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[[File:Antibiotic sensitivity and resistance.jpg|thumb|upright=1.4|[[Disk diffusion test|Antibiotic resistance tests]]: Bacteria are streaked on dishes with white disks, each impregnated with a different antibiotic. Clear rings, such as those on the left, show that bacteria have not grown—indicating that these bacteria are not resistant. The bacteria on the right are fully resistant to three of seven and partially resistant to two of seven antibiotics tested.<ref>[http://www.microbelibrary.org/component/resource/laboratory-test/3189-kirby-bauer-disk-diffusion-susceptibility-test-protocol Kirby-Bauer Disk Diffusion Susceptibility Test Protocol] {{webarchive|url=https://web.archive.org/web/20110626190940/http://www.microbelibrary.org/component/resource/laboratory-test/3189-kirby-bauer-disk-diffusion-susceptibility-test-protocol |date=26 June 2011 }}, Jan Hudzicki, ASM</ref>|alt=Two petri dishes with antibiotic resistance tests]]
'''Antimicrobial resistance''' ('''AMR''') occurs when [[microbe]]s evolve mechanisms that protect them from the effects of [[antimicrobials]] (drugs used to treat infections).<ref name="WHO2014">{{cite web|title=Antimicrobial resistance Fact sheet N°194|url=https://www.who.int/mediacentre/factsheets/fs194/en/|website=who.int|access-date=7 March 2015|date=April 2014|archive-url=https://web.archive.org/web/20150310081111/http://www.who.int/mediacentre/factsheets/fs194/en/|archive-date=10 March 2015|url-status=live}}</ref> All classes of microbes can evolve resistance whereto the point that one or more drugs used to fight them are no longer effective. [[Fungi]] evolve [[antifungal]] resistance, [[virus]]es evolve [[antiviral]] resistance, [[protozoa]] evolve [[antiprotozoal]] resistance, and [[bacteria]] evolve [[antibiotic]] resistance. Together all of these come under the umbrella of antimicrobial resistance.
Microbes resistant to multiple antimicrobials are called [[Multiple drug resistance|multidrug resistant]] (MDR) and are sometimes referred to as '''superbugs'''.<ref name="Magiorakos">{{cite journal | vauthors = Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, Harbarth S, Hindler JF, Kahlmeter G, Olsson-Liljequist B, Paterson DL, Rice LB, Stelling J, Struelens MJ, Vatopoulos A, Weber JT, Monnet DL | title = Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance | journal = Clinical Microbiology and Infection | volume = 18 | issue = 3 | pages = 268–281 | date = March 2012 | pmid = 21793988 | doi = 10.1111/j.1469-0691.2011.03570.x | doi-access = free }}</ref> Although antimicrobial resistance is a naturally occurring process, it is often the result of improper usage of the drugs and management of the infections.<ref name="Tanwar_2014">{{cite journal | vauthors = Tanwar J, Das S, Fatima Z, Hameed S | title = Multidrug resistance: an emerging crisis | journal = Interdisciplinary Perspectives on Infectious Diseases | volume = 2014 | pages = 541340 | date = 2014 | pmid = 25140175 | pmc = 4124702 | doi = 10.1155/2014/541340 | doi-access = free }}</ref><ref name="Saha_2021">{{cite journal | vauthors = Saha M, Sarkar A | title = Review on Multiple Facets of Drug Resistance: A Rising Challenge in the 21st Century | journal = Journal of Xenobiotics | volume = 11 | issue = 4 | pages = 197–214 | date = December 2021 | pmid = 34940513 | pmc = 8708150 | doi = 10.3390/jox11040013 | doi-access = free }}</ref>
'''Antibiotic resistance''' is a major subset of AMR, that applies specifically to [[bacteria]] that become resistant to [[antibiotic]]s.<ref name="WHO2014" /> Resistance in bacteria can arise naturally by [[genetic mutation]], or by one species acquiring resistance from another.<ref>{{cite web |title=General Background: About Antibiotic Resistance |url=http://www.tufts.edu/med/apua/about_issue/about_antibioticres.shtml |url-status=dead |archive-url=https://web.archive.org/web/20151023035356/http://www.tufts.edu/med/apua/about_issue/about_antibioticres.shtml |archive-date=23 October 2015 |access-date=30 October 2015 |website=www.tufts.edu}}</ref> Resistance can appear spontaneously because of random mutations, but also arises through spreading of resistant genes through [[horizontal gene transfer]]. However, extended use of antibiotics appears to encourage selection for mutations which can render antibiotics ineffective.<ref>{{cite journal | vauthors = Dabour R, Meirson T, Samson AO | title = Global antibiotic resistance is mostly periodic | journal = Journal of Global Antimicrobial Resistance | volume = 7 | pages = 132–134 | date = December 2016 | pmid = 27788414 | doi = 10.1016/j.jgar.2016.09.003 }}</ref> '''Antifungal resistance''' is a subset of AMR, that specifically applies to fungi that have become resistant to antifungals. Resistance to antifungals can arise naturally, for example by genetic mutation or through [[aneuploidy]]. Extended use of antifungals leads to development of antifungal resistance through various mechanisms.<ref name="Fisher_2022">{{cite journal | vauthors = Fisher MC, Alastruey-Izquierdo A, Berman J, Bicanic T, Bignell EM, Bowyer P, Bromley M, Brüggemann R, Garber G, Cornely OA, Gurr SJ, Harrison TS, Kuijper E, Rhodes J, Sheppard DC, Warris A, White PL, Xu J, Zwaan B, Verweij PE | title = Tackling the emerging threat of antifungal resistance to human health | journal = Nature Reviews. Microbiology | volume = 20 | issue = 9 | pages = 557–571 | date = September 2022 | pmid = 35352028 | pmc = 8962932 | doi = 10.1038/s41579-022-00720-1 }}</ref>
Clinical conditions due to infections caused by microbes containing AMR cause millions of deaths each year.<ref>{{cite journal | title = Global mortality associated with 33 bacterial pathogens in 2019: a systematic analysis for the Global Burden of Disease Study 2019 | journal = Lancet | volume = 400 | issue = 10369 | pages = 2221–2248 | date = December 2022 | pmid = 36423648 | pmc = 9763654 | doi = 10.1016/S0140-6736(22)02185-7 | vauthors = Ikuta KS, Swetschinski LR, Robles Aguilar G, Sharara F, Mestrovic T, Gray AP, Davis Weaver N, Wool EE, Han C, Gershberg Hayoon A, Aali A, Abate SM, Abbasi-Kangevari M, Abbasi-Kangevari Z, Abd-Elsalam S, Abebe G, Abedi A, Abhari AP, Abidi H, Aboagye RG, Absalan A, Abubaker Ali H, Acuna JM, Adane TD, Addo IY, Adegboye OA, Adnan M, Adnani QE, Afzal MS, Afzal S }}</ref> In 2019 there were around 1.27 million deaths globally caused by bacterial AMR.<ref name="Murray_2022" /> Infections caused by resistant microbes are more difficult to treat, requiring higher doses of antimicrobial drugs, more expensive antibiotics, or alternative [[medication]]s which may prove [[adverse effect|more toxic]]. These approaches may also cost more.<ref name="Tanwar_2014" /><ref name="Saha_2021" />
The prevention of [[antibiotic misuse]], which can lead to antibiotic resistance, includes taking antibiotics only when prescribed.<ref name="About Antimicrobial Resistance">{{cite web|url=https://www.cdc.gov/drugresistance/about.html|title=About Antimicrobial Resistance|website=www.cdc.gov|access-date=30 October 2015|archive-url=https://web.archive.org/web/20171001044758/https://www.cdc.gov/drugresistance/about.html|archive-date=1 October 2017|url-status=live|date=10 September 2018}}</ref><ref name="Swedish">{{cite book|title=Swedish work on containment of antibiotic resistance – Tools, methods and experiences|publisher=Public Health Agency of Sweden|year=2014|isbn=978-91-7603-011-0|url=http://www.folkhalsomyndigheten.se/pagefiles/17351/Swedish-work-on-containment-of-antibiotic-resistance.pdf|location=Stockholm|pages=16–17, 121–128|access-date=23 July 2015|archive-url=https://web.archive.org/web/20150723081110/http://www.folkhalsomyndigheten.se/pagefiles/17351/Swedish-work-on-containment-of-antibiotic-resistance.pdf|archive-date=23 July 2015|url-status=live|df=dmy-all}}</ref> [[Narrow-spectrum antibiotic]]s are preferred over [[broad-spectrum antibiotic]]s when possible, asfor effectively and accurately targeting specific organisms is less likely to cause resistance, as well as side effects.<ref name="NPS2013">{{cite web|title=Duration of antibiotic therapy and resistance|url=http://www.nps.org.au/publications/health-professional/health-news-evidence/2013/duration-of-antibiotic-therapy|website=NPS Medicinewise|publisher=National Prescribing Service Limited trading, Australia|access-date=22 July 2015|date=13 June 2013|archive-url=https://web.archive.org/web/20150723074759/http://www.nps.org.au/publications/health-professional/health-news-evidence/2013/duration-of-antibiotic-therapy|archive-date=23 July 2015|url-status=dead|df=dmy-all}}</ref><ref>{{cite journal | vauthors = Gerber JS, Ross RK, Bryan M, Localio AR, Szymczak JE, Wasserman R, Barkman D, Odeniyi F, Conaboy K, Bell L, Zaoutis TE, Fiks AG | title = Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections | journal = JAMA | volume = 318 | issue = 23 | pages = 2325–2336 | date = December 2017 | pmid = 29260224 | pmc = 5820700 | doi = 10.1001/jama.2017.18715 }}</ref><ref name="WHO_2022">{{cite book |url=https://www.who.int/publications/i/item/9789240062382 |title=The WHO AWaRe (Access, Watch, Reserve) antibiotic book |publisher=[[World Health Organization]] (WHO) |year=2022 |isbn=978-92-4-006238-2 |location=Geneva |access-date=28 March 2023 |archive-date=13 August 2023 |archive-url=https://web.archive.org/web/20230813134739/https://www.who.int/publications/i/item/9789240062382 |url-status=live }}</ref> For people who take these medications at home, education about proper use is essential. Health care providers can minimize the spread of resistant infections by use of proper [[sanitation]] and [[hygiene]], including [[handwashing]] and disinfecting between patients, and should encourage the same of theevery patient, visitorsvisitor, and family membersmember.<ref name="CDC Mission">{{cite web|url=https://www.cdc.gov/Features/AntibioticResistance/index.html|title=CDC Features – Mission Critical: Preventing Antibiotic Resistance|website=www.cdc.gov|access-date=22 July 2015|archive-url=https://web.archive.org/web/20171108202412/https://www.cdc.gov/features/antibioticresistance/index.html|archive-date=8 November 2017|url-status=live|date=4 April 2018}}</ref>
Rising drug resistance is caused mainly by use of antimicrobials in humans and other animals, and the spread of resistantAMR strains between the two.<ref name="About Antimicrobial Resistance"/> Growing resistance has also been linked to releasing inadequately treated effluents from the pharmaceutical industry, especially in countries where bulk drugs are manufactured.<ref>{{cite web |title=Impacts of Pharmaceutical Pollution on Communities and Environment in India |url=https://www.nordea.com/Images/35-107206/impacts%201-20.pdf|website=Nordea| date = February 2016 |access-date=1 May 2018|archive-url=https://web.archive.org/web/20170520031434/https://www.nordea.com/Images/35-107206/impacts%201-20.pdf|archive-date=20 May 2017|url-status=live}}</ref> Antibiotics increase [[selective pressure]] in bacterial populations, killing vulnerable bacteria; this increases the percentage of resistant bacteria, which continue growing. Even at very low levels of antibiotic, can give resistant bacteria canan haveadvantage ain growth advantagegrowing and growreproducing faster than vulnerable bacteria.<ref>{{cite journal | vauthors = Gullberg E, Cao S, Berg OG, Ilbäck C, Sandegren L, Hughes D, Andersson DI | title = Selection of resistant bacteria at very low antibiotic concentrations | journal = PLOS Pathogens | volume = 7 | issue = 7 | pages = e1002158 | date = July 2011 | pmid = 21811410 | pmc = 3141051 | doi = 10.1371/journal.ppat.1002158 | doi-access = free }}</ref> Similarly, the use of antifungals in agriculture increases selective pressure in fungal populations, which triggers the emergence ofcausing antifungal resistance.<ref name="Fisher_2022" /> As resistance to antimicrobials becomes more common there is a much greater need for alternative treatments. Calls for new antimicrobial therapies have been issued, but there is very little development of new drugs whichand wouldconsequently leadlittle toinnovation anin improved researchthe process of researching potential candidates for them.<ref>{{cite journal | vauthors = Cassir N, Rolain JM, Brouqui P | title = A new strategy to fight antimicrobial resistance: the revival of old antibiotics | journal = Frontiers in Microbiology | volume = 5 | pages = 551 | date = 2014 | pmid = 25368610 | pmc = 4202707 | doi = 10.3389/fmicb.2014.00551 | doi-access = free }}</ref>
AntimicrobialAntibiotic resistance is increasing globally due to increased prescriptionprescribing and dispensing of antibiotic drugs in [[developing countries]].<ref>{{cite news|url=https://www.theguardian.com/science/2018/mar/26/calls-to-rein-in-antibiotic-use-after-study-shows-65-increase-worldwide|title=Calls to rein in antibiotic use after study shows 65% increase worldwide| vauthors = Sample I |date=26 March 2018|journal=The Guardian|access-date=28 March 2018|archive-url=https://web.archive.org/web/20180408063812/https://www.theguardian.com/science/2018/mar/26/calls-to-rein-in-antibiotic-use-after-study-shows-65-increase-worldwide|archive-date=8 April 2018|url-status=live}}</ref> Estimates are that 700,000 to several million deaths worldwide result perannually yearfrom andantibiotic resistance, so it continues to pose a major public health threat worldwide.<ref name="Dramé_2020">{{cite journal | vauthors = Dramé O, Leclair D, Parmley EJ, Deckert A, Ouattara B, Daignault D, Ravel A | title = Antimicrobial Resistance of ''Campylobacter'' in Broiler Chicken Along the Food Chain in Canada | journal = Foodborne Pathogens and Disease | volume = 17 | issue = 8 | pages = 512–520 | date = August 2020 | pmid = 32130036 | pmc = 7415884 | doi = 10.1089/fpd.2019.2752 }}</ref><ref name="WHO 2014">{{cite web|url=https://www.who.int/drugresistance/documents/surveillancereport/en/ |title=Antimicrobial resistance: global report on surveillance 2014|author=WHO|date=April 2014|work=WHO|access-date=9 May 2015|archive-url= https://web.archive.org/web/20150515101620/http://www.who.int/drugresistance/documents/surveillancereport/en/ |archive-date=15 May 2015|url-status=dead}}</ref><ref name="AMR2016">{{cite web|url=https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf|title=Tackling drug-resistant infections globally: final report and recommendations | vauthors = O'Neill J |date=May 2016|website=amr-review.org/|access-date=10 November 2017|archive-url= https://web.archive.org/web/20171114170946/https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf |archive-date=14 November 2017|url-status=live}}</ref> Each year in the [[United States]], at least 2.8 million people become infected with bacteria that are antibiotic-resistant to antibiotics andbacteria, at least 35,000 peopleof them die, and US$55 billion is spent on increasedall their health care costs and lost productivity.<ref>{{cite journal | vauthors = Dadgostar P | title = Antimicrobial Resistance: Implications and Costs | language = English | journal = Infection and Drug Resistance | volume = 12 | pages = 3903–3910 | date = 2019-12-20 | pmid = 31908502 | pmc = 6929930 | doi = 10.2147/IDR.S234610 | doi-access = free }}</ref><ref>{{cite web |title=The biggest antibiotic-resistant threats in the U.S. |url=https://www.cdc.gov/drugresistance/biggest-threats.html |website=Centers for Disease Control and Prevention |access-date=15 November 2019 |language=en-us |date=6 November 2019 |archive-date=6 November 2019 |archive-url=https://web.archive.org/web/20191106224431/https://www.cdc.gov/drugresistance/biggest-threats.html |url-status=live }}</ref> According to the [[World Health Organization]] (WHO) estimates, 350 million deaths could be caused by AMR by 2050.<ref>{{cite news|vauthors=Chanel S, Doherty B|date=2020-09-10|title='Superbugs' a far greater risk than Covid in Pacific, scientist warns|language=en-GB|work=The Guardian|url=https://www.theguardian.com/world/2020/sep/10/superbugs-a-far-greater-risk-than-covid-in-pacific-scientist-warns|access-date=2020-09-14|issn=0261-3077|archive-date=5 December 2022|archive-url=https://web.archive.org/web/20221205165241/https://www.theguardian.com/world/2020/sep/10/superbugs-a-far-greater-risk-than-covid-in-pacific-scientist-warns|url-status=live}}</ref> By then, the yearly death toll will be 10 million, according to a [[United Nations]] report.<ref>{{cite web|vauthors=Samuel S|date=2019-05-07|title=Our antibiotics are becoming useless|url=https://www.vox.com/future-perfect/2019/5/7/18535480/drug-resistance-antibiotics-un-report|access-date=2021-01-28|website=Vox|language=en|archive-date=11 May 2021|archive-url=https://web.archive.org/web/20210511162852/https://www.vox.com/future-perfect/2019/5/7/18535480/drug-resistance-antibiotics-un-report|url-status=live}}</ref>
There are publicPublic calls for global collective action to address the threat that include proposals for [[international treaty|international treaties]] on antimicrobial resistance.<ref name="Hoffman" /> The [[Disease burden|burden]] of worldwide antibiotic resistance is not completely identified, but [[Developing country|low-and middle- income countries]] with weaker healthcare systems are more affected, with mortality being the highest in [[sub-Saharan Africa]].<ref name="Murray_2022" /><ref name="Swedish" /> During the [[COVID-19 pandemic]], priorities changed, withand action against antimicrobialAMR resistanceslowed slowingbecause duescientific toand scientistsgovernment andfocus governmentsmoved focusingto the more onpressing problem of [[SARS-CoV-2]] research.<ref>{{cite journal |title = The post-antibiotic era is here |vauthors = Kwon JH, Powderly WG |date = July 30, 2021 |journal = Science|volume = 373 |issue = 6554 |page = 471 |publisher = American Association for the Advancement of Science. |doi = 10.1126/science.abl5997 |pmid = 34326211 |bibcode = 2021Sci...373..471K |s2cid = 236501941 |doi-access = free }}</ref><ref name="pmid33772597">{{cite journal | vauthors = Rodríguez-Baño J, Rossolini GM, Schultsz C, Tacconelli E, Murthy S, Ohmagari N, Holmes A, Bachmann T, Goossens H, Canton R, Roberts AP, Henriques-Normark B, Clancy CJ, Huttner B, Fagerstedt P, Lahiri S, Kaushic C, Hoffman SJ, Warren M, Zoubiane G, Essack S, Laxminarayan R, Plant L|display-authors = 6 | title = Key considerations on the potential impacts of the COVID-19 pandemic on antimicrobial resistance research and surveillance | journal = Trans R Soc Trop Med Hyg | volume = 115| issue = 10| pages = 1122–1129| date = March 2021 | pmid = 33772597 | pmc = 8083707 | doi = 10.1093/trstmh/trab048 }}</ref> At the same time, the threat of AMR has increased during the pandemic.<ref>{{cite journal |title=COVID-19: U.S. Impact on Antimicrobial Resistance, Special Report 2022 |url=https://stacks.cdc.gov/view/cdc/117915 |access-date=2023-03-28 |website=CDC |year=2022 |doi=10.15620/cdc:117915 |s2cid=249320411 |doi-access=free |archive-date=22 March 2023 |archive-url=https://web.archive.org/web/20230322164814/https://stacks.cdc.gov/view/cdc/117915 |url-status=live }}</ref>
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== Further reading ==
[[File:Why won’t antibiotics cure us anymore.webm|thumb|Lecture by chemist prof. dr. Nathaniel Martin ([[Leiden University]]) on antibiotic resistance]]
* {{cite journal|author=Bancroft, EA|title=Antimicrobial resistance: it's not just for hospitals|journal=JAMA|volume=298|issue=15|pages=1803–1804|date=October 2007|doi=10.1001/jama.298.15.1803|pmid=17940239|pmc=2536104}}
* {{cite journal|author=Larson, E|title=Community factors in the development of antibiotic resistance|journal=Annual Review of Public Health|volume=28|pages=435–447|year=2007|pmid=17094768|doi=10.1146/annurev.publhealth.28.021406.144020|doi-access=free}}
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