The hope of altering these gloomy prospects

For any hope to materialize, there is an absolute need for cooperation between health administrations, health care agencies, scientists, practicing physicians, the public, and the industry, particularly the agricultural and pharmaceutical industries. What medical science has to offer is summarized in the section on ''The Future of Antibiotic Therapy.'' Molecular genetics and drug modeling may help produce engineered drugs designed to inhibit new bacterial targets. Bacteria-carrying engineered antiresistance genes may be used as colonizers and may be able to compete with invading pathogens. Although possible, these futuristic approaches are not predictable. What is predictable is that, through extensive and intensive interventions at multiple levels, the life-span of the existing and currently experimental antibiotics can be extended.

The role of community physicians lies in educating local communities and learning the most appropriate use of antimicrobial agents. The use of antibacterial agents for noninfectious illnesses and nonbacterial infections can only have harmful effects, eradicating the normal flora that are part of natural host defenses. Some of the measures to deal with antimicrobial resistance are listed in Box 1. Changes seen in antimicrobial prescribing for children after a community-wide campaign in Knox County (United States) certainly offer hope [62]. McCaig and colleagues [63] studied the impact of various national campaigns and interventions on the antimicrobial prescription rate for children and adolescents. The rate of antimicrobial prescribing in general and for respiratory tract infections in particular by office-based physicians for children and adolescents younger than 15 years differed significantly between 1989 to 1990 and 1990 to 2000. However, we must maintain reminders if these changes are to progress and spread.

The Alliance for Prudent Use of Antibiotics (APUA), founded by Dr. Stuart B. Levy in 1981, has provided a model that may be used to improve antimicrobial use at all levels and in all countries [64]. The group shares information with members in more than 90 countries. APUA, the Centers for Disease Control and Prevention, and many other public health agencies have published educational brochures for the public and for health professionals. APUA has published the findings and the recommendations of a 2-year project called "Facts About Antimicrobials in Animals and the Impact on Resistance" [65]. This report is expected to help United States officials determine how much of total antimicrobial use is directed toward food animals and what proportion is used for treatment and prevention of infections in animals as opposed to nontherapeutic uses. The panel concluded that the elimination of nontherapeutic use of antimicrobials in food animals and in agriculture, with the exception of inophores and coccidiostats, will lower the burden of antimicrobial resistance in the environment with consequent benefits to human and animal health. Restrictions on the agricultural uses of antimicrobials have been put in place by regulatory agencies in the European Union, Australia, New Zealand, Japan, and other nations. United States officials are in the process of considering the facts.

Medical schools all over the world need to extend and improve the curriculum for microbiology and infectious disease. The emphasis should be on understanding the fundamentals of host defenses, bacteriology, bacterial genetics, antibiotic chemistry, and pharmacokinetics. The disease-based study of infectious diseases is a suboptimal and dangerous approach. This is an area of medicine where new diseases are constantly discovered along with new organisms. The behavior of existing diseases and organisms changes because of the changing host susceptibilities and antibiotic resistance. "Empiric antibiotic" therapy is justified when it is properly controlled and based on host- as well as pathogen-related factors. This principle would help change empiric into "presumptive antibiotic" therapy and give a method to the madness.

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