Global surveillance of antimicrobial resistance

Antimicrobial resistance (AMR) is one of the most serious global public health threats, however, obtaining representative data on AMR for healthy human populations is difficult. We characterized the bacterial resistome from untreated sewage from 79 sites in 60 countries. We found systematic differences in abundance and diversity of AMR genes between Europe/North-America/Oceania and Africa/Asia/South-America. Antimicrobial use data only explained a minor part of the AMR variation and no evidence for cross-selection between antimicrobial classes nor effect of travel by flight between sites were found. However, AMR abundance was strongly correlated with socio-economic, health and environmental factors, which we used to predict AMR abundances in all countries in the world. Our findings suggest that the global AMR gene diversity and abundance varies by region and are caused by national circumstances. Improving sanitation and health could potentially limit the global burden of AMR. We propose to use sewage for an ethically acceptable and economically feasible continuous global surveillance and prediction of AMR.