Intensive care unit antimicrobial resistance and the role of the pharmacist

Benefits of pharmacist intervention in the critical care patients with infectious diseases: A propensity score matching retrospective cohort study

BACKGROUND

The importance of optimising antimicrobial therapy is highlighted in the hospital intensive care unit (ICU) patients. But roles of ICU pharmacists are still in its infancy in China.

OBJECTIVES

This study's objective was to evaluate the values of clinical pharmacist interventions in the antimicrobial stewardship (AMS) on ICU patients with infections.

AIM

The aim of this study was to evaluate the value of clinical pharmacist interventions in the antimicrobial stewardship (AMS) in critically ill patients with infections.

METHODS

From 2017 to 2019, a propensity score matching retrospective cohort research was conducted on critically ill patients with infectious illnesses. The trial was split into groups that received pharmacist assistance and those who did not. Baseline demographics, pharmacist actions, and clinical results were compared between the two groups. Factors influencing mortality were demonstrated using univariate analysis and bivariate logistic regression. The State Administration of Foreign Exchange in China monitored the exchange rate between the RMB and the US dollar and also gathered the charges of the agents as an economic indicator.

RESULTS

Out of the 1523 patients who were evaluated, 102 critically ill patients with infectious diseases were included in each group after matching. The top five prescription regimens adjusted were settled by sickness progression, microbiological results, de-escalation, drug withdrawal, and therapeutic drug monitoring suggestions. The pharmacist exposure group's antibiotic use density (AUD) decreased significantly (p = 0.018) compared to the control group, going from 241.91 to 176.64 defined daily doses/100 bed days. Following pharmacist interventions, the AUD proportion for carbapenems dropped from 23.7 to 14.43%, while for tetracyclines, it dropped from 11.5 to 6.26%. In the group exposed to the pharmacist, the median cost of antibiotics decreased significantly from $836.3 to $362.15 per patient stay (p < 0.001), and the median cost of all medications dropped from $2868.18 to $1941.5 per patient stay (p = 0.06). RMB was converted into US dollars according to the current exchange rate. According to univariate analyses, pharmacist interventions did not differ between the groups that survived and died (p = 0.288).

CONCLUSIONS

This study showed that antimicrobial stewardship had a significant financial return on investment without raising the mortality rate.

Role of Clinical Pharmacists in Intensive Care Units

The cost of health care has been rising in the United States and globally and will continue to increase. Intensive care unit (ICU) care carries a significant portion of the cost for the hospitals. The Institute of Medicine and subsequent studies have suggested that medication errors account for significant morbidity, mortality, and cost, frequently encountered in the ICU. Over the past three decades, clinical pharmacists have emerged from dispensing medication to getting involved in direct patient care and have become an integral part of the multidisciplinary critical care team. Clinical pharmacists play a significant role in reducing medication errors and costs, medication reconciliation, antibiotic stewardship, and patient and health care provider education. This review will discuss the health care and ICU cost, the evolving role of clinical pharmacists in managing critically ill patients, and their contributions in the ICU to mitigate the risks, improve patient outcomes, and decrease health care costs.

[Pharmacokinetic modifications and pharmacokinetic/pharmacodynamic optimization of beta-lactams in ICU]

Pharmacokinetic modifications in critically ill patients and those induced by ICU therapeutics raise a lot of issues about antibiotic dose adaptation. Beta-lactams are anti-infectious widely used in ICU. Frequent beta-lactam underdoses induce a risk of therapeutic failure potentially lethal and of emergence of bacterial resistance. Overdoses expose to a neurotoxic and nephrotoxic risk. Therefore, an understanding of pharmacokinetics modifications appears to be essential. A global pharmacokinetic/pharmacodynamic approach is required, including use of prolonged or continued beta-lactam infusions to optimise probability of pharmacokinetic/pharmacodynamic target attainment. Beta-lactam therapeutic drug monitoring should also be considered. Experts agree to target a free plasma betalactam concentration above four times the MIC of the causative bacteria for 100 % of the dosing interval. Bayesian methods could permit individualized doses adaptations.

Impact of Quality Bundle Enforcement by a Critical Care Pharmacist on Patient Outcome and Costs

OBJECTIVES

Surgical and medical ICU patients are at high risk of mortality and provide a significant cost to the healthcare system. The aim of this study is to describe the effect of pharmacist-led interventions on drug therapy and clinical strategies on ICU patient outcome and hospital costs.

DESIGN

Before and after study in two French ICUs (16 and 10 beds).

PATIENTS

ICU patients.

INTERVENTION

From January 1, 2013, to June 30, 2015, a pharmacist observation period was compared with an intervention period in which a critical care pharmacist provided recommendations to clinicians regarding sedative drugs and doses, choice of mechanical ventilation mode and related settings, antimicrobial de-escalation, and central venous and urinary catheters removal. Differences in ICU and hospital length of stay, duration of mechanical ventilation, mortality rate, and hospital costs per patient were quantified between groups with patients matched for severity of illness (Simplified Acute Physiology Score II) at admission.

MEASUREMENTS AND MAIN RESULTS

From the 1,519 and 1,268 admitted patients during the observation and intervention periods, respectively, 1,164 patients were evaluable in both groups after matching for Simplified Acute Physiology Score II score. The intervention period was associated with mean (95% CI) reductions in patient hospital length of stay (3.7 d [5.2-2.3 d]; p < 0.001), ICU length of stay (1.4 d [2.3-0.5 d]; p < 0.005), duration of mechanical ventilation (1.2 d [2.1-0.3 d]; p < 0.01), and hospital costs per stay (2,560 euros [3,728-1,392 euros]; p < 0.001). The overall cost savings were 10,840 euros (10,727-10,952 euros) per month, mostly due to reduced consumption of sedatives and antimicrobials. No impact on mortality rate was identified.

CONCLUSIONS

Critical care pharmacist-led interventions were associated with decreases in ICU and hospital length of stays and ICU drug costs.

The impact of clinical pharmacy services in China on the quality use of medicines: a systematic review in context of China's current healthcare reform

INTRODUCTION

Recently, China initiated an ambitious healthcare reform aiming to provide affordable and equitable basic health care to all by 2020. To meet these goals, new policies issued by China's Ministry of Health mandate clinical pharmacy services be integrated into China's hospitals. This review aims to highlight the impact of clinical pharmacy services on the quality use of medicines in hospitals in China.

METHODS

Both English and Chinese databases were used. For the English databases, Web of Science, Medline, International Pharmaceutical Abstracts and Embase were searched using the following keywords ('pharmacists' OR 'pharmacy' OR 'pharmaceutical services/pharmaceutical care') AND ('China'). For the Chinese database, Chinese Biomedical Literature Database on disc was searched using the following keywords ('clinical pharmacist' OR 'clinical pharmacy' OR 'pharmaceutical care' OR 'pharmaceutical services'). Articles were then retrieved from WanFang database and China Knowledge Resource Integrated Database.

RESULTS

A total of 75 published papers were included in this review. The majority of studies were conducted in the inpatient setting (68%), which included clinical pharmacy interventions such as educating doctors and patients, evaluating and monitoring the implementation of hospital policies and/or reviewing medications on the ward. In the outpatient setting, the majority of studies conducted involved educating patients. Clinical pharmacy services frequently focused on antimicrobials (44%). More than half of these studies employed an administrative intervention alongside the clinical pharmacy service.

CONCLUSION

Clinical pharmacy services in China, with its unique healthcare system and cultural nuances, appear to positively influence patient care and the appropriate use of medications. From the published literature, it is expected that clinical pharmacy services can make a strong contribution to China's healthcare reform with further governmental and educational support.

Emergency Medicine Pharmacists and Sepsis Management

Purpose:

To describe the role that an emergency medicine (EM) clinical pharmacist has on the management of patients presenting to the emergency department (ED) with sepsis, severe sepsis, or septic shock.

Methods:

The clinical consultations documented by the EM pharmacists at an academic, teaching hospital over a 2-year period were retrospectively reviewed.

Results:

During the study period, a total of 585 consultations were provided by the EM pharmacists to 130 patients who presented to the ED with a diagnosis of sepsis, severe sepsis, or septic shock. Dosing recommendations were the most frequent consultations provided (n = 309, 53%), followed by the addition of appropriate empiric antibiotics (n = 131, 22%) and medication preparation (n = 108, 19%). Antibiotics (n = 307, 83%) and vasopressors (n = 31, 8%) were the medication classes regularly involved in EM pharmacist consultations. Vancomycin (n = 90, 28%) and norepinephrine (n = 15, 48%) were the most common agents involved in these consultations.

Conclusion:

A clinical EM pharmacist has multiple roles in the early management of patients presenting with sepsis, severe sepsis, or septic shock in the ED. Most commonly, they have a role in optimizing empiric antibiotic selection and dosing; thereby ensuring adequate antimicrobial coverage in this complex patient population.

Pharmacist proactive medication recommendations using electronic documentation in a UK general critical care unit

BACKGROUND

Specific data on the actual clinical practice of United Kingdom pharmacists in Critical Care are limited. Within the general critical care units of Sheffield Teaching Hospitals, clinical pharmacists have the facility to electronically document, communicate and follow-up proactive recommendations using a Pharmacy Review Form via the Clinical Information System, MetaVision(®).

OBJECTIVE

The objective of the service evaluation was to describe the acceptance rate by medical staff of pharmacist proactive medication recommendations; including data on the types of recommendations and reasons thereof, for general intensive care patients of a UK teaching hospital trust.

SETTING

Sheffield Teaching Hospitals National Health Service Foundation Trust with 20 intensive care beds located on two hospital sites admitting Level 3 and 2 mixed general medical, surgical, trauma, burns and haematology/ oncology patients.

METHOD

Retrospective analysis of pharmacist proactive recommendations recorded electronically from January 2009 to July 2011 in general intensive care unit patients. Main outcome 5,623 electronic medication recommendations were documented, providing an average of 2.2 proactive recommendations per patient admitted to intensive care from January 2009 to July 2011. 5,101 (90.7%) of the recommendations were accepted and acted upon by medical staff.

RESULTS

The most common recommendations were Add Drug 1,862 (28.2%); Dose Review 1,707 (25.8%); Discontinue Drug 1,185 (17.9%); Alternative Drug 903 (13.7%); Alternative Route 770 (11.7%). The most common reasons for the proactive medication recommendations were related to changes in gastrointestinal absorption 951 (15.6%); compliance with medication guidelines 857 (14.1%); sedation/delirium/agitation management 764 (12.6%); dose adjustment for renal dysfunction or continuous renal replacement therapies 756 (12.4%); and medication reconciliation 612 (10.1%). The majority of medication recommendations involved drugs in Gastrointestinal, Central Nervous System, Cardiovascular, Infection, Nutrition and Blood classes (British National Formulary).

CONCLUSION

There was a high acceptance rate for proactive medication-related recommendations made by critical care pharmacists via the electronic review form. The majority of pharmacist recommendations were related to adding or refining currently prescribed medication. Ten percent of recommendations related to medication reconciliation of patients' pre-admission medication.

Impact of pharmacist's interventions on cost of drug therapy in intensive care unit

Pharmacist participation in patient care team has been shown to reduce incidence of adverse drug events, and overall drug costs. However, impact of pharmacist participation in the multidisciplinary intensive care team on cost saving and cost avoidance has little been studied in Thailand.

OBJECTIVE

To describe the characteristics of the interventions and to determine pharmacist's interventions led to change in cost saving and cost avoidance in intensive care unit (ICU).

METHODS

A Prospective, standard care-controlled study design was used to compare cost saving and cost avoidance of patients receiving care from patient care team (including a clinical pharmacist) versus standard care (no pharmacist on team). All patients admitted to the medical intensive care unit 1 and 2 during the same period were included in the study. The outcome measures were overall drug cost and length of ICU stay. Interventions made by the pharmacist in the study group were documented. The analyses of acceptance and cost saving and/or cost avoidance were also performed.

RESULTS

A total of 65 patients were admitted to either ICU 1 or 2 during the 5 week-study period. The pharmacist participated in patient care and made total of 127 interventions for the ICU-1 team. Ninety-eight percent of the interventions were accepted and implemented by physicians. The difference of overall drug cost per patient between two groups was 182.01 USD (1,076.37 USD in study group and 1,258.38 USD in control group, p=0.138). The average length of ICU stay for the intervention group and the control group was not significantly different (7.16 days vs. 6.18 days, p=0.995). The 125 accepted interventions were evaluated for cost saving and cost avoidance. Pharmacist's interventions yielded a total of 1,971.43 USD from drug cost saving and 294.62 USD from adverse drug event cost avoidance. The net cost saved and avoided from pharmacist interventions was 2,266.05 USD. Interventions involving antibiotic use accounted for the largest economic impact (1,958.61 USD).

CONCLUSIONS

Although the statistical was not significant, having a pharmacist participated in ICU patient care team tend to reduced overall drug cost, cost saving, and cost avoidance. The largest cost impact and intervention requirement involved antibiotic use.

Clinical and economic outcomes of pharmaceutical services related to antibiotic use: a literature review

AIM OF THE REVIEW

To identify and review the clinical and economic impact of pharmacists' interventions on antibiotic use.

METHOD

A literature search was conducted on Medline (1966-2003) to identify original articles measuring the impact of pharmacists' interventions on antimicrobial therapy at patient's or prescriber's level.

RESULTS

Forty-three articles were included: 20 uncontrolled before-after studies, four controlled before-after studies, five controlled trials, 12 randomized controlled trials and two interrupted time series (ITS). The described interventions were grouped into four categories: patient-specific recommendations (pharmacists' interventions concerning patient-specific drug therapy), implementation of policies, education, and therapeutic drug monitoring. These interventions were often combined to provide a multifaceted intervention, making it difficult to isolate the impact of one specific intervention. Measured outcomes were: appropriateness of prescribing (evaluated in 17 studies, 16 showing significant improvement), costs (analysed in 22 studies, nine showing a statistically significant reduction in costs after or with the intervention), and length of hospital stay (mixed results). Other measured outcomes were: drug use, prescriptions, length of treatment, dose intervals, switch to oral route, mortality rate, and treatment failure.

CONCLUSION

Over the years, the number of studies and quality of methodology has increased. The most frequently observed outcomes with a positive impact were appropriateness of prescribing and cost savings. The vast majority of studies used multiple interventions, in conjunction with pharmacists' recommendations to physicians. Coupled with the use of practice guidelines or educational strategies, these interventions demonstrated a positive impact on economic or clinical outcomes. However, the data are still sparse and sometimes contradictory; therefore, further studies with randomized controlled designs are needed.

Impact of the Hospital Pharmacy Initiative for promoting prudent use of antibiotics in hospitals in England

OBJECTIVES

In July 2003, the UK Department of Health announced an allocation of 12 million pounds sterling to hospital pharmacists to improve the monitoring and control of anti-infective use over the ensuing 3 year period (the Hospital Pharmacy Initiative, or HPI). Chief Pharmacists were asked to use this money for developments to promote prudent antibiotic use and monitoring of antimicrobials within their Trusts. This study aimed to evaluate the impact of the HPI funding, which at the time had been in place for nearly 2 years, on pharmacy activities in this area.

METHODS

A postal questionnaire was sent to the pharmacy department of each acute hospital Trust in England, aiming to provide a descriptive overview of the activities of hospital pharmacy staff in the field of anti-infectives and to explore the extent to which these activities were made possible by the HPI funding.

RESULTS

One hundred and forty-one specialist antimicrobial pharmacy staff were employed in 130 responding Trusts; 89% were pharmacists, 7% pharmacy technicians and the remainder administrative staff. Three-quarters of these staff had been employed due to the funding, resulting in review of antimicrobial prescribing guidelines, antibiotic audit projects and multidisciplinary work with Microbiology/Infectious Diseases staff. Thirteen Trusts gave details of drug acquisition cost savings; over the course of a year, these Trusts saved 1.1 million pounds sterling in total.

CONCLUSIONS

The HPI funding has facilitated greater interaction between Pharmacy and Microbiology/Infectious Diseases departments than was previously possible. Significant reductions in antibiotic acquisition costs have been demonstrated, though further work is warranted to fully establish the impact of pharmacy activities on clinical and microbiological outcomes.

The issue of antimicrobial resistance in human medicine

Antibiotics are used worldwide in human medicine and agriculture. In many cases the use of antibiotics is unnecessary or questionable. Consumption of antibiotics is linked to bacterial resistance. In hospitals, most common resistant bacteria include methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci and Gram-negative rods including Enterobacteriaceae and Pseudomonas aeruginosa. Vancomycin intermediate and resistant S. aureus, described just recently, represent a new treatment challenge. In the community, penicillin and macrolide-resistant pneumococci developed several decades ago and are now present all over the world. More recently, community-acquired methicillin-resistant S. aureus has become a problem in several countries causing skin infections but also severe diseases. Resistance to co-trimoxazole in Escherichia coli has changed empirical treatment of urinary tract infections, one of the most common causes of the visit to the physician's office. Several reports and studies trying to limit the use of antibiotics have shown that antimicrobial resistance of bacteria can be reversed, but in general the problem is far from being solved. World Health Assembly and the European Community Council have recognized the problem of antibiotic resistance as a priority. The relationship between agricultural use of antimicrobials and antibacterial resistance in humans should be further investigated.

Evaluación de la calidad en el proceso de utilización de fármacos peligrosos: prescripción y preparación

OBJECTIVE

To evaluate the quality of cytotoxic drug prescription based on the results of an interventional pharmaceutical program and the quality of the final product based on quality-control prior to preparation.

METHODS

STUDY PERIOD

July 2002-March 2003. Hazardous drug prescription was evaluated through an analysis of pharmaceutical interventions during therapeutical monitoring. Depending on repercussion in patients, they were classified in three categories (treatment optimization, resource optimization or criteria unification). Data obtained from manual quality control programs prior to hazardous drug preparation were evaluated.

RESULTS

Sixty-four interventions were made (9 interventions per 100 prescriptions): 55% were classified as treatment optimization, 28% as resource optimization and 17% as criteria unification. A total of 66% of the interventions focused on treatment optimization were caused by prescription errors. Ninety-seven per cent were accepted. Out of 2,074 preparations, 1,951 were evaluated (94.9%). A 5.1% of non-evaluated preparations were due to a lack of registration and 0.8% to violations in the established protocol.

CONCLUSIONS

Results of the interventional Pharmaceutical program show that an assisted prescription system is necessary, not only to detect prescription errors but also to prevent them. Manual controls in different stages of the process are useful and they should be complementary to other more reliable dosification controls.

Judicious Use of Antimicrobials in the Critical Care Setting

This article reviews the judicious use of antibiotics in an intensive care setting. Risk factors for both infection and antimicrobial resistance are discussed. Various methods hospitals can apply to promote the optimal use of antibiotics also are reviewed. These methods include empiric therapy, antibiotic cycling, treatment guidelines and protocols, and antibiotic susceptibility monitoring.

A hospitalwide intervention program to optimize the quality of antibiotic use: impact on prescribing practice, antibiotic consumption, cost savings, and bacterial resistance

Several findings from Argentina provide compelling evidence of the need for more rational use of antimicrobial agents. Thus, a multidisciplinary antimicrobial treatment committee for the development of a hospital-wide intervention program was formed to optimize the quality of antibiotic use in hospitals. Four successive steps were developed during 6-month periods: baseline data collection, introduction of a prescription form, education, and prescribing control. Sustained reduction of drug consumption was shown during the study (R2=0.6885; P=.01). Total cost savings was 913,236 US dollars. To estimate the consumption of cefepime and aminopenicillin-sulbactam in relation to that of the third-generation cephalosporins, 2 indices were calculated: Icfp and Iams, respectively. Decreasing resistance to ceftriaxone by Proteus mirabilis and Enterobacter cloacae proved to be associated with increasing Icfp. Decreasing rates of methicillin-resistant Staphylococcus aureus were related to increasing Iams. The present study indicates that a systematic program performed by a multidisciplinary team is a cost-effective strategy for optimizing antibiotic prescribing.

The impact of critical care pharmacists on enhancing patient outcomes

The highly specialized knowledge and skills needed to care for critically ill patients requires a multidisciplinary team approach. Pharmacists are integral members of this team. They make valuable contributions to improve clinical, economic, and humanistic outcomes of patients. The purpose of this article is to review the literature pertaining to pharmacists' contributions within a multidisciplinary intensivist-led intensive care unit (ICU) team. Pharmacist interventions include correcting/clarifying orders, providing drug information, suggesting alternative therapies, identifying drug interactions, and therapeutic drug monitoring. Pharmacist involvement in improving clinical outcomes of critically ill patients is associated with optimal fluid management and substantial reductions in the rates of adverse drug events, medication administration errors, and ventilator-associated pneumonia. Furthermore, economic evaluations of clinical pharmacy services in the ICU consistently reveal the potential for considerable cost savings.

Multidisciplinary antimicrobial management and the role of the infectious diseases pharmacist--a UK perspective

Improved clinical outcome, patient safety, cost savings and a reduction in the burden of antimicrobial resistance are outcomes associated with optimizing antimicrobial use. Despite this, the misuse of antimicrobials in the hospital setting remains a huge problem. The development of antimicrobial management teams and the promotion of the role of the clinical pharmacist in antimicrobial prescribing are recommended strategies for improving prescribing practice. It is recognized that there is a lack of published evidence-based research looking at the effects of antimicrobial control programmes and there is a need for more data. In the UK, the role of the hospital pharmacist in promoting responsible antimicrobial prescribing has been largely undervalued and needs to be encouraged and formalized in line with current directives. Managerial structures within hospitals need to endorse multidisciplinary antimicrobial management schemes with appropriate authoritative, administrative and information technology support.

Impact of intensive care unit (ICU) drug use on hospital costs: a descriptive analysis, with recommendations for optimizing ICU pharmacotherapy

OBJECTIVE

To determine the cost impact of intensive care unit (ICU) drug use on a hospital's total drug expense and to compare ICU pharmacy resource utilization with resource utilization of other hospital departments that provided services to the ICU. Additionally, to suggest strategies, based on these methods and results, to optimize ICU drug use.

METHODS

Financial transactions for all ICU patients (n = 23,107) treated during fiscal years 1999-2002 were retrieved from the hospital's data repository. ICU drug costs were calculated both as the percentage of total drug costs for each fiscal year and adjusted for hospital volume (ICU patient days). ICU department charges were calculated as a percentage of total ICU charges and analyzed by simple descriptive statistics (mean +/- sd). Drug utilization was retrieved for those patients accounting for the highest percentage of ICU pharmacy charges.

MAIN RESULTS

ICU drug costs accounted for 38.4% (+/-4.1% sd) of the total drug costs and have increased at a rate greater than non-ICU drug costs (12% vs. 6%). ICU pharmacy charges accounted for an average of 11.1% (+/-9.2% sd) of the total ICU charges, ranking as the fourth most costly of ICU charges. Both costly and highly used ICU therapies were identified for focus on cost-effectiveness analyses or application of an evidence-based drug use and disease state management program model to ICU pharmacotherapy.

CONCLUSIONS

ICU drug therapies have a significant impact on hospital costs, and effective clinical informatics services and multidisciplinary collaboration programs are necessary to optimize ICU pharmacotherapy.

Antimicrobial resistance in the intensive care unit: understanding the problem

Antimicrobial resistance is a problem that affects healthcare delivery around the globe. Factors associated with antimicrobial resistance include overuse or misuse of antimicrobial agents, immunosuppressed patients, and increased technology. Cellular mechanisms of antimicrobial resistance include the decreased uptake of a drug, efflux of the drug, enzymatic inactivation, and alterations in the antimicrobial target site. New treatment options are currently available for resistant organisms. Therapeutic strategies such as antibiotic control policies and antibiotic "cycling" have been proposed as methods for minimizing the emergence of more resistant organisms. Little evidence is available to indicate that these strategies are effective in limiting the emergence of resistance. Clinicians are urged to be judicious in their use and choice of antimicrobials.

Antibiotic policies and control of resistance

PURPOSE OF THE REVIEW

The current worldwide pandemic of antibiotic resistance shows no signs of abating. It is clear that it is driven mainly by heavy and often inappropriate antibiotic use. Although control measures are widely practised, it is important that we assess their efficacy critically in order to concentrate expensive control efforts where they will be most effective. The past year has seen much activity in this area, with evidence-based assessments of the literature according to strict guidelines, as well as progress in basic science studies of mechanisms of resistance, and their causes and relations to pathogenicity and adaptability.

RECENT FINDINGS

The present review summarizes current developments in the causes of antibiotic resistance, the classification of antibiotic stewardship and control measures, the evidence base for their efficacy, current problems in hospital practice, the adaptability of bacteria, the content of antibiotic policies and anticipated activities.

SUMMARY

The conclusions from the published literature are that much of it that pertains to changing prescribing practices does not stand up to modern evidence-based analysis concepts. Nevertheless, we can learn from experience in changing other areas of medical practice. We must be pragmatic and must not expect to change the world, but rather take it step by step, recognizing barriers and measuring outcomes and quality indicators. Studies into the molecular basis of resistance confirm the superb genetic adaptability of micro-organisms. They will always be several steps ahead of us. Nevertheless, we are learning how to modify our prescribing habits to minimize resistance, not only by using antibiotics less frequently but also by altering dosing schedules in various ways.