Controversies in the prevention and control of antimicrobial drug resistance.

In Hospitals William Jarvis, Centers for Disease Control and Prevention (CDC), discussed antimicrobial resistance related to hospitalization. Two major factors contribute to the emergence and spread of antimicrobial resistance in hospitals: a high rate of antimicrobial drug use and inadequate infection control practices. Much antimicrobial drug use in hospitals is inappropriate (e.g., the use of vancomycin to treat a staphylococcal infection susceptible to methicillin, or the continuation of perioperative prophylaxis beyond 24 to 48 hours). Educational efforts on antimicrobial drug use in hospitals have had mixed success. More aggressive and controversial approaches to improve the use of these drugs have been proposed; for example, excluding certain drugs (such as vancomycin) from the routine reporting of susceptibility results; monitoring antimicrobial use with feedback to physicians concerning inappropriate use; antibiotic-use audits targeting problem areas (e.g., no diagnostic test done, more than four drugs used during one hospitalization, use for more than 3 weeks continuously); regulating drug promotion; requiring justifications for use; using computergenerated stop orders; and developing formularies, restrictions, and protocols by a multidisciplinary team.