Between 1983 and 1987, Food and Drug Administration (FDA) approved 16 new systemic antibiotics, but since then antibiotic approvals have been on the decline. Since 2008, only two systemic antibiotics have been approved [2]. As time went on and the idea of antimicrobial resistance still had not caught on with mainstream medicine, the drying pipeline of antimicrobial agents along with increasing resistance got the Infectious Disease Society of America (IDSA) up in arms. The IDSA set forth their "Bad Bugs, No Drugs" campaign in 2004 [3]. Along with a series of papers, the IDSA and Society of Healthcare Epidemiology of America (SHEA) came out with the current antimicrobial stewardship guidelines that were published in 2007[4].

Antibiotics continue to save lives every day. This ability to control infection is critical to other advances in medicine be it neonatal care, organ transplantation, chemotherapy for malignancy, immunosuppression, safe surgery and obstetric care or intensive care interventions. But sadly antibiotic resistance has now become a major public health crisis. It is a common scenario to have a very sick patient with infection and the laboratory reports listing every single drug as resistant. The greater the volume of antibiotics used, the greater the chances that antibiotic-resistant populations of bacteria will prevail in the contest for survival of the fittest at the bacterial level.

An effective antimicrobial stewardship program will limit inappropriate and excessive antimicrobial use but more importantly, will improve and optimize therapy and clinical outcomes for the individual affected patient. The broad interventions of antibiotic stewardship includes antibiotic ‘time out’ prompting a reassessment of the continuing need and choice of antibiotics after initial empirical therapy, prior authorization, and lastly prospective audit and feedback. Some facilities restrict the use of certain antibiotics based on the spectrum of activity, cost, or associated toxicities to ensure the use is reviewed with an antibiotic expert. There is sufficient scientific evidence to support improvement in clinical outcome as a consequence of antibiotic stewardship program; the measures include curtailing the antibiotic abuse [5], decreased antimicrobial consumption [6], strict antibiotic usage guidelines [6,7], reduced length of hospital stay [8], improved ventilator-acquired pneumonia outcomes [9], and better patient outcomes with infection [5].

Antibiotics are the only drugs where use in one patient can impact the effectiveness in another. They are a shared resource and now becoming a scarce resource. Using antibiotics properly is analogous to developing and maintaining good roads. Practicing antibiotic invisibility days, rounds, operations, ICUs with or without justification forms, may preempt invisible antibiotic usage, in future, in our country. In resource-poor or deprived settings of rural healthcare, where no data exists or only sketchy utilization registers exist as well as in metropolises with swanky corporate health care settings, optimizing antibiotics by measures such as "justification for restricted usage antibiotics" and rational use of antimicrobials would tilt the balance in favour of the system in the ongoing war against deadly bugs.

In the current issue of Indian Pediatrics, Bhullar, et al. [10] have highlighted one such well-established method of calling to attention the indiscriminate use of antibiotics in intensive care units and its impact on the same. The study shows that implementation of an antibiotic justification form for restricted antibiotics and follow-up of the same is associated with a marked reduction in antibiotic consumption, and with acceptably appropriate use of the drugs under restricted use. This could be under the purview of the quality improvement initiatives undertaken by the hospital administration or as part of a departmental research activity. We need multifaceted approach to make the deadly bugs disappear before our antibiotics are pushed into oblivion.

Funding: None; Competing interest: None stated.

1. A call to arms. Nat Rev Drug Discov. 2007;6:8-12.

2. Brad S, Powers JH, Eric BP, Loren MG, John EE. Trends in antimicrobial drug development: implications for the future. Clin Infect Dis. 2004;38:1279-86

3. Infectious Diseases Society of America. Bad Bugs, No Drugs. As Antibiotic Discovery Stagnates, A Public Health Crisis Brews. Alexandria: IDSA; 2004. p14-19.

4. Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159-77.

5. Fishman N. Antimicrobial stewardship. Am J Med. 2006;119:S53-61; discussion S62-70.

6. Cheng VCC, To KKW, Li IWS, Tang BSF, Chan JFW, Kwan S, et al. Antimicrobial stewardship program directed at broad-spectrum intravenous antibiotics prescription in a tertiary hospital. Eur J Clin Microbiol Infect Dis. 2009; 28:1447-56.

7. Arnold FW, McDonald LC, Smith RS, Newman D, Ramirez JA. Improving antimicrobial use in the hospital setting by providing usage feedback to prescribing physicians. Infect Control Hosp Epidemiol. 2006;27:378-82.

8. White AC Jr, Atmar RL, Wilson J, Cate TR, Stager CE, Greenberg SB. Effects of requiring prior authorization for selected antimicrobials: expenditures susceptibilities, and clinical outcomes. Clin Infect Dis. 1997;25:230-9.

9. Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med. 2000; 162(2 Pt 1):505-11.