11 Introduction 1 process may ultimately lead to a post-antimicrobial era, in which few or no currently available antimicrobials remain effective and infections once again become a major cause of morbidity and mortality. Antimicrobial prescribing The discovery of antimicrobials was a major medical breakthrough and heralded a new era of effective treatment of bacterial infections (12). Before the discovery and use of antibiotics in clinical care, infections that are now considered minor were a leading cause of death. Use of antimicrobial treatment and prophylaxis is nowadays an indispensable routine medical treatment in primary and hospital care. Antimicrobial prescribing is part of routine medical care in primary care. General practitioners prescribe antimicrobial drugs daily to patients with an acute presumed or confirmed infection. Pneumonia and cellulitis, which could potentially evolve into life-threatening infections, can be managed effectively and relatively simply in a primary care setting with antimicrobial treatment. Antimicrobial prescribing in primary care is, in general, empiric for the whole duration of the treatment. Cultures are not routinely obtained, except in case of treatment failure or a complicated or recurrent urinary tract infection (UTI). The initially prescribed antimicrobial is not altered during an infection, except in case of treatment failure or when culture results show that bacteria are susceptible for a narrower spectrum antimicrobial than initially prescribed. This empirical approach makes the selection of an appropriate antimicrobial even more important. Choosing an antimicrobial with a spectrum too broad can lead to preventable AMR, while a too narrow-spectrum antimicrobial may not be effective against a particular bacterial infection. In hospital care antimicrobial medication is currently essential in many treatments, even if no actual infection is present, such as in the protocollary prevention of infection during an operation. In general, antimicrobial prescribing starts empirically with the treatment of an infection and a specific antimicrobial drug is chosen based on expected causative bacteria and the type and location of the presumed infection (13). Infections in patients admitted to the hospital are usually severe and these patients are at additional risk of complications. Hence, in hospital care initial treatment has to be effective to prevent further deterioration, usually resulting in the choice of a broad-spectrum antimicrobial effective against nearly all causative bacteria, often including less susceptible strains or species. As part of hospital treatment, cultures are routinely obtained, so when antimicrobial stewardship is practiced, antimicrobials
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