Antimicrobial use in hospital-acquired infections

The appropriate use of antibiotics in nosocomial infections has been a goal of infectious disease practitioners and hospital epidemiologists since the emergence of resistant staphylococci more than 30 years ago. This challenge has assumed new proportions in the 1980s for many reasons. First, resistant gram-positive and gram-negative bacteria are increasingly common. Thus many traditional drugs or combinations of drugs lack efficacy. Second, there are so many new antibiotics available that it is difficult for any but the most knowledgeable to use each of them appropriately. Third, economic reality has forced hospitals and physicians to alter their activities and focus more on cost considerations than was ever necessary before. Last, infectious disease as a subspecialty in internal medicine is profoundly different in the 1980s; many infections must be controlled for life rather than cured because of underlying infection with human immunodeficiency virus, which suppresses immunity. The use of antibiotics is now rapidly changing and the state of the art in 1989 is likely to be outdated very soon as new pathogens emerge and new drugs are developed. The appropriate use of the quinolones is a great challenge that we now face. Can we preserve this valuable class of drugs, or will resistance develop quickly because of widespread, indiscriminate, and inappropriate use? To what extent can we phase out aminoglycoside use without compromising efficacy and without promoting the development of resistance? Do the monobactams have a real role to play in combination therapy? How should formularies approach the diverse cephalosporins that now inundate the market? These are only a few of the fundamental questions that must be addressed as this decade ends.