Anaerobic　ammonia　oxidation　(anammox),　an　energy-efficient　technology　for　treating　ammonium-rich　wastewater,　faces　the　challenge　of　antibiotic　stress　in　sewage.　This　paper　systematically　evaluated　the　impact　of　antibiotics　on　anammox　by　considering　both　inhibitory　effects　and　recovery　duration.　This　review　focused　on　cellular　responses,　including　extracellular　polymeric　substances　(EPS),　quorum　sensing　(QS),　and　enzymes.　Then,　the　physiological　properties　of　cells　and　the　interactions　between　nitrogen　and　carbon　metabolism　under　antibiotic　stress　were　discussed,　particularly　within　the　anammoxosome.　The　microbial　community　evolution　and　the　development　and　transfer　of　antibiotic　resistance　genes　(ARGs)　were　further　analyzed　to　reveal　the　resistance　mechanisms　of　anammox.　To　address　the　limitations　imposed　by　antibiotics,　the　development　of　bio-augmentation　and　combined　processes　based　on　molecular　biology　techniques,　such　as　bio-electrochemical　systems　(BES),　has　been　suggested.　This　review　offered　new　insights　into　the　mechanisms　of　antibiotic　inhibition　during　the　anammox　process　and　aimed　to　advance　their　engineering　applications.　©　2024　Elsevier　Ltd