• Alison H Holmes, Luke S P Moore, Arnfinn Sundsfjord, Martin Steinbakk, Sadie Regmi, Abhilasha Karkey, Philippe J Guerin, and Laura J V Piddock.
• National Institute of Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, and Department of Infectious Diseases, Imperial College London, London, UK. Electronic address: alison.holmes@imperial.ac.uk.
• Lancet. 2016 Jan 9; 387 (10014): 176-87.

AbstractTo combat the threat to human health and biosecurity from antimicrobial resistance, an understanding of its mechanisms and drivers is needed. Emergence of antimicrobial resistance in microorganisms is a natural phenomenon, yet antimicrobial resistance selection has been driven by antimicrobial exposure in health care, agriculture, and the environment. Onward transmission is affected by standards of infection control, sanitation, access to clean water, access to assured quality antimicrobials and diagnostics, travel, and migration. Strategies to reduce antimicrobial resistance by removing antimicrobial selective pressure alone rely upon resistance imparting a fitness cost, an effect not always apparent. Minimising resistance should therefore be considered comprehensively, by resistance mechanism, microorganism, antimicrobial drug, host, and context; parallel to new drug discovery, broad ranging, multidisciplinary research is needed across these five levels, interlinked across the health-care, agriculture, and environment sectors. Intelligent, integrated approaches, mindful of potential unintended results, are needed to ensure sustained, worldwide access to effective antimicrobials. Copyright © 2016 Elsevier Ltd. All rights reserved.

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