persist for extended periods of time once established. Therefore, it is imperative to actively pursue and address the problem; it will be too late to effect useful change once most microbes have become resistant to the available drugs.

Antibiotic resistance resulting from the inappropriate overuse of antibiotics is not a new problem. A number of expert committees and professional organizations have studied the problem, issued reports, and made recommendations (Alliance for the Prudent Use of Antibiotics, 2001; CDC, 2001o; FDA, 2000; GAO, 1999; Center for Science in the Public Interest, 1998; NRC, 1999). Unfortunately, little has been done to change the situation, especially in the United States. Resistance due to the inappropriate use of antibiotics compromises the efficacy of many classic and highly effective antibiotics, such as penicillin for pneumococci and vancomycin for enterococci, as well as that of some newer antibiotics, such as ciprofloxacin and other types of fluorinated quinolones for gonococci, Salmonella, and Campylobacter. The recent discovery of an enterococcal gene for vancomycin resistance in S. aureus was alarming even though it had been predicted on the basis of the ability of the genes to transfer across species boundaries during mixed culture (CDC, 2002d). In the case of enterococcal and staphylococcal infection, alternative therapies have been introduced, but resistance to these new drugs has already been documented (Tsiodras et al., 2001; Herrero et al., 2002). The specter of untreatable infections—a regression to the pre-antibiotic era—is looming just around the corner.

Preventing the overuse of antimicrobials is not an easy task because of the revolutionary effects the drugs have had on human and animal health. Because antimicrobials are highly effective, there is an understandable tendency to use them in any situation in which they might be helpful. These effective drugs are relatively inexpensive compared with other medical interventions. Patients demand the drugs when they have an illness they imagine to be treatable with antibiotics. Doctors prescribe antibiotics for that same reason, often in the absence of diagnostic tests to determine the etiology of infection, and also because patients want and expect to be treated with them. In many areas of the world where little money is available for health care, antimicrobials are readily available without a doctor’s prescription, and as a result are often taken unnecessarily or inadequately. Many problems associated with antimicrobial resistance have arisen in poor and developing areas of the world, and have subsequently spread globally.

In addition to avoiding the inappropriate use of antibiotics to treat viral disease, prudence dictates use of the appropriate antimicrobial when an etiologic diagnosis is made. For example, the rapid rise in drug-resistant malaria has led to the development of newer, generally more expensive therapies for the disease. This in turn has resulted in an increase in the



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