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Background: The carriage of resistant bacteria and prior antimicrobial treatment are related, but in an individual, this diminishes over time. To better manage antimicrobial resistance risks, it is crucial that we better untangle any lasting impact of antibiotic use compared to other factors. This understanding is essential for informing antimicrobial stewardship programs and to better manage other important factors that likely contribute to persistently higher rates of antimicrobial resistance in different populations. The true association between antibiotic use and resistance is likely to be significantly overestimated due to the confounding influence of varying infection risk patterns within populations. Though missing explanatory covariates are a well-known cause of falsely interpreted statistical findings, how the problem manifests in this context has a particular and interpretable structure. This issue does not appear to have been previously addressed with clarity. To be more easily understood, a simple model is used to demonstrate this. Results: In our theoretical model case study, when we exclude an effect of past antibiotic usage, clinical history alone can predict future resistance patterns. Heterogeneity in infection risk and antibiotic resistance carriage rates, along with consequently observed antimicrobial treatment, often suffice to predict a pattern of resistance that mimics what is assumed to be caused by genuine biologically driven resistance by the associated use of antibiotics. The biological impact and/or lasting effects of antibiotics are not necessary for this prediction. Conclusions: Antimicrobial stewardship policies and future research must directly address how much of the apparent persistence of resistant bacteria results from biological consequences of antibiotic use compared to pure statistical confounding arising due to heterogeneous risks in community infection patterns. Full article

Antimicrobial resistance is a growing global problem that causes increased deaths as well as increased suffering for people. Overall, there are two main factors that drive antimicrobial resistance: the volumes of antimicrobials used and the spread of resistant micro-organisms along with the genes encoding for resistance. Importantly, a growing body of evidence points to contagion (i.e., spread) being the major, but frequently under-appreciated and neglected, factor driving the increased prevalence of antimicrobial resistance. When we aggregate countries into regional groupings, it shows a pattern where there is an inverse aggregate relationship between AMR and usage. Poor infrastructure and corruption levels, however, are highly and positively correlated with antimicrobial resistance levels. Contagion, antibiotic volumes, governance, and the way antibiotics are used are profoundly affected by a host of social and economic factors. Only after we identify and adequately address these factors can antimicrobial resistance be better controlled. Full article

Approaching any issue from a One Health perspective necessitates looking at the interactions of people, domestic animals, wildlife, plants, and our environment. For antimicrobial resistance this includes antimicrobial use (and abuse) in the human, animal and environmental sectors. More importantly, the spread of resistant bacteria and resistance determinants within and between these sectors and globally must be addressed. Better managing this problem includes taking steps to preserve the continued effectiveness of existing antimicrobials such as trying to eliminate their inappropriate use, particularly where they are used in high volumes. Examples are the mass medication of animals with critically important antimicrobials for humans, such as third generation cephalosporins and fluoroquinolones, and the long term, in-feed use of antimicrobials, such colistin, tetracyclines and macrolides, for growth promotion. In people it is essential to better prevent infections, reduce over-prescribing and over-use of antimicrobials and stop resistant bacteria from spreading by improving hygiene and infection control, drinking water and sanitation. Pollution from inadequate treatment of industrial, residential and farm waste is expanding the resistome in the environment. Numerous countries and several international agencies have now included a One Health Approach within their action plans to address antimicrobial resistance. Necessary actions include improvements in antimicrobial use, better regulation and policy, as well as improved surveillance, stewardship, infection control, sanitation, animal husbandry, and finding alternatives to antimicrobials. Full article