completeness using three levels:

Basic Completeness: Minimum required information (product name, active ingredient, dose, duration, clinical indication). Supports basic tracking and food safety compliance.

Moderate Completeness: Basic information plus diagnostic details, veterinary involvement, outcome tracking. Supports stewardship monitoring and quality improvement initiatives.

Complete Documentation: All relevant fields populated including diagnostic test results, culture sensitivity data, alternatives considered, detailed clinical signs, comprehensive outcome assessment. Supports regulatory compliance, research, comprehensive stewardship programmes.

Higher completeness provides better data for improving practices, demonstrating responsible use, supporting regulatory or certification requirements.

Record-Keeping Best Practices

Timeliness: Record antimicrobial use immediately after administration. Delayed recording increases risk of missing treatments, forgetting details, incorrect recording.

Accuracy: Verify product names, dosages, dates are correct. Inaccurate records can lead to improper withdrawal period calculations, incorrect stewardship metrics, compliance issues.

Completeness: Record as much relevant information as practical. More complete records provide better insights and support continuous improvement, even if not all fields required.

Consistency: Develop consistent practices for recording information (same terminology, detail level, workflow). Consistency improves data quality. Makes trend analysis more reliable.

Verification: When possible, have someone else verify critical information like withdrawal periods and dosages, especially for food-producing animals. Verification reduces errors affecting food safety.

Notes and Additional Information

The notes field provides space for additional context:

• Special circumstances surrounding treatment
• Communication with veterinarians or animal health workers
• Environmental factors affecting treatment effectiveness
• Follow-up plans or recommendations
• Lessons learned for future similar cases
• Reference to photographs, lab reports, or external documentation

Well-documented notes provide valuable context for future review. Support organisational learning over time.