拉克斯米納拉揚 (Ramanan Laxminarayan) / 2024 年 9 月 17 日 / 世界觀 / 自然
確保低收入和中等收入國家的診所備有充足的高品質抗生素，可以幫助醫生每年治療數百萬人，並減緩抗藥性的蔓延。
抗生素抗藥性（AMR）——細菌、真菌或原生動物對抗菌物質產生抗藥性——的問題正在惡化。本(9)月，各國元首齊聚紐約，出席第 79 屆聯合國大會，討論此議題以及其他全球挑戰。
這是抗生素藥物抗藥性問題第二次在聯合國高級別會議上受到關注。第一次發生在 2016 年，強調了這個問題的重要性，它與全球每年近 500 萬人死亡有關。儘管過去八年來取得了一些進展，例如許多國家制定了國家行動計畫，但變革的步伐仍然緩慢。作者將在即將舉行的會議上發言，我希望讓與會者相信，未來八年可能會非常不同。
解決抗生素抗藥性需要採取量身定制的方法—四位專家參與其中
推動全球抗生素藥物抗藥性上升的主要因素之一是使用不適當或不合格的抗生素。事實上，低收入和中等收入國家的人們往往缺乏「二線」抗生素——比首選治療藥物更有效，而且往往更昂貴——，且更有可能死於以下原因引起的感染：「比高收入國家具有更強的抗藥性的細菌」。然而，五月發表在《刺胳針》上的一項模型研究（作者參與了這項研究）顯示，即使是相當適度的全球投資（數億美元）也可以幫助預防細菌感染，並改善獲得相對便宜抗生素服務的機會，且可以避免數百萬人的死亡（J. A. Lewnard et al. Lancet 403, 2439–2454; 2024）。
每年約有 770 萬人死於細菌感染。其中五分之一是五歲以下的兒童。根據我們在《刺胳針》發表的研究，至少75 萬人的死亡可以透過預防策略來避免，例如提供安全的水和良好的衛生設施、確保兒童接種推薦的疫苗、感染抗藥性細菌個體的隔離以及實施增加洗手頻率的方案。我們的研究還顯示，死亡人數的最大減少將來自於人們獲得抗生素的機會之改善，而在世界上許多國家的大多數細菌感染相關死亡發生的事件中，抗生素是無法獲得的。
抗生素抗藥性是日益嚴重的威脅——氣候變遷是否會使情況變得更糟？
瘧疾和大多數細菌感染的持續時間不像結核病或愛滋病那麼長，人們往往在感染後數月或數年中死亡。如果感染的孩子早上發燒，而卻沒有接受正確的抗生素治療，第二天可能就會死亡。但在低收入和中等收入國家，許多公共部門診所都無法提供這些服務。父母和其他照護人員必須經常向當地藥局尋求協助。由於這些藥房在限制不適當、劣質或假藥進入系統上比起公共部門藥房更難確立，然而數億人卻正在使用它們。
細菌感染被不公平地忽視——可能是因為造成細菌感染的病原體多種及多樣，因此沒有像愛滋病、結核病和瘧疾的情況一樣，有明確的利害關係人組成之群體可以去倡導變革。總部位於瑞士日內瓦的全球抗愛滋病、結核病和瘧疾基金每年都會花費近 50 億美元，以確保低收入國家能夠獲得治療這些疾病的藥物。這三種疾病每年總共導致約 280 萬人死亡，卻不到與結核病以外的細菌感染有關的人數的一半。
對抗抗生素抗藥性
全球基金等國際資助者必須挺身而出。愛滋病毒感染者發生細菌、病毒、真菌和原蟲感染的風險很高。為人們提供有效的診斷和更廣泛地針對細菌感染的抗生素將是全球基金現有使命的自然延伸。
此外，預防策略——特別是提供疫苗、安全飲水和良好的衛生設施——需要全球疫苗和免疫聯盟(Gavi)、疫苗聯盟 (the Vaccine Alliance) 等組織以及雙邊捐助者的支持，其中包括位於華盛頓特區的美國國際開發署 (the United States Agency for International Development) ；它們還需要在低收入和中等收入國家的國家預算中優先被考慮。
從過去聯合國宣言的經驗顯示，各國所做的具體承諾將更有可能實現具體地轉化為行動，而不僅是那些不清楚對哪些組織期望的語言。 5 月出版的《刺胳針抗生素抗藥性系列》呼籲到 2030 年，將人類抗生素抗藥的死亡率降低 10%，將人類不當抗生素使用率降低 20%，將動物不當抗生素使用率降低 30%（見go .nature.com/4d4xg）—皆與2019 年的制定之水準有關。由世界衛生組織、聯合國環境規劃署、糧食及農業組織和世界動物衛生組織 (the World Health Organization, the United Nations Environment Programme, the Food and Agriculture Organization and the World Organisation for Animal Health) 這四個政府間組織設立的獨立小組的支持不斷增加，以評估應對抗菌素抗藥性的證據。
憑藉全球資助者的投資、具體目標以及獨立小組的問責制，今年大會的討論更有可能轉化為應對抗生素抗藥性的全球行動。
《自然》 633, 495 (2024)
doi：https://doi.org/10.1038/d41586-024-02993-3
利益競爭：作者聲明不存在競爭利益。
Stop delaying action on antimicrobial resistance —
it is achievable and affordable
Ramanan Laxminarayan / 17 September 2024 / WORLD VIEWN / nature
Ensuring that clinics in low- and middle-income countries are well-stocked with high-quality antibiotics could help physicians to treat millions of people each year and slow the spread of drug resistance.
The problem of antimicrobial resistance (AMR) — bacteria, fungi or protozoans evolving resistance to antimicrobial substances — is worsening. This month, heads of state are gathering in New York City at the 79th session of the United Nations General Assembly to discuss the issue, among other global challenges.
This is the second time that AMR has been featured at a high-level UN meeting. The first one, in 2016, highlighted the importance of the problem, which is associated with nearly five million deaths each year worldwide. Although there has been some progress in the past eight years, such as the development of national action plans by many countries, the pace of change has been slow. I am presenting at the upcoming meeting, and I hope to convince attendees that the next eight years could look very different.
Tackling antimicrobial resistance needs a tailored approach — four specialists weigh in
One of the main factors driving the global rise of AMR is the use of inappropriate or substandard antibiotics. Indeed, people in low- and middle-income countries, which often lack ‘second-line’ antibiotics — more effective, and often more expensive, than those that are the first choice for treatment — are much more likely to die of infections caused by resistant bacteria than are those in high-income nations. A modelling study published in The Lancet in May (which I was involved in) indicates, however, that even a fairly modest global investment — in the range of hundreds of millions of US dollars — to help prevent bacterial infections and improve access to relatively inexpensive antibiotics could avert millions of deaths (J. A. Lewnard et al. Lancet 403, 2439–2454; 2024).
Each year, about 7.7 million people die from bacterial infections. One-fifth of these are children under the age of five. According to our Lancet study, at least 750,000 of these deaths could be averted through prevention strategies such as providing safe water and good sanitation, ensuring that children receive recommended vaccines, isolating individuals infected with resistant bacteria and implementing protocols to increase the frequency of handwashing in hospitals. Our study also indicates that the largest reduction in deaths would come from improving people’s access to antibiotics that are not available in many countries where most of the world’s bacterial-infection-related deaths occur.
Antibiotic resistance is a growing threat — is climate change making it worse?
Malaria and most bacterial infections do not last as long as do tuberculosis or AIDS, from which people tend to die months or years after infection. A child with an infection who develops a fever in the morning can be dead the next day if they don’t receive the right antibiotics. But in low- and middle-income countries, those are unavailable in many public-sector clinics. Parents and other carers must frequently turn to their local pharmacies for help. Because it is harder in those pharmacies than in public-sector ones to set up systems that limit the entry of inappropriate, poor-quality or fake drugs, hundreds of millions of people are using them.
Bacterial infections have been unfairly neglected — probably because a diverse array of pathogens are responsible for them, so there is no clear group of stakeholders who can advocate for change, as is the case for AIDS, tuberculosis and malaria. Each year, the Global Fund to Fight AIDS, Tuberculosis and Malaria, based in Geneva, Switzerland, spends nearly US$5 billion to ensure that the drugs to treat these diseases are available in low-income countries. These three diseases collectively kill about 2.8 million people each year — less than half the number linked to bacterial infections other than tuberculosis.
The fight against antimicrobial resistance
International funders, such as the Global Fund, must step up. People with HIV have a high risk of developing bacterial, viral, fungal and protozoal infections. Providing people with access to effective diagnostics and antibiotics targeting bacterial infections more broadly would be a natural extension of the Global Fund’s existing mandate.
Furthermore, prevention strategies — especially the provision of vaccines, safe water and good sanitation — need to be supported by organizations such as Gavi, the Vaccine Alliance, as well as through bilateral donors, including the United States Agency for International Development in Washington DC. They also need to be prioritized in national budgets in low- and middle-income countries.
Experience from past UN declarations shows that specific commitments made by countries are more likely to translate into action than is language that is unclear about what is expected of which organizations. The Lancet Series on Antimicrobial Resistance, published in May, calls for a 10% reduction in human mortality from AMR, a 20% reduction in the inappropriate antibiotic use in people and a 30% reduction in the inappropriate antibiotic use in animals by 2030 (see go.nature.com/4d4xg) — all relative to levels in 2019. And support is growing for an independent panel set up by four intergovernmental organizations — the World Health Organization, the United Nations Environment Programme, the Food and Agriculture Organization and the World Organisation for Animal Health — to appraise the evidence around tackling AMR.
With investment from global funders, specific targets and accountability through an independent panel, there is a much higher chance of this year’s discussions at the General Assembly translating into global action to tackle AMR.
Nature 633, 495 (2024)
doi: https://doi.org/10.1038/d41586-024-02993-3
Competing Interests
The author declares no competing interests.