Resistance in hospitals: implications for empiric choice of therapy

Although some organisms were resistant to antimicrobial agents before such compounds were introduced into clinical practice, it is only since this occurred that the breadth, depth and complexity of this problem has developed. The early acceleration in the production of antimicrobial substances was uniformly matched by the observation of correspondingly resistant organisms. This article reviews whether the presence of antimicrobial resistance in hospitals should have implications for the empiric choice of such therapy. It is shown that although not an absolute, antimicrobial usage is directly reflected in the presence and nature of resistance with both indirect and direct effects. These resistance patterns have been demonstrated to alter the clinical outcome surrounding sepsis care in hospital patients where the key feature is to actually initiate management with an appropriate agent. It is less clear from the available data whether the control of antimicrobials within hospitals can prospectively influence the sustained susceptibility of organisms to the agents being used. The need for locally determined programmes to respond to the threat of hospital antimicrobial resistance development is highlighted. Attention is drawn to the essential interaction between such schemes and related issues such as infection control and microbiological surveillance.