Access to antibiotics: a safety and equity challenge for the next decade.

0.15 MB·English

by  Carlet, Jean

CarletandPittetAntimicrobialResistanceandInfectionControl2013,2:1
http://www.aricjournal.com/content/2/1/1
COMMENTARY Open Access
Access to antibiotics: a safety and equity
challenge for the next decade
Jean Carlet1,2* and Didier Pittet3
Abstract
Bacterial resistance to antibiotics is increasing worldwide inhealthcare settings and in the community. Some
microbial pathogens have become resistant to multiple antibiotics, if notall presently available, thus severely
compromising treatment success and contributing to enhanced morbidity, mortality, and resource use. The major
driver ofresistance is misuse of antibioticsinboth human and non-humanmedicine.Both enhanced access and
restricted use in many parts of theworldis mandatory. There is anurgentneed for an international, integrated,
multi-level action to preserve antibioticsinthe armamentarium of the21st century and address theglobal issue of
antimicrobial resistance.
Keywords: Antibiotics, Antimicrobial resistance, Antimicrobial resistance surveillance,Antibiotics –use, Multidrug-
resistant organisms
Background eradication of some pandemic infections, such as malaria,
Antibiotics are one of the most important discoveries in tuberculosis, and human immunodeficiency virus (HIV)/
medicine and have saved millions of lives. The current acquired immunodeficiency syndrome (AIDS), in particu-
paradoxical scandal is that although most resource- lar due to the generous support of the Global Fund,
limited countries still lack easy access to antibiotics, UNITAID, The Bill & Melinda Gates Foundation, and
their overuse and abuse is rife in developed nations and other large international funding organizations. However,
thecauseofacceleratingratesofresistancedevelopment. infectionsduetocommonmicroorganismsresponsiblefor
A global two-pronged approach is urgently needed to more widely-spread diseases still represent an extremely
promote facilitated access and to alert the scientific and high overall burden worldwide, such as pneumonia,
lay community to the dangers of misuse, potentially gastrointestinalinfections,andmeningitis.
leading to a severe lack of therapeutic agents to treat
infections inthenear future.
Resistanceinhealthcare
Access to antibiotics is a major concern in many coun-
Antibiotic resistance in healthcare facilities is a very se-
tries worldwide [1-4]. Reasons include the very low eco-
riousconcerninmostdevelopedanddevelopingnations.
nomic status of a large number of nations, inappropriate
Only a few Scandinavian countries and the Netherlands
use, the high cost of the most recent and efficacious anti-
biotics, extensive “over the counter” usage, an increasing have had the strategic vision to limit the invasion of
their country by resistant strains through the implemen-
number of counterfeit drugs, and a dramatic increase in
tation of very active programmes. Somewhat ironically,
antimicrobial resistance (AMR). Importantly, countries
some bacteria, particularly Gram-negatives, are now re-
withonlyafewantibioticsavailableandahighnumberof
sistant to almost every available antibiotic, including the
deathsfrominfectionarenotprotectedfromantibioticre-
most recent generation [7]. Some are still susceptible to
sistance [5,6]. Great strides have been made towards the
colistin, a 50-year-old and rather toxic compound, al-
most forgotten until recently or only used in resource-
*Correspondence:[email protected] limited countries [8]. Late-onset ventilator-associated
1WorldAllianceAgainstAntibioticResistance(WAAR),9ruedelaTerrasse, pneumonia is treated empirically with colistin in the
94000Creteil,France
intensive care units of several countries but, unfortu-
2HôpitalStJoseph,185rueRaymondLosserand,75014,Paris,France
Fulllistofauthorinformationisavailableattheendofthearticle nately, Pseudomonas aeruginosa and Acinetobacter spp.
©2013CarletandPittet;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
CarletandPittetAntimicrobialResistanceandInfectionControl2013,2:1 Page2of4
http://www.aricjournal.com/content/2/1/1
resistance has been described [9]. The worst case consequencesorharm.Therefore,cliniciansshouldensure
scenario for the future is that an unknown number of that the diagnosis is robust to prevent unnecessary treat-
patients might die because active antibiotics are no ment with broad spectrum antibiotics. All treatment
longer available. This is unacceptable, although far less should be subject to review after two or three days and
unacceptable than the lack of access to antibiotics in newantibioticsshouldrequirethepriorinputofaninfec-
many countries. tion specialist [19]. In many cases, antibiotics can be
stopped at days two or three or changed to narrower
Community-acquiredresistance spectrum compounds. If combination therapy has been
Resistance to antibiotics in the community is an emer- used empirically, subsequent reversion to monotherapy is
ging problem in developed and developing countries and possible in most cases. The term “de-escalation” is
possibly even more frightening. The best examples are sometimes used to describe such a strategy, but there are
community- acquired methicillin-resistant Staphylococcus two prerequisites for success. First, clinicians and micro-
aureus (MRSA), particularly in the USA [10], Escherichia biologists must be encouraged to obtain appropriate
coliorKlebsiellapneumonia-producingextended-spectrum microbiologicalsamplesbeforestartingempirictherapyto
beta-lactamases(ESBL)[11]and,morerecently,carbapene- streamlinetheantibioticstrategy,particularlyinthecritic-
mases [12]. The risk is that carbapenems could replace ally ill. Second, clinicians need to feel comfortable about
cephalosporins or broad-spectrum penicillins for the em- the decision to de-escalate, even when initial therapy was
piric treatment of community-acquired diseases, such as effective.Themotto“don’tchangeawinningteam”iscer-
pyelonephritisorintra-abdominalinfections,whereourlife- tainlynotapplicabletoantibiotictherapy.Microorganisms
long “partners”, enterobacteriacae, are involved. Carbape- represent very special therapeutic targets ― a living and
nems are the main antibiotics that remain efficient for the respectfultarget.Similartomanyantibiotics,bacteriahave
treatment of hospital-acquired ESBL infections and repre- beenpresentintheenvironmentlongbeforemananddue
sent our last line of defence in many regards. Many carba- respectisessential,atleastfromanecologicalstandpoint.
penemases have already been described, notably in E. coli In some European countries, physicians feel at ease to
andK.pneumonia[12],andthisclassofantibioticsisinreal change initial empiric antibiotic therapy even when it
dangerandmustbeprotected.Toachievethis,carbapenem works, thus following recommendations issued in re-
use must be regulated and restricted to severe infections cently published guidelines [20]. Prescribers need help,
treated with specialist input or in consultation with a clin- not blame. National guidelines have been elaborated
ical infectious diseases’ specialist. Combinations of beta- over the past few years [21,22], including for veterinary
lactams with beta-lactamases inhibitors are likely to be medicine[23],aswell asmany reportsontheprevention
helpfulinthefuture[13,14]. of AMR spread [21,24,25]. However, since the report of
We have available a good listof new compoundshighly aninternational task force meeting in1995[26],notruly
active against Gram-positive bacteria, but only very few coordinated, international efforts have been made to
active against multi-resistant Gram-negatives in the pipe- tackle the global issue of AMR and access to antibiotics,
line. This constitutes a critical safety issue worldwide and apart from specific diseases such as malaria, tubercu-
is certainly far more important in terms of potential losis,andHIV/AIDS.
impact than the H1N1influenzapandemic (25,000 versus
14,000,respectively,inEuropein2009)[15,16].Thereality Developingacollectiveconscience
is that both short- and long-term international reactions Limiting antibiotic consumption comprises a certain de-
to such a threat have been too weak and too slow. We gree of risk. Some diseases, such as post-streptococcal
have been unable or unwilling tomodify globalbehaviour infections could reappear. Some infections, like meningi-
towards antibiotic use, thus preparing a very dark future tis, might be more frequent if patients with high fever
forgenerationstocome. are no longer treated with antibiotics. Risks must be
evaluated, carefully followed, and balanced against the
Rethinkingcurrentclinicalpractice risk of resistance. National public health agencies and
In the critically ill, particularly for septic shock, recent international organizations, such as the World Health
international guidelines strongly encourage clinicians to Organization (WHO), must assume their responsibility
start broad spectrum antibiotics immediately, if possible and give clear recommendations, while taking such risks
within the first hour of admission [17]. In many institu- into account. There are additional philosophical and
tions,delayingthestartofantibioticstotreatcommunity- ecological reasons to focus on equity and access to anti-
acquired pneumoniais considered as anindicatorofpoor biotics. Most antibiotics, like animals and plants, are
quality of care. Such measures make sense and possibly natural products belonging to “mother nature” and hu-
save lives [18]. However, the use of such indicators and manity. Part of our collective ecological and moral duty
the desire to meet required targets may have unintended is not only to protect them, but also to make them
CarletandPittetAntimicrobialResistanceandInfectionControl2013,2:1 Page3of4
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Citethisarticleas:CarletandPittet:Accesstoantibiotics:asafetyand
equitychallengeforthenextdecade.AntimicrobialResistanceand
InfectionControl20132:1.
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