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Laxminarayan R, Impalli I, Rangarajan R, Cohn J, Ramjeet K, Trainor BW, Strathdee S, Sumpradit N, Berman D, Wertheim H, Outterson K, Srikantiah P, Theuretzbacher U. Expanding antibiotic, vaccine, and diagnostics development and access to tackle antimicrobial resistance. Lancet 2024; 403:2534-2550. [PMID: 38797178 DOI: 10.1016/s0140-6736(24)00878-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/13/2024] [Accepted: 04/26/2024] [Indexed: 05/29/2024]
Abstract
The increasing number of bacterial infections globally that do not respond to any available antibiotics indicates a need to invest in-and ensure access to-new antibiotics, vaccines, and diagnostics. The traditional model of drug development, which depends on substantial revenues to motivate investment, is no longer economically viable without push and pull incentives. Moreover, drugs developed through these mechanisms are unlikely to be affordable for all patients in need, particularly in low-income and middle-income countries. New, publicly funded models based on public-private partnerships could support investment in antibiotics and novel alternatives, and lower patients' out-of-pocket costs, making drugs more accessible. Cost reductions can be achieved with public goods, such as clinical trial networks and platform-based quality assurance, manufacturing, and product development support. Preserving antibiotic effectiveness relies on accurate and timely diagnosis; however scaling up diagnostics faces technological, economic, and behavioural challenges. New technologies appeared during the COVID-19 pandemic, but there is a need for a deeper understanding of market, physician, and consumer behaviour to improve the use of diagnostics in patient management. Ensuring sustainable access to antibiotics also requires infection prevention. Vaccines offer the potential to prevent infections from drug-resistant pathogens, but funding for vaccine development has been scarce in this context. The High-Level Meeting of the UN General Assembly in 2024 offers an opportunity to rethink how research and development can be reoriented to serve disease management, prevention, patient access, and antibiotic stewardship.
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Affiliation(s)
- Ramanan Laxminarayan
- One Health Trust, Bengaluru, India; High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA.
| | | | | | - Jennifer Cohn
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | | | | | - Steffanie Strathdee
- Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Nithima Sumpradit
- Food and Drug Administration, Ministry of Public Health, Nonthaburi, Thailand
| | | | - Heiman Wertheim
- Department of Medical Microbiology and Radboudumc Center for Infectious Diseases, Radboudumc, Netherlands
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Pokharel S, Adhikari B, Johnson T, Cheah PY. Interventions to address antimicrobial resistance: an ethical analysis of key tensions and how they apply in low- income and middle-income countries. BMJ Glob Health 2024; 9:e012874. [PMID: 38569658 PMCID: PMC11002359 DOI: 10.1136/bmjgh-2023-012874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 01/14/2024] [Indexed: 04/05/2024] Open
Abstract
Antimicrobial resistance (AMR) is a global health and one health problem. Efforts to mitigate the problem of AMR are challenging to implement due to unresolved ethical tensions. We present an in-depth ethical analysis of tensions that might hinder efforts to address AMR. First, there is a tension between access and excess in the current population: addressing lack of access requires facilitating use of antimicrobials for some populations, while addressing excessive use for other populations. Second, there is a tension between personal interests and a wider, shared interest in curbing AMR. These personal interests can be viewed from the perspective of individuals seeking care and healthcare providers whose livelihoods depend on using or selling antimicrobials and who profit from the sales and use of antimicrobials. Third, there is a tension between the interests of current populations and the interests of future generations. Last, there is a tension between addressing immediate health threats such as pandemics, and AMR as a 'silent', chronic threat. For each of these tensions, we apply 'descriptive ethics' methods that draw from existing evidence and our experiences living and working in low-income and middle-income countries to highlight how these ethical tensions apply in such settings.
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Affiliation(s)
- Sunil Pokharel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Bipin Adhikari
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University Phayathai Campus, Bangkok, Thailand
| | - Tess Johnson
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Phaik Yeong Cheah
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University Phayathai Campus, Bangkok, Thailand
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Arias P, Matta M, Strazzulla A, Le Mener C, Gallien S, Diamantis S. Identifying General Practitioners' Antibiotic Prescribing Profiles Based on National Health Reimbursement Data. Open Forum Infect Dis 2024; 11:ofae172. [PMID: 38595959 PMCID: PMC11002951 DOI: 10.1093/ofid/ofae172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
Background Antibiotic selection pressure in human medicine is a significant driver of antibiotic resistance in humans. The primary aspect of antibiotic consumption is associated with general practitioner (GP) prescriptions. We aimed to identify prescriber profiles for targeted antimicrobial stewardship programs using novel indicators. Methods A cross-sectional study was conducted in 2018 investigating GPs' antibiotic prescriptions in a French department, utilizing the reimbursement database of the national health service. Three antibiotic prescribing indicators were used. Specific targets were established for each indicator to identify the antibiotic prescribers most likely contributing to the emergence of resistance. Results Over 2018, we had 2,908,977 visits to 784 GPs, leading to 431,549 antibiotic prescriptions. Variations between GPs were shown by the 3 indicators. The median antibiotic prescription rate per visit was 13.6% (interquartile range [IQR], 9.8%-17.7%). Median ratios of the prescriptions of low-impact antibiotics to the prescriptions of high-impact antibiotics and of amoxicillin prescriptions to amoxicillin-clavulanic acid prescriptions were 2.5 (IQR, 1.7-3.7) and 2.94 (IQR, 1.7-5), respectively. We found 163 (21%) high prescribers of antibiotics with 3 distinct patterns: The first group overuses broad-spectrum antibiotics but without an overprescription rate per visit, the second group displays an overprescription rate but no excessive use of broad-spectrum antibiotics, and the third group shows both an overprescription rate and excessive use of broad-spectrum antibiotics. Conclusions Prescription-based indicators enable the identification of distinct profiles of antibiotic prescribers. This identification may allow for targeted implementation of stewardship programs focused on the specific prescribing patterns of each profile.
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Affiliation(s)
- Pauline Arias
- Infectious Diseases Department, Groupe Hospitalier Sud Ile-de-France, Melun, France
- Infectious Diseases Department, Centre hospitalier intercommunal de Villeneuve Saint Georges, Villeneuve Saint Georges, France
| | - Matta Matta
- Infectious Diseases Department, Groupe Hospitalier Sud Ile-de-France, Melun, France
| | - Alessio Strazzulla
- Infectious Diseases Department, Groupe Hospitalier Sud Ile-de-France, Melun, France
| | - Christine Le Mener
- Caisse primaire d’assurance maladie Seine-et-Marne, Ile-de-France, Melun, France
| | - Sébastien Gallien
- Infectious Diseases Department, Assistance Publique–Hôpitaux de Paris, Hôpital Henri Mondor, Université Paris Est Créteil, Créteil, France
- EA 7380 Dynamic, Université Paris Est Créteil, Créteil, France
| | - Sylvain Diamantis
- Infectious Diseases Department, Groupe Hospitalier Sud Ile-de-France, Melun, France
- EA 7380 Dynamic, Université Paris Est Créteil, Créteil, France
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Adebisi YA. Balancing the risks and benefits of antibiotic use in a globalized world: the ethics of antimicrobial resistance. Global Health 2023; 19:27. [PMID: 37081463 PMCID: PMC10116465 DOI: 10.1186/s12992-023-00930-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/14/2023] [Indexed: 04/22/2023] Open
Abstract
Antimicrobial resistance (AMR) is a "silent pandemic" that threatens the efficacy of antibiotics and other antimicrobials. It is imperative to take into account the ethical implications of how these resources are used and distributed as the world deals with this silent pandemic. This commentary discusses the ethical considerations surrounding the use and distribution of antibiotics in the age of resistance, including issues of equity and access, responsibility for antimicrobial stewardship, the environmental impact of antibiotic use, and the development and promotion of these drugs. The ethical implications of unequal access to antibiotics and the role of social determinants of health in shaping this access are considered, as well as the globalization of AMR and the need for multiple stakeholders to be involved in addressing this issue. The opportunities of antimicrobial stewardship programmes for optimising antibiotic use and reducing the emergence and spread of resistant bacteria, as well as the ethical implications of implementing such programmes, are examined. The potential environmental outcomes of antibiotic use and the ethical implications of these impacts are also discussed, as well as the role of the pharmaceutical industry in the development and promotion of these drugs, the potential conflicts of interest that may arise and the ethical dimension of resource transfer from Global North to Global South. This paper emphasises the significance of a holistic strategy to AMR that considers these ethical components, as well as the importance of preserving antibiotic efficacy for future generations.
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Affiliation(s)
- Yusuff Adebayo Adebisi
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
- Global Health Focus, Kigali, Rwanda.
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Synergistic Antimicrobial Action of Lactoferrin-Derived Peptides and Quorum Quenching Enzymes. Int J Mol Sci 2023; 24:ijms24043566. [PMID: 36834977 PMCID: PMC9965131 DOI: 10.3390/ijms24043566] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/13/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Combined use of various antimicrobial peptides (AMPs) with enzymes that hydrolyze the signaling molecules of the resistance mechanism of various microorganisms, quorum sensing (QS), to obtain effective antimicrobials is one of the leading approaches in solving the antimicrobial resistance problem. Our study investigates the lactoferrin-derived AMPs, lactoferricin (Lfcin), lactoferampin and Lf(1-11), as potential partners for combination with enzymes hydrolyzing lactone-containing QS molecules, the hexahistidine-containing organophosphorus hydrolase (His6-OPH) and penicillin acylase, to obtain effective antimicrobial agents with a scope of practical application. The possibility of the effective combination of selected AMPs and enzymes was first investigated in silico using molecular docking method. Based on the computationally obtained results, His6-OPH/Lfcin combination was selected as the most suitable for further research. The study of physical-chemical characteristics of His6-OPH/Lfcin combination revealed the stabilization of enzymatic activity. A notable increase in the catalytic efficiency of action of His6-OPH in combination with Lfcin in the hydrolysis of paraoxon, N-(3-oxo-dodecanoyl)-homoserine lactone and zearalenone used as substrates was established. Antimicrobial efficiency of His6-OPH/Lfcin combination was determined against various microorganisms (bacteria and yeasts) and its improvement was observed as compared to AMP without enzyme. Thus, our findings demonstrate that His6-OPH/Lfcin combination is a promising antimicrobial agent for practical application.
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Hays JP, Ruiz-Alvarez MJ, Roson-Calero N, Amin R, Murugaiyan J, van Dongen MBM. Perspectives on the Ethics of Antibiotic Overuse and on the Implementation of (New) Antibiotics. Infect Dis Ther 2022; 11:1315-1326. [PMID: 35608734 PMCID: PMC9127288 DOI: 10.1007/s40121-022-00656-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/05/2022] [Indexed: 11/28/2022] Open
Abstract
The continuing rise in global antimicrobial resistance is seen by many governments and international organizations as a major threat to worldwide health. This means that many publications have already described the problems concerning the overuse of currently available antibiotics and potential solutions to this crisis, including the development of new alternatives to antibiotics. However, in this manuscript, the authors approach the subject of increasing global antimicrobial resistance from two perspectives not normally covered by previous publications, namely the ethical use of antibiotics and potential issues relating to the implementation of new antibiotics.
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Affiliation(s)
- John P Hays
- Department of Medical Microbiology & Infectious Diseases, Erasmus University Medical Centre (Erasmus MC), Rotterdam, the Netherlands.
| | - Maria Jose Ruiz-Alvarez
- Research Coordination and Support Service (CORI), National Institute of Health (ISS) Viale Regina-Elena, 299, Rome, Italy
| | | | - Rohul Amin
- James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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