Abstract The increasing accumulation of antibiotic resistance genes (ARGs) in pathogens poses a severe threat to the treatment of bacterial infections. However, not all ARGs do not pose the same threats to human health. Here, we present a framework to rank the risk of ARGs based on three factors: “anthropogenic enrichment”, “mobility”, and “host pathogenicity”. The framework is informed by all available bacterial genomes (55,000), plasmids (16,000), integrons (3,000), and 850 metagenomes covering diverse global eco-habitats. The framework prioritizes 3% of all known ARGs in Rank I (the most at risk of dissemination amongst pathogens) and 0.3% of ARGs in Rank II (high potential emergence of new resistance in pathogens). We further validated the framework using a list of 38 ARG families previously identified as high risk by the World Health Organization and published literature, and found that 36 of them were properly identified as top risk (Rank I) in our approach. Furthermore, we identified 43 unreported Rank I ARG families that should be prioritized for public health interventions. Within the same gene family, homologous genes pose different risks, host range, and ecological distributions, indicating the need for high resolution surveillance into their sequence variants. Finally, to help strategize the policy interventions, we studied the impact of industrialization on high risk ARGs in 1,120 human gut microbiome metagenomes of 36 diverse global populations. Our findings suggest that current policies on controlling the clinical antimicrobial consumptions could effectively control Rank I, while greater antibiotic stewardship in veterinary settings could help control Rank II. Overall, our framework offered a straightforward evaluation of the risk posed by ARGs, and prioritized a shortlist of current and emerging threats for global action to fight ARGs.

Choosing Your Battles: Which Resistance Genes Warrant Global Action?