Statement for debate

Introduction Antibiotic stewardship programs are multidisciplinary initiatives whose primary aim is to optimize antibiotic usage. Th e Infectious Disease Society of America (IDSA) and the Society for Health Care Epidemiology of America (SHEA) published guidelines for antimicrobial stewardship in 2007 aimed at providing information on how to establish such programs within health care institutions [1]. Because antibiotics are used heavily in the ICU, stewardship programs appear particularly applicable to this setting. Antimicrobial stewardship is broadly defi ned as a practice that ensures the optimal selection, dose and duration of antimicrobials and leads to the best clinical outcome for the treatment or prevention of infection while producing the fewest possible side eff ects and the lowest risk for subsequent resistance [2]. Antimicrobial stewardship programs may contain a variety of interventions that are complementary to eff ective infection prevention and control programs. Inappropriate antimicrobial usage is a signifi cant problem, with approximately 50% of antimicrobial usage being unnecessary or suboptimal in hospital, community or ambulatory settings [3,4]. A recent study showed that approximately 20% of patients admitted to the ICU with Clostridium diffi cile-associated diarrhoea were receiving antibiotics without any obvious evidence of infection, with an accompanying 28% in-hospital mortality [5]. As a consequence of indiscriminate antibiotic use, there are reported increases in the incidence of infections caused by resistant organisms. A signifi cant correlation was demonstrated between the increase in fl uoroquinolone prescriptions in Canada from 0.8 to 5.5 per 100 persons per year and increased ciprofl oxacin-resistant Streptococcus pneumoniae from 0% to 1.7% [6]. Twelve percent of patients previously exposed to piperacillin-tazobactam were colonized with strains of enterobacteriaceae resistant to this antibiotic [7] and the use of third generation cephalosporins is associated with higher rates of vancomycin-resistant enterococci and extended-spectrum β-lactamase-producing organisms [8]. Anti microbial resistance emerging in response to the selective pressure exerted by antibiotics is also a clinical phenomenon, with outbreaks of antibiotic-resistant Pseudomonas aeuroginosa and Acinetobacter baumanii-calcoaceticus occurring in ICUs, where a huge antimicrobial pressure is present [9-11]. Although they are often life-saving, antibiotics can also cause serious harm to patients, including Clostridium diffi cile -associated diarrhoea, antibiotic-resistant infections and invasive candidiasis [12-14]. Antibiotics also result in dangerous drug interactions, life-threatening hypersensitivity reactions, nephrotoxicity, and QT prolongation, to name a few. Inappropriate antibiotic use also contributes to rising drug and hospitalisation costs, and the need to preserve our current antibiotic arsenal Abstract