9Antibiotic resistance is a global threat for public health. It is widely acknowledged that 10 antibiotics at sub-inhibitory concentrations are important in disseminating antibiotic 11 resistance via horizontal gene transfer. While there is high use of non-antibiotic human-12 targeted pharmaceuticals in our societies, the potential contribution of these on the spread of 13 antibiotic resistance has been overlooked so far. Here, we report that commonly consumed 14 non-antibiotic pharmaceuticals, including nonsteroidal anti-inflammatories (ibuprofen, 15 naproxen, diclofenac), a lipid-lowering drug (gemfibrozil), and a β-blocker (propanolol), at 16 clinically and environmentally relevant concentrations, significantly accelerated the 17 conjugation of plasmid-borne antibiotic resistance genes. We looked at the response to these 18 drugs by the bacteria involved in the gene transfer through various analyses that included 19 monitoring reactive oxygen species (ROS) and cell membrane permeability by flow 20 cytometry, cell arrangement, and whole-genome RNA and protein sequencing. We found the 21 enhanced conjugation correlated well with increased production of ROS and cell membrane 22 permeability. We also detected closer cell-to-cell contact and upregulated conjugal genes. 23Additionally, these non-antibiotic pharmaceuticals caused the bacteria to have responses 24 similar to those detected when exposed to antibiotics, such as inducing the SOS response, and 25 enhancing efflux pumps. The findings advance our understanding of the bacterial transfer of 26 antibiotic resistance genes, and importantly emphasize concerns of non-antibiotic human-27 targeted pharmaceuticals for enhancing the spread of antibiotic resistance. 28 29 Key Words: antibiotic resistance; non-antibiotic pharmaceuticals; horizontal gene transfer; 30 conjugation; reactive oxygen species; cell membrane 31 approximately 95% of the drug market 9,10 , the role of non-antibiotic pharmaceuticals in the 51 emergence and spread of antibiotic resistance has received relatively little attention. Recently, 52Maier et al. 11 screened more than 1 000 marketed drugs against 40 representative gut 53 bacterial strains, and reported that more than 200 non-antibiotic pharmaceuticals could 54 exhibit antibiotic-like effects on the bacteria. They found these non-antibiotic 55 pharmaceuticals contributed to the emergence of antibiotic resistance through mutation or 56 increased expression of efflux pump genes 11 . However, they did not investigate if these non-57 4 antibiotic pharmaceuticals can facilitate HGT 11 . If non-antibiotic pharmaceuticals have 58 effects on the spread of antibiotic resistance, there may be features and properties of the non-59 antibiotic pharmaceuticals, or shared mechanisms, that promote the horizontal transfer of 60 ARGs. 61
62In this study, we investigated the potential of different types of commonly consumed non-63 antibiotic human-targeted pharmaceuticals for promoting conjugative transfer of plasmid 64 borne ARGs. We also explored the un...