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Resistance to parenteral antimicrobials generally occurs within two years after introduction into general use. The site where de novo resistance develops has been acknowledged to be the gut. Overgrowth of abnormal flora, defined as 105 potential pathogens per g of faeces is a risk factor for resistance following increased spontaneous mutation leading to polyclonality and antimicrobial resistance. As parenteral antimicrobials generally fail to eradicate the abnormal carrier state in overgrowth concentrations due to sub-lethal concentrations in bile and mucus the enteral antimicrobials polymyxin/tobramycin aiming at converting the abnormal carrier state into normal carriage, are the essential component of selective decontamination of the digestive tract (SDD), because they eradicate carriage and overgrowth including resistant mutants, maintaining the usefulness of parenteral antimicrobials.

The addition of enteral to parenteral antimicrobials may prolong antibiotic era