Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.

Although the individual and societal consequences of antibiotic resistance spiral upwards, coordinated action has not kept pace on a global scale. The COVID-19 pandemic has highlighted the need for resilient health systems and has resulted in an unprecedented rate of collaboration in scientific, medical, social, and political dimensions. The pandemic has also created a renewed awareness of the importance of infectious diseases and is a substantial entry point for reigniting the momentum towards containing the silent pandemic of antibiotic resistance. In this Viewpoint, we discuss the limitations in the current narrative on antibiotic resistance and how it could be improved, including concerted efforts to close essential data gaps. We discuss the need for capacity building and coordination at the national and global levels to strengthen the understanding of the importance of sustainable access to effective antibiotics for all health systems that could generate tangible links to current processes for global health and development.

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On 21 st September 2016, for only the 4 th time in history, a health topic will take centre stage at a United Nations General Assembly (UNGA) high-level meeting where heads of state are present. A day-long session has been convened to discuss the global threat from the lack of access to antimicrobials and from increasing antimicrobial resistance (AMR). The main focus will be on antibiotic resistance. The involvement of the UN underlines the significance of this threat to public health, food security, global economic growth, and progress towards the 2030 Sustainable Development Goals. 1 Like climate change, AMR depends on effectively managing global public goods and common resources, in this case antimicrobials, whose use drives resistance, and thereby deprives others of their benefits. Such management requires interdependent action in three areas: conservation, access and innovation (figure 1).Akin to the reduction in use of fossil fuels to curb pollution levels that impact on climate, conserving antimicrobials to limit development of resistant microbes, thereby ensuring the continuation of their efficacy for all in need, is a critical strategic response. This must occur in parallel with existing efforts to promote greater, appropriate access to antimicrobials for the millions of people who currently, unfairly face disease without them. Simultaneously, reigniting a dormant antimicrobial research and development (R&D) pipeline to produce new classes of antimicrobials is equally important to renew this crucial man-made resource. The formation of DNDi/WHO's drug accelerator program, the Global Antibiotic Research and Development (GARD) Partnership 2 , as well as new funding streams like Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) 3 and the nascent Global Antimicrobial Resistance Innovation Fund (GAMRIF) 4 are welcome and timely initiatives. However, if we are to ultimately reverse or indeed decelerate our new reality of the post-antibiotic era, then antibiotic conservation is going to need to take centre stage in an overarching strategy for AMR control, while we wait for new products to be developed, and even once we have them. This will be an ever-lasting battle, which will require strong conservation policies to be put in place permanently.Much of the global overuse of antimicrobials occurs in low-and middle-income countries (LMICs), topped by the BRICS nations (Brazil, Russia, India, China and South Africa) driving consumption in both animal and human sectors. 5 In general, an increased demand for animal protein accompanies the transition from low to higher incomes 6 and is currently met by more intensive farming

One of the key drivers of antibiotic resistance (ABR) and drug-resistant bacterial infections is the misuse and overuse of antibiotics in human populations. Infection management and antibiotic decision-making are multifactorial, complex processes influenced by context and involving many actors. Social constructs including race, ethnicity, gender identity and cultural and religious practices as well as migration status and geography influence health. Infection and ABR are also affected by these external drivers in individuals and populations leading to stratified health outcomes. These drivers compromise the capacity and resources of healthcare services already over-burdened with drug-resistant infections. In this review we consider the current evidence and call for a need to broaden the study of culture and power dynamics in healthcare through investigation of relative power, hierarchies and sociocultural constructs including structures, race, caste, social class and gender identity as predictors of health-providing and health-seeking behaviours. This approach will facilitate a more sustainable means of addressing the threat of ABR and identify vulnerable groups ensuring greater inclusivity in decision-making. At an individual level, investigating how social constructs and gender hierarchies impact clinical team interactions, communication and decision-making in infection management and the role of the patient and carers will support better engagement to optimize behaviours. How people of different race, class and gender identity seek, experience and provide healthcare for bacterial infections and use antibiotics needs to be better understood in order to facilitate inclusivity of marginalized groups in decision-making and policy.