How do human and bacterial behaviour interact in urban and rural African environments to facilitate the stable acquisition of antimicrobial resistance

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The development of antibacterials has saved millions of lives; however, the massive global usage of these agents has created huge pressure for bacteria to become resistant to these drugs and to cause infections that are difficult or impossible to treat. This, combined with the flow of drugs slowing profoundly, has made antibiotic resistance a threat to health of global importance. New approaches are necessary to reduce illness caused by resistant bacteria. In Low and Middle Income countries (LMIC), there is a huge burden of severe illness caused by bacteria, a critical lack of clinics and hospitals to diagnose and appropriately treat bacterial infections and widespread availability of antibiotics without prescription. This situation is responsible for a huge amount of illness and is increasing the pressure on bacteria to become drug resistant. LMIC settings will be the last to benefit from new types of antibiotics and it is therefore of urgent importance to undertake research addressing antibiotic resistance in LMICs that aims to identify which are the most important causes or drivers of the development of drug resistance. This requires scientists from a variety of fields and with a variety skills, from the laboratory to policy implementation to work together. We will therefore describe both where bacteria live when not causing infections, whether in humans, animals or the environment, and how antimicrobials are used and misused in humans animals and the environment to: 1. Determine ways of using antibiotics make resistance come at a cost rather than as a benefit to bacteria2. Develop ways of using antibiotics across all sectors that both improves access for people that really need them, but protects medicines of last resort in a manner acceptable to governments, communities and doctors to minimise the local emergence of resistance;3. Identify ways in which different parts of government, the health and research sectors can more effectively work together to reduce antibiotic resistance at national and district level, both within and between human and animal health and the environment.