动员政治意愿，控制抗菌素耐药性
本帖最后由 潮水 于 2011-3-26 15:36 编辑Vemu Lakshmi是长期呼吁对耐药性采取更多行动的若干印度医生之一。去年在她的国家掀起了一股争议的旋风，涉及高度耐药的“超级细菌”，即含有所谓的“NDM-1”酶的细菌。
“在很长一段时间内，印度有些微生物学家一直强调，迫切需要为医生提供微生物学实验室支持并制定严格的抗生素处方准则和政策”，尼扎姆医学科学研究所（海得拉巴）微生物学系教授兼主任Lakshmi说。
Lakshmi及其同事知道，医院和社区中不适当使用抗生素（包括因不了解耐药机制而采用过低的治疗剂量）、无处方销售抗生素的情况广泛存在以及病人不能完成抗生素疗程，将不可避免地产生抗菌素耐药性。在2008年《印度医学生物学杂志》的一篇文章中，她详细地讨论了这些问题。
2010年8月《柳叶刀传染病》发表的一篇论文介绍了这种抗药性细菌在印度、巴基斯坦和大不列颠及北爱尔兰联合王国传播的情况。2008年首次在一名从新德里返回的瑞典病人身上识别出“NDM-1”，即新德里金属β-内酰胺酶。
专家们尤其关注的是，这种酶可见于人群中最常出现的细菌之一，即大肠杆菌，而且含有这种酶的菌株至少有十分之一似乎对所有已知抗生素具有耐药性。
抗菌素耐药性是影响所有国家的一个全球性问题。今年4月7日的世界卫生日将力图使各国政府更加重视这一问题，并鼓励它们采取措施抵御这一全球威胁。
“抗菌素耐药性是一个真实的公共卫生问题，正在全球和欧洲显现。我们需要采取更多的行动——不但在世卫组织，而且在会员国中”，世卫组织欧洲区域主任Zsuzsanna Jakab说。Jakab充分认识到针对欧洲抗菌素耐药性的斗争需要持续提高警惕，否则耐药性结核病等问题将恶化。“这是一个过程的开始；我们可以，而且必须提高决策者和公众的认识，并在世界卫生日之后落实各项战略”，Jakab说。
世卫组织已不是第一次出面应对这一问题。在2001年，世卫组织发表了《控制抗菌素耐药性全球战略》，其中包含各国可自己调整使用的建议。但是，在华盛顿（哥伦比亚特区）举行的发表仪式恰逢美国2001年9月11日的恐怖主义袭击，结果在随后的混乱中丧失了所有的动力。
尽管如此，对世卫组织患者安全规划的Gerald Dziekan博士来说，2001年的行动为一些国家应对这一问题提供了起始点。
“这肯定在有些国家启动了制定国家计划的工作，但在总体上，从全球认识和协调行动的角度来看，反应很弱”，Dziekan说。Dziekan认为，各国政府面临的挑战之一是如何执行法律禁止无处方销售抗生素。“这在低收入到中等收入国家中尤为困难，那儿常常没有医生来开处方，但人们总需要设法获得药物。”
但也正是在这些国家，对这一问题的感受越来越大。据美国杜克大学桑福德公共政策学院教授Anthony So说：“抗生素耐药性并不局限于欧洲和北美富裕国家的急救科。”
“这是一个不断增长的全球卫生问题，严重影响低收入国家的弱势群体”，So说，并补充道：“在非洲、亚洲和拉丁美洲，对肺炎、脑膜炎或血液感染患儿常常施用因耐药性而变得无效的陈旧药物，因为这是唯一可用的治疗方案。”
智利的例子显示，管制当局的协同努力可产生影响。该国强制性地规定抗生素需要处方并禁止在无处方的情况下出售，从而使情况大不相同。
智利比尼亚德尔马Clinica Reñaca内科主任Luis Bavestrello博士说，在媒体中强调抗菌素耐药性的风险，取得了效果。
“即使政府不认为抗菌素耐药性是一个优先重点问题，但也讨论了一些建议并采取了重要的措施”，兼任智利传染病学会抗菌素委员会协调员的Bavestrello说。作为例子，他介绍了全国医院抗菌素耐药性监测规划以及医学界和负责卫生与农业的政府部委代表组成的一个国家委员会。
与智利和印度的情况相同，肯尼亚的医学界也站在第一线，努力应对这一问题。“医生、药剂师、其他专业人员和学者注意到抗菌素耐药性的问题”，内罗毕大学兽医系药理学和毒理学教授Eric Mitema说。他还补充说：“这些专业人员努力使政府注意到抗菌素耐药性。”
在印度，正在开展若干行动以解决这一问题。正在制定国家抗生素政策，但尚未公开。据临床医生说，医院可根据自己的情况把该政策纳入其自己的准则。
“另一项积极的事态发展是政府正在敦促医院获得国家医院和卫生保健提供者资格认证委员会的资格认证”，Lakshmi说。她还补充说：“一旦一个医院获得资格认证，它就必须实行与明智使用抗生素相关的做法”
但Lakshmi补充说，至今“政府或其它任何组织都没有任何具体的法律或条规来防范抗菌素耐药性。”
即使在比利时和法国等已减少使用抗生素的西欧国家，也继续存在滥用的情况。只有少数国家有政策控制和防范抗菌素耐药性。宣传倡导者赞扬挪威和瑞典等北欧国家，因为它们做了大量工作以应对该问题。他们还提及荷兰，作为抗生素处方量较少和具备完善的抗生素使用准则的国家范例。
全球防范抗菌素耐药性的最有力措施之一是自2006年以来在27个欧盟国家中禁止使用抗生素作为牲畜生长促进剂。该禁令突出了问题的复杂性。“抗菌素耐药性是超越卫生部门的一个问题，所以很重要的是要由所有部门参与”，Jakab说。“每一国家的政府应当有关于如何处理和应对该问题的国家部门间计划。”
临床医生一致认为最大的挑战之一是了解每个国家中耐药性感染问题的真实规模。“我们需要更好的微生物实验室以便检测各种感染对抗生素的耐药性，但我们首先需要更好的数据以便充实政策”，全球抗生素耐药性伙伴关系——印度国家工作小组主席Nirmal Ganguly教授说。
对有些人来说，仅限制无处方销售抗菌素还不够。他们提出，需要更多的措施以减少使用二线抗生素。这种抗生素应当在一线抗生素失效时才用于治疗感染，而且可能是最后的办法。
钦奈的一名传染病和临床真菌学顾问Abdul Ghafur博士认为：“长期说来，限制无处方销售一线抗生素产生的有益作用将很明显，但我们最需要的是限制在医院中使用高端抗生素。” Bulletin of the World Health Organization
http://www.who.int/bulletin/volumes/89/3/11-030311/en/
Mobilizing political will to contain antimicrobial resistance
The third part of our series on antimicrobial resistance looks at what governments are doing and what they can do next to combat this global threat. Patralekha Chatterjee and Fiona Fleck report.
Bulletin of the World Health Organization 2011;89:168–169. doi:10.2471/BLT.11.030311
Vemu Lakshmi is one of several Indian physicians who had long been calling for more to be done about drug resistance. Then, last year, a whirlwind of controversy blew up in her country about the highly resistant “superbugs”, bacteria containing the so-called “NDM-1” enzyme.
“Some Indian microbiologists had been flagging the urgent need for microbiological laboratory support for doctors and strict guidelines on antibiotic prescriptions and policies for quite some time,” says Lakshmi, who is professor and head of the Department of Microbiology at Nizam’s Institute of Medical Sciences, in Hyderabad.
Lakshmi and her colleagues knew that antimicrobial resistance would be the inevitable result of inappropriate use of antibiotics in hospitals and in the community (including sub-therapeutic doses due to ignorance about resistance mechanisms), widespread over-the-counter sales of antibiotics and patients failing to complete their courses of antibiotics. She discussed these problems in detail in an article in the Indian Journal of Medical Microbiology in 2008.
The spread of the resistant bacteria in India, Pakistan and the United Kingdom of Great Britain and Northern Ireland was described in a paper published in the Lancet Infectious Diseases in August 2010. “NDM-1”, or New Delhi metallo-beta-lactamase, was first identified in a Swedish patient who had returned from New Delhi in 2008.
Antimicrobial resistance is a global problem that affects all countries. This year’s World Health Day on 7 April aims to make governments more aware of the problem and to encourage them to take measures to combat this global threat.
“ is a real public health problem and it is emerging globally and in Europe. We have to do much more about it – both in the World Health Organization (WHO) and also in Member States,” says Zsuzsanna Jakab, WHO Regional Director for Europe. Jakab is well aware that the struggle against antimicrobial resistance in Europe requires continuous vigilance if problems such as drug-resistant tuberculosis are not to get worse. “This is the start of a process; we can and have to raise awareness among policy-makers and the public, and follow up with strategies after World Health Day,” Jakab says.
It is not the first time WHO has tackled the issue. In 2001, WHO released the Global Strategy for Containment of Antimicrobial Resistance, containing recommendations that countries could customize for their own use. But the launch in Washington DC coincided with the attacks of 11 September 2001 in the United States of America (USA) and any momentum was lost in the subsequent turmoil.
For Dr Gerald Dziekan, from WHO’s Patient Safety Programme, the 2001 initiative nevertheless provided a start for some countries in tackling the problem.
“It certainly triggered the development of national plans in some countries, but all in all the response was quite weak in the sense of global awareness and coordinated action,” Dziekan says. One of the challenges governments face in Dziekan’s view is enforcing laws banning over-the-counter sales of antibiotics. “This is particularly difficult in countries where there are often no doctors to prescribe medicines but people need to get the drugs somehow.”
But it is also in these countries where the problem is increasingly being felt. “Antibiotic resistance is not confined to the emergency rooms of rich countries in Europe and North America,” according to Anthony So, professor at the Sanford School of Public Policy at Duke University in the USA.
“It is a growing, global health problem that severely affects disadvantaged populations in low-income countries,” So says, adding: “Children in Africa, Asia and Latin America suffering from pneumonia, meningitis or blood stream infections are often given old drugs rendered ineffective by resistance since they are the only available treatment options.”
A concerted effort on the part of regulatory authorities can have an impact, as shown in Chile, for example, where the mandatory prescription of antibiotics and the ban of over-the-counter sales has made a difference.
Dr Luis Bavestrello, medical director of Clinica Reñaca in Viña del Mar in Chile, says that highlighting the risks of antimicrobial resistance in the media has paid off.
“Even if antimicrobial resistance is not considered a priority problem by the government some suggestions are discussed and important measures have been taken,” says Bavestrello, who is also coordinator of the Antimicrobial Commission of the Chilean Infectious Diseases Society. He gives the examples of a nationwide surveillance programme of antimicrobial resistance in hospitals and a national committee of representatives from medical communities and government ministries responsible for health and for agriculture.
As in Chile and India, medical communities in Kenya, for example, are also at the forefront of efforts to tackle the problem. “Doctors, pharmacists, other professionals and academics are aware of the antimicrobial resistance problem,” says Eric Mitema, professor of pharmacology and toxicology at the faculty of Veterinary Medicine at the University of Nairobi, adding: “These professionals make efforts to make the government aware of antimicrobial resistance.”
In India, several initiatives are under way to address the problem. A national antibiotic policy is being prepared, though not yet in the public domain, which hospitals can customize into their own guidelines, clinicians say.
“ positive development is that the government is urging hospitals to get themselves accredited with the National Accreditation Board for Hospitals and Health Care Providers,” says Lakshmi, adding: “Once a hospital is accredited, it will have to put in practices relating to judicious use of antibiotics.”
But Lakshmi adds that as yet, “neither the government nor any other organization has any specific laws or regulations to prevent antimicrobial resistance”.
Even in western Europe, where countries such as Belgium and France have reduced the use of antibiotics, misuse continues. A few of these countries have policies on containing and preventing antimicrobial resistance. Campaigners praise Scandinavian countries such as Norway and Sweden for having done a lot to tackle the problem. They also cite the Netherlands as an example of a country with low prescribing of antibiotics and excellent guidelines on their use.
One of the most powerful measures globally to prevent antimicrobial resistance has been the ban of the use of antibiotics as growth promoters in livestock in the 27 European Union countries since 2006. The ban underlines the complex nature of the problem. “Antimicrobial resistance is a problem that goes beyond the health sector, so it is important to involve all sectors,” says Jakab. “Every government should have a national intersectoral plan on how to address the issue and respond to it.”
Clinicians agree that one of the biggest challenges is finding out the true size of the problem of resistant infections in each country. “We need better microbiology labs to test antibiotic resistance to infections but above all we need better data to inform policies,” says Professor Nirmal Ganguly, Chair of the Global Antibiotic Resistance Partnership – India National Working Group.
For some, simply restricting over-the-counter sales of antimicrobials does not go far enough, and they suggest that more is needed to curb the use of second-line antibiotics, which should be used to treat infections when first-line antibiotics fail and may be the last resort.
As Dr Abdul Ghafur, a consultant in infectious diseases and clinical mycology in Chennai, argues: “The beneficial effect of restriction of first-line antibiotics sold over the counter will be evident in the long term, but what we need most is restriction of higher-end antibiotics used in hospitals.” 谢谢版主提供的链接并翻译了全文！ 回复 1# 潮水
合理用药，提了多少年，效果如何？众人皆知。现在单靠职业道德已经不能控制抗菌药物的合理应用了，确实应该采取一些必要的行政干预，而且发现一个干预一个，干预措施一定要严格，否则又是虎头蛇尾。据说，某医院以前药品比例很高，后来听说检察院找该医院医生逐个谈心，现在药品比例降到50%以下了。 这个。。。。利益关系太复杂，恐怕。。。。如果中国能治理贪污腐败，就能治理抗生素，所以。。。。你懂的。。。。{:1_249:} 本帖最后由 Adler007 于 2011-3-27 13:29 编辑
医护人员和其他行业相比（如医药代表等等），我们医护人员的待遇实在太低了，住院医还不如个农民工。在国内，什么时候把医生的地位提高到和欧美国家的医生一样，我想也不会由商业贿赂了 今年的二会，不是有代表将合理使用抗菌药物以议案的形式提一去了吗？相信不久的将来这种不合理现象定会有所改变甚至是较大的改变的，政策的真正介入是解决问题的关键所在。 提高医务人员的待遇，切断利益链（包括现在的药品招标也存在腐败，为什么这么样定药品价格？），国家必须从根源斩断，才能从根本上治理抗菌药物！
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