The current issue of Medicina Intensiva publishes the analysis of results of a nationwide multimodal initiative known as the Zero Resistance (ZR) program1 intended to reduce the acquisition of multidrug-resistant (MDR) bacteria in patients admitted to intensive care units (ICU). The problem with infections following MDR bacteria is a significant and pressing problem of gram-negative infections with new patterns of resistance and treatment difficulties.2–4

The objective of the project was to analyze the impact of a set of 10 recommendations given between 2014 and 2016 on ICU-acquired MDR bacteria. These were a set of recommendations on preventive isolation based on risk factors. We should mention the significant effort made in training during the project and its association with a safety program at the ICU setting (implicit in the different infection control and management projects derived from the ENVIN registry).

The project included a total of 103 ICUs, 130000 patients, and over 800000 stay days at the ICU setting. Besides these spectacular numbers, I believe that the following results are relevant:

• 1.

  Gradual increase in the number of patients in whom MDR bacteria colonization/infection is detected at ICU admission (a 32% increase). This piece of information per se is extremely relevant, changes completely the concept of acquisition of MDR bacteria at the ICU setting, and focuses on the previous colonization of patients from different hospital settings or admitted directly from the community. Per se, this finding confirms the significance of monitoring colonizations at ICU admission with a higher rate of positivity in relation to running tests, which is something that we may have not done before.

• 2.

  Lower rate of MDR bacteria acquired at the ICU setting (around 25%). Although this result is not significant in the study statistical analysis, there is no doubt that it is an important and clinically relevant finding. Also, at the ICU setting, the acquisition MDR bacteria is associated with colonizations rather than infections. By the way, fewer infections (46%) were reported during the project.

The project has some limitations the authors have made public in the manuscript. Distinguishing infection from colonization is always controversial and requires unequivocal definitions to make sure we are talking about the same thing in all the cases. In the study it was difficult to measure reliably the compliance of the different ICUs to the measures proposed.

However, we should mention how important this type of collaborative projects among different health professionals really is. Undoubtedly, the ENVIN registry, in general, and the ZR program, in particular, lay the foundations for new collective efforts like the ones made to assess cancer patients admitted to the ICU (Onco-ENVIN)5 or recommendations made during the COVID-19 pandemic6 based on previous experiences. During the COVID-19 pandemic the issue of MDR bacterial infections has experienced setbacks that should make us rethink strategies7 and analyze the impact of different measures like preventive isolations.8

Undoubtedly, this project is part of a monitorization and prevention strategy regarding the appearance of infections at the ICU setting, which is a great advancement and a total heads-up to improve preventive activities in critically ill patients. This type of collective efforts is hard to make and even harder to keep across time. Only through individual and collective coordination efforts from all the investigators involved, and institutional support from scientific societies like different health agencies (both the ministry of health and autonomous communities) this type of collective efforts can become a reality. Both the fields of medicine and critical care nursing are associated with two different activities not fully recognized (early detection and prevention).

I would not want to end this editorial without mentioning Dr. Alvarez Lerma. Without his leadership—and knowing that this is a collective effort—it may have been impossible to conduct nationwide initiatives like this one.

Knowledge, leadership, and collaboration are key in today’s medicine, not only for infection control and management.