Spatial and temporal variation in the community prevalence of antibiotic resistance in Bangladesh: an integrated surveillance study protocol

Introduction: Increasing antibiotic resistance (ABR) in low and middle-income countries such as Bangladesh presents a major health threat. However, assessing the scale of the health risk is problematic in the absence of reliable data on the community prevalence of antibiotic-resistant bacteria. We describe the protocol for a small-scale integrated surveillance programme that aims to quantify the prevalence of colonisation with antibiotic resistant bacteria and concentrations of antibiotic resistant genes from a ‘One Health’ perspective. The holistic assessment of antibiotic resistance in humans, animals and within the environment in urban and rural Bangladesh will generate comprehensive data to inform human health risk. Methods and analysis: The study design focuses on three exposure-relevant sites where there is enhanced potential for transmission of ABR between humans, animals and the environment: i) rural poultry-owning households, ii) commercial poultry farms and iii) urban live-bird markets. The comparison of ABR prevalence in human groups with high and low exposure to farming and poultry will enable us to test the hypothesis that ABR bacteria and genes from the environment and foodproducing animals are potential sources of transmission to humans. Escherichia coli is used as an ABR indicator organism due to its widespread environmental presence and colonisation in both the human and animal gastrointestinal tract. Ethics and dissemination: The study has been approved by the Institutional Review Board of the International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b) and Loughborough University Ethics Committee. Data for the project will be stored on the open access repository of the Centre for Ecology and Hydrology, Natural Environment Research Council. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. STRENGTHS AND LIMITATIONS OF THIS STUDY • We present a study protocol focused on integrated surveillance of ABR in urban and rural Bangladesh using a One Health approach • Assessment of the human, poultry and environmental prevalence of antibiotic resistant E. coli will identify potential hotspots for transmission in Bangladesh • Seasonal and spatial variation on the occurrence of antibiotic resistant bacteria in humans, poultry and the wider environment will be assessed • The two regions included in the study may not be typical of all regions within Bangladesh