Selection of antibiotic resistance at very low antibiotic concentrations

Spatiotemporal variations and priority ranking of emerging contaminants in nanwan reservoir: A case study from the agricultural region in huaihe river basin in China

The presence of emerging contaminants (ECs) in drinking water sources is an increasing concern, yet limited data exists on their occurrence and risk in the upper Huaihe River Basin, an important agricultural region in Central China. This study investigated 70 ECs, including pesticide and antibiotics in surface water from drinking water source areas in Nanwan Reservoir along the upper reaches of the Huaihe River Basin to prioritize the ECs based on ecological risk and health risk assessment. A total of 66 ECs were detected in the surface water at least once at the selected 38 sampling sites, with concentrations ranging from 0.04 to 2508 ng/L. Ecological risk assessment using the risk quotient (RQ) method revealed high risks (RQ > 1) from 7 ECs in the dry season and 15 ECs in the wet season, with triazine pesticides as the main contributors. Non-carcinogenic risks were below negligible levels, but carcinogenic risks from neonicotinoid and carbamate pesticides and macrolide antibiotics were concerning for teenagers. Ciprofloxacin exhibited a high level of resistance risk during the wet season. A multi-indicator prioritization approach integrating occurrence, risk, and chemical property data ranked 6 pesticides and 3 antibiotics as priority pollutants. The results highlight EC contamination of drinking water sources in this agriculturally-intensive region and the need for targeted monitoring and management to protect water quality.

Cell morphology as biomarker of carbapenem exposure

Characterizing the physiological response of bacterial cells to antibiotics is crucial for designing diagnostic techniques, treatment choices, and drug development. While bacterial cells at sublethal doses of antibiotics are commonly characterized, the impact of exposure to high concentrations of antibiotics on bacteria after long-term serial exposure and their effect on withdrawal need attention for further characterization. This study investigated the effect of increasing imipenem concentrations on carbapenem-susceptible (S) and carbapenem-resistant (R) E. coli on their growth adaptation and cell surface structure. We exposed the bacterial population to increasing imipenem concentrations through 30 exposure cycles. Cell morphology was observed using a 3D laser scanning confocal microscope (LSCM) and transmission electron microscope (TEM). Results showed that the exposure resulted in significant morphological changes in E. coli (S) cells, while minor changes were seen in E. coli (R) cells. The rod-shaped E. coli (S) gradually transformed into round shapes. Further, the exposed E. coli (S) cells' surface area-to-volume ratio (SA/V) was also significantly different from the control, which is non-exposed E. coli (S). Then, the exposed E. coli (S) cells were re-grown in antibiotic-free environment for 100 growth cycles to determine if the changes in cells were reversible. The results showed that their cell morphology remained round, showing that the cell morphology was not reversible. The morphological response of these cells to imipenem can assist in understanding the resistance mechanism in the context of diagnostics and antibacterial therapies.

Review on antibiotic pollution dynamics: insights to occurrence, environmental behaviour, ecotoxicity, and management strategies

Antibiotic contamination poses a significant global concern due to its far-reaching impact on public health and the environment. This comprehensive review delves into the prevalence of various antibiotic classes in environmental pollution and their interactions with natural ecosystems. Fluoroquinolones, macrolides, tetracyclines, and sulphonamides have emerged as prevalent contaminants in environmental matrices worldwide. The concentrations of these antibiotics vary across diverse environments, influenced by production practices, consumer behaviours, and socio-economic factors. Low- and low-middle-income countries face unique challenges in managing antibiotic contamination, with dominant mechanisms like hydrolysis, sorption, and biodegradation leading to the formation of toxic byproducts. Ecotoxicity reports reveal the detrimental effects of these byproducts on aquatic and terrestrial ecosystems, further emphasizing the gravity of the issue. Notably, monitoring the antibiotic parent compound alone may be inadequate for framing effective control and management strategies for antibiotic pollution. This review underscores the imperative of a comprehensive, multi-sectoral approach to address environmental antibiotic contamination and combat antimicrobial resistance. It also advocates for the development and implementation of tailored national action plans that consider specific environmental conditions and factors. Thus, an approach is crucial for safeguarding both public health and the delicate balance of our natural ecosystems.

Effect of Stepwise Exposure to High-Level Erythromycin on Anaerobic Digestion

High-level erythromycin (ERY) fermentation wastewater will pose serious threats to lake environments. Anaerobic digestion (AD) has advantages in treating high-level antibiotic wastewater. However, the fate of antibiotic resistance genes (ARGs) and microbial communities in AD after stepwise exposure to high-level ERY remains unclear. In this study, an AD reactor was first exposed to 0, 5, 10, 50, 100 and 200 mg/L ERY and then re-exposed to 0, 50, 200 and 500 mg/L ERY to investigate the effect of ERY on AD. The results show that AD could adapt to the presence of high-level ERY (500 mg/L) and could maintain efficient CH4 production after domestication with low-level ERY (50 mg/L). The AD process could achieve higher removal of ERY (>94%), regardless of the initial ERY concentration. ErmB and mefA, conferring resistance through target alteration and efflux pumps, respectively, were dominant in the AD process. The first exposure to ERY stimulated an increase in the total ARG abundance, while the AD process seemed to discourage ARG maintenance following re-exposure to ERY. ERY inhibited the process of acetoclastic methanogenesis, but strengthened the process of hydrogenotrophic methanogenesis. This work provides useful information for treating high-level ERY fermentation wastewater by the AD process.

The sub-MIC selective window decreases along the digestive tract: determination of the minimal selective concentration of oxytetracycline in sterilised intestinal contents

Introduction

The administration of antibiotics can expose the digestive microbiota of humans and animals to sub-inhibitory concentrations, potentially favouring the selection of resistant bacteria. The minimal selective concentration (MSC) is a key indicator to understand this process. The MSC is defined as the lowest concentration of an antibiotic that promotes the growth of a resistant strain over a susceptible isogenic strain. It represents the lower limit of the sub-minimal inhibitory concentration (MIC) selective window, where resistant mutants can be selected. Previous studies focused on determining the MSC under standard culture conditions, whereas our research aimed to determine the MSC in a model that approximates in vivo conditions.

Methods

We investigated the MSC of oxytetracycline (OTC) in Mueller-Hinton broth (MHB) and sterilised intestinal contents (SIC) from the jejunum, caecum and rectum (faeces) of pigs, using two isogenic strains of Escherichia coli (one susceptible and one resistant to OTC). Additionally, the MIC of OTC against the susceptible strain was determined to assess the upper limit of the sub-MIC selective window.

Results

Our study took a novel approach, and the results indicated that MIC and MSC values were lower in MHB than in SIC. In the latter, these values varied depending on the intestinal segment, with distal compartments exhibiting higher MIC and MSC values. Moreover, the sub-MIC selective window of OTC in SIC narrowed from the jejunum to the rectum, with a significantly closer MSC to MIC in faecal SIC.

Discussion

The results suggest that OTC binds to digestive contents, reducing the fraction of free OTC. However, binding alone does not fully explain our results, and interactions between bacteria and intestinal contents may play a role. Furthermore, our findings provide initial estimates of low concentrations facilitating resistance selection in the gut. Finally, this research enhances the understanding of antimicrobial resistance selection, emphasising the intricate interplay between antibiotics and intestinal content composition in assessing the risk of resistance development in the gut.

A one health approach for monitoring antimicrobial resistance: developing a national freshwater pilot effort

Antimicrobial resistance (AMR) is a world-wide public health threat that is projected to lead to 10 million annual deaths globally by 2050. The AMR public health issue has led to the development of action plans to combat AMR, including improved antimicrobial stewardship, development of new antimicrobials, and advanced monitoring. The National Antimicrobial Resistance Monitoring System (NARMS) led by the United States (U.S) Food and Drug Administration along with the U.S. Centers for Disease Control and U.S. Department of Agriculture has monitored antimicrobial resistant bacteria in retail meats, humans, and food animals since the mid 1990's. NARMS is currently exploring an integrated One Health monitoring model recognizing that human, animal, plant, and environmental systems are linked to public health. Since 2020, the U.S. Environmental Protection Agency has led an interagency NARMS environmental working group (EWG) to implement a surface water AMR monitoring program (SWAM) at watershed and national scales. The NARMS EWG divided the development of the environmental monitoring effort into five areas: (i) defining objectives and questions, (ii) designing study/sampling design, (iii) selecting AMR indicators, (iv) establishing analytical methods, and (v) developing data management/analytics/metadata plans. For each of these areas, the consensus among the scientific community and literature was reviewed and carefully considered prior to the development of this environmental monitoring program. The data produced from the SWAM effort will help develop robust surface water monitoring programs with the goal of assessing public health risks associated with AMR pathogens in surface water (e.g., recreational water exposures), provide a comprehensive picture of how resistant strains are related spatially and temporally within a watershed, and help assess how anthropogenic drivers and intervention strategies impact the transmission of AMR within human, animal, and environmental systems.

Inappropriate prescription of intravenous antibiotics at a tertiary children's hospital in China

BACKGROUND

Antibiotics are one of the most frequently prescribed medication classes worldwide. Inappropriate prescription of antibiotics has increased the risk of drug-resistant infections and associated mortality. The aim of this study was to examine the patterns of intravenous antibiotics prescribing in emergency and outpatient departments of a tertiary children's hospital in China.

METHODS

Data on intravenous prescriptions dispensed by the emergency and outpatient department from January 1, 2015 to May 31, 2016 were extracted from the information system of the Children's Hospital of Fudan University. Prevalence of intravenous antibiotics use and the suitability of intravenous antibiotic prescription were evaluated on the basis of a completed microbiological examination, antibiotics susceptibility testing, and dose prescribed for patients diagnosed with pneumonia, acute bronchitis, fever, and acute upper respiratory infection (AURI) patients. The prescription rate was expressed as the number of intravenous antibiotic prescriptions per total number of prescriptions.

RESULTS

Overall, 94.2% of pediatric patients and 78.5% of issued intravenous prescriptions were for antibiotics. beta-lactam antibacterial (90.5%) and macrolides (18.5%) were the most commonly used categories of antibiotics, while cefuroxime (28.8%) was the most used antibiotic. Besides, pneumonia (31.3%), acute bronchitis (14.1%), fever (6.5%), and AURI (5.5%) were the most commonly recorded infections. However, in these four diseases, the rate of conducting microbiological examination was 0.3%, 0.2%, 2.1%, and 2.8%, respectively. Approximately, 52.1%, 40.0%, 40.4%, and 30.5% of intravenous antibiotic prescriptions were inappropriately used in pneumonia, acute bronchitis, fever, and AURI, respectively. Doses higher and lower than the recommended were often for each of these four diseases.

CONCLUSIONS

The frequency of intravenous antibiotic prescription was high in pediatric emergency and outpatient departments. Inappropriate use of intravenous antibiotics commonly occurred in pneumonia, acute bronchitis, fever, and AURI. Appropriate interventions and prevention strategies need to be developed to curtail inappropriate prescribing of antibiotics.

Selection of antibiotic resistance in pigs after exposure to feed cross-contaminated with oxytetracycline

Due to possible cross-contamination of animal feedstuff with antibiotics, food-producing animals may be exposed to undesirable low concentrations of antimicrobials. These sub-therapeutic levels of antibiotics can lead to the selection of resistant bacteria in the animal gut. The goal of this study was to assess, through analysis of the faeces of treated and control pigs, the risk of resistant E. coli being selected after daily exposure for three weeks to feed contaminated with oxytetracycline at 1% of the therapeutic dose. Liquid Chromatography coupled to tandem Mass Spectrometry was used to determine the oxytetracycline concentrations in faecal samples. In the treated group, concentrations were in the range of 4481.9 - 8671.2 µg/kg. In the control group, these concentrations were either below the method's limit of quantification or up to 60.5 µg/kg. After a transient increase in resistance in both groups, microbiological analysis showed that the treated group had a significantly higher oxytetracycline resistance rate by the end of the study than the control group (p < 0.001). Furthermore, the treated animals were found to select co-resistances to nalidixic acid and ampicillin. Finally, at tolerated antibiotic contamination levels of feed, the treated group had a higher proportion of multidrug-resistant isolates at the end of the study than the control one (p < 0.05). The present study demonstrates that, at the tolerated contamination rates, both antimicrobial resistance and multidrug-resistant bacteria can be selected and evidenced in the gut microbiota.

Association between quality of governance, antibiotic consumption, and antimicrobial resistance: an analysis of Italian regions

BACKGROUND

Emerging research has provided evidence suggesting the potential influence of governance on the development and spread of antimicrobial resistance (AMR), accounting for significant disparities observed both between and within countries. In our study, we conducted an ecological analysis to investigate the relationship between governance quality, antibiotic consumption, and AMR across Italian regions.

METHODS

By leveraging data from three distinct sources at the regional level, we compiled a comprehensive dataset comprising: AMR proportions for three specific pathogen-antibiotic combinations in the year 2021, antibiotic consumption data for systemic use in the year 2020, and the 2021 European Quality of Government Index (EQI) and its corresponding pillars. Employing mediation analysis, we investigated the potential mediating role of antibiotic consumption in the association between the EQI and an average measure of AMR.

RESULTS

Our analysis revealed substantial variation in the percentages of AMR across different regions in Italy, demonstrating a discernible North-to-South gradient concerning both antibiotic usage and governance quality. The EQI exhibited a statistically significant negative correlation with both antibiotic consumption and AMR percentages, encompassing both specific combinations and their average value. Regions characterized by higher levels of governance quality consistently displayed lower values of antibiotic consumption and AMR, while regions with lower governance quality tended to exhibit higher levels of antibiotic use and AMR. Furthermore, we observed a significant total effect of the EQI on average AMR (β = - 0.97; CI - 1.51; - 0.43). Notably, this effect was found to be mediated by antibiotic consumption, as evidenced by a significant indirect effect (β = - 0.89; CI - 1.45; - 0.32).

CONCLUSIONS

These findings draw attention to the regional disparities observed in AMR levels, antibiotic consumption patterns, and governance quality in Italy. Our study also highlights the mediating role of antibiotic consumption in the relationship between governance quality and AMR. This underscores the significance of implementing focused interventions and policies aimed at improving governance quality and promoting responsible antibiotic use.

Rapid Isolation of Low-Level Carbapenem-Resistant E. coli from Water and Foods Using Glycan-Coated Magnetic Nanoparticles

Carbapenem-resistant Enterobacterales (CRE) are one of the major global issues needing attention. Among them, carbapenemase-producing (CP) E. coli strains are commonly found in clinical and biological samples. Rapid and cost-effective detection of such strains is critical in minimizing their deleterious impact. While promising progress is being made in rapid detection platforms, separation and enrichment of bacteria are required to ensure the detection of low bacterial counts. The current separation methods, such as centrifugation, filtration, electrophoresis, and immunomagnetic separation, are often tedious, expensive, or ineffective for clinical and biological samples. Further, the extraction and concentration of antimicrobial-resistant bacteria (ARB) are not well documented. Thus, this study assessed the applicability of cost-effective glycan-coated magnetic nanoparticles (gMNPs) for simple and rapid extraction of CP E. coli. The study included two resistant (R)strains: Klebsiella pneumoniae carbapenemase (KPC)-producing E. coli (R: KPC) and New Delhi metallo-β-lactamase (NDM)-producing E. coli (R: NDM). A susceptible E. coli (S) strain was used as a control, a reference bacterium. The gMNPs successfully extracted and concentrated E. coli (R) and E. coli (S) at low concentrations from large volumes of buffer solution, water, and food samples. The gMNPs concentrated up to two and five times their initial concentration for E. coli (R) and E. coli (S) in the buffer solution, respectively. In water and food samples, the concentration of E. coli (S) and E. coli (R) were similar and ranged 1-3 times their initial inoculation. A variation in the concentration from different food samples was seen, displaying the impact of food microstructure and natural microflora. The cost-effective and rapid bacterial cell capture by gMNPs was achieved in 15 min, and its successful binding to the bacterial cells in the buffer solution and food matrices was also confirmed using Transmission Electron Microscopy (TEM). These results show promising applications of gMNPs to extract pathogens and ARB from biological samples.

Potential selection and maintenance of manure-originated multi-drug resistant plasmids at sub-clinical concentrations for tetracycline family antibiotics

The goal of this study was to (a) determine the minimum selection concentrations of tetracycline family antibiotics necessary to maintain plasmids carrying tetracycline-resistant genes and (b) correlate these results to environmental hotspot concentrations reported in previous studies. This study used two plasmids (pT295A and pT413A) originating from dairy manure in a surrogate Escherichia coli host CV601. The minimum selection concentrations of antibiotics tested in nutrient-rich medium were determined as follows: 0.1 mg/L for oxytetracycline, 0.45 mg/L for chlortetracycline, and 0.13-0.25 mg/L for tetracycline. Mixing oxytetracycline and chlortetracycline had minimum selection concentration values increased 2-fold compared to those in single antibiotic tests. Minimum selection concentrations found in this study were lower than reported environmental hotspot concentrations, suggesting that tetracycline family antibiotics were likely to be the driver for the selection and maintenance of these plasmids. Relatively high plasmid loss rates (>90%) were observed when culturing a strain carrying a tetracycline-resistant plasmid in antibiotic-free nutrient-rich and nutrient-defined media. Overall, results suggested that these plasmids can be maintained at concentrations environmentally relevant in wastewater treatment plants, sewage, manure, and manured soil; however, they are unstable and easily lost in the absence of antibiotics.

Bacteria exposed to antiviral drugs develop antibiotic cross-resistance and unique resistance profiles

Antiviral drugs are used globally as treatment and prophylaxis for long-term and acute viral infections. Even though antivirals also have been shown to have off-target effects on bacterial growth, the potential contributions of antivirals to antimicrobial resistance remains unknown. Herein we explored the ability of different classes of antiviral drugs to induce antimicrobial resistance. Our results establish the previously unrecognized capacity of antivirals to broadly alter the phenotypic antimicrobial resistance profiles of both gram-negative and gram-positive bacteria Escherichia coli and Bacillus cereus. Bacteria exposed to antivirals including zidovudine, dolutegravir and raltegravir developed cross-resistance to commonly used antibiotics including trimethoprim, tetracycline, clarithromycin, erythromycin, and amoxicillin. Whole genome sequencing of antiviral-resistant E. coli isolates revealed numerous unique single base pair mutations, as well as multi-base pair insertions and deletions, in genes with known and suspected roles in antimicrobial resistance including those coding for multidrug efflux pumps, carbohydrate transport, and cellular metabolism. The observed phenotypic changes coupled with genotypic results indicate that bacteria exposed to antiviral drugs with antibacterial properties in vitro can develop multiple resistance mutations that confer cross-resistance to antibiotics. Our findings underscore the potential contribution of wide scale usage of antiviral drugs to the development and spread of antimicrobial resistance in humans and the environment.

CPA-Cas12a-based lateral flow strip for portable assay of Methicillin-resistant Staphylococcus aureus in clinical sample

The rapid and accurate identification of methicillin-resistant Staphylococcus aureus at an early antibiotic therapy stage would be benefit to disease diagnosis and antibiotic selection. Herein, we integrated cross-priming amplification (CPA) and CRISPR/Cas 12a (designated as CPA-Cas 12a) systems to establish a sensitive and efficient lateral flow assay to detect methicillin-resistant Staphylococcus aureus. This assay relies on the CPA isothermal nucleic acid amplification strategy which can amplify the DNA extracted from Staphylococcus aureus and accompanying the indiscriminately trans-cleavage process of Cas 12a/CrRNA duplex after recognizing specific sequence. Taking the advantage of reporter and high turnover Cas 12a activity, a dramatic change in response was achieved to produce a significant increase in the analytical sensitivity. The signal conversion and output were realized using a lateral flow strip to achieve field-deployable detection. Furthermore, this bioassay was accommodated with a microfluidic device to realize automatically portable detection. This proposed assay completed within 30 min with the detection limit of 5 CFU mL^-1, was verified by testing bacterial suspension and 202 clinical samples. Given the high sensitivity, specificity and efficiency, this colorimetric readout assay through strip could be further promoted to the clinical diagnosis, clinical medication of multidrug-resistant bacteria.

Effects of Antibiotic Resistance Genes and Antibiotics on the Transport and Deposition Behaviors of Bacteria in Porous Media

Antibiotics present in the natural environment would induce the generation of antibiotic-resistant bacteria (ARB), causing great environmental risks. The effects of antibiotic resistance genes (ARGs) and antibiotics on bacterial transport/deposition in porous media yet are unclear. By using E. coli without ARGs as antibiotic-susceptible bacteria (ASB) and their corresponding isogenic mutants with ARGs in plasmids as ARB, the effects of ARGs and antibiotics on bacterial transport in porous media were examined under different conditions (1-4 m/d flow rates and 5-100 mM NaCl solutions). The transport behaviors of ARB were comparable with those of ASB under antibiotic-free conditions, indicating that ARGs present within cells had negligible influence on bacterial transport in antibiotic-free solutions. Interestingly, antibiotics (5-1000 μg/L gentamicin) present in solutions increased the transport of both ARB and ASB with more significant enhancement for ASB. This changed bacterial transport induced by antibiotics held true in solution with humic acid, in river water and groundwater samples. Antibiotics enhanced the transport of ARB and ASB in porous media via different mechanisms (ARB: competition of deposition sites; ASB: enhanced motility and chemotaxis effects). Clearly, since ASB are likely to escape sites containing antibiotics, these locations are more likely to accumulate ARB and their environmental risks would increase.

Collateral sensitivity: An evolutionary trade-off between antibiotic resistance mechanisms, attractive for dealing with drug-resistance crisis

Background

The discovery and development of antimicrobial drugs were one of the most significant advances in medicine, but the evolution of microbial resistance limited the efficiency of these drugs.

Aim

This paper reviews the collateral sensitivity in bacteria and its potential and limitation as a new target for treating infections.

Results and Discussion

Knowledge mechanisms of resistance to antimicrobial agents are useful to trace a practical approach to treat and control of resistant pathogens. The effect of a resistance mechanism to certain antibiotics on the susceptibility or resistance to other drugs is a key point that may be helpful for applying a strategy to control resistance challenges. In an evolutionary trade-off known as collateral sensitivity, the resistance mechanism to a certain drug may be mediated by the hypersensitivity to other drugs. Collateral sensitivity has been described for different drugs in various bacteria, but the molecular mechanisms affecting susceptibility are not well demonstrated. Collateral sensitivity could be studied to detect its potential in the battle against resistance crisis as well as in the treatment of pathogens adapting to antibiotics. Collateral sensitivity-based antimicrobial therapy may have the potential to limit the emergence of antibiotic resistance.

A Review of Carbapenem Resistance in Enterobacterales and Its Detection Techniques

Infectious disease outbreaks have caused thousands of deaths and hospitalizations, along with severe negative global economic impacts. Among these, infections caused by antimicrobial-resistant microorganisms are a major growing concern. The misuse and overuse of antimicrobials have resulted in the emergence of antimicrobial resistance (AMR) worldwide. Carbapenem-resistant Enterobacterales (CRE) are among the bacteria that need urgent attention globally. The emergence and spread of carbapenem-resistant bacteria are mainly due to the rapid dissemination of genes that encode carbapenemases through horizontal gene transfer (HGT). The rapid dissemination enables the development of host colonization and infection cases in humans who do not use the antibiotic (carbapenem) or those who are hospitalized but interacting with environments and hosts colonized with carbapenemase-producing (CP) bacteria. There are continuing efforts to characterize and differentiate carbapenem-resistant bacteria from susceptible bacteria to allow for the appropriate diagnosis, treatment, prevention, and control of infections. This review presents an overview of the factors that cause the emergence of AMR, particularly CRE, where they have been reported, and then, it outlines carbapenemases and how they are disseminated through humans, the environment, and food systems. Then, current and emerging techniques for the detection and surveillance of AMR, primarily CRE, and gaps in detection technologies are presented. This review can assist in developing prevention and control measures to minimize the spread of carbapenem resistance in the human ecosystem, including hospitals, food supply chains, and water treatment facilities. Furthermore, the development of rapid and affordable detection techniques is helpful in controlling the negative impact of infections caused by AMR/CRE. Since delays in diagnostics and appropriate antibiotic treatment for such infections lead to increased mortality rates and hospital costs, it is, therefore, imperative that rapid tests be a priority.

Interspecies interaction reduces selection for antibiotic resistance in Escherichia coli

Evolution of microbial traits depends on the interaction of a species with its environment as well as with other coinhabiting species. However, our understanding of the evolution of specific microbial traits, such as antibiotic resistance in complex environments is limited. Here, we determine the role of interspecies interactions on the dynamics of nitrofurantoin (NIT) resistance selection among Escherichia coli. We created a synthetic two-species community comprised of two variants of E. coli (NIT susceptible and resistant) and Bacillus subtilis in minimal media with glucose as the sole carbon source. We show that the presence of B. subtilis significantly slows down the selection for the resistant E. coli mutant when NIT is present and that this slowdown is not due to competition for resources. Instead, the dampening of NIT resistance enrichment is largely mediated by extracellular compounds produced by B. subtilis with the peptide YydF playing a significant role. Our results not only demonstrate the impact of interspecies interactions on the evolution of microbial traits but also show the importance of using synthetic microbial systems in unravelling relevant interactions and mechanisms affecting the evolution of antibiotic resistance. This finding implies that interspecies interactions should be considered to better understand and predict resistance evolution in the clinic as well as in nature.

Kanamycin and Ofloxacin Activate the Intrinsic Resistance to Multiple Antibiotics in Mycobacterium smegmatis

Drug resistance (DR) in Mycobacterium tuberculosis is the main problem in fighting tuberculosis (TB). This pathogenic bacterium has several types of DR implementation: acquired and intrinsic DR. Recent studies have shown that exposure to various antibiotics activates multiple genes, including genes responsible for intrinsic DR. To date, there is evidence of the acquisition of resistance at concentrations well below the standard MICs. In this study, we aimed to investigate the mechanism of intrinsic drug cross-resistance induction by subinhibitory concentrations of antibiotics. We showed that pretreatment of M. smegmatis with low doses of antibiotics (kanamycin and ofloxacin) induced drug resistance. This effect may be caused by a change in the expression of transcriptional regulators of the mycobacterial resistome, in particular the main transcriptional regulator whiB7.

Dose optimization in surgical prophylaxis: sub-inhibitory dosing of vancomycin increases rates of biofilm formation and the rates of surgical site infection

Antibiotic stewardship is viewed as having great public health benefit with limited direct benefit to the patient at the time of administration. The objective of our study was to determine if inappropriate administration of antibiotics could create conditions that would increase the rates of surgical infection. We hypothesized that sub-MIC levels of vancomycin would increase Staphylococcus aureus growth, biofilm formation, and rates of infection. S. aureus MRSA and MSSA strains were used for all experiments. Bacteria were grown planktonically and monitored using spectrophotometry. Quantitative agar culture was used to measure planktonic and biofilm bacterial burden. A mouse abscess model was used to confirm phenotypes in vivo. In the planktonic growth assay, increases in bacterial burden at ¼ MIC vancomycin were observed in USA300 JE2 by 72 h. Similar findings were observed with ½ MIC in Newman and SH1000. For biofilm formation, USA300 JE2 at ¼ and ½ MIC vancomycin increased biofilm formation by approximately 1.3- and 2.3-fold respectively at 72 h as compared to untreated controls. Similar findings were observed with Newman and SH1000 with a 2.4-fold increase in biofilm formation at ½ MIC vancomycin. In a mouse abscess model, there was a 1.2-fold increase with sub-MIC vancomycin at 3 days post infection. Our study showed that Sub-optimal vancomycin dosing promoted S. aureus planktonic growth and biofilm formation, phenotypic measures of bacterial virulence. This phenotype induced by sub-MIC levels of vancomycin was also observed to increase rates of infection and pathogenesis in our mouse model. Risks of exposure to sub-MIC concentrations with vancomycin in surgical procedures are greater as there is decreased bioavailability in tissue in comparison to other antibiotics. This highlights the importance of proper antibiotic selection, stewardship, and dosing for both surgical prophylaxis and treatment of infection.

Application of spray-dried erythromycin fermentation residue as a soil amendment: antibiotic resistance genes, nitrogen cycling, and microbial community structure

Erythromycin fermentation residue (EFR) after spray drying could be reused as a soil amendment. However, the effects of spray-dried EFR on antibiotic resistance genes (ARGs), nitrogen cycling, and microbial community structure in soil are rarely reported. In this study, a pot experiment was conducted by adding spray-dried EFR to soil. For the application of 1.0% spray-dried EFR, the residual erythromycin (ERY) could be rapidly removed with the half-life of 22.2 d; the total relative abundance of ARGs increased at first, but decreased to the initial level of the control group in the end; genes related to ammonium assimilation (glnA, gltB, gltD), ammonification (gdhA, gudB, cynT, cynS, ncd2), denitrification (narI, narG, narH), assimilatory nitrate reduction (nirA, nasA), and dissimilatory nitrate reduction (nirD) were enriched; soil microbial community structure presented temporary variation. Network analysis showed significant negative correlations between ARGs and nitrogen cycling genes. The addition of 6.0% spray-dried EFR resulted in the amplification of ARGs and inhibition of nitrogen cycling. This work provides new insights into the effects of spray-dried EFR on ARGs, nitrogen cycling, and microbial community structure within the fertilized soil.

Antibiotics that affect translation can antagonize phage infectivity by interfering with the deployment of counter-defenses

It is becoming increasingly clear that antibiotics can both positively and negatively impact the infectivity of bacteriophages (phage), but the underlying mechanisms often remain unclear. Here we demonstrate that antibiotics that target the protein translation machinery can fundamentally alter the outcome of bacteria-phage interactions by interfering with the production of phage-encoded counter-defense proteins. Specifically, using Pseudomonas aeruginosa PA14 and phage DMS3vir as a model, we show that bacteria with Clustered Regularly Interspaced Short Palindromic Repeat, CRISPR associated (CRISPR-Cas) immune systems have elevated levels of immunity against phage that encode anti-CRISPR (acr) genes when translation inhibitors are present in the environment. CRISPR-Cas are highly prevalent defense systems that enable bacteria to detect and destroy phage genomes in a sequence-specific manner. In response, many phages encode acr genes that are expressed immediately following the infection to inhibit key steps of the CRISPR-Cas immune response. Our data show that while phage-carrying acr genes can amplify efficiently on bacteria with CRISPR-Cas immune systems in the absence of antibiotics, the presence of antibiotics that act on protein translation prevents phage amplification, while protecting bacteria from lysis.

Can breeders prevent pathogen adaptation when selecting for increased resistance to infectious diseases?

Background

Recent research shows that genetic selection has high potential to reduce the prevalence of infectious diseases in livestock. However, like all interventions that target infectious diseases, genetic selection of livestock can exert selection pressure on pathogen populations. Such selection on the pathogen may lead to escape strategies and reduce the effect of selection of livestock for disease resistance. Thus, to successfully breed livestock for lower disease prevalence, it is essential to develop strategies that prevent the invasion of pathogen mutants that escape host resistance. Here we investigate the conditions under which such “escape mutants” can replace wild-type pathogens in a closed livestock population using a mathematical model of disease transmission.

Results

Assuming a single gene that confers sufficient resistance, results show that genetic selection for resistance in livestock typically leads to an “invasion window” within which an escape mutant of the pathogen can invade. The bounds of the invasion window are determined by the frequency of resistant hosts in the population. The lower bound occurs when the escape mutant has an advantage over the wild-type pathogen in the population. The upper bound occurs when local eradication of the pathogen is expected. The invasion window is smallest when host resistance is strong and when infection with the wild-type pathogen provides cross immunity to infection with the escape mutant.

Conclusions

To minimise opportunities for pathogens to adapt, under the assumptions of our model, the aim of disease control through genetic selection should be to achieve herd-level eradication of the infection faster than the rate of emergence of escape mutants of the pathogen. Especially for microparasitic infections, this could be achieved by placing animals into herds according to their genetic resistance, such that these herds stay completely out of the invasion window. In contrast to classical breeding theory, our model suggests that multi-trait selection with gradual improvement of each trait of the breeding goal might not be the best strategy when resistance to infectious disease is part of the breeding goal. Temporally, combining genetic selection with other interventions helps to make the invasion window smaller, and thereby reduces the risk of invasion of escape mutants.

Validation of a LC-MS/MS method for the quantitative analysis of four antibiotics in pig tissues and plasma to assess the risk of transfer of residues to edible matrices after exposure to cross-contaminated feed

Cross-contamination between medicated and non-medicated feed can occur during production, processing, transport or storage of animal feed. This may lead to the presence of low concentrations of antibiotics in supposedly drug-free feed for food production animals, which potentially could also harm consumers due to residues. In addition, consumption of sub-therapeutic concentrations of antibiotics may increase the risk of emergence of resistant bacteria. In this study, LC-MS/MS methods were developed to quantify four antibiotics (sulfadimethoxine, oxytetracycline, trimethoprim and amoxicillin) in several pig matrices, i.e. plasma, muscle, liver, kidneys and faeces. All methods were validated using the accuracy profile, except for amoxicillin in faeces, for which extraction could not be optimised for low concentrations. These methods were then applied as part of an animal study during which several pigs received contaminated feed at a concentration corresponding to 2% of therapeutic dose, in order to evaluate the risk of the presence of residues in animal faeces and tissues. The results showed that sulfadimethoxine is well absorbed and accumulates in the muscle, kidneys and liver, where concentrations were higher than the maximum residue limits (MRLs) authorised in EU legislation. Conversely, oxytetracycline was mostly found in faeces as its oral absorption is very low. Trimethoprim concentrations were slightly higher than the tolerated MRL in the kidneys, but they were below this level in the other tissues. Finally, amoxicillin concentrations remained below the lower limit of quantification of the methods in all matrices.

Application of pharmacokinetic/pharmacodynamic concepts to the development of treatment regimens for sporadic canine urinary tract infections: Challenges and paths forward

Antimicrobial efficacy can be predicted based on infection site exposure to the antimicrobial agent relative to the in vitro susceptibility of the pathogen to that agent. When infections occur in soft tissues (e.g., muscle, blood, and ligaments), exposure at the infection site is generally assumed to reflect an equilibrium between the unbound concentrations in plasma and that in the interstitial fluids. In contrast, for sporadic urinary tract infections (UTIs) in dogs and uncomplicated UTIs in humans, the primary site of infection is the bladder wall. Infection develops when bacteria invade the host bladder urothelium (specifically, the umbrella cells that form the urine-contacting layer of the stratified uroepithelium) within which these bacteria can avoid exposure to host defenses and antimicrobial agents. Traditionally, pathogen susceptibility has been estimated using standardized in vitro tests that measure the minimal concentration that will inhibit pathogen growth (MIC). When using exposure-response relationships during drug development to explore dose optimization, these relationships can either be based upon an assessment of a correlation between clinical outcome, drug exposure at the infection site, and pathogen MIC, or upon benchmark exposure-response relationships (i.e., pharmacokinetic/pharmacodynamic indices) typically used for the various drug classes. When using the latter approach, it is essential that the unbound concentrations at the infection site be considered relative to the MIC within the biological matrix to which the pathogen will be exposed. For soft tissue infections, this typically is the unbound plasma concentrations versus MICs determined in standardized media such as cation-adjusted Mueller Hinton broth, which is how many indices were originally established. However, for UTIs, it is the unbound drug concentrations within the urine versus the MICs in the actual urine biophase that needs to be considered. The importance of these relationships and how they are influenced by drug resistance, resilience, and inoculum are discussed in this review using fluoroquinolones and beta-lactams as examples.

Dispersal of Pathogen-associated Multispecies Biofilm by Novel Probiotic Bacillus subtilis in a Contact Dependent Manner

AIMS

Biofilms are involved in pathogenesis of various bacterial infections. Treatment of biofilm related bacterial infection remains a major challenge due to the reduced efficacy of antibiotics and associated antibiotic resistance. Given the increasing prevalence of Enterotoxic Escherichia. coli (ETEC), Salmonella Typhimurium (S. Typhimurium), and Methicillin-resistant Staphylococcus aureus (MRSA) related infections and associated drug resistance, it is imperative to develop alternative strategies for treatment and prevention. The current study investigated antibiofilm activity of a recently isolated Bacillus subtilis (B. subtilis-9) against these pathogens.

METHODS AND RESULTS

Crystal violet staining showed that treatment with B. subtilis-9 significantly reduced biofilm biomass of ETEC (60-80%), S. Typhimurium (68-73%) and MRSA (66-82%). In addition, B. subtilis-9 significantly reduced pre-formed biofilm biomass of ETEC (59%), S. Typhimurium (62%), MRSA (65%) and multispecies (58%). Fluorescence microscopy revealed that B. subtilis-9 treatment significantly reduced the thickness of biofilm and viability of the embedded bacteria. Additionally, B. subtilis-9 significantly reduced planktonic cell growth of ETEC (92%), S. Typhimurium (94%) and MRSA (93%). Interestingly, transwell assay showed that B. subtilis-9 exhibited antibiofilm properties in a cell-to-cell contact dependant manner and significantly reduced mRNA expression of biofilm related genes, bssS, luxS and ihfB in ETEC.

CONCLUSION

Novel B. subtilis-9 exhibits a strong inhibitory activity against ETEC, S. Typhimurium and MRSA biofilm formation and adhesion to abiotic surfaces. With further investigations, our study could bring forward a novel Bacillus based probiotic intervention strategy to combat pathogenic biofilms, in clinical and agricultural settings.

SIGNIFICANCE AND IMPACT OF THE STUDY

Probiotic bacteria propose a potential alternative in combating biofilm related infections, however, data on the efficacy and strain selection is limited. Data from this study is critical in further developing a Bacillus-based novel probiotic applications that may reduce the use of antibiotics in biofilm related infections in humans and animals.

Discrete stochastic models of SELEX: Aptamer capture probabilities and protocol optimization

Antibodies are important biomolecules that are often designed to recognize target antigens. However, they are expensive to produce and their relatively large size prevents their transport across lipid membranes. An alternative to antibodies is aptamers, short ([Formula: see text] bp) oligonucleotides (and amino acid sequences) with specific secondary and tertiary structures that govern their affinity to specific target molecules. Aptamers are typically generated via solid phase oligonucleotide synthesis before selection and amplification through Systematic Evolution of Ligands by EXponential enrichment (SELEX), a process based on competitive binding that enriches the population of certain strands while removing unwanted sequences, yielding aptamers with high specificity and affinity to a target molecule. Mathematical analyses of SELEX have been formulated in the mass action limit, which assumes large system sizes and/or high aptamer and target molecule concentrations. In this paper, we develop a fully discrete stochastic model of SELEX. While converging to a mass-action model in the large system-size limit, our stochastic model allows us to study statistical quantities when the system size is small, such as the probability of losing the best-binding aptamer during each round of selection. Specifically, we find that optimal SELEX protocols in the stochastic model differ from those predicted by a deterministic model.

Antibiotic resistance in dermatology: The scope of the problem and strategies to address it

Antibiotic resistance is a growing health concern that has attracted increasing attention from clinicians and scientists in recent years. Although resistance is an inevitable consequence of bacterial evolution and natural selection, misuse and overuse of antibiotics play a significant role in its acceleration. Antibiotics are the mainstay of therapy for common dermatoses, including acne and rosacea, as well as for skin and soft tissue infections. Therefore, it is critical for dermatologists and physicians across all disciplines to identify, appropriately manage, and prevent cases of antibiotic resistance. This review explores dermatologic conditions in which the development of antibiotic resistance is a risk and discusses mechanisms underlying the development of resistance. We discuss disease-specific strategies for overcoming resistant strains and improving antimicrobial stewardship along with recent advances in the development of novel approaches to counter antibiotic resistance.

Risk assessment of antibiotic resistance genes in the drinking water system

Antibiotic resistance genes (ARGs) are extensively detected in various environmental media, whose risk assessment in the drinking water systems has not been comprehensive. This study established a new risk assessment of ARGs in the drinking water systems, considering the chlorine-resistance ability, transferability, and ARGs harboring potential of pathogens. The risk of ARGs in a typical drinking water reservoir was also evaluated based on the detection of ARGs and antibiotic-resistant bacteria (ARB). Fourteen ARGs were detected with a relative concentration range of 10^-4-10^-3 (ARGs/16S rRNA gene). Five isolated ARB were identified as human opportunistic pathogens, one of which (Pseudomonas aeruginosa HLS-6, CCTCC AB 2017269) is resistant to hundreds of milligrams per liter levels of antibiotics and low-level chlorine. This result indicated that ARB tolerant to high-levels of antibiotics could be isolated from environments containing trace levels of antibiotics. Moreover, complete genome sequencing confirmed the inclusion of ARGs (sul1, aadA2) on the class I integron in HLS-6, indicating that the risk of ARGs in this drinking water reservoir could be classified as resistance risk ranking in drinking water system 1 (R³DW 1). The risk assessment of ARGs in this study provides a clear understanding of ARG risk in drinking water systems. The results reveal that the ARGs and ARB contamination of drinking water reservoirs pose significant challenges for drinking water treatment efficiency and affect drinking water safety.

Annual trends and health risks of antibiotics and antibiotic resistance genes in a drinking water source in East China

The extensive pollution of antibiotics and antibiotic resistance genes (ARGs) in drinking water has aroused worldwide concern. Successive monitoring of these pollutants has noteworthy significance for drinking water safety. Accordingly, this study conducted successive monitoring of antibiotics and ARGs from 2015 to 2017 in a drinking water source in East China. The total antibiotic concentration ranged from 19.68 ng/L to 497.00 ng/L, and decreased slightly from 2015 to 2017. Eighteen out of forty-one ARG subtypes showing resistance to six antibiotic classes and one class I integrase gene intI1, were detected in the drinking water source at concentrations ranging from 6.5 × 10⁴ copies/mL to 1.6 × 10⁶ copies/mL. Importantly, the total ARG concentration increased on an annual basis from 2015 to 2017 with an average annual increment of 0.25 orders of magnitude, which was mainly attributed to the increase in specific ARG subtypes, such as sul1, sul2, sul3, tetA, qnrB, and ermB. Most ARGs was positively correlated with the intI1 genes (r = 0.47-0.55, P < 0.01). Furthermore, the variation of antibiotics and ARGs appeared to be related to the water indices, particularly of the values of COD, BOD_5, NO₂-N (P < 0.05). This study provides basic data on antibiotic and ARG pollution in the studied drinking water source. Importantly, the findings expound that although the residual antibiotics in this drinking water source decreased slightly from 2015 to 2017, while its biological effect, the antibiotic resistance, increased annually, which give a warning of the antibiotic resistance pollution in the drinking water source.

High prevalence of unstable antibiotic heteroresistance in cyanobacteria causes resistance underestimation

Both cyanobacterial bloom and antibiotic resistance have aggravated worldwide and posed a global threat to public health in recent years. Cyanobacteria can exhibit discrepancy between their resistance genotype and susceptible phenotype due to antibiotic heteroresistance, which leads to difficulties in unambiguously classifying cyanobacterial strains as susceptible or resistant. Here we profiled the prevalence and mechanisms of antibiotic heteroresistance in cyanobacterial strains isolated from 50 sites across four eutrophicated lakes in China. Among 300 cyanobacterial isolates tested against 19 different antibiotics, over 90% of cyanobacterial isolates exhibited HR to multiple antibiotics and 19.5% of isolate/antibiotic interactions classified as susceptible by traditional minimum inhibitory concentration (MIC) estimates were designated heteroresistant. Over 97% of these monoclonal HR cases were unstable, with an increased resistance of subpopulations due to amplification of known resistance genes with high fitness cost. Wide-type cyanobacterial isolates of Synechococcus, Synechocystis, Anabaena and Microcystis aeruginosa exposed to sub-MIC level of four antibiotics evolved high-level resistance with little fitness cost, resulting in stable polyclonal HR. Both stable polyclonal HR and unstable monoclonal HR observed in different cyanobacterial strains can be promoted under environmental levels of antibiotic pressure. The highly prevalent and unstable monoclonal HR with the potential for susceptibility misclassification highlighted underestimation of cyanobacteria-derived antibiotic resistance. Cost-effective strategies should be developed to identify heteroresistance in cyanobacteria and to avoid false positive or negative results in traditional susceptibility testing.

Machine Learning Prediction of Resistance to Subinhibitory Antimicrobial Concentrations from Escherichia coli Genomes

Escherichia coli is an important cause of bacterial infections worldwide, with multidrug-resistant strains incurring substantial costs on human lives. Besides therapeutic concentrations of antimicrobials in health care settings, the presence of subinhibitory antimicrobial residues in the environment and in clinics selects for antimicrobial resistance (AMR), but the underlying genetic repertoire is less well understood. Here, we used machine learning to predict the population doubling time and cell growth yield of 1,407 genetically diverse E. coli strains expanding under exposure to three subinhibitory concentrations of six classes of antimicrobials from single-nucleotide genetic variants, accessory gene variation, and the presence of known AMR genes. We predicted cell growth yields in the held-out test data with an average correlation (Spearman's ρ) of 0.63 (0.36 to 0.81 across concentrations) and cell doubling times with an average correlation of 0.59 (0.32 to 0.92 across concentrations), with moderate increases in sample size unlikely to improve predictions further. This finding points to the remaining missing heritability of growth under antimicrobial exposure being explained by effects that are too rare or weak to be captured unless sample size is dramatically increased, or by effects other than those conferred by the presence of individual single-nucleotide polymorphisms (SNPs) and genes. Predictions based on whole-genome information were generally superior to those based only on known AMR genes and were accurate for AMR resistance at therapeutic concentrations. We pinpointed genes and SNPs determining the predicted growth and thereby recapitulated many known AMR determinants. Finally, we estimated the effect sizes of resistance genes across the entire collection of strains, disclosing the growth effects for known resistance genes in each individual strain. Our results underscore the potential of predictive modeling of growth patterns from genomic data under subinhibitory concentrations of antimicrobials, although the remaining missing heritability poses a challenge for achieving the accuracy and precision required for clinical use. IMPORTANCE Predicting bacterial growth from genome sequences is important for a rapid characterization of strains in clinical diagnostics and to disclose candidate novel targets for anti-infective drugs. Previous studies have dissected the relationship between bacterial growth and genotype in mutant libraries for laboratory strains, yet no study so far has examined the predictive power of genome sequence in natural strains. In this study, we used a high-throughput phenotypic assay to measure the growth of a systematic collection of natural Escherichia coli strains and then employed machine learning models to predict bacterial growth from genomic data under nontherapeutic subinhibitory concentrations of antimicrobials that are common in nonclinical settings. We found a moderate to strong correlation between predicted and actual values for the different collected data sets. Moreover, we observed that the known resistance genes are still effective at sublethal concentrations, pointing to clinical implications of these concentrations.

Diversity of Multidrug-Resistant Bacteria in an Urbanized River: A Case Study of the Potential Risks from Combined Sewage Overflows

Wastewater contamination and urbanization contribute to the spread of antibiotic resistance in aquatic environments. This is a particular concern in areas receiving chronic pollution of untreated waste via combined sewer overflow (CSO) events. The goal of this study was to expand knowledge of CSO impacts, with a specific focus on multidrug resistance. We sampled a CSO-impacted segment of the James River (Virginia, USA) during both clear weather and an active overflow event and compared it to an unimpacted upstream site. Bacteria resistant to ampicillin, streptomycin, and tetracycline were isolated from all samples. Ampicillin resistance was particularly abundant, especially during the CSO event, so these isolates were studied further using disk susceptibility tests to assess multidrug resistance. During a CSO overflow event, 82% of these isolates were resistant to five or more antibiotics, and 44% were resistant to seven or more. The latter statistic contrasts starkly with the upstream reference site, where only 4% of isolates displayed resistance to more than seven antibiotics. DNA sequencing (16S rRNA gene) revealed that ~35% of our isolates were opportunistic pathogens, comprised primarily of the genera Stenotrophomonas, Pseudomonas, and Chryseobacterium. Together, these results demonstrate that CSOs can be a significant source of viable clinically-relevant bacteria to the natural environment and that multidrug resistance is an important understudied component of the environmental spread of antibiotic resistance.

Identification of Antibiotics in Surface-Groundwater. A Tool towards the Ecopharmacovigilance Approach: A Portuguese Case-Study

Environmental monitoring, particularly of water, is crucial to screen and preselect potential hazardous substances for policy guidance and risk minimisation strategies. In Portugal, extensive data are missing. This work aimed to perform a qualitative survey of antibiotics in surface- groundwater, reflecting demographic, spatial, consumption and drug profiles during an observational period of three years. A passive sampling technique (POCIS) and high-resolution chromatographic system were used to monitor and analyse the antibiotics. The most frequently detected antibiotics were enrofloxacin/ciprofloxacin and tetracycline in surface-groundwater, while clarithromycin/erythromycin and sulfamethoxazole were identified only in surface water. The detection of enzyme inhibitors (e.g., tazobactam/cilastatin) used exclusively in hospitals and abacavir, a specific human medicine was also noteworthy. North (Guimarães, Santo Tirso and Porto) and South (Faro, Olhão and Portimão) Portugal were the regions with the most significant frequency of substances in surface water. The relatively higher detection downstream of the effluent discharge points compared with a low detection upstream could be attributed to a low efficiency in urban wastewater treatment plants and an increased agricultural pressure. This screening approach is essential to identify substances in order to perform future quantitative risk assessment and establishing water quality standards. The greatest challenge of this survey data is to promote an ecopharmacovigilance framework, implement measures to avoid misuse/overuse of antibiotics and slow down emission and antibiotic resistance.

Prevalence of Antibiotic Resistance Genes in Pharmaceutical Wastewaters

Pharmaceutical wastewaters are recognized as reservoirs of antibiotic resistance genes (ARGs) and antibiotic resistant bacteria (ARB), and also as hotspots for their horizontal gene transfer (HGT) using mobile genetic elements. Our study employed the use of PCR analysis of metagenomic DNA samples obtained from four pharmaceutical wastewaters using known primers to study the prevalence of thirty-six ARGs and four MGEs active against the commonly used antibiotics in Nigeria. The ARGs most frequently detected from the metagenomic DNA samples in each of the antibiotic classes under study include tetracycline [tet(G)], aminoglycoside [aadA, strA and strB], chloramphenicol [catA1], sulphonamides [sulI and sulII], and β-lactams and penicillins [blaOXA]. The ARGs showed a 100% prevalence in their various environmental sources. The pharmaceutical facility PFIV showed the highest concentration of ARGs in this study. The highest concentration for MGEs was shown by pharmaceutical facility PFIII, positive for intl1, intl2, and IFS genes. This study highlights the wide distribution of ARGs to the antibiotics tested in the wastewater, making pharmaceutical wastewater reservoirs of ARGs which could potentially be transferred from commensal microorganisms to human pathogens.

Reversing Antibiotic Resistance Caused by Mobile Resistance Genes of High Fitness Cost

The reversibility of antibiotic resistance is theoretically attractive due to the prospect of restoring the clinical potency of antibiotics. It is important to find out the factors that affect the reversibility of antibiotic resistance. Here, an mcr-1-positive multidrug-resistant (MDR) environmental Escherichia coli isolate was successively passaged under four antibiotic-free culture conditions. The relative abundances of multiple antibiotic resistance genes (ARGs) kept decreasing during the successive passages. The linear correlations between abundances of ARGs on the same MDR plasmid reflected that the decay of antibiotic resistance during the passage was mainly due to the elimination of the MDR plasmid (pMCR_W5-6). Colistin-susceptible strains were isolated at the end of the passage. The whole-genome sequencing of two susceptible isolates detected the elimination of the MDR plasmid and deletion of the mcr-1 gene. Deletions of DNA fragments from chromosome and plasmid were closely related to a variety of insertion sequences (ISs). The results of coculture of resistant and susceptible strains at different antibiotic concentrations indicated that the high fitness cost led to the poor stability of mobile ARGs. Strict control of the use of antibiotics can at least reverse the severe antibiotic resistance caused by mobile ARGs of high fitness cost.

IMPORTANCE The dissemination of bacterial antibiotic resistance is a serious threat to human health. The development of new antibiotics faces both economic and technological challenges. The reversibility of antibiotic resistance has become an important issue causing wide concern due to the prospect of restoring the clinical potency of antibiotics. Our study suggests that the high mobility of ARGs of high fitness cost may just reflect their poor stability. Therefore, strict control of the use of antibiotics can at least reverse the severe antibiotic resistance caused by mobile ARGs of high fitness cost. This study brings hope for the possibility of curbing the dissemination of antibiotic resistance.

Adaptation at different points along antibiotic concentration gradients

Antibiotic concentrations vary dramatically in the body and the environment. Hence, understanding the dynamics of resistance evolution along antibiotic concentration gradients is critical for predicting and slowing the emergence and spread of resistance. While it has been shown that increasing the concentration of an antibiotic slows resistance evolution, how adaptation to one antibiotic concentration correlates with fitness at other points along the gradient has not received much attention. Here, we selected populations of Escherichia coli at several points along a concentration gradient for three different antibiotics, asking how rapidly resistance evolved and whether populations became specialized to the antibiotic concentration they were selected on. Populations selected at higher concentrations evolved resistance more slowly but exhibited equal or higher fitness across the whole gradient. Populations selected at lower concentrations evolved resistance rapidly, but overall fitness in the presence of antibiotics was lower. However, these populations readily adapted to higher concentrations upon subsequent selection. Our results indicate that resistance management strategies must account not only for the rates of resistance evolution but also for the fitness of evolved strains.

Pharmaceutical effluent: a critical link in the interconnected ecosystem promoting antimicrobial resistance

Antimicrobial resistance (AMR) is a complex global health issue and will push twenty-four million people into extreme poverty by 2030, risking the sustainable development goals (SDGs) 2, 3, 6, 9, 12, and 17 if not addressed immediately. Humans, animals, and the environment are the reservoirs that contribute and allow AMR to propagate in interconnected ecosystems. The emergence of antibiotic-resistant bacteria and antibiotic-resistant genes in the water environment has become an important environmental health issue. One of the major influencers from environment sector is the pharmaceutical industry which is growing globally to meet the ever-increasing demand of antibiotics, especially in low- and middle-income countries. The pharmaceutical effluent has a mix of large concentrations of antibiotics and antibiotic resistance genes, and these sites act as hotspots for environmental contamination and the spread of AMR. Inadequate treatment of the effluent and its irresponsible disposal leads to unprecedented antibiotic contamination in the environment and their persistent presence in the environment significantly modulates the bacterial genomes' expression that is responsible for increase and spread of AMR. However, not much interventions are suggested in the National Action Plan developed on AMR by many countries. There are no regulations across the globe till date for the level of antibiotic residues in pharmaceutical effluent for the growing pharmaceutical industry. This review put together the work done showing several detrimental effects of the antimicrobial residues in the pharmaceutical effluent which leads to rise in development of AMR. The environment risk approach and need to have indicators to measure environment risk is a way forward for all countries engage in antibiotic manufacturing. Overall, efforts to address the problem are isolated and fragmented. Policymakers, regulators, manufacturers, researchers, civil society, and the community need to collaborate so that antibiotics are produced sustainably and continue to stay effective in treating bacterial infections.

Antibiotic prescription practices and opinions regarding antimicrobial resistance among veterinarians in Kentucky, USA

Background

Inappropriate antimicrobial use (AMU) is a global concern. Opinions of veterinarians regarding AMU and its role in the development of antimicrobial resistance (AMR) may influence their prescription practices. It is important to understand these opinions, prescription practices and their potential impact on the development of AMR in order to guide efforts to curb the problem. Therefore, the objective of this study was to investigate the antimicrobial prescription practices and opinions of veterinarians in Kentucky regarding AMU and AMR.

Methods

This cross-sectional study used a 30-question survey questionnaire administered to veterinarians who were members of the Kentucky Veterinary Medical Association. Survey responses from 101 participants were included in the study. Descriptive statistics were computed and associations between categorical variables assessed using Chi-square or Fisher’s exact tests. Firth logistic models were used to investigate predictors of “Compliance with prescription policies” and “Cost of antimicrobial affects prescription decisions”.

Results

Almost all (93%) respondents indicated that improper AMU contributed to selection for AMR. A total of 52% of the respondents believed that antimicrobials were appropriately prescribed, while the remaining 48% believed that antimicrobials were inappropriately prescribed. Significant predictors of compliance with prescription policies were availability of prescription policy at the veterinary facility (Odds Ratio (OR) = 4.2; p<0.001) and over-prescription (OR = 0.35; p = 0.025). Similarly, significant predictors of cost of antimicrobials affecting prescription decisions were lack of post-graduate training (OR = 8.3; p = 0.008) and practice type, with large animal practices having significantly lower odds of the outcome (OR = 0.09; p = 0.004) than small animal practices.

Conclusion

Most veterinarians indicated that improper AMU contributed to selection for AMR. Since the odds of compliance with prescription policies were 4-times higher among veterinarians working at facilities that had prescription policies compared to those at facilities that didn’t, more veterinary facilities should be encouraged to adopt prescription policies to help improve compliance and reduce AMR. Veterinarians would also benefit from continued professional education to help improve prescription practices, antimicrobial stewardship and curb AMR.

Effects of Clinical Wastewater on the Bacterial Community Structure from Sewage to the Environment

This study pertains to measure differences in bacterial communities along the wastewater pathway, from sewage sources through the environment. Our main focus was on taxa which include pathogenic genera, and genera harboring antibiotic resistance (henceforth referred to as "target taxa"). Our objective was to measure the relative abundance of these taxa in clinical wastewaters compared to non-clinical wastewaters, and to investigate what changes can be detected along the wastewater pathway. The study entailed a monthly sampling campaign along a wastewater pathway, and taxa identification through 16S rRNA amplicon sequencing. Results indicated that clinical and non-clinical wastewaters differed in their overall bacterial composition, but that target taxa were not enriched in clinical wastewater. This suggests that treatment of clinical wastewater before release into the wastewater system would only remove a minor part of the potential total pathogen load in wastewater treatment plants. Additional findings were that the relative abundance of most target taxa was decreased after wastewater treatment, yet all investigated taxa were detected in 68% of the treated effluent samples-meaning that these bacteria are continuously released into the receiving surface water. Temporal variation was only observed for specific taxa in surface water, but not in wastewater samples.

Selection of ESBL-producing Escherichia coli in the gut of calves experimentally fed with milk containing antibiotic residues

In the bovine sector, the spread of Enterobacterales producing extended-spectrum and AmpC β-lactamases (ESBL/AmpC) mostly concerns veal calves, and the use of waste milk containing antibiotic residues has been recurrently incriminated. In this study, calves were experimentally fed with milk containing either 2,000 μg/L or 20,000 μg/L of the critically important antibiotic cefquinome. The total counts of enterobacterales and ESBL-producing E. coli were monitored using non-selective and selective media. Our data highlighted the important combination of two main factors (cefquinome exposure and initial ESBL colonization level) in the ESBL selection and amplification process in the gut of calves. Results also proved the dose-independent effect of cefquinome administration on the selection and amplification of ESBL-producing E. coli. Finally, the bla_CTX-M-1/IncI1 ST3 plasmid was systematically recovered after cefquinome exposure, highlighting its epidemic success. Altogether, this work is one of the rare experimental studies providing quantitative information on the impact of waste milk containing antimicrobials on the ESBL load in calves' microbiota, and the first one using cefquinome. These data emphasise the need for global guidelines on the use of waste milk on dairy farms in order to decrease the antimicrobial resistance burden in this sector.

Detection and assessment of the antibiotic resistance of Enterobacteriaceae recovered from bioaerosols in the Choqueyapu River area, La Paz - Bolivia

As a highly contaminated waterway flowing through a densely populated urban area, microbiological pollution associated with the Choqueyapu River and the absence of a wastewater treatment plant in La Paz city threatens public health. We collected air samples adjacent to this river using impingement. Laboratory analyses identified the presence of Enterobacteriaceae, reporting a maximum concentration of 86,11 CFU/m³ of sampled air. Positive samples were tested for antibiotic susceptibility against the antibiotics amoxicillin-clavulanic acid, ciprofloxacin, gentamicin, meropenem, sulfamethoxazole-trimethoprim and tetracycline via disk diffusion. The highest percentages of antibiotic resistance were registered for tetracycline (50% of isolates) and sulfamethoxazole-trimethoprim (38,9%), while the lowest resistance profile was reported for meropenem (5,6%). A comparison of results obtained on the pilot studies [elaborated during the wet season of 2018 by Chavez, 2019 and Salazar et al., 2020] and the present study has been done, highlighting seasonal effects over airborne Enterobacteriaceae concentration. Also, it was determined an increase of antibiotic resistance for tetracycline, gentamicin and ciprofloxacin; and a reduction for sulfamethoxazole-trimethoprim, meropenem and amoxicillin-clavulanic acid.

Effect of chemically modified tetracycline-8 (CMT-8) on hematology, blood chemistry, cytokines and peripheral blood lymphocyte subsets of healthy dogs

Tetracyclines are antibiotics widely used in human and veterinary medicine. Effects on the immune system and inflammatory response, including effects on blood leukocytes proliferation and function and in cytokines synthesis, have been described. Chemically modified tetracyclines (CMT) have lost their antimicrobial activity, but maintain these other properties. This study analyzes the effect of chemically modified tetracycline-8 (CMT-8) on the evolution of complete blood count, blood chemistry, the mRNA expression of selected cytokines and peripheral blood lymphocyte subpopulations distribution in healthy dogs. CMT-8 at a dose of 10 mg/kg once daily was administered per os to six healthy dogs. A control group of five healthy dogs, living in the same conditions than dogs treated with CMT-8, received placebo with an identical therapeutic regimen. When given at the doses used in this study, no side effects of CMT-8 were detected, suggesting a good tolerance and a limited toxicity of the drug. Dogs treated with CMT-8 showed a gradual increase in mean corpuscular hemoglobin. The administration of CMT-8 in healthy dogs did not affect blood mRNA expression of IFN-γ, TNFα, IL-4, IL-6, IL-10, IL-12 p40 and IL-13. However, the lymphocytes expressing class II MHC on their surface decreased during the first two weeks of CMT-8 treatment and subsequently increased for the next three months. Considering the absence of antimicrobial properties of the drug, the effects of CMT-8 detected in this study seem to be unrelated to the classical antimicrobial activity attributed to tetracyclines.

Antibiotic Resistance in Agricultural Soil and Crops Associated to the Application of Cow Manure-Derived Amendments From Conventional and Organic Livestock Farms

The application of organic amendments to agricultural soil can enhance crop yield, while improving the physicochemical and biological properties of the recipient soils. However, the use of manure-derived amendments as fertilizers entails environmental risks, such as the contamination of soil and crops with antibiotic residues, antibiotic resistance genes (ARGs) and mobile genetic elements (MGEs). In order to delve into these risks, we applied dairy cow manure-derived amendments (slurry, fresh manure, aged manure), obtained from a conventional and an organic farm, to soil. Subsequently, lettuce and wheat plants were grown in the amended soils. After harvest, the abundance of 95 ARGs and MGE-genes from the amended soils and plants were determined by high-throughput qPCR. The structure of soil prokaryotic communities was determined by 16S rRNA amplicon sequencing and qPCR. The absolute abundance of ARGs and MGE-genes differed between treatments (amended vs. unamended), origins of amendment (conventional vs. organic), and types of amendment (slurry vs. fresh manure vs. aged manure). Regarding ARG-absolute abundances in the amendments themselves, higher values were usually found in slurry vs. fresh or aged manure. These abundances were generally higher in soil than in plant samples, and higher in wheat grain than in lettuce plants. Lettuce plants fertilized with conventional amendments showed higher absolute abundances of tetracycline resistance genes, compared to those amended with organic amendments. No single treatment could be identified as the best or worst treatment regarding the risk of antibiotic resistance in soil and plant samples. Within the same treatment, the resistome risk differed between the amendment, the amended soil and, finally, the crop. In other words, according to our data, the resistome risk in manure-amended crops cannot be directly inferred from the analysis of the amendments themselves. We concluded that, depending on the specific question under study, the analysis of the resistome risk should specifically focus on the amendment, the amended soil or the crop.

Natural Agents against Bovine Mastitis Pathogens

Bovine mastitis is the most widespread and economically important disease worldwide. The present study aimed to determine bioactive compounds in two essential oils (EOs) from wild (Thymus serpyllum) and common thyme (Thymus vulgaris) and to assess the antioxidant potential as well as antibacterial efficacy of the EOs against mastitis-associated bacteria. The study also included antibiotic susceptibility tests. The strains were previously isolated from lactating animals with clinical and subclinical mastitis. The antioxidant potential of the commercial EOs of wild and common thyme was evaluated by five in vitro assays. The antibacterial activity was performed using the microdilution technique, while antibiotic susceptibility testing was performed by the Kirby-Bauer disc diffusion method. The dominant compound in wild thyme was thymol (45.22%), followed by p-cymene (23.83%) and γ-terpinene (3.12%), while in common thyme, it was thymol (54.17%), followed by γ-terpinene (22.18%) and p-cymene (16.66%). Among the fourteen mastitis-associated bacteria, strain IX Streptococcus spp. (β-hemolytic) was the most sensitive to the tested EOs (minimum inhibitory concentration (MIC)/minimal bactericidal concentration (MBC) were 0.78/1.56 and 0.39/0.78 mg/mL for T. serpyllum (TS) and T. vulgaris (TV), respectively). Regarding Streptococcus spp. β heamoliticus, MICs for TS ranged from 0.78 to 1.56 mg/mL, while for the same oil, MBCs ranged from 1.56 to 12.5 mg/mL. In the case of T. vulgaris, MICs ranged from 0.39 to 3.125 mg/ mL, while MBCs ranged from 3.125 to 6.25 mg/mL. TV is more active against E. coli, E. sakazakii, and Streptococcus spp., while it is less effective against Staphylococcus spp. than TS. The study revealed that the tested EOs possess remarkable antioxidative and antibacterial activities and could be used in the development of pharmaceutical formulation as an alternative to conventional mastitis therapy.

Real-time tracking of bacterial membrane vesicles reveals enhanced membrane traffic upon antibiotic exposure

Membrane vesicles are ubiquitous carriers of molecular information. A broad understanding of the biological functions of membrane vesicles in bacteria remains elusive because of the imaging challenges during real-time in vivo experiments. Here, we provide a quantitative analysis of the motion of individual vesicles in living microbes using fluorescence microscopy, and we show that while vesicle free diffusion in the intercellular space is rare, vesicles mostly disperse along the bacterial surfaces. Most remarkably, when bacteria are challenged with low doses of antibiotics, vesicle production and traffic, quantified by instantaneous vesicle speeds and total traveled distance per unit time, are significantly enhanced. Furthermore, the enhanced vesicle movement is independent of cell clustering properties but rather is associated with a reduction of the density of surface appendages in response to antibiotics. Together, our results provide insights into the emerging field of spatial organization and dynamics of membrane vesicles in microcolonies.

Occurrence, spatiotemporal distribution and potential ecological risks of antibiotics in Dongting Lake, China

We investigated the occurrence and distribution of 18 antibiotics in surface water from Dongting Lake, as well as in influents and effluents from a municipal wastewater treatment plant (WWTP) and a swine farm. The total concentrations of target antibiotics in surface water ranged from limit of quantification to 3107 and 5.32-107 ng L^-1 in the dry season and wet season, respectively. Among these studied antibiotics, ciprofloxacin (CIP) and lomefloxacin were as the main components in the dry season, while CIP, oxytetracycline, and chlortetracycline were the main components in the wet season. The concentrations of target compounds exhibited obvious temporal-spatial variation characteristic in the studied region, suggesting their different emission sources related to pig breeding, aquaculture, and human activities, as well as possible degradation in the aquatic system. We estimated that the daily total input and output masses of antibiotics in the influent and effluent from the swine farm were 12.1 mg d^-1 pig^-1 and 7.49 μg d^-1 pig^-1, while they were 103 μg d^-1 inhabitant^-1 and 22.9 μg d^-1 inhabitant^-1 in the WWTP. The risk assessment results indicated that CIP posed a moderate or high risk to algae in most locations in Dongting Lake.

Unique Mode of Cell Division by the Mycobacterial Genetic Resister Clones Emerging De Novo from the Antibiotic-Surviving Population

The bacterial pathogens that are tolerant to antibiotics and survive in the continued presence of antibiotics have the chance to acquire genetically resistant mutations against the antibiotics and emerge de novo as antibiotic resisters. Once the antibiotic resister clone has emerged, often with compromise on growth characteristics, for the protection of the species, it is important to establish an antibiotic-resistant population quickly in the continued presence of the antibiotic. In this regard, the present study has unraveled multinucleation and multiseptation followed by multiple constrictions as the cellular processes used by the bacteria for quick multiplication to establish antibiotic-resistant populations. The study also points out the same phenomenon occurring in other bacterial systems investigated in our laboratory and others’ laboratories. Identification of these specific cellular events involved in quick multiplication offers additional cellular processes that can be targeted in combination with the existing antibiotics’ targets to preempt the emergence of antibiotic-resistant bacterial strains.

The emergence of antibiotic genetic resisters of pathogenic bacteria poses a major public health challenge. The mechanism by which bacterial antibiotic genetic resister clones formed de novo multiply and establish a resister population remained unknown. Here, we delineated the unique mode of cell division of the antibiotic genetic resisters of Mycobacterium smegmatis and Mycobacterium tuberculosis formed de novo from the population surviving in the presence of bactericidal concentrations of rifampicin or moxifloxacin. The cells in the rifampicin/moxifloxacin-surviving population generated elevated levels of hydroxyl radical-inflicting mutations. The genetic mutants selected against rifampicin/moxifloxacin became multinucleated and multiseptated and developed multiple constrictions. These cells stochastically divided multiple times, producing sister-daughter cells phenomenally higher in number than what could be expected from their generation time. This caused an abrupt, unexpectedly high increase in the rifampicin/moxifloxacin resister colonies. This unique cell division behavior was not shown by the rifampicin resisters formed naturally in the actively growing cultures. We could detect such abrupt increases in the antibiotic resisters in others’ and our earlier data on the antibiotic-exposed laboratory/clinical M. tuberculosis strains, M. smegmatis and other bacteria in in vitro cultures, infected macrophages/animals, and tuberculosis patients. However, it went unnoticed/unreported in all those studies. This phenomenon occurring in diverse bacteria surviving against different antibiotics revealed the broad significance of the present study. We speculate that the antibiotic-resistant bacillary clones, which emerge in patients with diverse bacterial infections, might be using the same mechanism to establish an antibiotic resister population quickly in the continued presence of antibiotics.

IMPORTANCE The bacterial pathogens that are tolerant to antibiotics and survive in the continued presence of antibiotics have the chance to acquire genetically resistant mutations against the antibiotics and emerge de novo as antibiotic resisters. Once the antibiotic resister clone has emerged, often with compromise on growth characteristics, for the protection of the species, it is important to establish an antibiotic-resistant population quickly in the continued presence of the antibiotic. In this regard, the present study has unraveled multinucleation and multiseptation followed by multiple constrictions as the cellular processes used by the bacteria for quick multiplication to establish antibiotic-resistant populations. The study also points out the same phenomenon occurring in other bacterial systems investigated in our laboratory and others’ laboratories. Identification of these specific cellular events involved in quick multiplication offers additional cellular processes that can be targeted in combination with the existing antibiotics’ targets to preempt the emergence of antibiotic-resistant bacterial strains.

Effect of Exposure to Chlorhexidine Residues at "During Use" Concentrations on Antimicrobial Susceptibility Profile, Efflux, Conjugative Plasmid Transfer, and Metabolism of Escherichia coli

There is no standardized protocol to predict the concentration levels of microbicides that are left on surfaces as a result of the use of these products, and there is no standardized method to predict the potential risk that such levels pose to emerging antibacterial resistance. The ability to distinguish between selection and adaption processes for antimicrobial resistance in bacteria and the impact of different concentrations of microbicide exposure have not been fully investigated to date. This study considers the effect of exposure to a low concentration of chlorhexidine digluconate (CHX) on selected phenotypes of Escherichia coli and relates the findings to the risk of emerging antimicrobial resistance. A concentration of 0.006 mg/ml CHX is a realistic "during use" exposure concentration measured on surfaces. At this concentration, it was possible for CHX-susceptible bacteria to survive, adapt through metabolic alterations, exhibit a transient decrease in antimicrobial susceptibility, and express stable clinical cross-resistance to front-line antibiotics. Efflux activity was present naturally in tested isolates, and it increased in the presence of 0.00005 mg/ml CHX but ceased with 0.002 mg/ml CHX. Phenotypic microarray assays highlighted a difference in metabolic regulation at 0.00005 mg/ml and 0.002 mg/ml CHX; more changes occurred after growth with the latter concentration. Metabolic phenotype changes were observed for substrates involved with the metabolism of some amino acids, cofactors, and secondary metabolites. It was possible for one isolate to continue transferring ampicillin resistance in the presence of 0.00005 mg/ml CHX, whilst 0.002 mg/ml CHX prevented conjugative transfer. In conclusion, E. coli phenotype responses to CHX exposure are concentration dependent, with realistic residual CHX concentrations resulting in stable clinical cross-resistance to antibiotics.

All nonadherence is equal but is some more equal than others? Tuberculosis in the digital era

Adherence to treatment for tuberculosis (TB) has been a concern for many decades, resulting in the World Health Organization's recommendation of the direct observation of treatment in the 1990s. Recent advances in digital adherence technologies (DATs) have renewed discussion on how to best address nonadherence, as well as offering important information on dose-by-dose adherence patterns and their variability between countries and settings. Previous studies have largely focussed on percentage thresholds to delineate sufficient adherence, but this is misleading and limited, given the complex and dynamic nature of adherence over the treatment course. Instead, we apply a standardised taxonomy - as adopted by the international adherence community - to dose-by-dose medication-taking data, which divides missed doses into 1) late/noninitiation (starting treatment later than expected/not starting), 2) discontinuation (ending treatment early), and 3) suboptimal implementation (intermittent missed doses). Using this taxonomy, we can consider the implications of different forms of nonadherence for intervention and regimen design. For example, can treatment regimens be adapted to increase the "forgiveness" of common patterns of suboptimal implementation to protect against treatment failure and the development of drug resistance? Is it reasonable to treat all missed doses of treatment as equally problematic and equally common when deploying DATs? Can DAT data be used to indicate the patients that need enhanced levels of support during their treatment course? Critically, we pinpoint key areas where knowledge regarding treatment adherence is sparse and impeding scientific progress.