Determining the clinical and environmental impact, burden and cost of extensively drug resistant Enterobacteriaceae in China (DETER-XDRE-CHINA) Antimicrobial resistance (AMR) is now deemed to be the biggest global threat facing humanity in the 21C. AMR has taken centre stage as a global health issue yet most non-specialists are unaware the impact AMR will have on global populations and the potential it has of taking humanity back to the "dark ages". Recent announcements from Prime Minister David Cameron, the UK Chief Medical Officer (Professor Sally Davies), and the US president, Barak Obama, is clear evidence that we are loosing one of medicines precious resources. Therefore, in keeping with the general notion of "One World Health", there clearly needs to a better alignment of thinking and closer co-operation between countries synergizing activities, knowledge and skills to better understand and prevent AMR.   Hitherto, most studies around the world studying the impact of AMR have been small, one dimensional and often biased -too focused on AMR bacteria as oppose to studying the whole bacterial population. Very recently, we published an article with our Chinese colleagues heralding the breech of the last antibiotic, colisitin, that is used to treat the very serious infections caused by already resistant bacteria such as Escherichia coli (commonly known as E. coli). The difference with this new discovery is that the mechanism of colistin resistance (named MCR-1) is mobile i.e. can be readily passed around from one bacteria to another - even between distantly related bacteria.   Following on from this discovery and using the same network of Chinese colleagues, hospitals and faming sectors, we intend to use MCR-1 (MCRPE) and carbapenem-resistant Enterobacteriaceae (E. coli and E. coli-like bacteria)(CRE) as markers to understand how it has spread throughout the Chinese animal population (colistin is used in animal feed in China). Firstly, we have a comprehensive sampling platform:  work package (WP) 1, primary and secondary care infections; WP2, normal flora carriage; WP3, chicken farms and slaughter houses; WP4, retail meat; WP5 Environmental sampling. We will analyze at least 100 samples every 3 months to examine seasonal variation and sample from three distinct provinces in China: Shandong, Zhejiang and Guangdong.  Bacteria will be analyzed by basic microbiology techniques and selected to be whole genome sequenced where we can interrogate the bacteria's whole DNA and compare it to other bacteria to see if they have spread from one sector (e.g. flies) to another (e.g. humans). This study will also sequence all the bacteria in the human gut to understand the dynamics of AMR bacterial populations. We will also undertake controlled experiments in chicken farms to monitor the spread on CRE and MRCPE and use mathematical models to understand how AMR spreads in animals. Importantly, the Chinese government is likely to withdraw colistin from animal feed so this study is very timely in measuring that effect i.e. will withdrawing colistin impact on MCRPE rates in the environment, human gut levels and MCRPE causing human infections?    Unlike previous studies, this study is deliberately holistic in its approach so as to understand the dynamics and transmission of AMR across a broad range of environmental and human sectors. This study will let us understand the impact of CRE and MCRPE on human populations and the burden and cost to the Chinese health system. It will also help us understand the impact AMR on the chicken and pig trade by using mathematical models. The impact of this study will have immense consequences for the animal, human and economic sectors in China. Our network is well established, has a proven track record of working together in China and expertise to undertake this exciting and challenging proposal. The Newton Fund builds research and innovation partnerships with developing countries across the world to promote the economic development and social welfare of the partner countries.