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Antibiotic resistance — how a resistant strain takes over

Selection drawn as a process rather than a warning poster: a resistant cell arising at about 10⁻⁹ per division or arriving ready-made on a plasmid, the course of treatment killing everything else, the survivor refilling the empty niche, and the MIC climbing from 0.5 to 64 mg L⁻¹ — with the stewardship and agricultural pressures that set the pace.

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{
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    { "id": "population", "type": "sphere", "label": "Mixed population, almost all susceptible", "x": 40, "y": 40, "width": 150, "height": 104, "fill": "#dbeafe", "stroke": "#1d4ed8", "bold": true },
    { "id": "mutation", "type": "dna", "label": "Mutation at about 10⁻⁹ per division", "x": 215, "y": 40, "width": 150, "height": 104, "fill": "#fef3c7", "stroke": "#b45309", "bold": true },
    { "id": "rarecell", "type": "star", "label": "One resistant cell in a billion", "x": 390, "y": 40, "width": 150, "height": 104, "fill": "#dcfce7", "stroke": "#15803d", "bold": true },
    { "id": "exposure", "type": "syringe", "label": "A course of antibiotic begins", "x": 565, "y": 40, "width": 150, "height": 104, "fill": "#e0f2fe", "stroke": "#0369a1", "bold": true },
    { "id": "kill", "type": "cross", "label": "Susceptible cells die above the MIC", "x": 740, "y": 40, "width": 150, "height": 104, "fill": "#fce7f3", "stroke": "#be185d", "bold": true },
    { "id": "survivor", "type": "conveyor", "label": "The resistant cell survives and divides", "x": 915, "y": 40, "width": 150, "height": 104, "fill": "#dcfce7", "stroke": "#15803d", "bold": true },
    { "id": "plasmid", "type": "ribbon", "label": "Plasmids carry resistance genes", "x": 40, "y": 200, "width": 150, "height": 104, "fill": "#dbeafe", "stroke": "#1d4ed8", "bold": true },
    { "id": "conjugation", "type": "bridge", "label": "Conjugation moves them between species", "x": 215, "y": 200, "width": 150, "height": 104, "fill": "#fef3c7", "stroke": "#b45309", "bold": true },
    { "id": "mechanisms", "type": "gear", "label": "β-lactamase, efflux pumps, target change", "x": 390, "y": 200, "width": 150, "height": 104, "fill": "#e0f2fe", "stroke": "#0369a1", "bold": true },
    { "id": "selection", "type": "gauge-chart", "label": "Selection pressure, not new resistance", "x": 565, "y": 200, "width": 150, "height": 104, "fill": "#f1f5f9", "stroke": "#475569", "bold": true },
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    { "id": "misuse", "type": "cross", "label": "Sub-therapeutic doses, unfinished courses", "x": 40, "y": 360, "width": 150, "height": 104, "fill": "#fee2e2", "stroke": "#b91c1c", "bold": true },
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    { "id": "hospital", "type": "first-aid", "label": "Hospital spread — MRSA, ESBL, CPE", "x": 390, "y": 360, "width": 150, "height": 104, "fill": "#fee2e2", "stroke": "#b91c1c", "bold": true },
    { "id": "stewardship", "type": "clipboard", "label": "Stewardship — right drug, dose, duration", "x": 565, "y": 360, "width": 150, "height": 104, "fill": "#e0f2fe", "stroke": "#0369a1", "bold": true },
    { "id": "burden", "type": "bar-chart", "label": "1.27 million deaths attributed in 2019", "x": 740, "y": 360, "width": 150, "height": 104, "fill": "#ccfbf1", "stroke": "#0f766e", "bold": true },
    { "id": "pipeline", "type": "flask", "label": "Few genuinely new classes since 1987", "x": 915, "y": 360, "width": 150, "height": 104, "fill": "#fee2e2", "stroke": "#b91c1c", "bold": true },
    { "id": "fitness", "type": "gauge-chart", "label": "Resistance carries a fitness cost", "x": 390, "y": 520, "width": 150, "height": 104, "fill": "#ccfbf1", "stroke": "#0f766e" },
    { "id": "combination", "type": "shield-check", "label": "Combination therapy needs two mutations", "x": 740, "y": 520, "width": 150, "height": 104, "fill": "#e0f2fe", "stroke": "#0369a1", "bold": true }
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    { "id": "e2", "source": "mutation", "target": "rarecell", "thickness": 2.5 },
    { "id": "e3", "source": "plasmid", "target": "conjugation", "thickness": 2.5 },
    { "id": "e4", "source": "conjugation", "target": "rarecell", "label": "resistance can arrive ready-made", "thickness": 2.5 },
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    { "id": "e8", "source": "mechanisms", "target": "survivor", "label": "how it survives the drug", "style": "dashed" },
    { "id": "e9", "source": "kill", "target": "regrowth", "label": "the niche is emptied for it" },
    { "id": "e10", "source": "survivor", "target": "regrowth", "thickness": 2.5 },
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    { "id": "e13", "source": "selection", "target": "survivor", "label": "the drug selects, it does not create", "style": "dashed" },
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    { "id": "e17", "source": "hospital", "target": "burden", "thickness": 2.5 },
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    { "id": "e21", "source": "fitness", "target": "regrowth", "label": "resistance can fade if the drug stops", "style": "dashed" },
    { "id": "e22", "source": "mic", "target": "stewardship", "label": "surveillance feeds back", "style": "dashed" }
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