EN    EN EN 
 
EN    EN  EUROPEAN COMMISSION 
Brussels, 19.4.2010 
SEC(2010) 399 final/2 
CORRIGENDUM 
Annule et remplace le document SEC(2010) 399 final du 9.4.2010 Pagination ajoutée 
  
COMMISSION STAFF WORKING DOCUMENT 
Accompanying document to the 
 
SECOND REPORT FROM THE CO MMISSION TO THE COUNCIL 
ON THE BASIS OF MEMBER STATES’ REPORTS ON THE IMPLEMENTATION 
OF THE COUNCIL RECOMMENDATION ( 2002/77/EC) ON THE PRUDENT USE 
OF ANTIMICROBIAL AGENTS IN HUMAN MEDICINE 
 
Detailed analysis of countries’ reports on the implementation of the Council 
recommendation (2002/77/EC) on the prudent use of antimicrobial agents in human 
medicine 
{COM(2010) 141} 
 
EN 2   EN  COMMISSION OF THE E UROPEAN COMMUNITIES 
Contents 
 Introduction.................................................................................................................. 3 
 Methods....................................................................................................................... .4  
 Participants.................................................................................................................. .5  
 Results....................................................................................................................... ... 6 
 1. National strategies, action plans and Intersectoral Coordinating Mechanisms 
(ICM).......................................................................................................................... .. 6 
 2. Surveillance systems for antimicrobial resistance ................................................. 12 
 3.Surveillance systems for the prescrip tion and use of antimicrobial agents ............ 15 
 4. Control and preventive measures........................................................................... 16  5. Education and training of health professionals ...................................................... 20  6. Information for the public ...................................................................................... 21  7. National research initiatives................................................................................... 22  8. Use of indicators to assess progress ma de since the first Report on implementation 
of the Council recommendation:................................................................................ 23 
 Discussion and future work........................................................................................ 24 
 
EN 3   EN INTRODUCTION  
In November 2001, the Council adopted the ‘C ouncil Recommendation on the prudent use of 
antimicrobial agents in human medicine’ (2002/77/EC)1 This Recommendation asks Member 
States to put in place specific strategies on the prudent use of antimicrobial agents aiming at 
containing antimicrobial resistance. These strategi es have to comprise measures in relation to 
surveillance of antimicrobial resistance, surv eillance of antimicrobial use, control and 
preventive measures, education and training of health professionals, awareness raising for the 
general public and research. 
Moreover, the Council recommended that each Me mber State should have in place an inter-
sectoral co-coordinating mechanism (ICM) to  ensure that these strategies are fully 
implemented. ICMs should also serve as plat forms to exchange information, and should 
coordinate action with the Commi ssion and other Member States.  
Within two years of its adoption the Commissi on has summarized the main actions taken at 
Member State and European Union level in a report on the implementation of the Recommendation to the C ouncil (COM (2005)684 final)
2. The Report highlighted the areas of 
the Recommendation needing further attention.  
In the Council Conclusions on Antimicrobial  Resistance adopted on 10 June 2008 (2876th 
Employment, social policy, health and consumer affairs Council meeting),3 the Council called 
upon the Member States to ensure that structures and resources to implement the Recommendation on the prude nt use of antimicrobial agents in  human medicine are in place. 
Member States were also encouraged to contin ue implementing specific strategies to contain 
antimicrobial resistance. It called upon the Co mmission to follow up the implementation of 
the Recommendation on the prudent use of an timicrobial agents in human medicine. 
Following this request, the Commission asked the Member States and EEA countries in 
August 2008 to report on the state of implementation.  
                                                
 
1 http://europa.eu.int/comm/health/ph/others/antimicrob_resist/ index_en.htm 
2 http://ec.europa.eu/health/ph_thr eats/com/mic_res/com684_en.pdf. 
3 http://www.consilium.europa.eu/ueDocs/cms_Data/docs/pressData/en/lsa/101035.pdf. 
 
EN 4   EN METHODS  
The template sent to the Member States and EEA Countries for the reports was based on the 
questionnaire used for the first report. However,  it was slightly modified  to take into account 
the recommendations made in the first report and suggestions from experts (project leaders of 
EU projects on antimicrobial resi stance, antimicrobial consump tion, and healthcare associated 
infections, experts from the European Centre  for Disease Prevention and Control (ECDC), 
and from the network of nationa l focal points (NFP) for antimicrobial resistance). This new 
questionnaire placed a strong em phasis on the use of indicators to follow up implementation 
of the action plan. As far as possible, the que stionnaire was developed in a format conducive 
to producing a concise and comparable report to improve data coll ation and analysis.  
The European Commission sent the questionnaire to  the health attachés of the Member States' 
Permanent Representations to the EU for further distribution. The National focal points for antimicrobial resistance (AMR NFP) were also informed of the request and received a copy of 
the questionnaire. Following the first replies fr om the Member States and EEA Countries, the 
Commission collected and analysed the data and provided clarification on the questionnaire 
during the AMR NFP meeting in Paris in November 2008. The quality of returned 
questionnaires was checked by e-mail correspon dence between the Commission and national 
respondents (e.g. missing data, confirming data fo r the report) and the preliminary findings 
were presented during the AMR NFP meeti ng in London on October 2009 for review and 
comments. 
 
EN 5   EN PARTICIPANTS  
The Commission received 28 responses:  
– 27 Member States (MS);  
– Norway  
In the following text ‘Member States’ will be used when the nations referred to are all 
members of the EU, otherwise (when referring to  a number of states including Norway), the 
term ‘Countries’ will be used.  
Only the UK stated that there were regional di fferences and sent back four questionnaires 
(England, Wales, Scotland, and Northern Ireland). In the report, information is given for the 
UK as one country when all four regions gave similar answers; differences between regions 
are reported when relevant.  
 
EN 6   EN RESULTS  
1. N ATIONAL STRATEGIES , ACTION PLANS AND INTERSECTORAL COORDINATING 
MECHANISMS (ICM) 
1a. National strategies and action plans 
Main findings 
Most countries had, or were about to have, a na tional strategy targeted to contain the problem 
of antimicrobial resistance, tr anslated into an action plan: 
– Fifteen (BE, BG, FI, FR, DE, EL, IE, LT, LU , MT, NL, SK, SI, SE and NO) countries and 
England, Northern Ireland, and Scotland had a strategy, translated into an action plan;  
– Eight countries (AT, CZ, DK, IT, PL, ES a nd PT) and Wales reported that strategy was 
under preparation, and four gave indications on the content of the future action plan (AT, 
CZ, PL, ES and RO); 
– By the end of 2008, four Member States rep lied that they did not have a strategy or 
national action plan, nor were they pr eparing one (CY, EE, HU and LV). 
• Content of the action plans  
Measures regarding the surveillance of antimic robial use and prudent use of antimicrobial 
agents were included in all existing action plans.  In addition to these topics, eight countries 
(FI, FR, DE, EL, IE, NL, SI, NO), England and No rthern Ireland had an action plan covering 
all the other topics listed in the Council Re commendation: surveillan ce of antimicrobial 
resistance, detection and control of outbreaks,  prevention policy, educ ation and training of 
health professionals, general pub lic information, and research.  
For the remaining countries, the following topi cs were not addressed in the existing action 
plans were: 
– research, in four countries (BG, LU, MT, SK); 
– detection and control of outbreaks, in three countries (LT, SK, SE); 
– prevention policy, in three countries (BE, LT, MT); 
– general public information, in one country (SK) and in Scotland;  
– surveillance of antimicrobial re sistance in one country (BG); 
– education and training of health pr ofessionals in one country (MT). 
However it should be highlighted that some of the topics not covered by the action plan to 
contain antimicrobial resistance may be addres sed in other sectors and action plans. For 
instance, the detection and cont rol of outbreaks is included in  another public health action 
plan or strategy in Sweden. 
 
EN 7   EN • Indicators  
One question sought to collect the indicators us ed by countries to assess the implementation 
of their strategy.  
Indicators are designed to measure, in a standa rdised way, a phenomenon or a situation and to 
monitor trends (often with a view of reach ing a target). Using indicators requires the 
implementation of a system to collect and analyse data.  
In the context of antimicrobial resistance, exam ples of outcome indicator s include the value of 
antimicrobial consumption, appropriate prescripti on rates and antimicrobial resistance figures. 
Process indicators measure compliance with ag reed activities, such as surveillance and 
standard operating procedures  (hand hygiene for instance). St ructure indicators refer to a 
resource, such as staff, infrastructure or committees (see the definitions laid down in the Council Recommendation on patient safety, in cluding the prevention and control of 
healthcare associated infections
: http://ec.europa.eu/health/ph_systems/docs/patient_rec2009_en.pdf  
Twelve countries (AT, BE, FI, FR, DE, IE, IT , LT, LU, MT, NL, RO) and Scotland reported 
that they used indicators to monitor the implementation of the action plan. Of these, three (AT, IT, RO) had a strategy under preparati on but had already defined indicators.  
These indicators were:  a) Outcome indicators
  
– antimicrobial resistance indicators were used in ten countries and Scotland 
• Five Member States gave a list of specific in dicators, one with quant itative objectives for a 
decrease (France, for methicillin-resistant Staphylococcus aureus  and for resistant 
Streptococcus pneumoniae ). 
– antimicrobial use or prescription indicators were used in nine countries and Scotland 
• Antimicrobial use in the community was ta rgeted by two countries (France gave an 
expected result of a 25  % decrease). Antimicrobial use in  hospitals was mentioned twice; 
• LT used qualitative indicators, with quantified objectives of  improvement: to reduce self-
medication to 10  %, antibiotic prescription for upper respiratory tract infections to 30  %, 
antibiotics prophylaxis for more than 3 days to 15  %; 
– Healthcare associated infection indicators were mentioned by five countries and Scotland. 
• The monitoring of surgical site infections was mentioned by Finland and the monitoring of 
Clostridium difficile -associated disease by Scotland. Ireland monitored methicillin-resistant 
Staphylococcus aureus  (MRSA) bloodstream infections  and MRSA in ICU. France 
specified objectives to decrease MRSA in hospitals. 
b) Structure and process indicators  at local or national level we re reported by five countries:  
• IE: volume of alcohol gel used – indicat or for prevention of transmission;  
 
EN 8   EN • BE, IT, LT, RO: implementation of antibiotic  management teams, education tools, 
guidelines, evaluation of compliance with guidelines, implementation of surveillance, 
expert groups, reference la boratories, control of drug sales, updated information on 
websites, number of research projects and continuing medical education activities.4 
Comments 
• Twelve countries and Wales did not ye t have an action plan to contain 
antimicrobial resistance. Eight of thes e countries and Wales reported having a 
strategy under preparation.  
• With only eight countries ha ving action plans covering all the topics listed in the 
Recommendation, the content of the action plans varied between countries. Based 
on the responses received, it appeared that actions that were not included in the 
specific action plan to contain antimicrobial  resistance might be addressed in other 
national strategies. Therefore,  it is important to coordi nate the activities developed 
and implemented in different sectors and strategies on the issues listed in the Recommendation. 
• As countries move from the development of strategies to im plementation through 
action plans, the focus should shift to the development of specific indicators a) to 
assess implementation of the strategy and b) to assess its impact help target policies at national and regional level. Tw elve countries and Scotland indicated 
that they have several types of indicators in place.  
Progress made since the first report 
• In 2008, more countries had an action plan  in place than in 2003. The situation had 
improved in eight Member States (DE,  EL, IE, LT, LU, SK, SI, and SE).  
• The use of indicators to follow up the implemen tation of strategies was not addressed in 
the first report. 
1b. Intersectoral coordinating mechanisms (ICM) 
Main findings 
Implementation of ICMs
 
Nineteen (AT, BE, CY, FR, FI, DE, EL, HU, IE, LU, MT, NL, PL, PT, SK, SI, UK and NO) 
out of 28 countries have an ICM in place fo r the coordinated implementation of the above 
mentioned strategies (overall 22 ICMs in pl ace taking into account the ICMs in England, 
Wales, Scotland and Northern Ireland). 
By the end of 2008, seven countries were in  the process of developing an ICM with 
completion planned for between the end of 200 8 and 2010. Latvia and Estonia did not report 
any plans to establish an IC M to implement the strategy. 
                                                 
4 Due to differences in the interpretation of the qu estion, it is possible that countries with outcome 
indicators also had process or structural indicators but did not mention them. 
 
EN 9   EN 1112
002
1222
17
012345678
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 
Figure 1: Year of establishment of an intersectoral mechanism. 
Out of the 19 countries with an ICM, 14 countri es clearly defined the status of the ICM:  
– by governmental decision in eight (CY,  DE, LU, PL, PT, SI, UK, and NO); 
– by regulation in six (BE, FR, EL, MT, NL, and SE). 
Eight countries (BE, FR, EL, LU, MT, SI, SE, and PT) and England provided a copy of the 
text defining the legal status. 
In addition, an ICM was created by a decision ta ken by the Chief Medical Officer in Hungary 
and was considered as an official working grou p in AT and IE. IE reported that, despite the 
lack of governmental text, the Ministry of Hea lth strongly supported th e work of the ICM.  
• ICM Working parties (Wp) were created in 12  out of 19 countries. Working parties were 
more frequent in countries where an ICM wa s established earlier (the median year of 
implementation of ICM was 2002 in countries with a Wp and 2005 in countries with no 
Wp).  
• The composition of ICMs was truly intersectoral  in most countries (see figure 2). The 
median number of members involved in th e plenary of the ICM was 17, ranging from six 
in Greece to 41 in France. 
– In all countries except LU, a representative from the animal health sector participated in 
the plenary of the ICM or in its Working parties (DE, EL). 
– Some institutions or organisations were less likely to participate in the ICM: 
• The Ministry of Employment was never repr esented in the plenary of the ICM nor 
in the ICM Wp (however the Ministry of  Employment is not always responsible 
for lifelong education, as mentioned by some respondents), 
• The Ministry of Education was involved in  the plenary group in  DE only, and in 
the ICM Wp in France, Year of 
establishment Number of ICM 
established 
 
EN 10   EN • The Ministry of Environment was pres ent in plenary in DE and Scotland, 
• The Ministry of Research only in DE , PL, Northern Ireland and Wales, 
• The pharmaceutical industry was presen t in two plenary groups and in two 
additional countries through the ICM Wp, 
• Nursing homes and representatives of the elderly and long-term care were 
involved in six countries and Wa les (only in ICM Wp in DE), 
• Nurses were represented in eight c ountries (in plenar y group or ICM Wp) 
including the UK (Intensive Care (IC) — nurses in Luxembourg). 
Patient groups were involved in the work of the ICM in FR (plenary), in IE, England and 
Northern Ireland (plenary and Wp), and in the ICM Wps in AT and DE.  
The involvement of health insurance representa tives also varied. They were involved in the 
plenary of the ICM in BE, FI, FR , HU, LU, PL, SK and in the wo rk of the WP in AT, DE, and 
EL. 
0 2 4 6 8 10 12 14 16 18 20Ministry of HealthMedicines agencyHealth insuranceInstitute of epidemiology in charge of antimicrobial resistanceReference laboratoriesHospital sectorAmbulatory sector/primary careNursing homes/elderly, long term carePharmacistNursesPrevention sectorMinistry of EducationAnimal healthFood chain safetyMinistry of AgricultureMinistry of EnvironmentMinistry of ResearchProfessional societyPatients groupsPharmaceutical industry
Working Parties
Plenary
Figure 2: Composition of the Plenary ICM (N=22) and ICM working parties (N= 15) 
• The median number of annual meetings was 3 in 16 countries, varying from one 
to 24 in Malta. Generally, in countries where the ICM plenary met only once a year, working parties were in place (SK, DE). 
• Minutes of the ICM were available in 18 out of 19 countries or in 21 out of 22 
existing ICMs. Half of the ICMs (1 1/22) issued an annual report.  
• A written mandate existed for 14 out of 22 ICMs (no mandate in CY, FI, HU, SI, 
SE, or Wales, England, Northern Ireland).  
 
EN 11   EN • The mandate covered all topics listed in the Council Recommendation in IE and 
NO.  
• The topics not addressed in the other mandates included:  
• the detection of outbreaks in 8 /14; 
• prevention policy in 6/14; 
• the development of guidelines in 4/14;  
• research in 7/14. 
It should be noted, however, that these activities could be part of  the remits of other groups or 
committees — for instance a group in charge of h ealthcare-associated infections or a medicine 
agency. In some countries, the ICM also had ad ditional tasks. In Scotland, the ICM was also 
responsible for infection management guidance. SE indicated that its ICM had no mandate to 
coordinate action as this was the rem it of the national board of health. 
• ICMs had the mandate to cooperate with MS and the EC in 11 countries and 
Scotland and Wales. As indicated earlier, cooperation may also be part of the 
remits of other structures (e.g. Mini stry of Health, Board of Health). 
• Nine countries and Scotland reported that the ICM managed a budget for its 
activities. In Belgium, annual and occasional budget came from health insurance 
while in all other countries , the government allocated budge t (on an annual and/or 
occasional basis). In two countries, budget was only occasional. PL indicated that 
occasional funding might come from the pharmaceutical industry. France and 
Ireland reported that the Ministry of Hea lth had a budget and allocated it directly 
to relevant projects or institutions. 
Comments 
• All countries but two had an ICM in place or under preparation. The status of the ICM was 
well defined in most countries (14/19 with ICM), and written mandate exists for 14/22 
ICM meaning that the ICM should have  clear responsibil ities and power. 
• All but one existing ICMs were truly intersector al and had links with veterinary / animal 
health sectors. Nurses and re presentatives of institutions for long-term care, such as 
nursing homes/homes for elderly, were involved in less than half of  the ICMs, even though 
these institutions are important in containing th e development and transf er of antimicrobial 
resistance. 
• An annual report was issued by only 11/22 ICMs,  although it may be useful to provide 
health authorities and the public with such a document (with indicators) to communicate 
the achievements made and what remains to be done. 
• ICMs did not always have a defined budget for their operations, but entities such as the 
Ministry of Health or National Institute fo r Epidemiology/Public Health may manage the 
budget reserved for operations of the ICM.  
 
EN 12   EN Progress made since the first report  
• Major improvements have been made rega rding the status of ICMs (in 2003, eight 
countries stated that ICM had been established by ministerial order or legislation and in 
most countries, the ICM was part of the government or department of health). 
• Regarding the composition of ICMs, true collab oration with the animal health sector has 
been established. In 2008 the animal health wa s represented in all but one ICM. On the 
other hand, the involvement of patient gr oups had not improved much (only in five 
countries in 2008, up from three in 2003). 
• Some ICMs had been established fairly recen tly or were still under preparation, even in 
countries where an ICM was reported to exist in 2003. This may mean that former structure had evolved or that a new structur e was set up to better fulfil the recommendation 
(for instance, countries where the ICM was a part of the department of health or an 
advisory body). 
2. S
URVEILLANCE SYSTEMS FOR ANTIMICROBIAL RESISTANCE  
Main findings 
• All countries had implemented a surveillance system for antim icrobial resistance. All but 
SK participated in the European Antimicrobial Resistance Surveillance System (EARSS). 
All but CY, EL, and LU had an additional national system to monitor antimicrobial 
resistance. This additional national syst em collected information on antimicrobial 
resistance in the community (AT, CZ), in hospitals (EE, IT, MT, SI) or in both (18 
countries: BE, BG, DK, FI, FR, DE, HU, IE, LV, LT, NL, PL, RO, SK, ES, SE, UK and 
NO).  
• At least 80% of hospital laboratories were involved in the surveillance system in 11 
countries, and in Scotland and Wales.  
• At least 80% of commun ity laboratories were involved in the surveillance system in six 
countries and in Scotland, Wa les, and Northern Ireland.  
• Micro-organisms covered by the su rveillance system (Figure 3) 
• Most surveillance systems covered S. pneumoniae,  followed by methicillin-
resistant Staphylococcus aureus  (MRSA); Enterobacteriacae  producing extended-
spectrum betalactamases (ESBL); Enterococci  resistant to vancomycin (VRE); 
and Acinetobacter baumannii resistant to carbapenems . 
• Clostridium difficile was surveyed in 12 countries (BE, DK, EE, FI, FR, DE, IE, 
MT, NL, RO, ES and UK) of which eight had described outbreaks due to a new, 
highly virulent strain of C. difficile PCR ribotype 027.5 
                                                 
5 Kuijper EJ and al. update of Clostridium difficile infection due to PCR ribotype 027 in Europe, 2008. 
Euro Surveill. 2008; 13(31):pii=18942. Available online: 
http://www.eurosurveillance.org/Vi ewArticle.aspx?ArticleId=18942  
 
EN 13   EN • Fifteen countries reported that they al so surveyed resistance in other micro-
organisms. The most common types of bacteria specified were Haemophilus 
influenzae, Neisseria meningitidis and pathogens causing food-borne infections. 
0510152025
Staphylococcus
aureus resistant to
meticillin (MRSA)
ESBL-producing
Enterobacteriaceae
S. pneumoniae
resistant/intermediate
to penicillins
Enterococci resistant
to vancomycin
Carbapenem-
resistant
Pseudomonas
aeruginosa
Carbapenem-
resistant
Acinetobacter
baumannii
Clostridium difficile
OthersHospitals
Community
 
Figure 3: Micro-organisms covered by the su rveillance of AMR in hospitals and in the 
community (27 respondents (24 countries) with surveillance system) 
• In most countries, the structure of the anti microbial resistance su rveillance system was 
governmental and continuously implemented (1 8 out of 23). Surveilla nce was carried out 
through research projects only in AT, IT, PT and SI. In BG, CZ and EL, surveillance was 
carried out by independent scie ntific societies. In RO, su rveillance was organised through 
research projects and by an i ndependent scientific society. 
• An external quality assurance (EQA) system was in place in all countries but Slovenia 
(missing data). Three countries  mentioned only a national system for EQA, and all 
countries but BG, EE and SK (that did not pa rticipate in EARSS) mentioned the National 
External Quality Assessment Service (NE QAS), which is provided by the UK to the 
laboratories participating in the EARSS. NEQAS was the only EQA in 12 countries. 
• Health authorities had access to antimicrobial resistance surveillance data in all but two 
countries (LT, PT). In these two countries, th e stated obstacles were  legal status, budget 
shortage, and poor information technology suppor t. In other countries (BE, CZ, DK, FR, 
LU, NL and SI) and in England and Northern Ireland, data were available but respondents 
listed obstacles which prevent rapid and eas y access to more detailed data, such as 
ownership, poor information technology support, legal status and budget.  
• National data on antimicrobial resistance were publicly available in all but six countries. In 
three of these six countries, data were available for the ICM (LU, MT and SI).  
 
EN 14   EN • More detailed data were av ailable in 14 countries: 
• Regional and, in some cases, sub-regional data in 12 countries: AT, BE, FI, FR, 
IT, NL (access for ICM only), RO, SK, ES, SE, UK and NO.  
• Hospital data on antimicrobial resistance were publicly available in eleven: AT, 
BE, CY, EE, FI, IE, IT, PL, RO, SK, NO and Wales. In EL, MT, NL, and 
Scotland hospital data could be accessed by ICM.  
• Overall, more than half of the countries reported that  hospital data were available. Most of 
the countries that indicated that hospital data  could not be accessed also mentioned that 
health authorities were facing obstacles re garding access to antimicrobial resistance 
surveillance data (see above fo r list of obstacles in CZ, FR, LT, LU, NL, PT, SI and the 
UK). 
• Most countries had an operational link betw een antimicrobial resistance surveillance 
services and those in charge of disease control/infection control (22/28) and outbreak 
investigation (21/27). Half of the responde nts had implemented operational links with 
veterinary surveillance for antimicrobial re sistance (16/28). In 2008, only a few countries 
had established a link with environmental surveillance.  
• National reports on antimicrobial  resistance were issued in seventeen countries with the 
last publication being rel eased between 2007 and 2008 in most countries where 
information was available. 
Comments 
• In ten countries there were still no sustainabl e national systems for an timicrobial resistance 
surveillance, supported by the government in addition to EARSS. As regards external 
quality control of laboratories, many countries  appeared to rely on the system provided to 
laboratories participating in the EARSS proj ect without having a national EQA system in 
place (12 countries). 
• Data on antimicrobial resistance were not yet av ailable at regional or local levels, including 
hospitals, although these levels are us eful to better steer policies. 
• Not all countries issued national reports on an timicrobial resistance, although they may be 
helpful for policy-makers and public information. 
• Links with veterinary surveillance systems for antimicrobial resistance and with 
environment sector were not well established in all countries.  
Progress made since the first report  
As regards the structure of the surveillance sy stem, national reports, and operational links 
with antimicrobial resistance surveillance in an imals, minimal progress appears to have been 
made between these two reports. In 2008, governme nt support for surveillance existed in 18/ 
28 countries (19/28 in 2003), 17 countries had i ssued national reports (16 in 2003), 16 had 
established links with surveilla nce in animals (13 in 2003). There have been improvements in 
access to surveillance data, as in 2003, 14 countries reported obstacles to access (in 2008 10 countries, of which only two reporte d no access to surveillance data)  
 
EN 15   EN 3. S URVEILLANCE SYSTEMS FOR THE PRESCRIPTION AND USE OF ANTIMICROBIAL 
AGENTS  
Main findings 
• All countries participated in the European Surveillance of Antim icrobial Consumption 
project (ESAC). In addition, another system fo r surveying antimicrobial use was in place 
in more than half of the countries (BE, BG , DK, FI, FR, DE, IE, LT, LU, NL, PL, RO, SI, 
SE, SK, ES, UK and NO). 
• Seventeen countries issued national annual repo rts on antimicrobial use; the date of last 
publication was 2008 in most countries  where information was provided. 
• Hospitals collected antimicrobial consump tion data in almost all countries (24, no 
collection in BG, HU, LT, no data for PT).  Greece reported that it had not implemented 
regular data collection. In 7 countries and Nort hern Ireland, health authorities do not have 
access to individual hospital da ta. The obstacles mentioned were weak legal status 
(mentioned in 4 countries), private owners hip (in 4 countries) and poor information 
technology support (in 1 country). Other limits me ntioned included the poor quality of data 
(expressed in cost (CZ), not representative a nd not in a standardised format (AT)) and the 
fact that hospitals are the ow ners of the data (NL). In addition, France mentioned that the 
weak legal status and insufficient inform ation technology support prevented health 
authorities from having detailed and comprehensive data. 
• In 20 countries, prescription data  in the community were availa ble for prescribers (data not 
available in BG, CZ, EE, EL, HU, IT, MT, mi ssing data for PT). Access was possible at 
national level in general. Indi vidual data were available in 13 countries (BE, DK, FR, DE, 
IE, PL, RO, SK, SI, ES, SE, UK, and NO). Data are used for continuing education in eight 
countries and in Scotland. 
• Health authorities in 12 countries could access these individual data (BE, CY, DK, FR, IE, 
LT, NL, PL, RO, ES, SE and UK). Obstacles to access listed by five out  of seven countries 
where data could not be accessed were lega l status, ownership, information technology, 
resources, and concern over data security. Ev en countries where data could be accessed 
reported difficulties. Norway specified that he alth authorities coul d not access individual 
but only anonymous data. In addition, France stated that inform ation technology support 
did not allow access to individua l data by health authorities. 
• Data on antimicrobial consumption could be  broken down by indica tion in 13 countries 
(including the UK, except Scotland), main ly for ambulatory care (12 including the UK, 
except Scotland) and less often for hospitals (s even and Wales). In half of the cases, this 
was carried out by research projects (five c ountries and Wales) and on a continuous basis 
in only seven countries, Engl and and Northern Ireland.  
• Hospital data on antimicrobial consumption coul d be broken down to hos pital level in most 
countries: 18 and in England, Wales, and No rthern Ireland. They could be accessed at 
speciality or ward level in 12 countries and in  Wales. This surveilla nce in hospitals was 
carried out by research project s in seven countries, was continuous in 9, and England, 
Wales, and Northern Ireland, and mixed in two (DE, ES). 
 
EN 16   EN • Resistance data could be linked to consumption data in 14 countries and in Wales, half of 
which did this through research projects (seven). It was cont inuous in seven countries and 
in Wales (along with research projects in f our countries and Wales). A regional level for 
this analysis was mentio ned by AT, FI and Wales. 
• Prescription practice indicators existed in 15 c ountries and Wales, mainly for hospitals (12 
and Wales). Measures to improve prescription pr actices were carried out  in most countries 
(19/28) and they addressed both community a nd hospital practices, except in NL and MT 
where only hospital practices were concerned. 
• Action regarding AMR and veterinary issues: 
• Fourteen countries plus England, Wales and Scotland also had surveillance in 
place for antimicrobial consumption in animals.  
• Actions to improve the prescription practices  of veterinarians were carried out in 
16 countries. 
Comments 
• Information on antimicrobial consumption is collated in a nationa l report in 17/27 
countries. To provide appropriate feedback for prescribers and hospitals  more detailed data 
would be useful. Less than half of the countries  were able, on a conti nuous basis, to break 
down data to individual level, to hospital ward, or by indication. 
• Countries reported that the co llection of comprehensive data  on antimicrobial consumption 
and prescription practices was hindered by the weak legal status of data (including the 
issue of ownership) and problems w ith information technology systems. 
• Indicators to monitor prescrib ing practices were still underd eveloped in several countries. 
Progress made since the first report 
The following improvements can be noted: 
• Obstacles to obtain antimicrobial  consumption data, in particul ar financial ones, have been 
largely overcome ;  
• Improved collection of broken-down data by in dication, hospital wa rd and speciality; 
• Improved links of antimicrobial resistance data  to antibiotic consum ption data: no country 
had a sustainable system in place for this purpose in 2003; 
• The use of indicators to monitor prescr ibing practices doubled from 2003 to 2008.  
4. C ONTROL AND PREVENTIVE MEASURES  
Main findings 
• In 2008, 11 countries (FI, FR, DE, HU, IE, LU , SK, SI, SE and NO) indicated that no 
antibiotics were sold without prescription. In  addition, seven countries (AT, BE, CZ, EE, 
 
EN 17   EN IT, NL and UK) reported that such sa les might contribute to less than 1  % of total sales of 
antibiotics. This gave 18 count ries where sales without prescr iption were not considered as 
a significant source of misuse of antibiotics. The percentage  of antibiotics sold without 
prescription was assumed to be between 1 an d 5 percent in five c ountries (BG, CY, LV, 
LT, PL), between 5 and 10 percent in three c ountries (MT, RO and ES) and more than 15 
percent in Greece (data missing for PT).  
• Among countries where sales were assumed to differ from zero, all but Estonia, Greece, 
Latvia, Poland and the Netherlands  indicated that they were ta king measures to enforce the 
law on prescription-only use for antibiotics. 
• Topical antibiotic marketing aut horisation had been assessed in  five countries. Regarding 
regulations on advertis ing, only Wales mentioned a nationa l regulation that goes further 
than European rules. 
Guidelines on the appropri ate use of antimicrobials6 
• All but four countries (CY, EE, LV and ES) and Wales had national guidelines on the 
appropriate use of antimicrobials. Spain resp onded that guidelines had been issued by 
several medical societies (e.g. infectious disease specialis ts, paediatricians, general 
practitioners). Four countries and Northern Ireland had guid elines only in the community 
and two other countries only in hospitals. 
• The most common guidelines were for co mmunity-acquired pneumonia, which were 
issued in 20 countries, England and Scotland. Guid elines for otitis media, acute bronchitis, 
tonsillopharyngitis, acute exacerba tion of chronic bronchitis, a nd urinary tract infections 
were issued in more than half of the countries. Seven countries and Scotland had 
guidelines on each type of infection listed. So me countries also reported guidelines in 
ambulatory care addressing skin infections and sexually transmitted infections. 
• In hospitals, guidelines were less frequent and existed in half of the countries. Ten 
countries and Scotland have a comprehensiv e set of guidelines — for each type of 
infection listed. Other hospi tals guidelines were for th e treatment of endocarditis, 
meningitis and, in some countries, a variety of infections. 
• Countries reported that it was common pract ice to have guidelines endorsed by national 
health authorities.  
• It was still rare to assess whether prescribi ng doctors comply with national guidelines, or 
the impact of guidance on prescription practice s. However, there were some assessments 
regarding the impact of guidelines in the treatment of community-acquired pneumonia. 
These kinds of evaluations were  more frequent in hospitals. 
                                                 
6 Only guidelines made or validated by scientific panels or medical societies were to be reported. 
Guidelines sponsored by the pharmaceutical industr y would not be considered. According to this, 
Belgium emphasised in its answer the fact that only guidelines developed by the ICM (not sponsored by 
the pharmaceutical industry) were taken into acco unt and not additional guidelines developed by 
different Belgian scientific organisations, often sponsored by the pharmaceutical industry. 
 
EN 18   EN 0510152025
Otitis media
Acute sinusitis
Acute exacerbation
of chronic sinusitis
Tonsillopharyngitis
Bronchiolitis/children 
Acute bronchitis
Community acquired
pneumonia
Acute exacerbation
of chronic bronchitis
Urinary tract
infection
Gastrointestinal
tract infection
Surgical prophylaxis
Urinary tract
infection
Surgical site
infection
Blood stream
infection
Hospital acquired
pneumoniaavailable
endorsed
compliance assessed
impact assessed
Ambulatory care Hospital care
Figure 4: Number and status of guidelin es (N=25 incl. 4 re sponses for the UK)  
Guidelines for hand hygiene 
• All responding countries (27) except two had guidelines for hand hygiene. The compliance 
of healthcare workers with th ese guidelines had been assessed in more than half of the 
countries. 
National programme for hospital hygiene and infection control  
A national programme for hospital hygiene and in fection control was in place in 22 out of 27 
responding countries. CZ, EE, HU, MT and PL lack a national programme.  
The impact of the required hygiene and infectio n control measures on the incidence of some 
defined infections had been assessed in hospitals  in 13 countries and in  Scotland and Wales. 
Among these countries, MT did not have an inf ection control programme , but guidelines for 
hand hygiene. In nursing homes,7 this kind of evaluation is rare and has only been performed 
in BE, DK, IE, SE and Scotland. 
National or regional networks to surv ey healthcare associated infections 
• All but four countries had regional or national networks to survey healthcare associated 
infections (no network in CY , EE, LV and PL; no data for PT). Networks were mainly 
national, with some additional regional netw orks. In DK, the only network was regional. 
Most of the existing networks monitored bl oodstream infections. Nine countries had a 
network to survey surgical site infections ( SSI), infections in intensive care units (ICU), 
bloodstream infections, and hospital wide survei llance. In addition, three countries had a 
network to monitor SSI, infect ions in ICU, and bloodstream infections. This could be 
                                                 
7 Despite a definition in the questionnaire, character istics of nursing homes may vary among countries. 
 
EN 19   EN interpreted as 12 countries having relatively co mprehensive system for the surveillance of 
healthcare-associated infections. 
Infection control committee and infection control nurses 
• In most countries, it was mandatory to have an infection control committee in hospitals (20 
countries and Wales, Scotland, and Northern Ir eland). However, this requirement was valid 
for nursing homes in only three countries (IE, RO, and NO). 
• Where there was an infection control committee,  management of the institution participates 
in the committee, except in EE, LU, NO (hos pitals and nursing homes), and in RO for 
nursing homes (no data for Spain). 
• More than half of the re spondent countries (15 countries and Wales) had legal 
requirements or national recommendations fo r the numbers of inf ection control nurses 
needed in hospitals. These requirements or  recommendations did not exist for nursing 
homes in any country. 
National guidelines for the prevention and control of healthcare associated infections 
• Guidelines for the prevention and control of he althcare associated infections were available 
in all but three responding c ountries (EE, SK and ES – no data for PT). MRSA was the 
topic most often addressed in the guidelines . Guidelines on MDR bacteria in general 
always came in addition to specific guideline s on MRSA and frequently in addition to 
guidelines on gram-negatives. 
• Guidelines were half as frequent in nursi ng homes as in hospitals. The most frequent 
guidelines in nursing homes are for healthcare-a ssociated infections in general and MRSA. 
Prevention and control of C. difficile  infections in nursing ho mes was addressed in six 
countries. 
0510152025
HCAI (in
general)MDR bacteria
(in general) MRSA Clostridium
difficileVRE MDR gram
negatives MDR-TB and
XDR-TBHospitals Nursing homes
 
 
EN 20   EN Figure 5: Number of guidelines for the preven tion and control of healthcare-associated 
infections (HCAI) and microorganisms (N= 27 responses, 4 responses for UK) 
Streptococcus pneumoniae  
Most countries issued recomm endations on vaccination against Streptococcus pneumoniae  
infections, addressing both children and the el derly in most cases. The trends of invasive 
pneumococcal infections were monitored in most countries. 
Comments 
• In nine countries, sales of systemic antimic robials without prescrip tion were assumed to 
represent a potential source of misuse. Whatev er their situation, most countries were 
implementing measures to better enforce Eur opean regulations on pr escription-only use of 
systemic antimicrobials. 
• National scientific guidelines on the appropria te use of antimicrobials are available and 
endorsed by public health authorities in 16 countries and in the UK, except Wales. 
Assessments of compliance with guidelines and evaluation of their impact are still rare. 
• 15 countries, Scotland and Wales assessed th e impact of guidelines for hand hygiene 
and/or of hygiene measures.  
• 13 countries and Wales had requirements for infection control (IC) committee committees 
and the required numbers of IC nurses in hospitals (19, Northern  Ireland, Scotland and 
Wales have requirements for IC committees and/or the required  numbers of IC nurses in 
hospitals); however, requirements regarding infection control comm ittees in nursing homes 
exist in only three countries. 
• Most countries have developed guidelines  for hand hygiene, a national programme for 
infection control, networks to survey health care-associated infections and measures to 
prevent and assess invasive infections due to S. pneumoniae . 
Progress made since the first report  
• Most countries which in 2003 reported that antimicrobials sold without 
prescription were believed to be a relevant source of inappropriate use still faced 
this problem in 2008 (BG, CY, EL, LT, MT and ES).  
• More countries reported that they asse ssed guidelines for appropriate use of 
antimicrobials (12 countries and Scotland versus 6 in 2003). 
• National programmes and requirements re garding infection control committees 
and infection control nurses in hosp ital existed for most countries in 2003. 
However, in 2008 two countri es, (CZ and HU) lacked a national programme and 
requirements for hospital hygiene. Malt a and Poland reported having a national 
programme for infection control/hos pital hygiene in 2003 and not in 2008. 
5. E DUCATION AND TRAINING OF HEALTH PROFESSIONALS  
Main findings 
 
EN 21   EN • In all but two countries, the curriculum of healthcare prof essionals includes  matters related 
to antimicrobial resistance such as hygiene and infection control,  appropriate use of 
antimicrobials, vaccination programmes and antimicrobial resistance. In Belgium, 
requirements only cover medicine and pharm acy. In EE and EL, requirements only cover 
medicine. 
• Twelve countries had no requirement in 2006/2007 for non-sponsored lifelong education. 
Where they existed, requirements concerned hy giene and infection cont rol more often than 
any other issues. In NO, continuing medical education was mandatory for specialists only. 
PL indicated that they were working on a propos al to include infection control topics in 
post-graduate training in medici ne, dentistry and nursing. ES reported that the Ministry of 
Health had provided funding to autonomous regions for trai ning on rational use of drugs, 
including antibiotics. 
• More than half of the count ries (16/28,) implemented awar eness raising campaigns on 
antimicrobial resistance for h ealthcare professionals in 2006 /2007. In most countries, the 
campaigns targeted medical doctors (in all c ountries but DK, NL and Wales), pharmacists 
(10 countries and England, Wales, and Northern  Ireland), nurses (seven countries, England 
and Northern Ireland) and veterinarians (six  countries, Scotland and Wales). Campaigns 
targeting dentists were rare (BG, IE, ES and Scotland). DK and NL conducted campaigns 
targeting veterinarians only. 
Comments 
• Almost all countries had established undergradu ate training for healthcare professionals on 
issues related to antimicrobial resistance. 
• Non-sponsored continuing education was require d in 15 countries but did not concern all 
healthcare professions nor did it cover the prob lem of inappropriate use of antimicrobials 
in every country. 
Progress made since the first report  
• In 2003, almost all countries reported that init ial education covered the appropriate use of 
antimicrobials and that non-sponsored lifelong education was available for prescribers. 
Due to differences in the questions between 2003 and 2008, direct comparisons may not be relevant. 
6. I
NFORMATION FOR THE PUBLIC  
Main findings 
• Reports on the public’s knowledge and/or perception of antimicrobial resistance, 
inappropriate use of antimicr obials, vaccination programmes, and their role in preventing 
infection or the importance of hygiene were issued in 2006/2007 in 13 countries (including 
the UK, except Wales,). 
• During the last two years, 17 countries im plemented awareness raising campaigns on 
antimicrobial resistance, inappropriate use of antimicrobials, vaccination programmes and 
their role in preventing infections, and the impo rtance of hygiene. They were targeted to 
 
EN 22   EN the general public rather than to a specific audience, such as patie nt associations or 
patients. Only Sweden reported that it had im plemented campaigns specifically targeting 
patient associations (vaccinations) a nd patients (vaccinations and hygiene).  
• Topics addressed in public campaigns we re vaccination programme s (regardless of the 
target), followed by the importance of hygiene a nd inappropriate use of antimicrobials. The 
problem of antimicrobial resistance, certainly  more complex, was addressed less often.  
• Thirteen countries had launched campaigns  for health professionals and for non-
professionals. 
Comments 
Reports on public awareness were available in less than half  of the countries. Seventeen 
countries had implemented awareness raising campaigns on the problem of antimicrobial 
resistance and the appropriate use of antimic robials. Most campaigns included messages on 
hygiene and vaccination.  
Progress made since the first report  
• While 12 countries reported having implem ented awareness raising campaigns in 2003, 
they were seventeen countries in 2008. As in 2003 the most common topic addressed was 
vaccinations in 2008.  
7. N ATIONAL RESEARCH INITIATIVES  
Main findings 
• Six countries and Northern Ireland reported having a national plan for research into 
antimicrobial resistance. The ICM was involved in  developing this plan in three countries 
and Northern Ireland. 
• Several countries stated that research into antimicrobial resistance covered topics listed in 
the Recommendation, and was conducted under the auspices of Ministry of Health (NO), 
Ministry of Research (DE), re ference laboratories (NO, FR),  Institute for Epidemiology or 
other Public Health Institute (FR, DK, FI),  depending on the country. Some countries gave 
a list of projects or topics covered.  
Comments 
• In addition to the list of European funded projects, a mechanism could be implemented to 
collect and disseminate information on nati onal projects to fulfil the recommendation 
regarding information and comm unication on national research initiatives in the field of 
antimicrobial resistance. 
Progress made since the first report:  
• As replies to the question rega rding research varied greatly, comparisons are not relevant. 
 
EN 23   EN 8. U SE OF INDICATORS TO ASSESS PROGRESS MADE SINCE THE FIRST REPORT ON 
IMPLEMENTATION OF THE COUNCIL RECOMMENDATION : 
The aim of this question was to assess the way countries use indicators to monitor their 
situation regarding prevention a nd control of antimicrobial resi stance. Countries were asked 
to report figures for some indicators at the time of the first report and at the time they 
answered this survey. 
Twenty-two countries and Wales provided inform ation on indicators for the current situation 
at the time of the survey, and nineteen and Wales (no information provided by EE, EL, IT, 
PT, England, Northern Ireland and Scotland) for the situation five years before. The most 
frequently used indicators were linked to antim icrobial resistance. Si x countries followed-up 
the requirement regarding the number of infec tion control nurses in hospitals (BG, CY, FR, 
LU, PL, and SI). 
The year of data collection for i ndicators reflecting the situation at  the time of the first report 
varied from 1999 (IE) to 2005 (and even 2006 for Wa les). Indicators reflec ting the situation at 
the time of the survey were based on data fr om 2006 (FR and SK) or la ter. Many countries 
found questions regarding the valu e of resistance indicators for S. aureus  and antibiotic 
consumption difficult and asked for clarification. As these questions were also included in the 
questionnaire for the first time, responses should be considered as preliminary information, 
and interpreted with caution. This  is the reason why figure 6 s hows the number of countries 
that provided the information and not the value of indicators. Data used for antimicrobial 
resistance and antimicrobial consumption were  mostly collected through EARSS and ESAC 
and not via national systems. 
Figure 6: Number of countries reporting a value for the listed indicators 0 5 10 15 20 25% of hospitals meeting requirements for the
number of infection control nurses per bed % of participating laboratories to AMR surveillance
system% MRSA from clinical isolates in hospitalsData expressed in defined daily doses per 1,000
inhabitants per day (DID) in outpatients% hospitals reporting annual data on antimicrobial
consumptionAntimicrobial consumption expressed in daily
defined doses (DDD)/ 100 patient-days (hospitals)% of system ic antibiotics sold w ithout prescriptionNumber of national guidelines on appropriate use
of antimicrobials
Number of countries with the informationInformation at the time of the first
report 
Information at the time of thesecond report 
 
EN 24   EN DISCUSSION  
Despite the short timeframe to respond, most c ountries returned their questionnaires on time. 
Some of the questions left room for diffe rent interpretations, which can hamper the 
comparability of answers. This questionnaire was a self-assessment exercise rather than an 
external evaluation, hence natu ral variations between countri es regarding the practical 
implementation of recommendations and the e ffectiveness of measures implemented could 
not be addressed. Nevertheless, these results gi ve a relatively clear pi cture of the state of 
implementation of the Council Recommendation a nd the areas in which greater focus and 
further measures are needed.  
As some countries are still developing their action plans, they could benefit from the 
experience of other countries ( during NFP meetings for instan ce) regarding existing systems 
for developing indicators, implementing data co llection, and their use. There are also ongoing 
European research projects on indicators, e.g. for patient safety, and their results should be 
disseminated more widely. 
As the Commission has established stronger links between AMR, patient safety and 
healthcare associated infections, future wo rk must encompass the impact of these 
developments and the need to involv e and inform the public and patients.