XXXX resistance: a worldwide perspective.

@entity1 @entity801 @entity8 @entity2890 @entity3405 @entity4509 @entity581 @entity166 @entity4028
Two concerns, neither of which is particularly new, underlie the current reluctance to use @entity581 more broadly. First, an undeniable fact is that these compounds can be toxic, particularly in @entity1 with @entity8 or those receiving other nephrotoxic medications. Second, a more emotional concern is that widespread use of @entity581 , particularly the newer compounds that are more resistant to enzymatic inactivation, may engender widespread resistance. In fact, several sources lead one to doubt whether widespread use of potent and highly effective agents like @entity4509 will by itself increase a clinical reservoir of more resistant microbes. First, the surveillance studies undertaken in many hospitals show some modest reduction in overall @entity4028 resistance even when a drug like @entity4509 is used to supplant antecedent compounds of the same class. Second, in institutions where no official surveillance programs have been undertaken but where ongoing surveillance has been maintained, susceptibility to @entity4509 has remained constant when recent blood isolates are compared with blood isolates from more than 10 years ago. Third, in controlled clinical trials, particularly in immunocompromised @entity1 , the overall emergence of resistance has been remarkably low and contrasts rather strikingly with what has been observed in some monotherapeutic studies of @entity3405 agents. The presence of @entity4028 -resistant strains cannot be denied, but the circumstances leading to the emergence of such resistance must be carefully assessed, particularly outside of the setting in which these drugs are used as first-line therapy for critically ill @entity1 . For instance, there is substantial evidence to suggest that the topical use of @entity581 or the use of these agents when there may be environmental contamination could lead to the emergence of resistance. Before one incriminates the use of any one drug as predisposing to the emergence of resistance, one needs to have more information about the total exposure of a given bacterial population to @entity4028 therapy. The emergence of resistance to @entity581 has been associated with exposure to the more commonly used agents such as @entity801 or @entity2890 . With some of the newer @entity3405 agents, the rate of emergence of resistance, unlike that of the @entity581 , has appeared to be remarkably high. If the concern about emergence of resistance is genuine, and to maintain consistency of approaches, the @entity166 community should focus more attention on limiting or restricting the use of the more widely used @entity3405 compounds.(ABSTRACT TRUNCATED AT 400 WORDS)
