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Narayan Paudyal, Min Yue, Antimicrobial Resistance in the “Dark Matter”, Clinical Infectious Diseases, Volume 69, Issue 2, 15 July 2019, Pages 379–380, https://doi.org/10.1093/cid/ciz007
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To the Editor—Much is known about the human infections associated with bacterial antimicrobial resistance (AMR) in China. However, AMR’s significant drivers and reservoirs for humans are still controversial. We read the supplemental issue on “Current Status and Challenge of Antimicrobial Resistance in China,” proposed by Wang [1], with great interest. The topics discussed are related only to AMR in clinical diseases, except an interesting study on mobile colistin resistance [2]. The interdisciplinary crises, like AMR, cannot be tackled successfully by a mere unilateral focus on human medicine.
The China Antimicrobial Resistance Surveillance System and the China Antimicrobial Surveillance Network, functional since 2005, provide a foundation for quantifying human illnesses and AMR pathogens. However, they do not include all types of AMR bacteria, such as the commensals (the “dark matter”) or AMR bacteria from other possible exposures.
Incremental changes in the antibiotics used in animals, from 50 to 703 mg/kg biomass during 2001 to 2007 in China, suggest that those animals used for food have a significant role in AMR dynamics [3]. In 2017, the Chinese government restricted the use of antimicrobials in veterinary clinics and as growth promoters [4]. Modelling studies have implied that AMR transmission from agricultural and allied environments could possibly surpass the hospital transmission to humans [5].
Current Chinese studies emphasize the roles of animal husbandry, commercial crop farming, and intensive aquaculture as the primary risk factors that trigger selection pressure on the microbial fauna in their related environments [3, 6]. Human sewage, environmental contamination by hospital-related waste, and the usage of untreated animal manure in crop production also accelerate AMR dynamics [7]. The animal-product processing environment induces stress or hypermutation, thus serving as an underappreciated reservoir for the selection and enrichment of AMR bacteria. The physio-chemical parameters (sanitizers, biocides, X-rays) used during slaughter, processing, or preservation potentially enhance AMR bacteria in foods and, eventually, transmit those to humans [8]. Importantly, commensal or environmental bacteria possibly could be contributing as the “dark matter,” due to their lack of clinical significance, for indirect AMR dissemination.
Given the gravity of this multidisciplinary threat, we reiterate the “One Health” approach. Chinese researchers need to remove hurdles and bring One Health to the mainstream of research from the periphery of discussion. The comprehensive burden estimate—including burdens of the total environment; of animals, including both those raised for food and those used as companion; of humans; and of hotspot dark matter—should provide an improved understanding of the critical issues on AMR emergence and dynamics in China. This will serve as a guideline towards developing effective and cost-efficient strategies for reducing the overall burden of AMR in humans.
Notes
Financial support. The study was supported by the National Program on Key Research Project of China (grant numbers 2017YFC1600103; 2018YFD0500501; and 2018YFD0701001), the Fundamental Research Funds for the Central Universities (grant number 2-2050205-18-237), and Zhejiang Provincial Natural Science Foundation of China (grant number LR19C180001).
Potential conflicts of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
