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Antimicrobial resistance constitutes a global burden and is one of the major threats to public health. Although the emergence of resistant microorganisms is a natural phenomenon, selection is driven by an excessive or inappropriate use of antimicrobials in health care and agricultural settings. With the looming prospect of current antimicrobials no longer being effective, understanding the resistance mechanisms of multidrug-resistant microorganisms, such as bacteria, fungi and parasites, as well as the development of novel antimicrobial agents to combat drug-resistant infections and the rapid diagnosis of resistance are major focuses of scientific investigation.
In this series of articles, Nature Reviews Microbiology explores the insights that have been gained from a flurry of research into the origin, evolution and spread of multidrug-resistant pathogens, the identification of resistance markers, the mechanistic links between the drug target and the associated resistant mutations, the need to improve quantitative risk assessment and the surveillance of resistance gene distribution, as well as the latest developments in antimicrobial drug discovery to produce the next generation of new, safe and effective antimicrobials.
In this Review, Blair, Webber and colleagues explore our understanding of the mechanisms of antibiotic resistance, including reduced permeability, antibiotic efflux, modification or alteration of the antibiotic target, modification or destruction of the drug itself, and bypass of metabolic pathways. They also discuss how this information can aid in developing the next generation of antimicrobial therapies.
Combining several antibiotics, either in mixtures or sequential order, is proposed to increase treatment efficacy and reduce resistance evolution. In this Review, Andersson and colleagues discuss the effects of antibiotic combinations, the directional effects of previous antibiotic treatments and the role of stress-response systems as well as the interactions between drugs and resistance mutations.
Chronic infections caused by microbial biofilms represent an important clinical challenge owing to the recalcitrance of microbial biofilms to antimicrobials and the immune system, causing persistence and clinical recurrence of these infections. In this Review, Ciofu and colleagues discuss our current understanding of the mechanisms of tolerance of such biofilms to the immune system as well as of tolerance and resistance to antimicrobials.
In this Review, Larsson and Flach discuss the drivers of and bottlenecks for environmental evolution and transmission of antibiotic resistance, and they explore environmental surveillance strategies that could complement clinical surveillance systems.
In this Review, Perry, Meirelles and Newman review the growing body of evidence that microbial secondary metabolites can modulate susceptibility to commonly used antibiotics, focusing on the mechanisms and why this phenomenon occurs, and they discuss the implications for the diagnosis of antibiotic resistance and therapeutic strategies.
There is considerable variability in antimicrobial pharmacokinetics and pharmacodynamics, which can pose challenges for treatment of infection and antimicrobial resistance development. In this Review, Holmes and colleagues discuss how precision antimicrobial therapy, including biosensors and individualized treatment, can contribute to antimicrobial stewardship.
In this Review, Rappuoli and colleagues discuss evidence that vaccines can have a major role in fighting antimicrobial resistance, they describe the current state of development of vaccines against antimicrobial-resistant bacterial pathogens and discuss possible opportunities to overcome obstacles that hinder progress in vaccine development.
Recent studies have revealed that the evolutionary impact of plasmids goes above and beyond their being mere gene delivery platforms. In this Review, Rodríguez-Beltrán, San Millán and colleagues discuss the advances that underscore the importance of plasmids in bacterial ecology and evolution beyond horizontal gene transfer.
We know a lot about antibiotics and their targets; however, how antibiotics actually kill bacteria is not entirely clear and is up for debate. In this Perspective, Baquero and Levin reflect on this ultimate action of antibiotics and consider different mechanisms and modulating factors.
The rapid emergence of antibiotic resistance is recognized as a major public health threat. Nanomaterials have risen to tackle this problem through either improving the potency of existing antibiotics or generating entirely new antibacterial mechanisms.
In this Review, Rotello and colleagues discuss the mechanisms by which nanomaterials can be used to target antibiotic-resistant bacterial infections, highlight design elements and properties of nanomaterials that can be engineered to enhance potency, and explore recent progress and remaining challenges for clinical implementation of nanomaterials as antimicrobial therapeutics.
Newly developed antibacterial nanostructured surfaces show excellent prospects as next-generation biomaterials. In this Review, Ivanova, Stoodley and colleagues explore the different mechanisms by which various surface nanopatterns exert the necessary physico-mechanical forces on the bacterial cell membrane that will ultimately result in cell death.
During target protection, a resistance protein physically associates with an antibiotic target to rescue the latter from antibiotic-mediated inhibition. In this Review, O’Neill and colleagues describe the different molecular mechanisms underlying target protection and emphasize the importance of this phenomenon as a cause of clinically significant antibiotic resistance.
In this Review, Berman and Krysan define and distinguish resistance and tolerance, and discuss the current understanding of the molecular, genetic and physiological mechanisms that contribute to those phenomena. Distinguishing tolerance from resistance might provide important insights into the reasons for treatment failure in some settings.
With rising rates of antibiotic resistance, it is essential that new antibiotics are developed. In this Review, Theuretzbacher et al. take stock of the preclinical antibiotic pipeline and discuss challenges and opportunities for the discovery and development of novel antibacterial therapies.
In this Viewpoint article, seven experts discuss the challenges that are contributing to the decline in antibiotic drug discovery and development, and the international and national initiatives aimed at incentivizing research and the development of new antibiotics to improve the economic feasibility of antibiotic development.
Protozoa use various mechanisms to establish persistent infections. In this Review, Barrett and colleagues describe protozoan parasite ‘persister-like cells’, and they explore their possible role in persistent infections and drug treatment failure, and outline possible treatment options.
In this Review, Andersson and colleagues outline factors to consider when studying and defining heteroresistance, and they explore the different genetic mechanisms underlying heterogeneity in antibiotic resistance phenotypes, the impact of such mechanisms on the efficacy of treatment and the methods and difficulties in diagnosing heteroresistance in clinical bacterial isolates.
In this Review, Bush and Bradford describe medically relevant β-lactamase families and various combinations of a β-lactam with a β-lactamase inhibitor that have been developed, or that are being developed, to counteract these enzymes.
Methicillin-resistant Staphylococcus aureus (MRSA) is a major pathogen both within hospitals and in the community. In this Review, Fowler and colleagues provide an overview of basic and clinical MRSA research and explore the epidemiology, transmission, genetic diversity, evolution, surveillance and treatment of MRSA.
Combinations of antibiotics and of antibiotics with non-antibiotic activity-enhancing compounds offer a productive strategy to address the widespread emergence of antibiotic-resistant strains. In this Review, Tyers and Wright outline a theoretical and practical framework for the development of effective drug combinations.
This Consensus Statement presents the barriers that currently prevent the timely development and implementation of novel and rapid antimicrobial susceptibility testing platforms, including the costs involved, uptake of new tools, legal and regulatory aspects, difficulties conducting clinical trials and quality control, and presents possible solutions.
Alex van Belkum
Till T. Bachmann
the JPIAMR AMR-RDT Working Group on Antimicrobial Resistance and Rapid Diagnostic Testing
One factor contributing to the emergence of antimicrobial resistance is the capacity of bacteria to rapidly export drugs through the intrinsic activity of efflux pumps. This Review describes recent insights into the structure, function and regulation of efflux pumps.
Haldar and colleagues discuss markers and mechanisms of resistance to artemisinins and artemisinin-based combination therapies. They describe the identification ofPlasmodium falciparum Kelch 13 as the primary and, to date, sole causative marker of artemisinin resistance in P. falciparumand explore two proposed resistance mechanisms. They emphasize continuing challenges to improve detection strategies and new drug development strategies.
Recently, virulence mechanisms beyond canonical drug resistance were uncovered that enableAcinetobacter baumanniito thrive in the health-care environment and cause infections in critically ill patients. Harding, Hennon and Feldman explore the molecular features that promote environmental persistence and the most recently identified virulence factors that enable successful human infection.
Risk assessment for the development of antibiotic resistance against a new drug candidate is of paramount importance in preclinical development. In this Opinion article, Sommeret al. propose a new preclinical paradigm for the prediction of antibiotic resistance.
An improved understanding of the origins and spread of drug-resistant bacteria, as well as the identification of novel antimicrobial compounds and new drug combinations, will facilitate the development of better dosing regimens and novel strategies to manage drug resistance and prevent the dissemination of resistant bacteria.
Antimicrobial resistance constitutes a global health burden and research efforts are aimed at combatting the emergence of resistant microorganisms. In this Viewpoint article, several experts in the field discuss the role that rapid diagnostic tests have in managing the challenge of antimicrobial resistance, the drawbacks of current diagnostic methods, novel diagnostic strategies, and how such rapid diagnostic tools can inform drug development and the surveillance of resistance evolution.
Antibiotic resistance is a global problem that threatens individual and societal well-being. In this Review, Crofts, Gasparrini and Dantas summarize how research has changed from the discovery of resistant bacteria to community-level resistome studies, and they propose future therapeutic and surveillance approaches.