Epidemiology and control of antibiotic resistance in the intensive care unit

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Abstract
Resistance to antibiotics is very high in the intensive care units of many countries, although there are several exceptions. Some infections are becoming extremely difficult to treat. The risk of cross-transmission of those strains is very high. This review focuses on recent data (2003 to the present) that may help understanding and dealing with this serious public health problem. Intensive care units can be considered as ‘factories’ for creating, disseminating and amplifying resistance to antibiotics, for many reasons: importation of resistant microorganisms at admission, selection of resistant strains with an extensive use of broad-spectrum antibiotics, cross-transmission of resistant strains via the hands or the environment. Some national programs can be considered as failures, as in the UK and the USA. Other countries have been able to maintain a low level of resistance (Scandinavian countries, Netherlands, Switzerland, Germany, Canada). There is clearly an ‘inoculum effect’ above which preventive measures become poorly efficient. Several preventive measures have been proposed including preventive isolation, systematic screening at admission, local, national or international antibiotic guidelines, antibiotic prescriptions advice by infectious-disease teams, antibiotic prevention with selective digestive decontamination, antibiotic strategies such as ‘cycling’, or rather, for some authors, the use of an ‘à la carte’ antibiotic strategy which could be considered as a ‘patient-to-patient antibiotic rotation’. There is obviously an international concern regarding the level of resistance to antibiotics in the intensive-care-unit setting. A strong program including prevention of cross-transmission and better usage of antibiotics seems to be needed in order to be successful. We do not know if this kind of program will enable countries with a very high endemic level of resistance to decrease the level in future years.

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