Introduction

Optimal antimicrobial use is essential in the face of escalating antibiotic resistance. The problem of antibiotic resistance affects all sectors of the health care system—the patient, the health care team, the payor, and the public health system. Previous antibiotic use has consistently been identified as a risk factor for individual colonization with resistant pneumococcus (1). Community-wide consumption of antibiotics is strongly associated with infection or colonization with resistant organisms (2). Antibiotic resistance has been shown to be proportional to the volume of antimicrobial consumption, and reductions in resistance require a proportional reduction in consumption (3). Although there is evidence to document the futility and possible harm of antibiotic therapy for many respiratory tract infections, antibiotic prescribing continues for these primarily viral conditions (4).

The overall goal of reducing antibiotic prescribing should be an effort to minimize antibiotic resistance while appropriately delivering quality health care—other goals would include decreasing antibiotic costs and minimizing harm to exposed patients. In Finland, a nationwide reduction in the outpatient use of macrolide antibiotics resulted in a reduction of resistant Group A Streptococcus from 16.5% in 1992 to 8.6% in 1996. Practitioners were regulated to substitute macrolides for other antibiotics, and although macrolide use decreased, overall antibiotic use did not change (5). Icelandic researchers have reduced the proportion of resistant pneumococcal infections through an intervention program delivered to patients and the health care team (6). Effective strategies must be identified, and all groups must promote and participate in efforts to reduce antibiotic resistance. Otherwise, the current concern of a "post-antimicrobial era," in which antimicrobial agents will no longer be effective, may become a reality. In this chapter we present a discussion of a variety of strategies that have been used to promote judicious antibiotic use.

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