Emerging antimicrobial strategies for one health and their relevance to low and middle income countries

Abstract

Antimicrobial resistance (AMR) is a major global health threat, with a disproportionate burden in low- and middle-income countries (LMICs) due to limited diagnostic capacity, constrained health systems, and restricted access to novel therapeutics. Emerging antimicrobial technologies offer promising alternatives, but their translational maturity and implementation relevance in LMIC settings remain insufficiently characterized. To map the evidence on five next-generation antimicrobial modalities—bacteriophage therapy, CRISPR-Cas-based antimicrobials, antimicrobial peptides (AMPs), enzybiotics, and nanotechnology-enabled antimicrobial systems—with emphasis on translational maturity, LMIC representation, implementation considerations, and One Health integration. This scoping review followed Joanna Briggs Institute methodology and PRISMA-ScR reporting guidance. PubMed/MEDLINE, Embase, Scopus, and Web of Science were searched for studies published between January 2010 and December 2025. Two reviewers independently conducted study selection and data extraction. Findings were synthesized descriptively because of substantial heterogeneity in interventions, experimental models, and outcomes. Eighty-two studies were included. The evidence base was overwhelmingly preclinical, with 79/82 (96.3%) studies comprising in vitro, animal, or other preclinical investigations, whereas only 3/82 (3.7%) reported early clinical, pilot, or compassionate-use evaluations. Bacteriophage therapy demonstrated the greatest translational maturity, followed by AMPs with limited early clinical progression. Enzybiotics, CRISPR-Cas systems, and nanotechnology-based platforms remained largely at the discovery or preclinical stage. Only 18/82 (22.0%) studies were conducted in or explicitly addressed LMIC contexts, with most evidence originating from high-income countries. Next-generation antimicrobial strategies remain largely in early developmental stages, with persistent gaps in clinical validation, regulatory preparedness, manufacturing capacity, and LMIC-focused implementation research. Accelerating equitable translation will require coordinated investment in clinical research, implementation science, regulatory innovation, computational approaches, and context-adapted One Health strategies.