(4) If reducing AMR needs to be reflected within our regulatory framework, how could this best be tackled? (3) How well do current technologies and approaches limit AMR in the environment? (2) What is the relative contribution from the release of antibiotics, metals, biocides, and antibiotic resistance genes (ARGs) to the emergence, maintenance and spread of AMR in the environment? (1) What are the benefits of controlling AMR in the environment over and above mitigating the potential transmission of resistance to humans? The inability to answer these questions, in this point in time, highlights some of the evidence gaps that need to be prioritized to facilitate a holistic, evidence-based AMR Action Plan: The following five questions exemplify the approach taken by an environmental regulator when tackling the AMR challenge. We argue that there is an evidence gap that hinders the ability of policymakers and environmental regulators from delivering environmental protection from AMR. In this review, we aim to present the AMR challenge through the lens of an environmental regulator, using the Environment Agency (England’s regulator) as an example from which parallels can be drawn globally. BAIXAR CD ELIANE FERNANDES A CRUZ PLAYBACK 2016 DRIVERSIt is further argued that without inclusion or consideration of all the drivers and pathways of AMR into the environment, AMR Action Plans are incomplete and at risk of not achieving the desired goals of ensuring and improving the efficacy of existing and future antibiotics. It is argued, that our inability to satisfactorily answer fundamental questions about AMR in the environment is responsible for the lack of any significant environmental focus in existing AMR Action Plans and the O’Neill AMR Reviews ( O’Neill and The Review on Antimicrobial Resistance, 2016). Many of the hurdles to combating antibiotic-resistant infections in the clinic are well understood and, as such, have been used to inform existing antimicrobial resistance (AMR) Action Plans ( European Commission, 2011 Department of Health/Defra, 2013 World Health Organisation, 2015). We conclude that: (1) AMR Action Plans do not tackle all the potentially relevant pathways and drivers of AMR in the environment and (2) AMR Action Plans are deficient partly because the science to inform policy is lacking and this needs to be addressed. The issues that are pertinent to environmental regulators are drawn out to answer: What are the drivers and pathways of AMR? How do these relate to the normal work, powers and duties of environmental regulators? What are the knowledge gaps that hinder the delivery of environmental protection from AMR? We offer several thought experiments for how different mitigation strategies might proceed. Here, we aim to present the problem with AMR in the environment through the lens of an environmental regulator, using the Environment Agency (England’s regulator) as an example from which parallels can be drawn globally. It is argued that the lack of environment-facing mitigation actions included in existing AMR action plans is likely a function of our poor fundamental understanding of many of the key issues. Hence, environmental regulators should be contributing significantly to the development of global and national antimicrobial resistance (AMR) action plans. Environmental regulators monitor and control many of the pathways responsible for the release of resistance-driving chemicals into the environment (e.g., antimicrobials, metals, and biocides). The environment is increasingly being recognized for the role it might play in the global spread of clinically relevant antibiotic resistance.
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