The environmental dimension of antimicrobial resistance: the transition from policy formation to implementation

前首席医疗官、现任英国抗菌素耐药性问题特使Dame Sally Davies教授说，如果抗菌素药物失去效力，那将意味着“现代医学的终结”。据估计，到2050年，每年将有1000万人死于抗微生物药物耐药性，是目前COVID-19大流行造成的死亡人数的7倍多。到2050年，抗菌素耐药性感染的全球经济成本估计将达到1万亿美元。越来越多的人一致认为，抗菌素耐药性必须通过“同一个健康”方法来解决。人类和动物的健康必须与环境联系起来考虑。我们知道，细菌病原体获得的耐药机制可能起源于环境细菌，这些细菌在进化过程中进化出了耐药性。细菌的不寻常之处在于，它们可以水平传递遗传物质（基因），包括在不同物种之间，而不是像大多数动物和植物那样，基因从父母垂直传递给后代。还应记住，许多用作药物的抗菌素是由细菌和真菌自然产生的，因此早于人类使用抗菌素。因此，环境细菌中存在大量抗菌素耐药性基因就不足为奇了。除了这种抗菌素耐药性细菌和基因的“天然”储存库之外，人类和动物粪便还将抗菌素耐药性细菌和抗菌素引入环境，从而可能发生耐药性的进一步演变，并伴有环境传播给人类的相关风险。这项知识交流（KE）奖学金将以will Gaze教授及其同事以前的工作为基础，这些工作为国际、欧盟和英国的抗微生物药物耐药性政策提供了信息。它将侧重于为环境、食品和农村事务部（Defra）和环境署（EA）的环境AMR监测的规划和实施提供信息。此外，由于努力降低与人类废物中的抗菌素耐药性细菌和抗微生物残留物相关的风险（这些细菌和残留物可能到达水生环境，并有传播给人类的相关风险），因此将与关注这一主题的水行业进行KE。欧盟《水框架指令》的重点是某些抗菌素水生残留物带来的风险，这可能会转化为对河流和沿海地区排放的监管。制药行业也将进行KE，他们热衷于确保他们的药物在推动AMR进一步增加方面不会构成环境风险。这对于保护我们剩余的有用抗菌药物的活性也很重要。KE与Defra， EA水和制药行业的结合为跨部门发展思想提供了机会，并且在KE的这个阶段，朝着实施新战略和政策的方向发展。

Prof Dame Sally Davies, the previous Chief medical officer and current UK Special Envoy on Antimicrobial Resistance (AMR) said that if antimicrobial drugs lose their effectiveness it would spell "the end of modern medicine". It has been estimated that by 2050, 10 million deaths a year will be attributable to AMR, more than seven times the current mortality caused by the COVID-19 pandemic. The global economic cost of AMR infections is estimated at a trillion US dollars by 2050. There is a growing consensus that AMR must be tackled using a One Health approach, ie. that human and animal health must be considered in relation to the environment. We know that resistance mechanisms bacterial pathogens acquire can originate in environmental bacteria that have evolved resistance over evolutionary time. Bacteria are unusual in that they can pass on genetic material (genes) horizontally, including to different species, rather than the vertical transfer of genes from parents to offspring that occurs in most animals and plants. It should also be remembered that many antimicrobials used as drugs are produced naturally by bacteria and fungi, so predate human antimicrobial usage. It is therefore not surprising that there is a vast reservoir of AMR genes present in environmental bacteria. In addition to this "natural" reservoir of AMR bacteria and genes, human and animal waste also introduces AMR bacteria and antimicrobials to the environment, where further evolution of resistance can take place with associated risks of environmental transmission to humans. This Knowledge Exchange (KE) Fellowship will build on previous work by Professor Will Gaze and colleagues that has informed international, EU and UK policy on AMR. It will focus on informing planning and implementation of environmental AMR surveillance with the Department for Environment, Food and Rural Affairs (Defra) and the Environment Agency (EA). In addition, KE will take place with the water industry who are focusing on this subject, due to efforts to reduce risk associated with AMR bacteria and antimicrobial residues in human waste which can reach aquatic environments with associated transmission risk to humans. The European Union Water Framework Directive is focusing on risks posed by aquatic residues of certain antimicrobials, and this may translate into regulation of discharge to rivers and coastal areas. KE will also take place with the pharmaceutical industry who are keen to ensure that their drugs do not pose an environmental risk in terms of driving further increases in AMR. This is also important in safeguarding the activity of our remaining useful antimicrobial drugs. The combination of KE with Defra, EA water and pharmaceutical industries provides opportunities for cross-sectoral development of ideas, and in this phase of KE, moving towards implementation of new strategy and policy.