Interventions to optimize the use of antibiotics in China: A scoping review of evidence from humans, animals, and the environment from a One Health perspective

Policy text analysis of antimicrobial resistance governance in China: A focus on national-level policies

OBJECTIVE

To explore the structure and characteristics of China's national policies regarding antimicrobial resistance (AMR) governance.

METHOD

This research constitutes a quantitative content analysis of AMR policies issued by the central government from 2004 to 2023. A systematic search identified 112 policy documents, which were analysed using a three-dimensional framework. This framework included policy objectives, policy instruments (The supply-focused instrument aims to promote rational and prudent antibiotic prescriptions. The demand-focused instrument affects consumer use of antibiotics, either directly or indirectly. The environment-focused instrument provides a favourable and systematic policy environment for the prudent use of antibiotics.) and policy evolvement. Sub-themes under the framework were identified through a deductive process, followed by descriptions of frequency distributions of the sub-themes and categories.

RESULTS

The majority of policy documents originated from individual governmental departments, with only 8 (7.14%) being jointly issued. The National Health Commission (NHC) remained the predominant policy maker, issuing 56 (48.21%) policies. A clear preference emerged for utilizing environment-focused policy instruments (69.70%), compared with the demand-focused (18.45%) and supply-focused (11.85%) instruments. 'Optimizing the use of antimicrobial medicines' ranked on top of the policy objectives, with 185 (31.25%) citations extracted across 74 (30.58%) policy documents. In addition to increasing numbers of policies over the three stages (2004-2011, 2012-2015, 2016-2023) of development, the use of various instruments became more comprehensive and balanced in the third stage.

CONCLUSIONS

AMR governance has become increasingly comprehensive in China, despite a deficit in inter-sectoral collaborations. A whole-of-government approach is required to maximize the value of various policy initiatives.

Occurrence and dissemination of antibiotics and antibiotic resistance in aquatic environment and its ecological implications: a review

The occurrence of antibiotics and antibiotic-resistant bacteria (ARBs), genes (ARGs), and mobile genetic elements (MGEs) in aquatic systems is growing global public health concern. These emerging micropollutants, stemming from improper wastewater treatment and disposal, highlight the complex and evolving nature of environmental pollution. Current literature reveals potential biases, such as a geographical focus on specific regions, leading to an insufficient understanding of the global distribution and dynamics of antibiotic resistance in aquatic systems. There is methodological inconsistency across studies, making it challenging to compare findings. Potential biases include sample collection inconsistencies, detection sensitivity variances, and data interpretation variability. Gaps in understanding include the need for comprehensive, standardized long-term monitoring programs, elucidating the environmental fate and transformation of antibiotics and resistance genes. This review summarizes current knowledge on the occurrence and dissemination of emerging micropollutants, their ecological impacts, and the global health implications of antimicrobial resistance. It highlights the need for interdisciplinary collaborations among researchers, policymakers, and stakeholders to address the challenges posed by antibiotic resistance in aquatic resistance in aquatic systems effectively. This review highlights widespread antibiotic and antibiotic resistance in aquatic environment, driven by human and agricultural activities. It underscores the ecological consequences, including disrupted microbial communities and altered ecosystem functions. The findings call for urgent measures to mitigate antibiotics pollution and manage antibiotic resistance spread in water bodies.

Urban agglomerations as an environmental dimension of antibiotics transmission through the "One Health" lens

The spatiotemporal distributions of antibiotics in different media have been widely reported; however, their occurrence in the environmental dimension of the Chinese urban agglomerations has received less attention, especially in bioaccumulation and health risks of antibiotics through the "One Health" lens. The review presents the current knowledge on the environmental occurrence, bioaccumulation, as well as health exposure risks in urban agglomerations through the "One Health" lens, and identifies current information gaps. The reviewed studies suggested antibiotic concentrations in water and soil were more sensitive to social indicators of urban agglomerations than those in sediment. The ecological risk and resistance risk of antibiotics in water were much higher than those of sediments, and the high-risk phenomenon occurred at a higher frequency in urban agglomerations. Erythromycin-H2O (ETM-H2O), amoxicillin (AMOX) and norfloxacin (NFC) were priority-controlled antibiotics in urban waters. Tetracyclines (TCs) posed medium to high risks to soil organisms in the soil of urban agglomerations. Health risk evaluation based on dietary intake showed that children had the highest dietary intake of antibiotics in urban agglomerations. The health risk of antibiotics was higher in children than in other age groups. Our results also demonstrated that dietary structure might impact health risks associated with target antibiotics in urban agglomerations to some extent.

Bioinspired silver nanoparticle-based nanocomposites for effective control of plant pathogens: A review

Plant pathogens, including bacteria, fungi, and viruses, pose significant challenges to the farming community due to their extensive diversity, the rapidly evolving phenomenon of multi-drug resistance (MDR), and the limited availability of effective control measures. Amid mounting global pressure, particularly from the World Health Organization, to limit the use of antibiotics in agriculture and livestock management, there is increasing consideration of engineered nanomaterials (ENMs) as promising alternatives for antimicrobial applications. Studies focusing on the application of ENMs in the fight against MDR pathogens are receiving increasing attention, driven by significant losses in agriculture and critical knowledge gaps in this crucial field. In this review, we explore the potential contributions of silver nanoparticles (AgNPs) and their nanocomposites in combating plant diseases, within the emerging interdisciplinary arena of nano-phytopathology. AgNPs and their nanocomposites are increasingly acknowledged as promising countermeasures against plant pathogens, owing to their unique physicochemical characteristics and inherent antimicrobial properties. This review explores recent advancements in engineered nanocomposites, highlights their diverse mechanisms for pathogen control, and draws attention to their potential in antibacterial, antifungal, and antiviral applications. In the discussion, we briefly address three crucial dimensions of combating plant pathogens: green synthesis approaches, toxicity-environmental concerns, and factors influencing antimicrobial efficacy. Finally, we outline recent advancements, existing challenges, and prospects in scholarly research to facilitate the integration of nanotechnology across interdisciplinary fields for more effective treatment and prevention of plant diseases.

Joining Forces against Antibiotic Resistance: The One Health Solution

Antibiotic resistance is a significant global health concern that affects both human and animal populations. The One Health approach acknowledges the interconnectedness of human health, animal health, and the environment. It emphasizes the importance of collaboration and coordination across these sectors to tackle complex health challenges such as antibiotic resistance. In the context of One Health, antibiotic resistance refers to the ability of bacteria to withstand the efficacy of antibiotics, rendering them less effective or completely ineffective in treating infections. The emergence and spread of antibiotic-resistant bacteria pose a threat to human and animal health, as well as to the effectiveness of medical treatments and veterinary interventions. In particular, One Health recognizes that antibiotic use in human medicine, animal agriculture, and the environment are interconnected factors contributing to the development and spread of antibiotic resistance. For example, the misuse and overuse of antibiotics in human healthcare, including inappropriate prescribing and patient non-compliance, can contribute to the selection and spread of resistant bacteria. Similarly, the use of antibiotics in livestock production for growth promotion and disease prevention can contribute to the development of antibiotic resistance in animals and subsequent transmission to humans through the food chain. Addressing antibiotic resistance requires a collaborative One Health approach that involves multiple participants, including healthcare professionals, veterinarians, researchers, and policymakers.

Multidrug-Resistant Salmonella Species and Their Mobile Genetic Elements from Poultry Farm Environments in Malaysia

The prevalence and persistent outbreaks of multidrug-resistant (MDR) Salmonella in low-income countries have received growing attention among the public and scientific community. Notably, the excessive use of antibiotics in chicken feed for the purpose of treatment or as prophylaxis in the poultry industry have led to a rising rate of antimicrobial resistance. Therefore, this study aimed to determine the presence of antimicrobial-resistant Salmonella species and its mobile genetic elements from soil and effluent samples of 33 randomly selected poultry farms in Selangor, Malaysia. Salmonella species were isolated on selective media (CHROMagar™ Salmonella). VITEK® 2 system was used to identify the isolates and their antimicrobial susceptibility. Subsequently, eight isolates were subjected to the whole genome sequencing (WGS). Based on the results, Salmonella spp. was detected in 38.1% (24/63) of samples, with the highest resistance to ampicillin (62.5%), followed by ampicillin/sulbactam (50.0%) and ciprofloxacin (45.8%). Meanwhile, the identified serovars were Salmonella enterica subspecies enterica serovar Weltevreden (S. Weltevreden), S. Jedburgh, and S. Brancaster. The most prevalent resistance genes detected include qnrS1, blaTEM-176, dfrA14, and tet(A). The IncX1 plasmid, with encoded resistance genes, was also detected in four isolates. Furthermore, mutations in the quinolone resistant-determining regions (QRDR) were discovered, specifically in the gyrA, gyrB, and parC genes. In short, surveillance such as continuous monitoring of antimicrobial resistance and emerging trends in resistance patterns through farm environmental samples could provide information to formulate public health interventions for effective infection prevention and disease control.

Tributyrin alleviates gut microbiota dysbiosis to repair intestinal damage in antibiotic-treated mice

Tributyrin (TB) is a butyric acid precursor and has a key role in anti-inflammatory and intestinal barrier repair effects by slowly releasing butyric acid. However, its roles in gut microbiota disorder caused by antibiotics remain unclear. Herein, we established an intestinal microbiota disorder model using ceftriaxone sodium via gavage to investigate the effects of different TB doses for restoring gut microbiota and intestinal injury. First, we divided C57BL/6 male mice into two groups: control (NC, n = 8) and experimental (ABx, n = 24) groups, receiving gavage with 0.2 mL normal saline and 400 mg/mL ceftriaxone sodium solution for 7 d (twice a day and the intermediate interval was 6 h), respectively. Then, mice in the ABx group were randomly split into three groups: model (M, 0.2 mL normal saline), low TB group (TL, 0.3 g/kg BW), and high TB group (TH, 3 g/kg BW) for 11 d. We found that TB supplementation alleviated antibiotics-induced weight loss, diarrhea, and intestinal tissue damage. The 16S rRNA sequence analysis showed that TB intervention increased the α diversity of intestinal flora, increased potential short-chain fatty acids (SCFAs)-producing bacteria (such as Muribaculaceae and Bifidobacterium), and inhibited the relative abundance of potentially pathogenic bacteria (such as Bacteroidetes and Enterococcus) compared to the M group. TB supplementation reversed the reduction in SCFAs production in antibiotic-treated mice. Additionally, TB downregulated the levels of serum LPS and zonulin, TNF-α, IL-6, IL-1β and NLRP3 inflammasome-related factors in intestinal tissue and upregulated tight junction proteins (such as ZO-1 and Occludin) and MUC2. Overall, the adjustment ability of low-dose TB to the above indexes was stronger than high-dose TB. In conclusion, TB can restore the dysbiosis of gut microbiota, increase SCFAs, suppress inflammation, and ameliorate antibiotic-induced intestinal damage, indicating that TB might be a potential gut microbiota modulator.

A comprehensive and global evaluation of residual antibiotics in agricultural soils: Accumulation, potential ecological risks, and attenuation strategies

The occurrence of antibiotics in agricultural soils has raised concerns due to their potential risks to ecosystems and human health. However, a comprehensive understanding of antibiotic accumulation, distribution, and potential risks to terrestrial ecosystems on a global scale is still limited. Therefore, in this study, we evaluated the accumulation of antibiotics and their potential risks to soil microorganisms and plants, and highlighted the driving factors of antibiotic accumulation in agricultural soils based on 134 peer-reviewed studies (between 2000 and 2022). The results indicated that 56 types of antibiotics were detected at least once in agricultural soils with concentrations ranging from undetectable to over 7000 µg/kg. Doxycycline, tylosin, sulfamethoxazole, and enrofloxacin, belonging to the tetracyclines, macrolides, sulfonamides, and fluoroquinolones, respectively, were the most accumulated antibiotics in agricultural soil. The accumulation of TCs, SAs, and FQs was found to pose greater risks to soil microorganisms (average at 29.3%, 15.4%, and 21.8%) and plants (42.4%, 26.0%, and 38.7%) than other antibiotics. East China was identified as a hot spot for antibiotic contamination due to high levels of antibiotic concentration and ecological risk to soil microorganisms and plants. Antibiotic accumulation was found to be higher in vegetable fields (245.5 µg/kg) and orchards (212.4 µg/kg) compared to croplands (137.2 µg/kg). Furthermore, direct land application of manure resulted in a greater accumulation of TCs, SAs, and FQs accumulation in soils than compost fertilization. The level of antibiotics decreased with increasing soil pH and organic matter content, attributed to decreasing adsorption and enhancing degradation of antibiotics. In conclusion, this study highlights the need for further research on the impacts of antibiotics on soil ecological function in agricultural fields and their interaction mechanisms. Additionally, a whole-chain approach, consisting of antibiotic consumption reduction, manure management strategies, and remediation technology for soil contaminated with antibiotics, is needed to eliminate the potential environmental risks of antibiotics for sustainable and green agriculture.

Deciphering the antibiotic resistome and microbial community in municipal wastewater treatment plants at different elevations in eastern and western China

Antibiotic resistance genes (ARGs) as emerging environmental contaminants pose severe global risks to public health and ecosystems. Municipal wastewater treatment plants (WWTPs) are crucial transmitters for the dissemination and propagation of ARGs into receiving water bodies via mobile genetic elements (MGEs). However, the comprehensive and deep deciphering of the diversity, abundance, and potential hosts of ARGs in two distinct altitudinal WWTPs is scarce. In this work, we revealed the elevational distribution characteristics of the resistance genes and microbial community of six WWTPs from two distinct geographical zones: a low-elevation (LE) region (Shandong, 10-22 m above sea level) and a high-elevation (HE) region (Gansu, 1,520-1,708 m above sea level). Significant elevational variations in the diversity and relative abundance of resistance genes were observed. Wastewater treatment could significantly reduce the concentrations of ARGs and MGEs by about 1-2 and 2-3 orders of magnitude, respectively. However, above 69.95% of resistance genes were enriched in effluent. In particular, 24 ARG subtype, 3 MGE subtypes, and 59 bacterial genera were persistent in all samples. More potential hosts for ARGs in LE region and more abundant human gut microbiota in HE region were identified. This work provides helpful information for controlling the spread of ARGs for their management and assessment, thereby mitigating the risks of ARGs in WWTPs.

Unpacking Multi-Level Governance of Antimicrobial Resistance Policies: the Case of Guangdong, China

Against the backdrop of universal healthcare coverage and pre-existing policies on antimicrobial use, China has adopted a state-governed, multi-level, top-down policy governance approach around an antimicrobial resistance (AMR) national action plan (NAP). The Plan relies on tightening control over antimicrobial prescription and use in human and animal sectors. At the same time, medical doctors and veterinarians operate in an environment of high rates of infectious diseases, multi-drug resistance and poor livestock husbandry. In exploring the way that policy responsibilities are distributed, this study aims to describe how Guangdong as a province adopts national AMR policies in a tightly controlled public policy system and an economy with high disparity. We draw on an analysis of 225 AMR-relevant Chinese policy documents at the national and sub-national levels. We adopt a multi-level governance perspective and apply a temporal sequence framework to identify and analyse documents. To identify policy detail, we conducted keyword analysis using the Consolidated Framework for Implementation Research (CFIR) on policies that conserve antimicrobials. We also identify pre-existing medical and public policies associated with AMR. Our findings highlight the emphasis and policies around antimicrobial use regulation to address AMR in China.