Chemical and Strategic Approaches to Addressing Antimicrobial Resistance and Preserving Antibiotic Efficacy: A Systematic Review

The global misuse of antimicrobial medication has further exacerbated the problem of antimicrobial resistance (AMR), enriching the pool of genetic mechanisms previously adopted by bacteria to evade antimicrobial drugs. AMR can be either intrinsic or acquired. It can be acquired either by selective genetic modification or by horizontal gene transfer that allows microorganisms to incorporate novel genes from other organisms or environments into their genomes. To avoid an eventual antimicrobial mistreatment, the use of antimicrobials in farm animal has been recently reconsidered in many countries. We present a systematic review of the literature discussing the cases of AMR and the related restrictions applied in North American countries (including Canada, Mexico, and the USA). The Google Scholar, PubMed, Embase, Web of Science, and Cochrane databases were searched to find plausible information on antimicrobial use and resistance in food-producing animals, covering the time period from 2015 to 2024. A total of 580 articles addressing the issue of antibiotic resistance in food-producing animals in North America met our inclusion criteria. Different AMR rates, depending on the bacterium being observed, the antibiotic class being used, and the farm animal being considered, have been identified. We determined that the highest average AMR rates have been observed for pigs (60.63% on average), the medium for cattle (48.94% on average), and the lowest for poultry (28.43% on average). We also found that Cephalosporines, Penicillins, and Tetracyclines are the antibiotic classes with the highest average AMR rates (65.86%, 61.32%, and 58.82%, respectively), whereas the use of Sulfonamides and Quinolones leads to the lowest average AMR (21.59% and 28.07%, respectively). Moreover, our analysis of antibiotic-resistant bacteria shows that Streptococcus suis (S. suis) and S. auerus provide the highest average AMR rates (71.81% and 69.48%, respectively), whereas Campylobacter spp. provides the lowest one (29.75%). The highest average AMR percentage, 57.46%, was observed in Mexico, followed by Canada at 45.22%, and the USA at 42.25%, which is most probably due to the presence of various AMR control strategies, such as stewardship programs and AMR surveillance bodies, existing in Canada and the USA. Our review highlights the need for better strategies and regulations to control the spread of AMR in North America.

Photo by Adam Nieścioruk on Unsplash ABSTRACT Antibiotics are useful to stave off infection, though their misuse can be detrimental by creating drug-resistant infections. It is essential that we closely examine the leading causes of antibiotic resistance and consider the serious clinical and ethical ramifications around the issue. This paper will aim to achieve these goals, as well as to propose practical solutions directed towards combating this looming crisis. INTRODUCTION As drug companies race to develop vaccines and treatments in response to the COVID-19 pandemic, other impending public health threats may easily be forgotten and tucked away for another day. Experts are warning that “the same governmental inaction that helped foster the rapid, worldwide spread of the coronavirus may spur an even deadlier epidemic of drug-resistant infection…”[1] Dr. Jeffrey R. Strich, a researcher at the National Institutes of Health Clinical Center remarked, “If there’s anything that this COVID-19 pandemic has taught the world, it is that being prepared is more cost-effective in the long run.”[2] Antibiotic resistant infections cause an estimated 700,000 annual deaths globally.[3] According to the Centers for Disease Control, in the United States alone, drug resistant infections sicken 2.8 million people annually and are responsible for at least 35,000 deaths each year.[4] The United Nations has suggested that, if the problem is not soon addressed, antibiotic resistant infections could kill up to 10 million people by 2050.[5] The genesis of antibiotic resistance is complex and multifaceted. Successfully combating antibiotic resistance will require a global response. This paper will closely examine the leading causes of antibiotic resistance. It will also devote discussion to the clinical and ethical ramifications of antibiotic use and misuse. Lastly, the paper will propose practical measures that countries, such as the US, should be taking now to help stem this ever-evolving public health emergency. I. Antibiotic misuse Antibiotic resistance develops when bacteria are exposed to antibiotics, and propelled by the forces of evolutionary selection, mutate over time to adapt to the antibiotics.[6] This process is greatly accelerated when bacteria are overexposed to antibiotics.[7] Overexposure occurs in two primary ways – the first is through overuse/misuse of antibiotics in humans and the second is misuse/overuse in animals. A. In humans According to studies, treatment decisions involving antibiotics, including whether to use an antibiotic, which antibiotic to use, and the appropriate duration of such use, are incorrect in 30 percent to 50 percent of cases.[8] Antibiotics may be overprescribed in cases where they are not truly needed, or the wrong type or dosage of antibiotic can be prescribed. These issues can contribute to the problem of antibiotic resistance.[9] In many cases, faulty clinical determinations can be attributed to the lack of available microbial testing. Consequently, healthcare providers are unable to properly identify and classify bacteria, thus impairing their ability to make clinically sound treatment decisions. In one US study involving hospitalized patients suffering from community acquired pneumonia, for example, a pathogen was identified in only 7.6% of cases.[10] There is existing technology, specifically polymerase chain reaction (PCR) and semiquantitative PCR, that accurately identifies pathogens in approximately 89 percent of cases.[11] However, this technology is not widely used. When healthcare providers do use testing, they often rely upon culture testing, which is not rapid response and can delay proper treatment assessments.[12] As a result, providers may substitute inappropriate antibiotics in the interim. Another type of antibiotic misuse among humans occurs when patients stop their antibiotic regimens prematurely, thereby allowing harmless bacteria, not fully eradicated due to the abbreviated treatment, to acquire resistance. This resistance is then genetically transferred to dangerous bacteria.[13] Antibiotic resistance is also an unfortunate, frequent occurrence in developing countries where antibiotics are often available without a prescription and can be accessed through unregulated supply chains.[14] Developing nations also frequently suffer from a dearth of standard antibiotic treatment guidelines, which further precipitates antibiotic overprescribing.[15] B. In animals Approximately half of the world’s consumption of antibiotics is for agricultural purposes.[16] In the US, only 20 percent of antibiotic sales are intended for human use, while the remaining 80 percent is for use in livestock.[17] Despite this gross disparity, only 10 percent of publications discussing antibiotic resistance address the role that misuse of antibiotics in animals plays.[18] Antibiotic misuse in animals contributes to antibiotic resistance. Farmers and agribusinesses widely distribute antibiotics, through feed or water, to healthy animal populations for non-therapeutic purposes -- including for growth promotion and disease prevention.[19] The need for antibiotic use for disease prevention arises when animals’ living quarters are cramped and prone to disease.[20] Low concentrations of antibiotics have routinely been observed in the gastrointestinal tracts of livestock.[21] The presence of sub-therapeutic levels of these drugs fosters the growth of resistant bacteria and antibiotic resistance genes in the animals’ guts.[22] When the animals that have developed these resistant bacteria and genes are used as sources of food, both the bacteria and genes are passed along to the food supply, contaminating milk, meat, and eggs.[23] Because the antibiotics used in animals are those that have critically important human applications, the resistant bacteria and genes that develop in response to these drugs can destroy the prospect of their use as effective treatment options in both animals and humans.[24] According to the Environmental Working Group, supermarket meat and poultry contain extremely high levels of antibiotic resistant bacteria. Specifically, ground turkey was found to contain 79 percent resistant bacteria, pork 71 percent, ground beef 62 percent, and chicken 36 percent.[25] While antibiotic resistant bacteria may be killed with proper levels of heat (from cooking, for instance), antibiotic resistance DNA that accompanies the bacteria is not always eradicated. This resistance can then be transferred to the humans who consume it, conferring resistance upon otherwise benign bacteria in their digestive systems.[26] Resistant bacteria and genes contained in animal waste can also enter the environment as pollutants, settling in the ground, air, and water systems.[27] This further increases the transmissibility of antibiotic resistance from animals to humans and, ultimately, from human to human when a person acquires an antibiotic resistant infection from food and/or the environment and passes it along to others.[28] Another unintended adverse consequence of antibiotic use in animals is that foods like meat, milk, and eggs often contain antibiotic residues.[29] Since up to 90 percent of antibiotics are excreted through an animal’s waste, the drugs may also pollute the ground and groundwater.[30] Unnecessarily prolonged exposure to antibiotics increases the risk of acquiring bacterial resistance and/or an antibiotic resistant infection. The constant exposure to antibiotics can have other adverse health effects, ranging from drug hypersensitivity to carcinogenic effects.[31] II. Ethical considerations and obligations of stakeholders A. Tackling antibiotic resistance created through the healthcare sector First, with respect to antibiotic misuse in humans, there needs to be vastly scaled-up pathogenic testing. This will help ensure that treatment decisions involving antibiotics are made with empirical data, rather than being an exercise in supposition. Increased testing would lead to a reduction in unnecessary antibiotic prescriptions and scripts for the wrong antibiotic. PCR technology should be made widely available, at least until more effective testing is developed. At the most basic level, physicians should seek out this testing to make it available in their practices and hospitals. Third-party payors should be poised to approve the costs associated with these tests, since they may expedite improvements in patients’ health, thereby resulting in an overall cost savings. The pharmaceutical industry should also develop accurate, rapid testing technology. Rapid testing could abbreviate patients’ immediate illnesses, because knowledge provided by testing can help physicians quickly determine proper diagnoses. This will allow them to immediately prescribe the correct antibiotics. Finally, on a global level, countries that lack regulations around antibiotic access and use must implement sufficient restrictions. Addressing antibiotic resistance on a global level is imperative. Like with COVID-19, from a pragmatic and ethical perspective, we must create global solutions to antibiotic resistance to prevent resistant bacteria from spreading.[32] B. Ethical considerations around antibiotic prescriptions for human use Some ethicists have argued that antibiotics are a public good, and their overuse can result in a sort of “tragedy of the commons.”[33] In order to ensure the equitable distribution of antibiotics for all patients, society must create disincentives around antibiotic use. One such proposal involves taxing patients who use antibiotics for “minor and self-limiting” infections.[34] However, patients should not be punished for following their physicians’ recommendations. Things like taxing schemes unjustifiably interfere with the doctor-patient relationship and can result in adverse clinical consequences for patients. Others have asserted that physicians owe a duty of care to both present and future patients. Pursuant to this argument, physicians are ethically justified in increasing the risk of harm to present patients by a “small” amount by denying them antibiotics, if, in doing so, they are decreasing a significant risk of harm to future patients.[35] As per the Hippocratic Oath, physicians have an obligation first and foremost, to their current patients. This duty includes the obligation to act for the good of the patient (with beneficence) and to prevent harm from befalling the patient (non-maleficence). Nowhere in the Oath does it say that “a little” harm is acceptable. Failing to provide a patient with an antibiotic when it is warranted in order to “preserve” the drug for use by future patients is a violation of the physicians’ bioethical obligations to the patient. There are cases where it may be in patients’ best interests to avoid antibiotics, thus decreasing their own risk of antibiotic resistance from superfluous use. However, physicians must make these determinations on a case-by-case basis, relying on clinical evidence, rather than an impermissible ethical imperative to future patients. It is also a breach of the patient’s right of autonomy if the patient believes the physician is acting strictly in his or her best interest and relies on the physician’s treatment recommendations due to this belief. From a clinical perspective, a “small” amount of harm could easily become a “large” amount of harm, depending upon the patient and the infection at issue. A physician could also misjudge the level of risk involved in depriving a patient of an antibiotic, thereby creating an increased risk of morbidity or mortality for the patient. This is not to imply that the physician is never justified in proposing a reasonable waiting period before prescribing an antibiotic in order to determine if the illness is self-limiting and begins to improve on its own. However, again, this decision should be driven strictly by clinical criteria and the best interest of the present patient. In addition, proposals that seek to disincentivize antibiotic use can be clinically and ethically dangerous. Although prudence around antibiotic use is necessary, physicians should not be dissuaded from prescribing them when, in the physicians’ clinical judgements, they are necessary. Without antibiotics, seemingly benign infections can quickly turn deadly. Untreated bronchitis can rapidly progress to pneumonia. Untreated strep throat can lead to heart damage. A lingering urinary tract infection can induce sepsis.[1] III. Combating antibiotic resistance created by the agricultural sector As one scholar aptly observed, “[t]he current debate on the ethics of [antimicrobial resistance] is heavily and disproportionately focused on the use of antibiotics in humans…this focus reflects the traditional discourse in medical ethics…”[36] It seems relevant to note the seeming irrationality of ethicists advocating for withholding antibiotics from people while failing to consider the widespread, indiscriminate, unregulated use of antibiotics in the agricultural sector. The bottom line is that the focus on antibiotic use in humans, while important, cannot overshadow the substantial role that antibiotic use in animals has played in the antibiotic resistance crisis. There are several key stakeholders that are under an ethical obligation to take immediate action. The FDA should create a rule immediately banning the non-therapeutic use of antibiotics in healthy animals. The FDA took a small step in 2017 towards limiting antibiotic use in healthy animals when it finally restricted farms from using medically important drugs as growth promotion agents for animals.[37] This move, however, has been described as grossly insufficient. For one, antibiotics can still be used in healthy animals for purposes other than growth promotion, such as for “preventive health” purposes or in “times of stress,” which the FDA never clearly defines.[38] Therefore, the newly imposed restriction is easy to circumvent. Farms simply can purchase antibiotics for use as a “preventive health” measure rather than for growth promotion purposes.[39] To complicate matters further, at least 30 percent of antibiotics intended for animals have labels that lack any parameters around duration of use, meaning they can be used indefinitely throughout animals’ lives.[40] Farms and pharmaceutical companies are still promoting “growth” as an ancillary benefit of antibiotics, encouraging their unbridled use.[41] The next measure that the FDA must implement is the elimination of crowded, inhumane animal conditions in farms which create the need to administer “preventive” antibiotics. It is well established that “[a]ntibiotics are used at subtherapeutic levels to promote growth and to prevent disease in the extremely crowded conditions that food animals are raised in.”[42] The conditions present in many livestock farms has been compared to crowded hospitals “where everyone is given antibiotics, patients lie in unchanged beds, hygiene is nonexistent, infections and re-infections are rife, waste is thrown out the window, and visitors enter and leave at will.”[43] Eliminating crowded conditions will greatly reduce the need for preventive antibiotics. Finally, the FDA must establish a surveillance and enforcement mechanism to ensure proper compliance with limiting antibiotic use in healthy animals and addressing crowded conditions. Surprisingly, and notwithstanding the documented link between antibiotic use in animals and adverse human health effects, the FDA lacks any means of monitoring farms’ use of antibiotics in animals. The only measure it uses to assess possible antibiotic use is the sale of antibiotics to farms.[44] The pharmaceutical and chemical companies that manufacture the antibiotics are required to provide this information to the FDA.[45] Although reports have indicated that around 80 percent of antibiotics are sold for agricultural purposes, the FDA contends that it cannot discern actual use from these numbers. At the same time, the FDA has failed to create any other rules that would establish an alternative means of monitoring use.[46] As a New York Times investigation revealed, public health investigators are often unable to access the most basic information regarding a farm’s practices.[47] The agricultural industry constructs roadblocks so that the government’s access to farms, and how they are using antibiotics in animals, is hindered.[48] Further complicating the matter are conflicts of interest where livestock industry executives hold high positions on advisory committees for government agencies, such as the US Department of Agriculture (USDA).[49] The USDA does have a monitoring system that studies antibiotic use in the agricultural sector.[50] However, as an expert in a recent Washington Post article opined, “[t]he USDA’s oversight is laissez-faire. They test such a small fraction it can’t even be taken seriously…and they rotate the drugs they are testing for, because they can’t afford to test for all of them. They just don’t have the funds to do it. We raise 9 billion animals, and they test hundreds of cattle, not even thousands.”[51] The USDA’s antibiotic surveillance system also relies upon agricultural industry self-reporting, using voluntary questionnaires,[52] which calls into question the completeness and veracity of the data. In addition to the US government, the pharmaceutical industry must also help reign in imprudent antibiotic use in the agricultural sector. In 2007, legislation was introduced that would have required drug manufacturers to phase out use of antibiotics for healthy animals.[53] The meat and poultry industries, and several major pharmaceutical companies opposed the legislation.[54] It is ethically incumbent upon the pharmaceutical industry to support the fight against antibiotic resistance. The industry creates the products, doing a great deal of good, so some may argue they should not be tasked with overseeing poor uses of their products. But the pharmaceutical industry should encourage measures that ensure the responsible use of their products. It should also refrain from touting the “ancillary benefits” of antibiotics, such as “growth promotion,” which encourages their injudicious and illegal use. Consumers pay the ethical price of all three industries’ actions. People eating animal products have no opportunity to consent to the use of antibiotics. Although they may choose antibiotic-free meat and dairy, or choose not to consume animal products, people do not have the opportunity to consent to the presence of antibiotic residues, antibiotic resistant bacteria, and resistance genes in their food supply, and they may not be aware of the risks. Consumers bear the burden while industries profit. While there are animal food products designated “organic,” and their producers allege that no antibiotics were used in their production use, these foods tend to be significantly more expensive than food that is not organic. Therefore, those in lower socio-economic brackets are forced to buy foods that are detrimental to their health, while those in higher brackets can afford healthier food products. This is a violation of the ethical principle of distributive justice. Industry must work to find innovative ways to level the playing field and make all food safe for consumers, regardless of economic disposition. Simply put, no consumer should have to worry about antibiotics, antibiotic resistant bacteria, or resistance genes in their food supply. IV. Creating incentives around antibiotic development Addressing antibiotic resistance by chipping away at its causes is an important approach, though it is not sufficient to truly win the antibiotic resistance war. Since, even with mitigation of causal factors, resistance is inevitable on some level. Therefore, we must also address the crisis from the tail-end. This involves ensuring that, when resistance does occur, we are prepared for it. In order to do this, new classes of antibiotics that have the potential to treat resistant pathogens must be developed. The current landscape for antibiotic research and development is a barren one. Pharmaceutical companies have largely bailed on this area and biotechnology startups are going bankrupt pursuing this venture. As a recent New York Times piece noted, “[i]n the 1980s, there were 18 major pharmaceutical companies developing new antibiotics; today there are three.”[55] Pharmaceutical companies prefer to focus on the development of drugs for chronic diseases, which ensure long term, continuous profits.[56] Antibiotics, on the other hand, tend to be prescribed on a short-term basis for acute infections. 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Antimicrobial resistance (AMR) has emerged as one of the most serious global health crises, especially among pediatric populations. MRSA, VRE, and CRE are examples of multidrug-resistant organisms that pose significant challenges in infection management, especially among weak children in intensive care units. Increasing resistance among infections such as Escherichia coli and Klebsiella pneumoniae makes them more challenging to manage. Contributing factors to this problem are the misuse of antibiotics and the lack of pediatric-specific research, calling for comprehensive action. Root causes like the misuse of antibiotics and the lack of pediatric-relevant research are fueling the crisis, and that is why collective action is paramount. Interventions like implementing surveillance networks like the WHO’s Global Antimicrobial Resistance Surveillance System (GLASS) and facilitating antimicrobial stewardship programs (ASPs) age-specific for children, like the effective ASP model at Johns Hopkins Children’s Center, must be undertaken. Public health campaigns, for example, the CDC’s “Get Smart” program, show the power of education in averting the abuse of antibiotics. Treatment attempts are made more difficult by other serious multidrug-resistant pathogens that affect children, particularly in hospital settings, such as Pseudomonas aeruginosa, Acinetobacter baumannii, and Clostridium difficile. To that end, multiple strategies are essential, such as establishing strong surveillance systems and antimicrobial stewardship programs (ASPs) that take into account the pediatric population. Understanding local resistance patterns is central to designing of region-specific public health interventions, especially in low-resource settings, where AMR burdens healthcare systems and threatens their fragile infrastructures. The discovery of genetic factors that cause resistance and the emergence of new drugs will play crucial roles in curbing this evolving threat while improving the well-being of children. A strategic approach to the challenge of AMR in the hospitalized child requires coordinated, multi-pronged efforts-education for health professionals and their families, public campaigns, and improved access to quality medical care. Prescription guidelines strengthened, and more effective surveillance systems should be put in place; targeted educational initiatives will ensure effective management of the rising tide of AMR within healthcare systems. Long-term solutions will only be achieved through collaboration among healthcare providers, policymakers, and researchers. Such collaboration will encourage over time, promote innovation, and ensure that better treatment options are developed. It is also crucial that evidence-based treatments are provided as well as healthcare systems are ready to address the pediatric patients because of the increase in multidrug-resistant like E. coli and Staphylococcus aureus. Commitment to vigilance, education, and innovation will be vital for mitigating AMR risks and protect the most vulnerable populations worldwide. This study focuses on the treatment challenges and adverse clinical outcomes associated with antimicrobial resistance (AMR) in pediatric populations. It highlights the role of resistance mechanisms, emerging pathogens, and the urgent need for targeted stewardship programs to protect child health.

1The Review on AMR was an expert panel commissioned by the UK Government in 2014 tasked with analysing the economic and social impacts of AMR and proposing solutions to these. 2NICE is a UK non-departmental public body that sponsored by but separate from the Department of Health that produces evidence-based guidance for health practitioners. 3NHS England is a non-departmental public body sponsored by the Department of Health that oversees planning and delivery of health services in England. 4Note that circulation of the News of the World ceased in July 2011; the Sun on Sunday was launched by the same newsgroup in 2012, but is unavailable on the Nexis database.

Pharmacists critical to managing antimicrobials, developing infection control procedures

Europe to boost development of new antimicrobial drugs

Antimicrobial resistance (AMR) is a critical global health issue driven by antibiotic misuse and overuse in various sectors, leading to the emergence of resistant microorganisms. The history of AMR dates back to the discovery of penicillin, with the rise of multidrug-resistant pathogens posing significant challenges to healthcare systems worldwide. The misuse of antibiotics in human and animal health, as well as in agriculture, contributes to the spread of resistance genes, creating a "Silent Pandemic" that could surpass other causes of mortality by 2050. AMR affects both humans and animals, with resistant pathogens posing challenges in treating infections. Various mechanisms, such as enzymatic modification and biofilm formation, enable microbes to withstand the effects of antibiotics. The lack of effective antibiotics threatens routine medical procedures and could lead to millions of deaths annually if left unchecked. The economic impact of AMR is substantial, with projected losses in the trillions of dollars and significant financial burdens on healthcare systems and agriculture. Artificial intelligence is being explored as a tool to combat AMR by improving diagnostics and treatment strategies, although challenges such as data quality and algorithmic biases exist. To address AMR effectively, a One Health approach that considers human, animal, and environmental factors is crucial. This includes enhancing surveillance systems, promoting stewardship programs, and investing in research and development for new antimicrobial options. Public awareness, education, and international collaboration are essential for combating AMR and preserving the efficacy of antibiotics for future generations.

Antimicrobial resistance: Current challenges and future directions

A clinician’s guide to the appropriate and accurate use of antibiotics: the Council for Appropriate and Rational Antibiotic Therapy (CARAT) criteria

Antimicrobial resistance (AMR) is a growing global health crisis, threatening the effectiveness of antibiotics and other antimicrobial agents. The widespread misuse and overuse of antibiotics in healthcare, agriculture, and animal husbandry have accelerated the emergence of resistant pathogens, leading to increased morbidity, mortality, and economic burdens. This review critically examines existing global policies and best practices aimed at curbing AMR while proposing innovative, actionable strategies to mitigate its impact. The study explores the effectiveness of national and international AMR action plans, including the World Health Organization’s Global Action Plan (WHO-GAP) and country-specific frameworks such as the U.S. National Action Plan for Combating Antibiotic-Resistant Bacteria and the European One Health Action Plan against AMR. It evaluates regulatory policies, antibiotic stewardship programs, surveillance systems, and public awareness campaigns designed to promote responsible antimicrobial use. Key innovations in AMR reduction include the use of artificial intelligence (AI) and big data analytics for early detection of resistance patterns, precision medicine for targeted antimicrobial therapies, and the development of novel antibiotic alternatives such as bacteriophages and antimicrobial peptides. Additionally, advancements in rapid diagnostic tools and blockchain-based supply chain monitoring are examined for their potential to improve antimicrobial governance and reduce counterfeit medications. Challenges in implementing AMR policies, including regulatory fragmentation, lack of global coordination, and economic constraints, are discussed. The review highlights the need for interdisciplinary collaboration between governments, healthcare providers, pharmaceutical industries, and agricultural sectors to enforce stricter antimicrobial regulations, promote research and development of new treatments, and improve infection prevention measures. Findings suggest that a multifaceted approach integrating policy reforms, technological innovations, and public engagement is essential to slowing AMR progression. Strengthening surveillance networks, incentivizing antibiotic research, and enforcing antibiotic stewardship across all sectors can significantly reduce antimicrobial misuse and resistance. This review provides a roadmap for policymakers and stakeholders to develop sustainable, evidence-based AMR mitigation strategies.

Antimicrobial resistance (AMR) is a growing global health crisis, threatening the effectiveness of antibiotics and other antimicrobial agents. The widespread misuse and overuse of antibiotics in healthcare, agriculture, and animal husbandry have accelerated the emergence of resistant pathogens, leading to increased morbidity, mortality, and economic burdens. This review critically examines existing global policies and best practices aimed at curbing AMR while proposing innovative, actionable strategies to mitigate its impact. The study explores the effectiveness of national and international AMR action plans, including the World Health Organization’s Global Action Plan (WHO-GAP) and country-specific frameworks such as the U.S. National Action Plan for Combating Antibiotic-Resistant Bacteria and the European One Health Action Plan against AMR. It evaluates regulatory policies, antibiotic stewardship programs, surveillance systems, and public awareness campaigns designed to promote responsible antimicrobial use. Key innovations in AMR reduction include the use of artificial intelligence (AI) and big data analytics for early detection of resistance patterns, precision medicine for targeted antimicrobial therapies, and the development of novel antibiotic alternatives such as bacteriophages and antimicrobial peptides. Additionally, advancements in rapid diagnostic tools and blockchain-based supply chain monitoring are examined for their potential to improve antimicrobial governance and reduce counterfeit medications. Challenges in implementing AMR policies, including regulatory fragmentation, lack of global coordination, and economic constraints, are discussed. The review highlights the need for interdisciplinary collaboration between governments, healthcare providers, pharmaceutical industries, and agricultural sectors to enforce stricter antimicrobial regulations, promote research and development of new treatments, and improve infection prevention measures. Findings suggest that a multifaceted approach integrating policy reforms, technological innovations, and public engagement is essential to slowing AMR progression. Strengthening surveillance networks, incentivizing antibiotic research, and enforcing antibiotic stewardship across all sectors can significantly reduce antimicrobial misuse and resistance. This review provides a roadmap for policymakers and stakeholders to develop sustainable, evidence-based AMR mitigation strategies.

Poverty and antibiotic misuse: a complex association

The abuse and misuse of antibiotics is one of the main drivers of antimicrobial resistance (AMR). Globally, AMR in food-producing animals is a significant public health concern. This study, therefore, assessed the knowledge, attitudes, and practices related to antibiotic usage (AMU) and AMR among poultry farmers in Nepal. We conducted a cross-sectional survey of 605 poultry farmers from six districts of Nepal from May to June 2022 to assess the status of knowledge, attitude, as well as practices toward prudent antibiotic usage (AMU) and AMR. The majority of the participants in our study were from the Chitwan district (31.6%; n = 191/605), aged 30-44 (54.2%; n = 328/605), males (70.4%; n = 426/605), and farmers with a higher secondary (28.76%; n = 174/605) level of education. The tetracyclines (28%, n = 228/828), aminoglycosides (23%, n = 188/828), and fluoroquinolones (15%, n = 126/828) were the most used antibiotics classes among poultry farmers. Although 87.8% (n = 531/605) of poultry farmers used antibiotics, 49.8% (n = 301/605) of them were aware of AMR, and 55.7% (n = 337/605) knew that the misuse of antimicrobials could affect human and environmental health. There were significant differences in the knowledge, attitude, and practices toward prudent AMU and AMR among farmers who reared different birds. The mean knowledge, attitude, and practice score of the respondents were 7.81 ± 3.26, 5.8 ± 2.32, and 7.59 ± 3.38 when measured on a scale of 12, 10, and 15, respectively. Based on a cut-off of 75% of the maximum score, 49.4% (n = 299/605), 62.8% (n = 380/605), and 12.73% (n = 77/605) of the respondents had good knowledge, attitude, and practices toward prudent AMU and AMR, respectively. The multivariable logistic regression analyses revealed that the positive predictors of good knowledge and attitude were male gender, higher level of education, district, and the types of birds (layers). Similarly, those of the male gender (OR: 3.36; 95% CI: 1.38-8.20; p = 0.008) and those that rear layers (OR: 4.63; 95% CI: 1.75-12.25; p = 0.003) were more likely to practice prudent usage of antimicrobials. The findings of this study show poor practice toward prudent antibiotic usage despite good knowledge of AMR. This study provides essential baseline data on the knowledge, attitudes, and practices of poultry farmers in Nepal and offers valuable insights that could help in the design of interventions and policies aimed at addressing illicit AMU and AMR in poultry in Nepal.

The 2024 discovery of a new class of antibiotics is cause for cautious celebration. However, media coverage of this discovery shows overstated optimism, potentially leading to a false sense of safety in the general public. We investigated whether informing participants about the discovery of new antibiotics changes their perceptions of new antibiotics as a solution to antimicrobial resistance and their expectations for receiving antibiotics for a hypothetical illness. In two preregistered online experiments, participants read a fictional newspaper article. In the Optimistic news condition, participants read about antimicrobial resistance and the discovery of new antibiotics. In the Cautious news condition, they additionally received a message about the importance of prudent antibiotic use. In the Control condition, participants read about antimicrobial resistance only. In Study 1 (n = 404), participants encountered the article in a hypothetical doctor's consultation and indicated their expectations to receive antibiotics before and after reading the article, as well as their perception of the new antibiotics. Study 2 (n = 443) was a partial replication in a neutral context, independent of a doctor's consultation. Antibiotic expectations decreased in all conditions after reading the article, which always provided information about antimicrobial resistance. However, unrealistic perceptions to solve antimicrobial resistance were higher in the Optimistic news condition (versus Control). This negative effect was mitigated in the Cautious news condition. News about the development of new antibiotics can influence public perceptions about antimicrobial resistance. Balanced communication is important to prevent a false sense of safety.

BackgroundAntibiotics are available in the marketplace in the form of tablets and capsules, and are mostly self‐prescribed by patients, with the consequent emergence of antimicrobial resistance (AMR). This study evaluated the consumption patterns of antimicrobials in these dosage forms during 2017 in Pakistan.MethodsData were acquired retrospectively from the International Medical Statistics (IMS) survey, Pakistan. Only the dosage forms of tablets and capsules constituting four major classes of antibiotics were included in the present study. Antibiotic consumption was measured using the World Health Organization's Anatomical Therapeutic Chemical Classification System with Daily Defined Doses (ATC/DDD) methodology. In addition, we calculated the DID as the total DDDs of antibiotic consumed in a defined period in that area per 1000 people. Expenditure was measured in Pakistan rupees (PKR) and converted to US dollars.ResultsTotal consumption of tablet and capsule dosage forms of antibiotics was found to be 10.6 DID, whereas total expenditure was US$221.5 million (26.69 billion PKR). Of all antibiotics, the most widely consumed were co‐amoxiclav (1.89 DID), levofloxacin (DID 1.41), ciprofloxacin (DID 1.38) and amoxicillin (DID 1.32). The top class of antibiotics based on expenditure was fluoroquinolones (ATC code J01MA), followed by combinations of penicillins (J01CR), third‐generation cephalosporins (J01DD) and macrolides (J01FA).ConclusionsExcessive consumption of broad‐spectrum and clinically important classes of antibiotics was observed. The study findings can serve as baseline data for policy makers and authorities to shape and design policies for the rational and cost‐effective use of antibiotics, reducing the burden of AMR and ensuring the economic use of antibiotics.