Metals such as mercury, arsenic, copper and silver have been used in various forms as antimicrobials for thousands of years with until recently, little understanding of their mode of action. The discovery of antibiotics and new organic antimicrobial compounds during the twentieth century saw a general decline in the clinical use of antimicrobial metal compounds, with the exception of the rediscovery of the use of silver for burns treatments and niche uses for other metal compounds. Antibiotics and new antimicrobials were regarded as being safer for the patient and more effective than the metal-based compounds they supplanted. Bacterial metal ion resistances were first discovered in the second half of the twentieth century. The detailed mechanisms of resistance have now been characterized in a wide range of bacteria. As the use of antimicrobial metals is limited, it is legitimate to ask: are antimicrobial metal resistances in pathogenic and commensal bacteria important now? This review details the new, rediscovered and 'never went away' uses of antimicrobial metals; examines the prevalence and linkage of antimicrobial metal resistance genes to other antimicrobial resistance genes; and examines the evidence for horizontal transfer of these genes between bacteria. Finally, we discuss the possible implications of the widespread dissemination of these resistances on re-emergent uses of antimicrobial metals and how this could impact upon the antibiotic resistance problem.
IntroductionMetals and metalloids have a long empirical history of human usage in medicine and agriculture (as reviewed below), despite problems of host toxicity or doubts about their efficacy. Even now, a few toxic metal(loid) compounds are still first-line drugs or preferred-choice chemotherapeutics or antimicrobials, although the use of most of the previously popular antimicrobial metal(loid)s, such as mercury and arsenic/antimony compounds, has been reduced or phased out in the past 50 or so years. Other metals, such as silver and copper, still have limited uses in agriculture and medicine, but are also increasingly being included in consumer products, from clothing to computer keyboards, and are being promoted as useful additions to our arsenal of antimicrobials. Against this background of their current usage, it is reasonable to ask: what is the relevance of antimicrobial metals and bacterial resistances to them to medical microbiology in the twentyfirst century?Any attempt to address this question must be set against the backdrop of widely known problems and opportunities. We are faced with new and emerging opportunistic nosocomial and community-acquired pathogens; and increasing epidemic and pandemic multidrug-resistant (MDR) pathogens. There is a recognition that the antibiotic discovery pipeline has not delivered significant quantities of new antibiotics in the past few decades, and new formulations and uses for antimicrobial metals as weapons in the antimicrobial armoury are being proposed (Department of Health, 2013;Lemire et al., 2013). ...