Resistance to antimicrobial agents: a personal view.

Problems of antimicrobial drug resistance are presently serious, but not yet desperate. The principal areas of concern are two-fold: multiresistant opportunist bacteria that affect vulnerable patients in high dependency areas of hospitals (the most pressing problem for developed countries); and multidrug resistance among classic pathogens like Mycobacterium tuberculosis, Salmonella typhi, Shigella spp., Neisseria gonorrhoeae and Plasmodium falciparum (mainly, although not exclusively, a problem for developing countries). The first type can be contained to a large extent by good infection control practices and careful prescribing based on agreed policies of antimicrobial drug use. The input of infection control nurses and laboratory-based clinical microbiologists is crucial and these services deserve full support. The second type additionally requires coordinated action to regulate more effectively the manufacture, availability, promotion and use of antimicrobial drugs. In this case the input of governments, international agencies and pharmaceutical companies is essential. Prescription-only status for antimicrobial drugs used in man and animals should be the norm. The number of drugs available for the treatment of viral, fungal and parasitic infections is comparatively small and much less is known about resistance. More research in these areas would be welcome. Teaching good prescribing habits to medical students is presently haphazard and needs to be formalised. Surveillance needs to be improved. The second half of the 20th century has been a golden age of antibiotics, but the outlook is uncertain. If antimicrobial chemotherapy is to have a secure future, prescribers must learn to use these powerful tools with greater discretion and their use worldwide must be regulated effectively.