1 Introduction

Antimicrobial resistance (AMR) is defined as the ability of microorganisms to survive and remain viable despite exposure to antimicrobial agents [1, 2]. Various types of antimicrobial agents, including antibiotics, disinfectants, and food preservatives, are used to combat microorganisms by reducing their growth, inhibiting their reproduction, or killing them outright. These agents can be natural, semi-synthetic, or synthetic, each with distinct mechanisms of action [1, 2]. They can induce significant changes at the metabolic and physiological levels, such as altering cell wall synthesis (e.g., β-lactams and glycopeptides), inhibiting protein synthesis (e.g., macrolides and tetracyclines), disrupting metabolic pathways (e.g., sulfonamides), or interfering with DNA replication and translation (e.g., fluoroquinolones) [3-5]. AMR is a significant public health issue in the 21st century and poses a serious threat to our ability to prevent and treat a variety of infections caused by bacteria, parasites, viruses, and fungi [6]. The first World Health Organization (WHO) global report on AMR surveillance revealed the worldwide extent of AMR and highlighted significant gaps in existing surveillance systems [6]. Drug-resistant infections contributed to more than 4.95 million deaths globally in 2019, and without urgent intervention, this number could rise to 10 million deaths annually by 2050 [6-8]. Several recent outbreaks linked to AMR have underscored the severity of this crisis. The global spread of carbapenem-resistant Klebsiella pneumoniae (CRKP) has been a major concern, particularly in healthcare settings, where it causes severe pneumonia, bloodstream infections, and urinary tract infections with limited treatment options [6]. In 2017, an outbreak of CRKP in Italy led to high mortality rates among hospitalized patients due to the pathogen's resistance to last-line antibiotics [6, 9]. Similarly, methicillin-resistant Staphylococcus aureus (MRSA) remains a leading cause of hospital-acquired infections worldwide, with outbreaks occurring in intensive care units and postsurgical patients. In the United States, MRSA is responsible for an estimated 10,000 deaths annually [6, 10] (Table 1).

Another alarming example is the emergence of drug-resistant Neisseria gonorrhoeae, which has rendered first-line treatments ineffective in many regions. In 2018, the United Kingdom reported its first case of a gonorrhea strain resistant to ceftriaxone and azithromycin, raising concerns about the potential for untreatable sexually transmitted infections [6, 11]. Additionally, multidrug-resistant (MDR) Salmonella strains have led to outbreaks linked to contaminated food products, such as the extensively drug-resistant (XDR) Salmonella typhi outbreak in Pakistan, which left thousands infected and was only treatable with a single remaining antibiotic [6, 12]. The emergence and rapid spread of AMR are driven by multiple interconnected factors, including the misuse and overuse of antibiotics in human medicine, veterinary practice, and agriculture. In many low- and middle-income countries, the unrestricted availability of antibiotics, coupled with inadequate regulatory oversight, leads to self-medication, inappropriate prescribing practices, and incomplete treatment regimens, major contributors to the selection and propagation of resistant bacterial strains. In the agricultural sector, antibiotics are extensively used not only for therapeutic purposes but also as growth promoters and prophylactic agents in livestock and aquaculture, fostering the emergence of resistant pathogens that can be transmitted to humans through direct contact, food consumption, and environmental exposure [13]. Additionally, environmental reservoirs play a crucial role in AMR dissemination, as pharmaceutical waste, untreated industrial effluents, and inadequately treated hospital sewage facilitate the persistence and horizontal gene transfer (HGT) of resistance determinants among bacterial populations. Poor sanitation, inadequate infection control measures, and global travel further exacerbate the problem by enabling the transboundary spread of resistant pathogens [14].

Distal drivers of AMR, including rapid urbanization, population growth, poor healthcare infrastructure, and ineffective policy implementation, have further exacerbated the crisis [15]. Additionally, bacterial resistance is fueled by genetic mutations, HGT, and selective pressure from antimicrobial use [4, 9]. These factors have made AMR one of the most pressing global health challenges, threatening modern medicine and increasing the risk of untreatable infections. Given the urgency of the situation, it is crucial to develop novel therapeutic strategies targeting AMR mechanisms. In this review, we aim to analyze the current understanding of AMR pathways and explore innovative approaches that could be leveraged to combat resistance effectively.

2 Traditional Mechanisms of Antibiotic Resistance

2.1 Overview of Classical Antibiotic Resistance Mechanisms

Antibiotic resistance in bacteria arises through several key mechanisms: alteration of drug targets, active efflux, reduced membrane permeability, and enzymatic inactivation of antimicrobial agents (Figure 1) [14]. These mechanisms, either individually or in combination, contribute to the growing threat of AMR. Clinically, the consequences of AMR are evident in the rise of drug-resistant pathogens. MRSA, for instance, has become a major cause of hospital- and community-acquired infections. Resistance is largely attributed to the mecA gene, which encodes PBP2a, an altered penicillin-binding protein with low affinity for β-lactams, rendering drugs like methicillin ineffective and complicating the management of pneumonia, sepsis, and osteomyelitis [5, 8, 15].

Likewise, extended-spectrum β-lactamase-producing Escherichia coli and K. pneumoniae pose a major threat by hydrolyzing third-generation cephalosporins, leaving carbapenems as one of the few effective treatments. Alarmingly, the emergence of carbapenem-resistant Enterobacteriaceae, through genes such as blaKPC, blaNDM, and blaOXA-48, has further restricted therapeutic options and is associated with high mortality, especially in bloodstream and ventilator-associated infections [12, 14, 16].

MDR Pseudomonas aeruginosa represents another high-risk pathogen, utilizing a combination of efflux pumps, porin mutations, and β-lactamase production to evade treatment. It is particularly problematic in immunocompromised patients, including those with cystic fibrosis or burn injuries [12, 15].

These cases collectively underscore the global urgency of AMR. The evolution of resistance mechanisms continues to outpace drug development, threatening to render once-effective antibiotics obsolete. Combating AMR requires a multipronged approach: investment in novel antimicrobials, enhanced global surveillance, and strict infection prevention and control strategies.

2.1.1 Drug Inactivation by Enzymes

Antibiotics can be degraded by enzymes produced by bacteria, which also renders them ineffective as an antibacterial agent. As a result, the medicine fails to reach the bacterial cell and is destroyed [15]. Drug-inactivating enzymes can be divided into three categories: β-lactamases, aminoglycoside inactivating/modifying enzymes, and chloramphenicol acetyltransferases [9, 17]. The unstable hydrolytically sensitive chemical bonds in medicines can be targeted and broken down by the enzymes produced by both chromosomal and plasmid genes [18]. Many clinically relevant enzymes, such as blaCTX-M, blaTEM, and blaSHV, and so forth, contain β-lactamase enzymes that confer antibiotic resistance in bacteria [19].

2.1.2 Alteration of Drug Target

The bacteria contain a large number of antibiotic-binding targets [20, 21]. A key mechanism for drug resistance is the modification of the target site, which can make it challenging for antibiotics to adhere to the bacteria [18]. The two main hallmarks of this mechanism are witnessed in the resistance of drugs in Gram-positive bacteria, as well as polymyxin. For instance, PBP2a, which is a low-affinity binding protein, is created when S. aureus' PBP is transformed into it, leading to resistance against all β-lactam antibiotics [22, 23].

2.1.3 Modifications in the Permeability of the Outer Membrane

Beta-lactam antibiotics mainly pass through hydrophilic channel proteins and penetrate the outer membrane of Gram-negative bacteria, and mutations leading to changes in channel protein or a decrease in expression can lessen the susceptibility of the bacteria to multiple β-lactam antibiotics. For instance, the absence of the channel protein named Opal D2 in hepatocytes results in imipenem resistance [22, 23]. The severe natural susceptibility of P. aeruginosa to antiseptics and antibiotics is due to its narrow outer membrane permeability [24]. It is anticipated that the mutation in the outer membrane porins gene may impact drug resistance (Figure 2).

2.1.4 Active Antimicrobial Compound Efflux

It is often called a drug efflux system or an efflux pump mechanism. Antibiotic resistance occurs because the antibiotic's concentration inside the pathogenic bacteria is too low to have any antimicrobial activity. The process uses energy and interacts with numerous antibiotics [25]. Examples include the ability of the OprK protein in the outer membrane of P. aeruginosa to transport different antibiotics to the bacteria's surface [26]. Resistance nodulation division, major facilitator superfamily (MFS), multidrug toxic compound extrusion (MATE), small multidrug-resistant (SMR), and ATP-binding cassette (ABC) superfamilies are the most significant efflux transporters [27-29]. Several crucial genes are present in each efflux family, including acrB, emrE, bcr, cmr in MFS, mdtK, yeeO in MATE, ydgE in SMR, and macB in ABC [30, 31].

3 HGT: A Key Driver of Antibiotic Resistance Evolution

Bacteria can develop antibiotic resistance in two different ways: either by spontaneous gene mutation or through HGT [47, 48]. The transmission of genetic information between organisms that are not related as parents and offspring is known as HGT [48]. The introduction of foreign DNA by the HGT mechanism is one of the factors responsible for the formation of antibiotic resistance in bacteria [48]. The majority of antibacterial substances employed in clinical settings are obtained from elements naturally occurring in the environment, primarily soil [49]. There is strong evidence suggesting that the emergence of antibiotic resistance genes (ARGs) in therapeutically important bacteria mostly originates from the environmental resistome [50]. Since bacteria that share the environment with these compounds carry internal genetic determinants of resistance. It has also been proven that the spread of antibiotic resistance is a result of this genetic exchange (Figure 3).

There have been three main ways for bacteria to take in foreign genetic material: the incorporation of bare DNA from the surrounding environment by a mechanism called transformation, transduction, which is mediated by viruses, and conjugation, in which DNA is transferred between bacteria through a conjugating pilus [48]. The most common type of HGT mechanism is transformation [48]. Conjugation is also a very efficient form of gene transfer that involves cell-to-cell contact and is frequently implicated in the development of resistance in hospital settings [51]. It has been discovered that contact with minimal limiting concentrations of two antibiotics, such as gentamycin and chloramphenicol, or aminoglycosides such as streptomycin stimulates conjugation between certain Gram-negative bacteria [52] (Figure 3).

4 Adaptive Responses and Phenotypic Heterogeneity

Phenotypic heterogeneity refers to the phenomenon in which genetically identical bacteria residing in a homogenous environment exhibit distinct traits, thus enabling the emergence of novel functional capabilities [61]. Even genetically identical bacterial cells can exhibit distinct behaviors and responses to stimuli [62]. The origin of heterogeneity in bacterial populations can be attributed to the stochastic nature of gene expression, which brings forth phenotypic variations in the generations [62]. Fundamentally, gene expression entails inherently stochastic biochemical reactions responsible for generating mRNA and proteins, ultimately leading to diversification [62]. Bacteria have adapted to leverage this phenomenon to their benefit by utilizing feedback-driven circuits and forming increasingly diverse phenotypic subgroups [63]. It is hypothesized that individual cells undergo stochastic transitions between activating and deactivating a metabolic pathway, potentially providing a fitness advantage to a subpopulation [62]. In situations where a bacterial population faces sudden environmental changes, any subpopulations possessing advantageous traits that enable them to endure stressors like exposure to antibiotics will still have the opportunity to thrive, consequently enhancing the overall survival of the population [64].

Research has shown that subpopulations within genetically identical populations can have different antibiotic susceptibilities, as seen with persister cells [65]. Persisters are subsets of a bacterial population that can withstand antibiotic treatment in otherwise antibiotic-sensitive cultures. They typically exhibit slow growth or growth suspension and can restart their growth after the subsidence of a severe stressor [66]. The existence of persister cells can lead to the resilience and resurgence of persistent bacterial infections and the development of antibiotic resistance during treatment [66]. The development of tolerance in persisters appears to operate through a mechanism involving the shutdown of their molecular targets. Bactericidal drugs exert their lethal effects by disrupting these targets rather than merely inhibiting them. Inactivating these targets serves as a defense mechanism, allowing persister cells to evade the lethal effects of antibiotics [67].

The gene expression profile of persisters was found to encompass toxin-antitoxin modules along with other genes capable of impeding crucial cellular processes, particularly translation [68]. Notably, a marked escalation in the population of persisters was observed upon the overproduction of the RelE toxin, which acts as a translation inhibitor [68]. The inhibition of translation results in the cessation of vital cellular functions, thereby thwarting the action of antibiotics in corrupting their intended targets. This, in turn, contributes to the emergence of persister cells that exhibit multidrug tolerance [69]. Persister cells have been detected across all significant pathogens and are a leading factor behind chronic infections [69].

Other than the natural existence of persister cells within bacterial populations, antibiotic-tolerant and resistant bacterial populations can also arise from specific external triggers. Bacteria are significantly influenced by environmental stress. It triggers numerous adaptive and protective reactions that modify gene expression patterns and cell physiology, ultimately affecting their susceptibility to antimicrobial agents [70]. This influence occurs through indirect mechanisms, such as stress-induced growth cessation or dormancy, which render bacteria less vulnerable to antimicrobials that target actively growing cells. Additionally, stress can directly contribute to AMR by altering antimicrobial targets, mitigating changing membrane barrier functions, inducing resistance mutations, or encouraging resistant growth patterns like biofilms [70]. Among other stressors like nutrient starvation, hypoxia, pH fluctuations, changes in osmotic pressure, and extreme temperature shifts, one of the main stressors for bacteria is antibiotic exposure. Exposure to bactericidal agents can initiate protective responses in bacteria, potentially fostering resistance-promoting reactions [70].

Antibiotics-induced stress can activate the SOS (Save Our Souls) response in bacteria through DNA damage or replication arrest. For example, fluoroquinolone blocks DNA gyrase and trimethoprim impacts purine and pyrimidine synthesis [71, 72]. These effects lead to abnormal amounts of single-stranded DNA within the cells, which is the primary signal for the SOS response. During the SOS response, bacteria can reorganize and alter their genetic makeup, leading to various changes in their characteristics. This response can result in the differential regulation of genes, leading to outcomes like increased virulence, enhanced persistence, and the development of antibiotic resistance [73]. SOS response also increases the mutation rate, called adaptive mutagenesis [73]. The higher mutation rate increases the chances of mutations that allow adaptation to the stressor. For instance, resistance to ciprofloxacin and rifampicin is due to mutations caused during the induction of the SOS response through the action of the error-prone polymerases [74].

Notably, the SOS response can also be activated by minimal amounts of antibiotics, referred to as sub-MIC (sub-minimal inhibitory concentration). This holds significance because it implies that even the small quantities of antibiotics frequently detected in the environment, wastewater treatment facilities, hospitals, and soil can play a role in developing and disseminating antibiotic resistance [73]. Sub-MICs can result in changes in gene expression, including genes related to resistance to oxidative stress, motility, virulence, and biofilm formation [73, 75]. Additionally, sub-MICs of antibiotics increase mutation frequencies and promote the spread of ARGs even without direct DNA damage, potentially through the generation of reactive oxygen species that damage DNA and trigger the SOS response [73, 75].

5 Antibiotic Resistance in Biofilms

Biofilms are structured communities of bacteria encased in a self-produced matrix of polysaccharides, proteins, and extracellular DNA. This matrix offers physical protection and biochemical resistance, shielding bacteria from environmental stressors such as UV radiation, extreme pH or salinity, nutrient scarcity, and—most notably—antibiotics and immune defenses [76].

Biofilm formation occurs on both artificial surfaces (e.g., catheters, stents, prosthetic joints) and natural tissues (e.g., teeth, heart valves, lungs in cystic fibrosis, chronic wounds, and the middle ear), contributing significantly to persistent and chronic infections [76]. The initial stage involves reversible attachment of planktonic (free-floating) bacteria to a surface, aided by structures like flagella in motile species such as P. aeruginosa [77]. If not interrupted, this progresses to irreversible attachment, microcolony formation, and development of a mature biofilm—often reaching thicknesses of up to 50 μm and forming complex, mushroom-like structures [78]. During early formation, bacteria remain more susceptible to antibiotics, underscoring the importance of timely prophylaxis [78].

Lastly, bacteriophages offer a promising biological approach by targeting bacteria within biofilms. These viruses degrade the biofilm matrix, promote bacterial lysis, and improve antibiotic penetration. However, concerns remain about potential immune responses and phage resistance, requiring further research [93].

6 Antibiotic Resistance in the Microbiome

7 Role of MGEs in Antibiotic Resistance Dissemination

8 Evolutionary Trade-Offs: Fitness Costs and Compensatory Mutations

The fitness cost of AMR refers to the trade-off between a bacterium's ability to grow and compete in the absence of antibiotics versus its ability to survive in the presence of antimicrobial agents. Studies have shown that the fitness cost associated with resistance varies depending on the specific mutation, with some mutations imposing a significant burden on bacterial growth, while others have minimal impact. The extent of this cost is largely mutation-dependent, as different resistance mechanisms affect bacterial physiology in diverse ways [126]. Detailed reconstructions of resistance mutations have revealed that in clinical settings, resistant strains often carry mutations that impose lower fitness costs, as determined by in vitro assays. This suggests that bacteria may preferentially retain mutations that balance resistance with viability [127]. In some cases, certain resistance mutations appear to have no detectable fitness cost, although it remains unclear whether these mutations carry subtle disadvantages that current methods fail to detect or if specific environmental conditions may reveal their effects.

One documented example is the K42R mutation in the 30S ribosomal protein S12, which confers streptomycin resistance in E. coli, Mycobacterium tuberculosis, and Salmonella enterica serovar Typhimurium without an apparent reduction in fitness [128, 129]. Interestingly, some studies have even suggested that certain resistance mutations can enhance bacterial fitness under specific conditions. Furthermore, the impact of resistance mutations can vary depending on the genetic background of the bacterial strain or clonal lineage, highlighting the role of epistatic interactions, where genetic factors influence the fitness effects of resistance mutations. Understanding these dynamics is crucial for predicting the evolutionary trajectory of resistant pathogens and designing effective strategies to mitigate AMR [130-132].

In fact, a meta-analysis research revealed that certain resistance mutations in Borrelia burgdorferi and Enterococcus faecium exhibited an average fitness score > 1 without the use of antibiotics, whereas the mutations in organisms like M. tuberculosis and S. aureus were costly [133]. In addition, the GyrA C257T mutation, which provides quinolone resistance, was demonstrated to boost the performance of a single strain of Campylobacter in a chicken model with infections and reduce fitness once transferred into a different strain of the same bacterium, confirming how variable fitness costs may be the justification for epistatic consequences [134].

It is crucial to keep in mind that secondary mutations are one of the most common methods used to offset fitness costs. By altering the resistant allele of the altered protein's impacted function, removing the necessity for this process, or restoring the compromised protein's activity, mutations like these can improve microbial fitness [135]. Based on whether mutations happen at a single locus as the resistant mutation or at different loci, compensatory mutations may be classified as intragenic or extragenic [136]. Whereas the secondary mutations, primarily in the context of intragenic compensation, occasionally return the vulnerability to antimicrobial agents, it often happens that the compensated mutants retain their ANR [127] (Table 3).

Several studies have demonstrated that the fusidic acid resistance effect in S. aureus and S. enterica (acquired by amino acid exchanges within the elongation factor G, EF-G) is linked to a substantial decrease in bacterial fitness [127, 137, 138]. This is relevant to intragenic mutations [137]. Many times, particular changes to the fusA gene can significantly lessen these harmful effects [127]. One crucial feature of compensating mutations is that, occasionally, other resistant mutations result in compensation [139]. In the instance of P. aeruginosa rifampicin-resistant mutations, this epistatic influence was noted. Resistance mutations in various genes may potentially enable compensatory fitness costs in addition to intragenic compensatory mutation. This is an example of secondary mutations in topoisomerase IV (a target of quinolones) genes, which can offset the expense of primary mutations in marR [138].

To reduce fitness costs, the abuse of antibiotics should be regulated. To stop the abuse, misuse, and eventual growth in AMR of antibiotics, it is crucial to strike an equilibrium between autonomy and the significance of antimicrobial stewardship. Programs that encourage the responsible use of antibiotics, or “antimicrobial stewardship,” can help to keep this equilibrium (Table 3). Healthcare professionals can promote safe usage of antibiotics through the use of such initiatives without interfering with people's right to privacy. These programs involve collaborative decision-making among patients and medical professionals, ensuring only essential prescriptions are written for antibiotics, and tracking the consumption of antibiotics to spot and treat abuse trends [140].

9 Genomic and Metagenomic Approaches to Study Antibiotic Resistance Evolution

A mix of traditional culture-dependent phenotypic techniques (such as broth microdilution, disk diffusion, gradient diffusion, and automated systems) and culture-independent fast molecular techniques is currently used by the majority of clinical microbiology labs to forecast antibiotic resistance [141]. This method offers quicker turnaround times employing molecular approaches for a portion of the intended pathogens while maintaining historical results data and the species range of traditional screening [141]. It is important to note that this strategy is not ideal. For instance, only a small portion of important resistance indicators from quite a few clinical pathogens are amenable to fast molecular analysis. Any culture-dependent approach has drawbacks, including the need for in vitro growth, longer turnaround periods for slow-growing microorganisms, bias against dominating microbial populations, and the possibility of contaminant overgrowth [141].

However, the adoption of genomic-based resistance predictions is a little delayed in the discipline of clinical microbiology. Turnaround time and additional expenditures as comparison to conventional procedures, as well as the dearth of conclusive outcomes data indicating clinical efficacy, are major issues of dispute. Studies have revealed that certain elements might not be as problematic as once thought [142]. Another important issue is the dearth of reliable predictive techniques, particularly for Gram-negative bacteria like P. aeruginosa. There are benefits to using genomic-based resistance identification in a clinical microbiology lab. First, the turnaround time for infections with slow growth rates could be accelerated. Second, a larger variety of microorganisms may be tested in labs. Fastidious bacteria and other microorganisms, such as fungi or parasites, may fall under this category. Third, an isolated relationship could be assessed by a clinical laboratory. It is crucial for laboratories to detect contamination, evaluate unsuccessful therapy versus new infections, as well as infection management and preventive procedures. Instead of submitting an isolate, such isolate-relatedness data might be given straight to public health, which might result in a quicker identification of epidemics [143, 144].

An alternate method involves doing Metagenomics Next Generation Sequencing directly from a clinical specimen, capturing all of the pathogenic nucleic acids, other microorganism nucleic acids, and the individual's human nucleic acids, as opposed to sequencing pure cultures of a separate microbe [145] (Table 3). Avoiding culture bottlenecks is a key benefit of this objective method of identifying pathogens, which is why clinical metagenomic sequencing is becoming more popular [146, 147]. This strategy can be very beneficial for infections that develop slowly, like Mycobacterium species [148]. According to a prospective examination of “cerebrospinal fluid for metagenomic sequencing,” 22% (13/58) of infections may be detected through sequencing rather than by conventional laboratory techniques [147].

Additionally, metagenomic sequencing gave clinicians other advantages, such as the detection of Klebsiella aerogenes (formerly known as Enterobacter aerogenes) ARGs and the prediction of HIV-1 treatment resistance [147]. The disadvantage of this approach is the fact that there will be no isolate available for phenotypic susceptibility testing, which would impede confirmation of ARG-based resistance predictions (Table 3). Additionally, clinical evaluation of the results can be difficult when numerous putative infections have been identified with unique readings [149].

10 Recommendations

10.1 Development of New Antibiotics and Combination Therapies

To overcome emerging antibiotic resistance mechanisms, several strategies can be implemented. Developing new antibiotics with novel mechanisms of action that target bacterial processes not affected by existing drugs is crucial. Utilizing advanced technologies such as high-throughput screening, genomics, and bioinformatics can help identify new antibiotic candidates, including natural products, synthetic compounds, and biologics. Additionally, focusing on nontraditional targets like bacterial virulence factors, biofilm formation, and quorum sensing can weaken bacteria and enhance the effectiveness of existing antibiotics [150] (Figure 4).

Using synergistic combinations of existing antibiotics can enhance efficacy and reduce the likelihood of resistance development by attacking bacteria through multiple mechanisms simultaneously. Pairing antibiotics with adjuvants that inhibit resistance mechanisms, such as beta-lactamase inhibitors, or with nonantibiotic agents like immunomodulators or efflux pump inhibitors, can further improve outcomes. Investing in rapid diagnostic tools to quickly identify bacterial infections and their resistance profiles allows for targeted therapy with the most effective antibiotics, reducing misuse and slowing resistance spread [151].

11 Conclusion

The continuous evolution of AMR underscores the urgent need to understand the intricate relationship between microorganisms and antibiotics, as it remains one of the most significant global health challenges. Addressing AMR in contemporary healthcare requires a comprehensive approach to elucidate the mechanisms through which microorganisms adapt and evolve to withstand antibiotic treatment. To combat AMR and preserve the effectiveness of antimicrobial therapies, a multifaceted strategy is essential. This includes advancing scientific research to develop novel antibiotics and alternative therapies, strengthening antimicrobial stewardship programs, and enhancing global surveillance efforts. However, scientific advancements alone are insufficient. Success in mitigating AMR relies on coordinated action and collaboration among healthcare professionals, researchers, policymakers, and the pharmaceutical industry.

Healthcare providers must implement evidence-based prescribing practices, while researchers should continue exploring innovative treatment strategies and rapid diagnostic tools. Policymakers play a crucial role in enforcing regulations to curb antibiotic misuse in healthcare and agriculture, and pharmaceutical companies must prioritize the development of new antimicrobial agents despite financial and regulatory challenges. Furthermore, international partnerships and funding initiatives are necessary to support low- and middle-income countries in their fight against AMR.

The battle against AMR requires immediate, sustained, and collective action. By fostering interdisciplinary collaboration, promoting responsible antibiotic use, and investing in groundbreaking research, we can work toward a future where the threat of AMR is effectively controlled. If we act now, we have the opportunity to preserve the efficacy of antimicrobial therapies and safeguard global public health for generations to come.

Author Contributions

Abubakar Nazir: conceptualization, writing – original draft, writing – review and editing, project administration, supervision, validation, visualization. Awais Nazir: writing – original draft, writing – review and editing. Varisha Zuhair: writing – original draft, writing – review and editing. Shafaq Aman: writing – review and editing, formal analysis, supervision. Safi Ur Rehman Sadiq: conceptualization, project administration, writing – review and editing, validation, supervision. Abdul Haseeb Hasan: writing – original draft, writing – review and editing. Maryam Tariq: writing – original draft, writing – review and editing. Latif Ur Rehman: writing – original draft, writing – review and editing. Mubarak Jolayemi Mustapha: writing – original draft, writing – review and editing. Deusdedith Boniphace Bulimbe: writing – original draft, writing – review and editing.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author, Abubakar Nazir, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.