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INTRODUCTION

GUIDING QUESTIONS

  1. Are we at the end of the antibiotic era?

  2. Why are “superbugs” continuing to increase in our hospitals?

  3. How do bacteria become resistant to antibiotics?

  4. How can the continued selection of highly resistant organisms be prevented?

  5. Is antibiotic treatment always the wisest course of action?

  6. Does one antibiotic cure all infections?

  7. What are the strategies that underlie optimal antibiotic usage?

  8. How is colonization distinguished from infection, and why is this distinction important?

Despite dire warnings in the 1990s that we were approaching the end of the antibiotic era, the incidence of antibiotic-resistant bacteria has continued to rise. The proportions of penicillin-resistant and macrolide-resistant Streptococcus pneumoniae, hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA), and community-acquired S. aureus (cMRSA) as well as vancomycin-resistant enterococci (VRE) strains continue to steadily increase in many hospitals. Clostridium difficile colitis has reached epidemic proportions and multiresistant Acinetobacter and Pseudomonas are everyday realities in most of our hospitals. The pharmaceutical industry has been slow to develop new anti-infective agents to overcome these highly resistant bacteria, and when they have been successful, the prices charged for these new medications are consistently high. As never before, it is critical that health care providers understand the principles of proper anti-infective therapy and use anti-infective agents judiciously. These agents need to be reserved for treatable infections—not used to calm the patient or the patient’s family. Too often caregivers treat patients with antibiotics at the first sign of fever, and despite evidence suggesting a viral infection and negative bacterial cultures they continue this treatment for prolonged periods.

Physicians unschooled in the principles of microbiology utilize anti-infective agents just as they would prescribe other classes of medications, such as anti-inflammatory agents, antihypertensive medications, and cardiac drugs. They use one or two broad-spectrum antibiotics to treat all patients with suspected infections, and fail to consult an expert in infectious disease or utilize well-established guidelines to assist in the proper management of anti-infective therapy.

Many excellent broad-spectrum antibiotics can effectively treat most bacterial infections without requiring a specific causative diagnosis. However, overuse of empiric broad-spectrum antibiotics has resulted in the selection of highly resistant pathogens. A simplistic approach to anti-infective therapy and establishment of a fixed series of simple rules concerning the use of these agents is unwise and has proved harmful to patients. This approach ignores the remarkable adaptability of bacteria, fungi, and viruses. It is no coincidence that these more primitive life forms have survived for millions of years, far longer than the human race.

KEY POINTS ABOUT ANTI-INFECTIVE THERAPY

  1. Too often, antibiotics are prescribed to fulfill the patient’s expectations, rather than to treat a true bacterial infection.

  2. A single antibiotic cannot meet all infectious disease needs.

  3. Physicians ignore the remarkable adaptability of bacteria, fungi, and viruses at their patient’s peril.

  4. Anti-infective therapy is dynamic and requires a basic understanding of microbiology.

  5. The “shotgun” approach to infectious diseases must end, or we ...

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