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The endless struggle
Editorial
Almost 10 years ago, in an editorial in this journal advocating the prudent use of antibiotics to limit development of resistance, we described these drugs as a “gift to be used sparingly”. In 2001, antibiotic resistance was not very fashionable beyond clinicians and researchers with first-hand knowledge of the topic. However, now that it is the focus of WHO’s World Health Day on April 7, resistance has joined the front rank of global health concerns. What has brought antibiotic resistance into the limelight, and can this new-found status be harnessed to “safeguard these medicines for future generations”, to use the words of the World Health Day website? In 2001, WHO launched its Global Strategy for Containment of Antimicrobial Resistance. This report was, arguably, strong on recommendations but not on implementation. Besides, its impact was completely overshadowed by the events September 11, 2001, and subsequent posting of anthrax spores through the US mail, which shifted attention onto the threat of bioterrorism. Campaigning groups such as The Alliance for the Prudent Use of Antibiotics (APUA) and ReAct helped maintain the impetus to combat antibiotic resistance. The 2004 Infectious Diseases Society of America report Bad Bugs, No Drugs was important in bringing antibiotic resistance back to the attention of policy makers. But emerging epidemics of antibiotic-resistant infections are probably what has brought the issue into the public domain and thus piqued the interest of governments. A subject that might once have seemed rather distant from the man or woman in the street now frequently makes headlines. At times during the past decade, the casual observer could have been forgiven for thinking that hospitals in some countries were on the point of collapse from a wave of meticillin-resistant Staphylococcus aureus (MRSA) infections. And MRSA has now escaped into community settings, particularly in the USA. Clostridium difficile, the emergence of which as a serious health-careassociated infection is due to overuse of broad-spectrum antibiotics, shows increasing signs of resistance to several antibiotics, and has enjoyed a rise to public attention similar to that of MRSA. β-lactam resistance among Gram-negative bacteria is hardly a recent concern, but a carbapenemase-producing form called NDM-1, which also confers resistance to almost all antibiotics, grabbed attention worldwide last August when clusters www.thelancet.com/infection Vol 11 April 2011
of cases were reported from the Indian subcontinent and UK. Human infections with bacteria carrying the NDM-1 enzyme have now been reported from at least 20 countries. Let us also not forget the 440 000 or so cases of multidrug-resistant tuberculosis that occur worldwide every year. Indeed, a troubling feature of recent years is the increasing frequency of multidrug resistance among common bacteria, with around 400 000 Europeans having such infections annually. Our very rough estimate is that resistant infections double mortality, cost of treatment, and length of hospital stay. Bearing in mind that our objective is to contain antibiotic resistance rather than eradicate it, several policies could be adopted to help guarantee a future for antibiotics. We need reliable data to tackle antibiotic resistance. Thus establishment of a worldwide network of resistancesurveillance laboratories is essential, and a policy that WHO seems suited to implement. Prescribers relied on a stream of new antibiotics to treat infections with resistant organisms. Yet that stream reduced to a trickle by the end of the past century. There are signs of hope—by some estimates around 70 new antibacterials are undergoing clinical development, but few of these represent new classes of drugs or are active against Gram-negative infections. Market forces alone will likely not reinvigorate the antibiotic pipeline. Various ways have been suggested of incentivising the pharmaceutical industry including patent pooling, advanced market commitments, and prize funds. In the end, governments and other major global health donors may have to take a more active role in building on the model of public–private partnerships for development of drugs for neglected diseases. Ensuring that antibiotics are used only when indicated and not— for example—sold without prescription is essential. It is encouraging then that India and China, the world’s two most populous nations, are preparing to announce new antibiotic policies and regulations. At the end of 2009 the presidents of the USA and EU agreed to establish a taskforce on antibiotic resistance, due to report this year. The interest of world leaders indicates that resistance is no longer being sidelined as a vital health issue. Although this interest is not itself sufficient to combat resistance, the post-antibiotic era is not yet upon us. █ The Lancet Infectious Diseases
WHO
The endless struggle
For the 2001 editorial see Leading Edge Lancet Infect Dis 2001; 1: 1 For more on World Health Day 2011 see http://www.who.int/ world-health-day/2011/en/ index.html For the 2001 WHO strategy see http://whqlibdoc.who.int/ hq/2001/WHO_CDS_CSR_ DRS_2001.2.pdf For APUA see http://www.tufts. edu/med/apua/ For ReAct see http://www. reactgroup.org/ For Bad Bugs, No Drugs see http://www.idsociety.org/ WorkArea/linkit.aspx? LinkIdentifier=id&ItemID=5554 For NDM-1 see Articles Lancet Infect Dis 2010; 10: 597–602 For more on the USA-EU taskforce see Newsdesk Lancet Infect Dis 2010; 10: 12–13
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Almost 10 years ago, in an editorial in this journal advocating the prudent use of antibiotics to limit development of resistance, we described these drugs as a “gift to be used sparingly”. In 2001, antibiotic resistance was not very fashionable beyond clinicians and researchers with first-hand knowledge of the topic. However, now that it is the focus of WHO’s World Health Day on April 7, resistance has joined the front rank of global health concerns. What has brought antibiotic resistance into the limelight, and can this new-found status be harnessed to “safeguard these medicines for future generations”, to use the words of the World Health Day website? In 2001, WHO launched its Global Strategy for Containment of Antimicrobial Resistance. This report was, arguably, strong on recommendations but not on implementation. Besides, its impact was completely overshadowed by the events September 11, 2001, and subsequent posting of anthrax spores through the US mail, which shifted attention onto the threat of bioterrorism. Campaigning groups such as The Alliance for the Prudent Use of Antibiotics (APUA) and ReAct helped maintain the impetus to combat antibiotic resistance. The 2004 Infectious Diseases Society of America report Bad Bugs, No Drugs was important in bringing antibiotic resistance back to the attention of policy makers. But emerging epidemics of antibiotic-resistant infections are probably what has brought the issue into the public domain and thus piqued the interest of governments. A subject that might once have seemed rather distant from the man or woman in the street now frequently makes headlines. At times during the past decade, the casual observer could have been forgiven for thinking that hospitals in some countries were on the point of collapse from a wave of meticillin-resistant Staphylococcus aureus (MRSA) infections. And MRSA has now escaped into community settings, particularly in the USA. Clostridium difficile, the emergence of which as a serious health-careassociated infection is due to overuse of broad-spectrum antibiotics, shows increasing signs of resistance to several antibiotics, and has enjoyed a rise to public attention similar to that of MRSA. β-lactam resistance among Gram-negative bacteria is hardly a recent concern, but a carbapenemase-producing form called NDM-1, which also confers resistance to almost all antibiotics, grabbed attention worldwide last August when clusters www.thelancet.com/infection Vol 11 April 2011
of cases were reported from the Indian subcontinent and UK. Human infections with bacteria carrying the NDM-1 enzyme have now been reported from at least 20 countries. Let us also not forget the 440 000 or so cases of multidrug-resistant tuberculosis that occur worldwide every year. Indeed, a troubling feature of recent years is the increasing frequency of multidrug resistance among common bacteria, with around 400 000 Europeans having such infections annually. Our very rough estimate is that resistant infections double mortality, cost of treatment, and length of hospital stay. Bearing in mind that our objective is to contain antibiotic resistance rather than eradicate it, several policies could be adopted to help guarantee a future for antibiotics. We need reliable data to tackle antibiotic resistance. Thus establishment of a worldwide network of resistancesurveillance laboratories is essential, and a policy that WHO seems suited to implement. Prescribers relied on a stream of new antibiotics to treat infections with resistant organisms. Yet that stream reduced to a trickle by the end of the past century. There are signs of hope—by some estimates around 70 new antibacterials are undergoing clinical development, but few of these represent new classes of drugs or are active against Gram-negative infections. Market forces alone will likely not reinvigorate the antibiotic pipeline. Various ways have been suggested of incentivising the pharmaceutical industry including patent pooling, advanced market commitments, and prize funds. In the end, governments and other major global health donors may have to take a more active role in building on the model of public–private partnerships for development of drugs for neglected diseases. Ensuring that antibiotics are used only when indicated and not— for example—sold without prescription is essential. It is encouraging then that India and China, the world’s two most populous nations, are preparing to announce new antibiotic policies and regulations. At the end of 2009 the presidents of the USA and EU agreed to establish a taskforce on antibiotic resistance, due to report this year. The interest of world leaders indicates that resistance is no longer being sidelined as a vital health issue. Although this interest is not itself sufficient to combat resistance, the post-antibiotic era is not yet upon us. █ The Lancet Infectious Diseases
WHO
The endless struggle
For the 2001 editorial see Leading Edge Lancet Infect Dis 2001; 1: 1 For more on World Health Day 2011 see http://www.who.int/ world-health-day/2011/en/ index.html For the 2001 WHO strategy see http://whqlibdoc.who.int/ hq/2001/WHO_CDS_CSR_ DRS_2001.2.pdf For APUA see http://www.tufts. edu/med/apua/ For ReAct see http://www. reactgroup.org/ For Bad Bugs, No Drugs see http://www.idsociety.org/ WorkArea/linkit.aspx? LinkIdentifier=id&ItemID=5554 For NDM-1 see Articles Lancet Infect Dis 2010; 10: 597–602 For more on the USA-EU taskforce see Newsdesk Lancet Infect Dis 2010; 10: 12–13
253