title: Human Health Risk Assessment (HHRA) for environmental development and transfer of antibiotic resistance.
abstract: BACKGROUND
  Only recently has the environment been clearly implicated in the risk of antibiotic resistance to clinical outcome, but to date there have been few documented approaches to formally assess these risks.
  
  
  OBJECTIVE
  We examined possible approaches and sought to identify research needs to enable human health risk assessments (HHRA) that focus on the role of the environment in the failure of antibiotic treatment caused by antibiotic-resistant pathogens.
  
  
  METHODS
  The authors participated in a workshop held 4-8 March 2012 in Québec, Canada, to define the scope and objectives of an environmental assessment of antibiotic-resistance risks to human health. We focused on key elements of environmental-resistance-development "hot spots," exposure assessment (unrelated to food), and dose response to characterize risks that may improve antibiotic-resistance management options.
  
  
  CONCLUSIONS
  Various novel aspects to traditional risk assessments were identified to enable an assessment of environmental antibiotic resistance. These include a) accounting for an added selective pressure on the environmental resistome that, over time, allows for development of antibiotic-resistant bacteria (ARB); b) identifying and describing rates of horizontal gene transfer (HGT) in the relevant environmental "hot spot" compartments; and c) modifying traditional dose-response approaches to address doses of ARB for various health outcomes and pathways.
  
  
  CONCLUSIONS
  We propose that environmental aspects of antibiotic-resistance development be included in the processes of any HHRA addressing ARB. Because of limited available data, a multicriteria decision analysis approach would be a useful way to undertake an HHRA of environmental antibiotic resistance that informs risk managers.
authors.affiliation: US Environmental Protection Agency, Office of Research and Development, Cincinnati, Ohio 45268, USA. Ashbolt.Nick@epa.gov
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Ashbolt
authors.forename: Alejandro
authors.initials: A
authors.lastname: Amézquita
authors.forename: Thomas
authors.initials: T
authors.lastname: Backhaus
authors.forename: Peter
authors.initials: P
authors.lastname: Borriello
authors.forename: Kristian K
authors.initials: KK
authors.lastname: Brandt
authors.forename: Peter
authors.initials: P
authors.lastname: Collignon
authors.forename: Anja
authors.initials: A
authors.lastname: Coors
authors.forename: Rita
authors.initials: R
authors.lastname: Finley
authors.forename: William H
authors.initials: WH
authors.lastname: Gaze
authors.forename: Thomas
authors.initials: T
authors.lastname: Heberer
authors.forename: John R
authors.initials: JR
authors.lastname: Lawrence
authors.forename: D G Joakim
authors.initials: DG
authors.lastname: Larsson
authors.forename: Scott A
authors.initials: SA
authors.lastname: McEwen
authors.forename: James J
authors.initials: JJ
authors.lastname: Ryan
authors.forename: Jens
authors.initials: J
authors.lastname: Schönfeld
authors.forename: Peter
authors.initials: P
authors.lastname: Silley
authors.forename: Jason R
authors.initials: JR
authors.lastname: Snape
authors.forename: Christel
authors.initials: C
authors.lastname: Van den Eede
authors.forename: Edward
authors.initials: E
authors.lastname: Topp
mesh_terms: D004305:Dose-Response Relationship, Drug; D004352:Drug Resistance, Microbial; D004493:Education; D004777:Environment; D006305:Health Status Indicators; D006801:Humans; D008962:Models, Theoretical; D018570:Risk Assessment / Q000379:methods*