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By Dearbháile Morris and Martin Cormican A ntimicrobial resistance is a worldwide public health emergency. In the last few decades, there has been widespread and increased use of antibiotics in both human and veterinary medicine. In addition, there is a huge market for antibacterial agents in personal care products (such as soap), in disinfectants, and as surface coatings on containers and appliances. As antimicrobial agents have been used more widely, microorganisms have become increasingly resistant to them. It is now commonplace for antimicrobial agents, which could be relied upon 20 years ago, to fail. The increased use of antimicrobial agents is influenced by an increasing population, an aging population, longer survival of people with complex illnesses, changes in food production systems, and by other social and economic factors. Infection associated with antimicrobial-resistant bacteria results in significant increases in healthcare costs, morbidity, and mortality. The World Health Organization (WHO) has ranked antimicrobial resistance as a "major threat to human health." 1 The European Centre for Disease Prevention and Control (ECDC) estimates that antimicrobial resistance results in 25,000 deaths and related costs of over €1.5 billion in healthcare expenses and productivity losses in Europe annually. 2 The Review on Antimicrobial Resistance commissioned by the UK Government estimates that if appropriate action is not taken, by the year 2050, 10 million deaths each year will be due to antimicrobial- resistant organisms at a global economic cost of $100 trillion USD. 3 It is increasingly recognized that an intersectoral approach is required to mitigate the problem of antimicrobial resistance. The May 2015 World Health Assembly adopted the Global Action Plan on Antimicrobial Resistance, 1 which endorses a "One Health" approach to tackle the issue. The One Health concept recognizes that there is a relationship among human health, animal health, and the environment, and that the well-being of each sector is influenced by the others. Antimicrobial Agents And Wastewater Antimicrobial residues can enter the aquatic environment in effluent from industries involved in the production of antimicrobial products or following direct disposal (intentional and unintentional) into waste streams (landfill and wastewater). In addition, a significant quantity of the antimicrobial agents used therapeutically in human and veterinary medicine is shed into waste streams in urine or feces, in a form that is still biologically active. In most of Europe, hospital effluent is released into the urban wastewater system without any specific measurement of antimicrobial levels or antimicrobial- resistant bacteria and without any pretreatment. Despite European Union (EU) directives, many European countries lack appropriate policies with regard to disposal of unused pharmaceuticals including antimicrobial agents. 4 Antimicrobial agents in water and wastewater are a potential problem in two ways: First, there is potential for direct human health effects through ingestion as chemical contaminants; second, there is potential harm if they change the microorganisms in the water. The immediate public health concern regarding the effect of antimicrobial agents in water is that microorganisms in water change to become more antimicrobial-resistant. There is also concern that antimicrobial agents may change the natural balance in the microbial ecosystem. Changes in the microbial cells and populations can last long after the antimicrobial agent has broken down or been removed. If people drink the water or swallow it during recreation, this may help to spread antimicrobial-resistant microorganisms over a large population very quickly. In research funded by the Irish Environmental Protection Agency (EPA), urban wastewaters and two wastewater treatment systems (one of the systems receives and treats effluent that includes effluent from a major hospital, and the other does not) were examined for the presence of antimicrobial residues and antimicrobial-resistant bacteria. 5 A computer model was 8 wateronline.com n Water Innovations What Lies Beneath: Antimicrobials And Antimicrobial- Resistant Bacteria In Wastewater Antimicrobials coursing through wastewater are making bacteria stronger, a problem that could lead to 10 million deaths per year if left unchecked. The immediate public health concern regarding the effect of antimicrobial agents in water is that microorganisms in water change to become more antimicrobial-resistant.