扩展治疗 对日益增长的抗生素耐药性威胁的政策反应Extending the Cure Policy responses to the growing threat of antibiotic resi

现代医学依靠有效的抗生素来控制细菌感染。自从这些神奇的药物中的第一种问世仅在65年前，它们就改变了医学的实践并挽救了数百万人的生命。但是今天，在21世纪初，对抗生素产生抗药性的细菌病原体的迅速出现和传播威胁着我们回到一个普通感染无法治愈的时代。耐药性金黄色葡萄球菌（金黄色葡萄球菌或“葡萄球菌”）的日益严重的问题是可以说明的（图ES.1）。在 1987年，有2％的金黄色葡萄球菌感染患者对甲氧西林没有反应，甲氧西林是一种廉价的抗生素，自1960年代以来一直有效对抗这些感染。到2004年，超过50％的金黄色葡萄球菌患者对甲氧西林没有反应，造成了可怕的后果。已经报道了几例对万古霉素耐药的药物，该药物常用于治疗MRSA感染。 肺炎链球菌（S. pneumoniae），另一种常见病原体，引起细菌性脑膜炎和细菌性 肺炎等疾病。 1987年，每10,000例肺炎链球菌感染中只有2例（0.02％）对青霉素（所选的抗生素）有抗药性。到2004年，这一数字已上升到5％（即20％），增长了1000倍（CDC 2005）。 根据美国食品药品监督管理局（FDA）的说法，“除非能够及时发现抗生素耐药性问题并采取措施加以遏制，否则世界可能会面临以前无法治愈的疾病，就像过去那样在开发抗生素之前”（机构间抗菌素特别工作组 抵抗2001）。近年来的主要报道称采取措施解决这一日益严重的威胁，然后再吞并医疗系统（ASM 1994； OTA 1995； Harrison and Lederberg 1998），但政策制定者却采取了惊人的行动。 抗菌功效可以被视为一种天然资源， 很像石油，鱼类或森林（Laxminarayan and Brown 2001; “世界可能面临着以前无法治愈的可治愈疾病……” —抗菌素耐药性机构间工作队 Laxminarayan 2003）：任何人都可以使用的资源 可以购买。所有抗生素的使用，无论适当与否，都会“消耗”该抗生素的某些功效，从而削弱了我们将来使用该抗生素的能力。通过过度使用抗生素来加速耐药性的传播，就像其他人分享的一样 资源问题，例如全球变暖或过度捕捞 这种现象被称为“公地悲剧”（Hardin 1968）。

Modern medicine depends on effective antibiotics to control bacterial infections. Since the first of these wonder drugs appeared a mere 65 years ago, they have transformed the practice of medicine and saved millions of lives. But today, at the start of the 21st century, the rapid rate of emergence and spread of bacterial pathogens resistant to antibiotics threatens to return us to an era when common infections were untreatable.

The growing problem of antibiotic-resistant Staphylococcus aureus (S. aureus or “staph”) is illustrative (Figure ES.1). In

1987, 2 percent of patients infected with S. aureus failed to respond to methicillin, an inexpensive antibiotic that had been effective against these infections since the 1960s. By 2004, more than 50 percent of patients with S. aureus failed to respond to methicillin, with terrible consequences. Already a few cases of resistance to vancomycin, the drug often used to treat MRSA infections, have been reported.

Streptococcus pneumoniae (S. pneumoniae), another common pathogen, causes bacterial meningitis and bacterial

pneumonia, among other conditions. In 1987, only 2 of every 10,000 S. pneumoniae infections—0.02 percent—were resistant to penicillin, the antibiotic of choice. By 2004, this figure had risen to 1 in 5—20 percent—a 1,000-fold increase (CDC 2005).

According to the U.S. Food and Drug Administration (FDA), “Unless antibiotic resistance problems are detected as they emerge, and actions are taken to contain them, the world could be faced with previously treatable diseases that have again become untreatable, as in the days before antibiotics were developed” (Interagency Task Force on Antimicrobial

Resistance 2001). Major reports in recent years have called

for steps to address this growing threat before it engulfs the medical system (ASM 1994; OTA 1995; Harrison and Lederberg 1998), yet policymakers have taken astonishingly little action.

Antibiotic effectiveness can be thought of as a natural resource,

much like oil, fish, or forests (Laxminarayan and Brown 2001;

“The world could be faced with previously treatable diseases that have again become untreatable…”

— Interagency Task Force on Antimicrobial Resistance

Laxminarayan 2003): it is a resource accessible to anyone who

can purchase it. All antibiotic use, appropriate or not, “uses up” some of the effectiveness of that antibiotic, diminishing our ability to use it in the future. Hastening the spread of resistance by overuse of antibiotics is like other shared

resource problems, such as global warming or overfishing—a

phenomenon referred to as “the tragedy of the commons” (Hardin 1968). Approaching antibiotic resistance as a resource