Non-antibiotic drugs enhance AMR in mixture with ciprofloxacin

Antimicrobial resistance (AMR) is a major health concern, and a range of antibiotic concentrations and non-antibiotic agents can select for AMR. Selection for AMR is often investigated using single compounds, however, in the natural environment and the human body, pharmaceuticals will be present as mixtures, including both non-antibiotic drugs (NADs), and antibiotics. Here, we assessed the effects of one of three NADs in combination with ciprofloxacin, a commonly used antibiotic that is often found at concentrations in global freshwaters sufficiently high to select for AMR. We used a combination of growth assays and qPCR to determine selective concentrations of mixtures and used metagenome sequencing to identify changes to the resistome and community composition. The selective concentration of ciprofloxacin was reduced in mixtures, and some changes in selection for specific genes or species were observed. Results show that NADs and ciprofloxacin are more selective than ciprofloxacin alone and these mixtures can cause distinct changes to the community composition. This indicates that future work should on the maintenance and spread of AMR should consider combinations of antibiotics and NADs.