Fig. 1

Conceptual framework for understanding how different forms of bystander selection could result in N. gonorrhoeae antimicrobial resistance (AMR) to the antibiotic-x (AB-x). The blue-pathway represents STI bystander selection where the use of antibiotic-x to treat STIs selects for AMR to other STIs that were not the target of the antibiotic. The red-pathway depicts community bystander selection whereby high-levels of consumption of antibiotic-x would select for resistance to ‘x’ in circulating commensal and pathogenic bacteria. This community bystander selection could also act on STIs (striped red arrow), one of the hypotheses tested in this paper. The other hypothesis tested is that the prevalence of AMR to ‘x’ in N. gonorrhoeae will be positively associated with that in Escherichia coli and other pathobionts