Antimicrobial resistance (AMR or AR) occurs when microbes evolve mechanisms that protect them from antimicrobials, which are drugs used to treat infections in humans, animals, and plants. Any microbe can develop resistance, including bacteria (antibiotic resistance), viruses (antiviral resistance), parasites (antiparasitic resistance), and fungi (antifungal resistance). Together, these adaptations fall under the AMR umbrella, posing a challenge to all countries and all demographics. Misuse and improper management of antimicrobials are primary drivers of this resistance, though it can also occur naturally through genetic mutations and the spread of resistant genes. Microbes resistant to multiple drugs are termed multidrug-resistant (MDR) and are sometimes called superbugs. Antibiotic resistance is a serious result of AMR. Resistance arises through spontaneous mutation, horizontal gene transfer, and increased selective pressure from antibiotic overuse, both in medicine and agriculture, which accelerates resistance development. Preventive measures, such as using narrow-spectrum antibiotics and improving hygiene practices, aim to reduce the spread of resistance. The World Health Organization (WHO) claims that AMR is one of the top global public health and development threats, estimating that bacterial AMR was directly responsible for 1.27 million global deaths in 2019 and contributed to over 4 million deaths in 2021. The burden of AMR is immense, with nearly 5 million annual deaths associated with resistant infections. Infections from AMR microbes are more challenging to treat and often require costly alternative therapies that may have more severe side effects. Moreover, the WHO and other international bodies warn that AMR could lead to up to 10 million deaths annually by 2050 unless actions are taken. Global initiatives, such as calls for international AMR treaties, emphasize coordinated efforts to limit misuse, fund research, and provide access to necessary antimicrobials in developing nations. However, the COVID-19 pandemic redirected resources and scientific attention away from AMR, intensifying the challenge. In 2026, Israeli scientists announced the discovery of bacteria able to create dozens of copies of genes which help them survive antibiotics.
Definition
Antimicrobial resistance means that a microorganism is resistant to an antimicrobial drug that was once able to treat an infection by that microorganism. Resistance is a property of the microbe, not a person or other organism infected by a microbe. All types of microbes can develop drug resistance. Thus, there are antibiotic, antifungal, antiviral and antiparasitic resistance. Antibiotic resistance is a subset of antimicrobial resistance. This more specific resistance is linked to bacteria and thus broken down into two further subsets, microbiological and clinical. Microbiological resistance is the most common and occurs from genes, mutated or inherited, that allow the bacteria to resist the mechanism to kill the microbe associated with certain antibiotics. Clinical resistance is shown through the failure of many therapeutic techniques where the bacteria that are normally susceptible to a treatment become resistant after surviving the outcome of the treatment. In both cases of acquired resistance, the bacteria can pass the genetic catalyst for resistance through horizontal gene transfer: conjugation, transduction, or transformation. This allows the resistance to spread across the same species of pathogen or even similar bacterial pathogens.
Overview WHO report released April 2014 stated, "this serious threat is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country. Antibiotic resistance—when bacteria change so antibiotics no longer work in people who need them to treat infections—is now a major threat to public health." In 2024, nearly 5 million deaths were associated with AMR and deaths attributable to AMR numbered 1.27 million. One in five people who died due to AMR were children under five years old. In 2018, WHO considered antibiotic resistance to be one of the biggest threats to global health, food security and development. Deaths attributable to AMR vary by area:
The European Centre for Disease Prevention and Control calculated that in 2015 there were 671,689 infections in the EU and European Economic Area caused by antibiotic-resistant bacteria, resulting in 33,110 deaths. Most were acquired in healthcare settings. In 2019 there were 133,000 deaths caused by AMR.
Causes AMR is driven largely by the misuse and overuse of antimicrobials. They reproduce and spread quickly, and they also can adapt to their environment and change how well they can survive. (NIAID, 2025). Yet, at the same time, many people do not have access to essential antimicrobials. This leads to microbes either evolving a defense against drugs used to treat them, or certain strains of microbes that have a natural resistance to antimicrobials becoming much more prevalent than the ones that are easily defeated with medication. Genetic changes can also occur, which would allow the microbe to survive. While antimicrobial resistance does occur naturally over time, the use of antimicrobial agents in a variety of settings both within the healthcare industry and outside of has led to antimicrobial resistance becoming increasingly more prevalent. Although many microbes develop resistance to antibiotics over time through natural mutation, overprescribing and inappropriate prescription of antibiotics have accelerated the problem. During mutation, when replication happens, these mutations help individual microbes survive exposure. (NIAID, 2025) It is possible that as many as 1 in 3 prescriptions written for antibiotics are unnecessary. Every year, approximately 154 million prescriptions for antibiotics are written. Of these, up to 46 million are unnecessary or inappropriate for the condition that the patient has. Microbes may naturally develop resistance through genetic mutations that occur during cell division, and although random mutations are rare, many microbes reproduce frequently and rapidly, increasing the chances of members of the population acquiring a mutation that increases resistance. In contrast to that, recent research suggests that, contrary to the traditional model of rapid genetic mutation, mycobacteria maintain high genomic stability under antibiotic pressure, relying instead on phenotypic tolerance and DNA-repair mechanisms for survival. Many individuals stop taking antibiotics when they begin to feel better. When this occurs, it is possible that the microbes that are less susceptible to treatment still remain in the body. If these microbes are able to continue to reproduce, this can lead to an infection by bacteria that are less susceptible or even resistant to an antibiotic. Microbes may also get genes from each other, which makes them drug-resistant. Bacteria that have drug-resistant DNA often transfer a copy of these genes to the other bacteria. They can then multiply and thrive. This process, known as horizontal gene transfer, allows resistance genes to spread rapidly between different bacterial species through mechanisms such as conjugation, transformation, and transduction. Bacteria become resistant to antibiotics by changing themselves or acquiring resistance genes from other bacteria. Over the past 20 years, antimicrobial resistance (AMR) has grown, making common infections like respiratory infections, urinary tract infections, STDs, and tuberculosis harder to treat. New antibiotics are not being developed fast enough and may lead to a "post-antibiotic era" where some infections are untreatable. AMR makes infections more difficult and costly to treat. Proper antibiotic use—correct drug, dose, and duration—and strict hospital hygiene are essential. Combating AMR requires cooperation among governments, healthcare workers, researchers, pharmaceutical companies, farmers, and the public through responsible antibiotic use, monitoring resistance, limiting antibiotics in animals, and improving access to medicines, vaccines, and tests. Prevention is the most effective strategy. Along with careful antibiotic use, there is a need for new drugs, alternative treatments, better diagnostics, and vaccines. Without coordinated global action, vital medical procedures like surgery, organ transplants, neonatal care, and cancer treatment could be at risk.
Natural occurrence
AMR is a naturally occurring process. Antimicrobial resistance can evolve naturally due to continued exposure to antimicrobials. Natural selection means that organisms that are able to adapt to their environment, survive, and continue to produce offspring. As a result, the types of microorganisms that are able to survive over time with continued attack by certain antimicrobial agents will naturally become more prevalent in the environment, and those without this resistance will become obsolete. Some contemporary antimicrobial resistances have also evolved naturally before the use of antimicrobials of human clinical uses. For instance, methicillin-resistance evolved as a pathogen of hedgehogs, possibly as a co-evolutionary adaptation of the pathogen to hedgehogs that are infected by a dermatophyte that naturally produces antibiotics. Also, many soil fungi and bacteria are natural competitors and the original antibiotic penicillin discovered by Alexander Fleming rapidly lost clinical effectiveness in treating humans and, furthermore, none of the other natural penicillins (F, K, N, X, O, U1 or U6) are currently in clinical use. Antimicrobial resistance can be acquired from other microbes through swapping genes in a process termed horizontal gene transfer. This means that once a gene for resistance to an antibiotic appears in a microbial community, it can then spread to other microbes, potentially moving from a non-disease causing microbe to a disease-causing microbe. This process is heavily driven by the natural selection processes that happen during antibiotic use or misuse. Over time, most of the strains of bacteria and infections present will be the type resistant to the antimicrobial agent being used to treat them, making this agent now ineffective to defeat most microbes. With the increased use of antimicrobial agents, there is a speeding up of this natural process.
Self-medication In the vast majority of countries, antibiotics can only be prescribed by a doctor and supplied by a pharmacy. Self-medication by consumers is defined as "the taking of medicines on one's own initiative or on another person's suggestion, who is not a certified medical professional", and it has been identified as one of the primary reasons for the evolution of antimicrobial resistance. Self-medication with antibiotics is an unsuitable way of using them but a common practice in resource-constrained countries. The practice exposes individuals to the risk of bacteria that have developed antimicrobial resistance. Many people resort to this out of necessity, when access to a physician is unavailable, or when patients have a limited amount of time or money to see a doctor. This increased access makes it extremely easy to obtain antimicrobials. An example is India, where in the state of Punjab 73% of the population resorted to treating their minor health issues and chronic illnesses through self-medication. Self-medication is higher outside the hospital environment. The prevalence of self-medication in low- and middle-income countries (LMICs) ranges from 8.1% to 93%. Accessibility, affordability, and conditions of health facilities, as well as the health-seeking behavior, are factors that influence self-medication in low- and middle-income countries. Two issues with self-medication are the lack of knowledge of the public on the dangerous effects of certain antimicrobials (for example ciprofloxacin which can cause tendonitis, tendon rupture and aortic dissection) and broad microbial resistance and when to seek medical care if the infection is not clearing. To determine the public's knowledge and preconceived notions on antibiotic resistance, a screening of 3,537 articles published in Europe, Asia, and North America was done. Of the 55,225 total people surveyed in the articles, 70% had heard of antibiotic resistance previously, but 88% of those people thought it referred to some type of physical change in the human body.
Clinical misuse
Clinical misuse by healthcare professionals is another contributor to increased antimicrobial resistance. Studies done in the US show that the indication for treatment of antibiotics, choice of the agent used, and the duration of therapy was incorrect in up to 50% of the cases studied. In 2010 and 2011 about a third of antibiotic prescriptions in outpatient settings in the United States were not necessary. Another study in an intensive care unit in a major hospital in France has shown that 30% to 60% of prescribed antibiotics were unnecessary. These inappropriate uses of antimicrobial agents promote the evolution of antimicrobial resistance by supporting the bacteria in developing genetic alterations that lead to resistance. According to research conducted in the US that aimed to evaluate physicians' attitudes and knowledge on antimicrobial resistance in ambulatory settings, only 63% of those surveyed reported antibiotic resistance as a problem in their local practices, while 23% reported the aggressive prescription of antibiotics as necessary to avoid failing to provide adequate care. This demonstrates that many doctors underestimate the impact that their own prescribing habits have on antimicrobial resistance as a whole. It also confirms that some physicians may be overly cautious and prescribe antibiotics for both medical or legal reasons, even when clinical indications for use of these medications are not always confirmed. This can lead to unnecessary antimicrobial use, a pattern which may have worsened during the COVID-19 pandemic. Studies have shown that common misconceptions about the effectiveness and necessity of antibiotics to treat common mild illnesses contribute to their overuse. Important to the conversation of antibiotic use is the veterinary medical system. Veterinary oversight is required by law for all medically important antibiotics. Veterinarians use the Pharmacokinetic/pharmacodynamic model (PK/PD) approach to ensuring that the correct dose of the drug is delivered to the correct place at the correct timing.
Pandemics, disinfectants and healthcare systems Increased antibiotic use during the early waves of the COVID-19 pandemic may exacerbate this global health challenge. Moreover, pandemic burdens on some healthcare systems may contribute to antibiotic-resistant infections. The use of disinfectants such as alcohol-based hand sanitizers, and antiseptic hand wash may also have the potential to increase antimicrobial resistance. Overuse of disinfectants can lead to mutations that induce antimicrobial resistance. On the other hand, "increased hand hygiene, decreased international travel, and decreased elective hospital procedures may have reduced AMR pathogen selection and spread in the short term" during the COVID-19 pandemic. Critically ill patients are prone to infections, and because of that, they often require antimicrobials. The more antimicrobials, the more resistance one becomes to it. Antimicrobial resistance (AMR) significantly strains healthcare systems and national economies. The World Bank estimates that by 2050, AMR could increase healthcare costs by around US$1 trillion and cause global economic losses of US$1–3.4 trillion annually by 2030. Resistant infections are harder to treat, often requiring longer hospital stays, additional tests, and stronger, more expensive medications, placing extra pressure on hospitals and health systems, especially during pandemics. A 2024 United Nations High-Level Meeting on AMR has pledged to reduce deaths associated with bacterial AMR by 10% over the next six years. In their first major declaration on the issue since 2016, global leaders also committed to raising $100 million to update and implement AMR action plans. However, the final draft of the declaration omitted an earlier target to reduce antibiotic use in animals by 30% by 2030, due to opposition from meat-producing countries and the farming industry. Critics argue this omission is a major weakness, as livestock accounts for around 73% of global sales of antimicrobial agents, including antibiotics, antivirals, and antiparasitics.
Environmental pollution Considering the complex interactions between humans, animals and the environment, it is also important to consider the environmental aspects and contributors to antimicrobial resistance. One of these factors is human and hospital waste, which is a substantial contributor to environmental antimicrobial resistance (AMR). It is estimated that around 50–80% of antibiotics are passed unmetabolized in urine and 4–30% in feces, causing large quantities of active antibiotics to enter sewage systems. Sewage environments contain high levels of antimicrobial-resistant bacteria (ARB), antimicrobial resistance genes (ARGs), and mobile genetic elements such as plasmids, which enable rapid gene exchange. Wastewater treatment plants (WWTPs) are typically not designed to remove AMR; in some cases, multidrug-resistant species such as Escherichia, Shigella, and Klebsiella can increase twofold in treated wastewater. Methicillin-resistant Staphylococcus aureus (MRSA) has also been detected in both raw and treated sewage. Agriculture is also a major contributor to environmental AMR. Manure from livestock (such as cattle, sheep, etc.) contains residual antibiotics, which enter the soil as farmers usually use it as fertilizer. These are typically at levels of 1–10 mg/kg, and also contain ARBs and ARGs. One megaton of antibiotics has been estimated to have entered global soils through manure application. Pathogens can survive in soil for up to 10 years and on plant surfaces for up to 1 year, thereby enabling long-term environmental continuation of AMR. Because manure can be applied to diverse crops, residual antibiotics and resistance genes can enter plant tissues and the surrounding soil microbiota, contributing to AMR detected on fruits and vegetables. Heavy metals in soil, often introduced through fertilizers or industrial processes, can drive cross- and co-resistance mechanisms that select for antibiotic-resistant bacteria even when no antibiotics are present. Similar selective results happen with biocides and pesticides. Aquaculture is an underrecognized source of environmental AMR. Approximately 70% of antibiotics administered in aquaculture enter surrounding waterways, and tetracycline-resistant genes have been found even in isolated environments such as Antarctica and the Arctic. Antibiotic usage varies substantially across countries, showing the major differences in regulatory oversight. High antibiotic use in many Asian aquaculture systems has added to the elevated levels of clinically important resistance genes in sediments and river systems. Recent research has shown that AMR also occurs through the air. Airborne resistance genes have been detected at high levels in major urban centers, and farms have been determined as hotspots for airborne AMR, with resistance markers detected in the air surrounding animal operations.
Food production
Livestock
The antimicrobial resistance crisis also extends to the food industry, specifically with food producing animals. With an ever-increasing human population, there is constant pressure to intensify productivity in many agricultural sectors, including the production of meat as a source of protein. Antibiotics are fed to livestock to act as growth supplements, and a preventive measure to decrease the likelihood of infections. Farmers typically use antibiotics in animal feed to improve growth rates and prevent infections. However, this is illogical as antibiotics are used to treat infections and not prevent infections. 80% of antibiotic use in the U.S. is for agricultural purposes and about 70% of these are medically important. Overusing antibiotics gives the bacteria time to adapt leaving higher doses or even stronger antibiotics needed to combat the infection. Though antibiotics for growth promotion were banned throughout the EU in 2006, 40 countries still use antibiotics to promote growth. This can result in the transfer of resistant bacterial strains into the food that humans eat, causing potentially fatal transfer of disease. While the practice of using antibiotics as growth promoters does result in better yields and meat products, it is a major issue and needs to be decreased to prevent antimicrobial resistance. Though the evidence linking antimicrobial usage in livestock to antimicrobial resistance is limited, the World Health Organization Advisory Group on Integrated Surveillance of Antimicrobial Resistance strongly recommended the reduction of use of medically important antimicrobials in livestock. Additionally, the Advisory Group stated that such antimicrobials should be expressly prohibited for both growth promotion and disease prevention in food producing animals. By mapping antimicrobial consumption in livestock, it was predicted that in 228 countries there would be a total 67% increase in consumption of antibiotics by livestock by 2030. In some countries such as Brazil, Russia, India, China, and South Africa it is predicted that a 99% increase will occur. Several countries have restricted the use of antibiotics in livestock, including Canada, China, Japan, and the US. These restrictions are sometimes associated with a reduction of the prevalence of antimicrobial resistance in humans. In the United States the Veterinary Feed Directive went into practice in 2017 dictating that All medically important antibiotics to be used in feed or water for food animal species require a veterinary feed directive (VFD) or a prescription.
Pesticides
Most pesticides protect crops against insects and plants, but in some cases antimicrobial pesticides are used to protect against various microorganisms such as bacteria, viruses, fungi, algae, and protozoa. The overuse of many pesticides in an effort to have a higher yield of crops has resulted in many of these microbes evolving a tolerance against these antimicrobial agents. Currently there are over 4000 antimicrobial pesticides registered with the US Environmental Protection Agency (EPA) and sold to market, showing the widespread use of these agents. It is estimated that for every single meal a person consumes, 0.3 g of pesticides is used, as 90% of all pesticide use is in agriculture. A majority of these products are used to help defend against the spread of infectious diseases, and hopefully protect public health. But out of the large amount of pesticides used, it is also estimated that less than 0.1% of those antimicrobial agents, actually reach their targets. That leaves over 99% of all pesticides used available to contaminate other resources. In soil, air, and water these antimicrobial agents are able to spread, coming in contact with more microorganisms and leading to these microbes evolving mechanisms to tolerate and further resist pesticides. The use of antifungal azole pesticides that drive environmental azole resistance have been linked to azole resistance cases in the clinical setting. The same issues confront the novel antifungal classes (e.g. orotomides) which are again being used in both the clinic and agriculture.
Wild birds Wildlife, including wild and migratory birds, serve as indicators of ecosystem health. They act as a reservoir for zoonotic diseases and antimicrobial-resistant organisms. Birds are a key link between the transmission of zoonotic diseases to human populations. By the same token, increased contact between wild birds and human populations (including domesticated animals), has increased the amount of anti-microbial resistance (AMR) to the bird population. The introduction of AMR to wild birds positively correlates with human pollution and increased human contact. Additionally, wild birds can participate in horizontal gene transfer with bacteria, leading to the transmission of antibiotic-resistant genes (ARG). For simplicity, wild bird populations can be divided into two major categories, wild sedentary birds and wild migrating birds. Wild sedentary bird exposure to AMR is through increased contact with densely populated areas, human waste, domestic animals, and domestic animal/livestock waste. Especially if they are predators, wild, sedentary birds can come into contact with prey that interact more closely with humans. Wild migrating birds interact with sedentary birds in different environments along their migration route. This increases the rate and diversity of AMR across varying ecosystems. Neglect of wildlife in the global discussions surrounding health security and AMR, creates large barriers to true AMR surveillance. The surveillance of antimicrobial-resistant resistant organisms in wild birds is a potential metric for the rate of AMR in the environment. This surveillance also allows for further investigation into the transmission routes between different ecosystems and human populations (including domesticated animals and livestock). Such information gathered from wild bird biomes, can help identify patterns of diseased transmission and better target interventions. These targeted interventions can inform the use of antimicrobial agents and reduce the persistence of multidrug resistant organisms. Recent studies demonstrate the importance of wild birds as sentinels for AMR. For example, Escherichia coli isolated from free-ranging Bonelli's eagles (Aquila fasciata) in eastern Spain showed that 53.3% of isolates were resistant to at least one antimicrobial, and 29.3% were multidrug-resistant, despite the species' minimal exposure to human-associated environments. The study also reported resistance to colistin and meropenem, two last-resort antibiotics, and documented 19 different multidrug-resistance patterns, suggesting persistent and heterogeneous selective pressures in the environment. Because Bonelli's eagles live far from humans and urban areas, they acquire resistance largely through interactions with prey species that interact with humans. These findings demonstrate how AMR can spread into remote ecosystems via indirect pathways, strengthening the role of wild birds, particularly apex predators, as effective bioindicators in AMR surveillance.
Prevention
There have been increasing public calls for global collective action to address the threat, including a proposal for an international treaty on antimicrobial resistance. Further detail and attention is still needed to recognize and measure trends in resistance on the international level; the idea of a global tracking system has been suggested but implementation has yet to occur. A system of this nature would provide insight to areas of high resistance as well as information necessary for evaluating programs, introducing interventions and other changes made to fight or reverse antibiotic resistance.
One Health approach Antimicrobial resistance (AMR) is commonly described within a One Health framework, which emphasizes the interconnected relationships between human health, animal health, and the environment. Antimicrobial use in clinical medicine, veterinary practice, and agriculture has been associated with the selection and spread of resistant microorganisms across these sectors. Research indicates that resistant bacteria and antimicrobial resistance genes can move between humans, animals, and environmental reservoirs through multiple pathways, including food production systems, direct contact, and exposure to contaminated water or soil. These pathways contribute to the persistence and wider dissemination of antimicrobial resistance beyond individual settings. Environmental sources have been increasingly examined in relation to AMR. Wastewater systems, agricultural runoff, and pharmaceutical residues have been identified as potential reservoirs where resistant microorganisms and resistance genes may persist. Such reservoirs may facilitate ongoing transmission between environmental, animal, and human populations. Efforts to address AMR within a One Health framework typically involve coordinated strategies across sectors, including antimicrobial stewardship, infection prevention and control, and improvements in sanitation and hygiene. Evidence from systematic reviews suggests that interventions such as farm biosecurity and water, sanitation, and hygiene (WASH) practices may reduce antimicrobial use and contribute to limiting the development and spread of resistance.
Duration of antimicrobials Delaying or minimizing the use of antibiotics for certain conditions may help safely reduce their use. Antimicrobial treatment duration should be based on the infection and other health problems a person may have. For many infections once a person has improved there is little evidence that stopping treatment causes more resistance. Some, therefore, feel that stopping early may be reasonable in some cases. Other infections, however, do require long courses regardless of whether a person feels better. Delaying antibiotics for ailments such as a sore throat and otitis media may have no difference in the rate of complications compared with immediate antibiotics, for example. When treating respiratory tract infections, clinical judgement is required as to the appropriate treatment (delayed or immediate antibiotic use).
Monitoring and mapping There are multiple national and international monitoring programs for drug-resistant threats, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant S. aureus (VRSA), extended spectrum beta-lactamase (ESBL) producing Enterobacterales, vancomycin-resistant Enterococcus (VRE), and multidrug-resistant Acinetobacter baumannii (MRAB). ResistanceOpen is an online global map of antimicrobial resistance developed by HealthMap which displays aggregated data on antimicrobial resistance from publicly available and user submitted data. The website can display data for a 25 miles (40 km) radius from a location. Users may submit data from antibiograms for individual hospitals or laboratories. European data is from the EARS-Net (European Antimicrobial Resistance Surveillance Network), part of the ECDC. ResistanceMap is a website by the Center for Disease Dynamics, Economics & Policy and provides data on antimicrobial resistance on a global level. The WHO's AMR global action plan also recommends antimicrobial resistance surveillance in animals. Initial steps in the EU for establishing the veterinary counterpart EARS-Vet (EARS-Net for veterinary medicine) have been made. AMR data from pets in particular is scarce, but needed to support antibiotic stewardship in veterinary medicine. By comparison there is a lack of national and international monitoring programs for antifungal resistance.
Limiting antimicrobial use in humans
Antimicrobial stewardship programmes appear useful in reducing rates of antimicrobial resistance. The antimicrobial stewardship program will also provide pharmacists with the knowledge to educate patients that antibiotics will not work for a virus for example. Excessive antimicrobial use has become one of the top contributors to the evolution of antimicrobial resistance. Since the beginning of the antimicrobial era, antimicrobials have been used to treat a wide range of infectious diseases. Overuse of antimicrobials has become the primary cause of rising levels of antimicrobial resistance. Prescribers are willing to prescribe antimicrobials to individuals who believe that antimicrobials can cure nearly all illnesses, including viral infections like the common cold. In an analysis of drug prescriptions, 36% of individuals with a cold or an upper respiratory infection (both usually viral in origin) were given prescriptions for antibiotics. These prescriptions increase the risk of further evolution of antibiotic resistant bacteria. Using antimicrobials without prescription is another driving force leading to the overuse of antibiotics to self-treat diseases like the common cold, cough, fever, and dysentery resulting in an epidemic of antibiotic resistance in countries like Bangladesh, risking its spread around the globe. Introducing strict antibiotic stewardship in the outpatient setting to reduce inappropriate prescribing of antibiotics may reduce the emerging bacterial resistance. The WHO AWaRe (Access, Watch, Reserve) guidance and antibiotic book has been introduced to guide antibiotic choice for the 30 most common infections in adults and children to reduce inappropriate prescribing in primary care and hospitals. Narrow-spectrum antibiotics are preferred due to their lower resistance potential, and broad-spectrum antibiotics are only recommended for people with more severe symptoms. Some antibiotics are more likely to confer resistance, so are kept as reserve antibiotics in the AWaRe book. Various diagnostic strategies have been employed to prevent the overuse of antifungal therapy in the clinic, proving a safe alternative to empirical antifungal therapy, and thus underpinning antifungal stewardship schemes.
At the hospital level Antimicrobial stewardship teams in hospitals are encouraging optimal use of antimicrobials. The goals of antimicrobial stewardship are to help practitioners pick the right drug at the right dose and duration of therapy while preventing misuse and minimizing the development of resistance. Stewardship interventions may reduce the length of stay by an average of slightly over 1 day while not increasing the risk of death. Dispensing the exact number of antibiotic pharmaceutical units necessary to complete an ongoing treatment can reduce excess antibiotics. A 2026 systematic review of 73 studies examined arthropod-mediated pathogen transmission in hospitals. Research indicates that cockroaches, flies, and ants frequently harbor multidrug-resistant bacteria, fungi, and viruses. While direct causality is difficult to prove, genetic evidence links these pests to hospital-associated infections.
At the primary care level Given the volume of care provided in primary care (general practice), recent strategies have focused on reducing unnecessary antimicrobial prescribing in this setting. Simple interventions, such as written information explaining when taking antibiotics is not necessary, for example in common infections of the upper respiratory tract, have been shown to reduce antibiotic prescribing. Various tools are also available to help professionals decide if prescribing antimicrobials is necessary. Parental expectations, driven by the worry for their children's health, can influence how often children are prescribed antibiotics. Parents often rely on their clinician for advice and reassurance. However a lack of plain language information and not having adequate time for consultation negatively impacts this relationship. In effect parents often rely on past experiences in their expectations rather than reassurance from the clinician. Adequate time for consultation and plain language information can help parents make informed decisions and avoid unnecessary antibiotic use. The prescriber should closely adhere to the five rights of drug administration: the right patient, the right drug, the right dose, the right route, and the right time. Microbiological samples should be taken for culture and sensitivity testing before treatment when indicated and treatment potentially changed based on the susceptibility report. Health workers and pharmacists can help tackle antibiotic resistance by: enhancing infection prevention and control; only prescribing and dispensing antibiotics when they are truly needed; prescribing and dispensing the right antibiotic(s) to treat the illness. A unit dose system implemented in community pharmacies can also reduce antibiotic leftovers at households. Despite these, written guideline intervention for prescriber to do history taking and provision of advice and knowledge of pharmacists and non‐pharmacists may not reduce the sales of non‐prescription antimicrobial drugs in community pharmacies, drugstores, and other medicine outlets.
At the individual level People can help tackle resistance by using antibiotics only when prescribed for a bacterial infetion as well as completing the full treatment course, never sharing medication with others, and using proper disposal methods for excess drugs. Basic hygiene practices also help prevent the spread of bacteria.
Countries The Netherlands has the lowest rate of antibiotic prescribing in the OECD, at a rate of 11.4 defined daily doses (DDD) per 1,000 people per day in 2011. DDD is a statistical measure of drug consumption, defined by the World Health Organization (WHO). • Germany and Sweden also have lower prescribing rates, with Sweden's rate having been declining since 2007. • Greece, France and Belgium have high prescribing rates.
Water, sanitation, hygiene Infectious disease control through improved water, sanitation and hygiene (WASH) infrastructure needs to be included in the antimicrobial resistance (AMR) agenda. The "Interagency Coordination Group on Antimicrobial Resistance" stated in 2018 that "the spread of pathogens through unsafe water results in a high burden of gastrointestinal disease, increasing even further the need for antibiotic treatment." This is particularly a problem in developing countries where the spread of infectious diseases caused by inadequate WASH standards is a major driver of antibiotic demand. Growing usage of antibiotics together with persistent infectious disease levels have led to a dangerous cycle in which reliance on antimicrobials increases while the efficacy of drugs diminishes. The proper use of infrastructure for water, sanitation and hygiene (WASH) can result in a 47–72 percent decrease of diarrhea cases treated with antibiotics depending on the type of intervention and its effectiveness. A reduction of the diarrhea disease burden through improved infrastructure would result in large decreases in the number of diarrhea cases treated with antibiotics. This was estimated as ranging from 5 million in Brazil to up to 590 million in India by the year 2030. The strong link between increased consumption and resistance indicates that this will directly mitigate the accelerating spread of AMR. Sanitation and water for all by 2030 is Goal Number 6 of the Sustainable Development Goals. An increase in hand washing compliance by hospital staff results in decreased rates of resistant organisms. Water supply and sanitation infrastructure in health facilities offer opportunities for combatting AMR, and investment should be increased. There is much room for improvement: WHO and UNICEF estimated in 2015 that 38% of health facilities did not have a source of water, nearly 19% had no toilets and 35% had no water and soap or alcohol-based hand rub for handwashing.
Industrial wastewater treatment Manufacturers of antimicrobials need to improve the treatment of their wastewater (by using industrial wastewater treatment processes) to reduce the release of residues into the environment.
Limiting antimicrobial use in animals and farming
It is established that the use of antibiotics in animal husbandry can give rise to AMR resistances in bacteria found in food animals to the antibiotics being administered (through injections or medicated feeds). For this reason only antimicrobials that are deemed "not-clinically relevant" are used in these practices. Unlike resistance to antibacterials,