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In this case study, students will have the opportunity to model the spread of tuberculosis and development of antibiotic resistance in a hypothetical prison environment. After reading a brief handout and viewing a short video, students play a simulation game by first identifying a group of prison inmates represented by index cards. The placement of the cards will influence how drug resistance spreads from one inmate to another. Using a dice roll to mimic random probability of infection and antibiotic misuse, students then track the development of resistance to four specific antibiotics, determined by selection of playing card suit. Opportunity for release or transfer on inmates from one facility to another introduces a further level of complexity, allowing students to study resistance spread. This activity was originally designed for a section of an upper-division biology course about antibiotic resistance, but it would also be appropriate for lower-division undergraduate and high school biology courses discussing antibiotic use.

This case study presents the story of Phil, an undergraduate majoring in biology, whose Russian cousin Dimitri has contracted tuberculosis (TB) from inmates at the prison where he works.  Phil learns that his cousin's failure to complete his antibiotic regimen likely contributed to the evolution of antibiotic-resistant TB in his body.  Phil consults with his friend Stacy, and together they try to understand Dimitri's condition by applying what they are learning in their genetics lab experiment about the role of random mutation in bacterial evolution (including the development of antibiotic resistance) through Luria- Delbrück fluctuation analysis. The same analysis includes calculation of the mutation rate, which Phil realizes is sufficient to cause MRSA and other antibiotic-resistant infections. This case study was originally developed for concurrent use in freshman/sophomore-level genetics, elementary statistics, and precalculus. However, it is also very appropriate for courses in introductory biology, evolutionary biology, and biostatistics. The teaching notes discuss various ways to run the case depending on the mathematics and biology background of students.