Commission staff working document - Accompanying document to the second Report from the Commission 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}
Date: 2010-04-09
Institutions: European Commission
Subjects: antibiotic, health control, health policy, infectious disease, medicine, pharmaceutical legislation, pharmaceutical product, public health, report

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COMMISSION OF THE EUROPEAN COMMUNITIES 

Brussels, 9.4.2010 
SEC(2010) 399 final 

COMMISSION STAFF WORKING DOCUMENT 

Accompanying document to the 

SECOND REPORT FROM THE COMMISSION 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} 

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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 prescription 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 made since the first Report on implementation 
of the Council recommendation:................................................................................ 23 

Discussion and future work........................................................................................ 24 

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INTRODUCTION 

In November 2001, the Council adopted the ‘Council 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 strategies have to comprise measures in relation to 
surveillance  of  antimicrobial  resistance,  surveillance  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 Member 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  platforms  to  exchange  information,  and  should 
coordinate action with the Commission and other Member States.  

Within two years of its adoption the Commission has summarized the main actions taken at 
Member  State  and  European  Union  level  in  a  report  on  the  implementation  of  the 
Recommendation to the Council (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 prudent use of antimicrobial agents in human medicine are in place. 
Member States were also encouraged to continue implementing specific strategies to contain 
antimicrobial  resistance.  It  called  upon  the  Commission  to  follow  up  the  implementation  of 
the Recommendation on the prudent use of antimicrobial 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 
2 
3 

http://europa.eu.int/comm/health/ph/others/antimicrob_resist/ index_en.htm 

http://ec.europa.eu/health/ph_threats/com/mic_res/com684_en.pdf. 

http://www.consilium.europa.eu/ueDocs/cms_Data/docs/pressData/en/lsa/101035.pdf. 

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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 resistance, antimicrobial consumption, and healthcare associated 
infections,  experts  from  the  European  Centre  for  Disease  Prevention  and  Control  (ECDC), 
and from the network of national focal points (NFP) for antimicrobial resistance). This new 
questionnaire placed a strong emphasis on the use of indicators to follow up implementation 
of the action plan. As far as possible, the questionnaire was developed in a format conducive 
to producing a concise and comparable report to improve data collation 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 from 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 correspondence between the Commission and national 
respondents  (e.g.  missing  data,  confirming  data  for  the  report)  and  the  preliminary  findings 
were  presented  during  the  AMR  NFP  meeting  in  London  on  October  2009  for  review  and 
comments. 

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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  differences  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.  

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RESULTS 

1. 

NATIONAL  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 national strategy targeted to contain the problem 
of antimicrobial resistance, translated 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  and  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  replied  that  they  did  not  have  a  strategy  or 

national action plan, nor were they preparing one (CY, EE, HU and LV). 

•  Content of the action plans 

Measures  regarding  the  surveillance  of  antimicrobial  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 Northern Ireland had an action plan covering 
all  the  other  topics  listed  in  the  Council  Recommendation:  surveillance  of  antimicrobial 
resistance,  detection  and  control  of  outbreaks,  prevention  policy,  education  and  training  of 
health professionals, general public information, and research.  

For  the  remaining  countries,  the  following  topics  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 resistance in one country (BG); 

–  education and training of health professionals 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  addressed  in  other  sectors  and  action  plans.  For 
instance,  the  detection  and  control  of  outbreaks  is  included  in  another  public  health  action 
plan or strategy in Sweden. 

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•  Indicators  

One question sought to collect the indicators used by countries to assess the implementation 
of their strategy.  

Indicators are designed to measure, in a standardised way, a phenomenon or a situation and to 
monitor  trends  (often  with  a  view  of  reaching  a  target).  Using  indicators  requires  the 
implementation of a system to collect and analyse data.  

In the context of antimicrobial resistance, examples of outcome indicators include the value of 
antimicrobial consumption, appropriate prescription rates and antimicrobial resistance figures. 
Process  indicators  measure  compliance  with  agreed  activities,  such  as  surveillance  and 
standard  operating  procedures  (hand  hygiene  for  instance).  Structure  indicators  refer  to  a 
resource,  such  as  staff,  infrastructure  or  committees  (see  the  definitions  laid  down  in  the 
Council  Recommendation  on  patient  safety,  including  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 preparation 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 indicators, one with quantitative 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  targeted  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 were reported by five countries:  

•  IE: volume of alcohol gel used – indicator for prevention of transmission;  

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•  BE,  IT,  LT,  RO:  implementation  of  antibiotic  management  teams,  education  tools, 
guidelines,  evaluation  of  compliance  with  guidelines,  implementation  of  surveillance, 
expert  groups,  reference  laboratories,  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  yet  have  an  action  plan  to  contain 
antimicrobial  resistance.  Eight  of  these  countries  and  Wales  reported  having  a 
strategy under preparation.  

•  With only eight countries having 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 coordinate 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 implementation 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.  Twelve  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 implementation 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  for  the  coordinated  implementation  of  the  above 
mentioned  strategies  (overall  22  ICMs  in  place  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 2008 and 2010. Latvia and Estonia did not report 
any plans to establish an ICM to implement the strategy. 

4 

Due  to  differences  in  the  interpretation  of  the  question,  it  is  possible  that  countries  with  outcome 
indicators also had process or structural indicators but did not mention them. 

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Number  of  ICM 
established 

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1996

1997

1998

1999

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2001

2002

2003

2004

2005

2006

2007

2008

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Year 
establishment 

of 

Figure 1: Year of establishment of an intersectoral mechanism. 

Out of the 19 countries with an ICM, 14 countries 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 taken by the Chief Medical Officer in Hungary 
and was considered as an official working group in AT and IE. IE reported that, despite the 
lack of governmental text, the Ministry of Health strongly supported the 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  was  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 the 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 represented 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, 

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•  The Ministry of Environment was present in plenary in DE and Scotland, 

•  The Ministry of Research only in DE, PL, Northern Ireland and Wales, 

•  The  pharmaceutical  industry  was  present  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 Wales (only in ICM Wp in DE), 

•  Nurses  were  represented  in  eight  countries  (in  plenary  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  representatives  also  varied.  They  were  involved  in  the 
plenary of the ICM in BE, FI, FR, HU, LU, PL, SK and in the work of the WP in AT, DE, and 
EL. 

Working Parties

Plenary

Pharmaceutical industry

Patients groups

Professional society

Ministry of Research

Ministry of Environment

Ministry of Agriculture

Food chain safety

Animal health

Ministry of Education

Prevention sector

Nurses

Pharmacist

Nursing homes/elderly, long term care

Ambulatory sector/primary care

Hospital sector

Reference laboratories

Institute of epidemiology in charge of antimicrobial resistance

Health insurance

Medicines agency

Ministry of Health

Figure 2: Composition of the Plenary ICM (N=22) and ICM working parties (N= 15) 

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•  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 (11/22) 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).  

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•  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 healthcare-associated infections or a medicine 
agency. In some countries, the ICM also had additional 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 remit 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. Ministry 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 budget (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 Health 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 responsibilities and power. 

•  All but one existing ICMs were truly intersectoral and had links with veterinary / animal 
health  sectors.  Nurses  and  representatives  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 the development and transfer 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 for Epidemiology/Public Health may manage the 
budget reserved for operations of the ICM.  

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Progress made since the first report  

•  Major  improvements  have  been  made  regarding  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 collaboration  with  the animal health sector has 
been  established.  In  2008  the  animal  health  was  represented  in  all  but  one  ICM.  On  the 
other  hand,  the  involvement  of  patient  groups  had  not  improved  much  (only  in  five 
countries in 2008, up from three in 2003). 

•  Some  ICMs  had  been  established  fairly  recently  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 structure 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. 

SURVEILLANCE SYSTEMS FOR ANTIMICROBIAL RESISTANCE 

Main findings 

•  All countries had implemented a surveillance system for antimicrobial 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  system  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  community  laboratories  were  involved  in  the  surveillance  system  in  six 

countries and in Scotland, Wales, and Northern Ireland.  

•  Micro-organisms covered by the surveillance 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 

EN 

Kuijper EJ and al. update of Clostridium difficile infection due to PCR ribotype 027 in Europe, 2008. 
Euro 
online: 
13(31):pii=18942. 
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=18942 

Available 

Surveill. 

2008; 

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•  Fifteen  countries  reported  that  they  also  surveyed  resistance  in  other  micro-
organisms.  The  most  common  types  of  bacteria  specified  were  Haemophilus 
influenzae, Neisseria meningitidis and pathogens causing food-borne infections. 

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Figure 3: Micro-organisms covered by the surveillance of AMR in hospitals and in the 
community (27 respondents (24 countries) with surveillance system) 

•  In  most  countries,  the  structure  of  the  antimicrobial  resistance  surveillance  system  was 
governmental and continuously implemented (18 out of 23). Surveillance was carried out 
through research projects only in AT, IT, PT and SI. In BG, CZ and EL, surveillance was 
carried out by independent scientific societies. In RO, surveillance was organised through 
research projects and by an independent 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 participate in EARSS) mentioned the National 
External  Quality  Assessment  Service  (NEQAS),  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,  the  stated  obstacles  were  legal  status,  budget 
shortage,  and poor information  technology support. 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  easy  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 

   EN 

 
 
 
 
 
 
 
 
 
 
 
•  More detailed data were available 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  regarding  access  to  antimicrobial  resistance 
surveillance data (see above for list of obstacles in CZ, FR, LT, LU, NL, PT, SI and the 
UK). 

•  Most  countries  had  an  operational  link  between  antimicrobial  resistance  surveillance 
services  and  those  in  charge  of  disease  control/infection  control  (22/28)  and  outbreak 
investigation  (21/27).  Half  of  the  respondents  had  implemented  operational  links  with 
veterinary surveillance for antimicrobial resistance (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  released  between  2007  and  2008  in  most  countries  where 
information was available. 

Comments 

•  In ten countries there were still no sustainable national systems for antimicrobial 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 project without having a national EQA system in 
place (12 countries). 

•  Data on antimicrobial resistance were not yet available at regional or local levels, including 

hospitals, although these levels are useful to better steer policies. 

•  Not all countries issued national reports on antimicrobial 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  system,  national  reports,  and  operational  links 
with antimicrobial resistance surveillance in animals, minimal progress appears to have been 
made between these two reports. In 2008, government support for surveillance existed in 18/ 
28  countries  (19/28  in  2003),  17  countries  had  issued  national  reports  (16  in  2003),  16  had 
established links with surveillance 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 reported no access to surveillance data)  

EN 

   EN 

 
 
3. 

SURVEILLANCE  SYSTEMS  FOR  THE  PRESCRIPTION  AND  USE  OF  ANTIMICROBIAL 
AGENTS 

Main findings 

•  All  countries  participated  in  the  European  Surveillance  of  Antimicrobial  Consumption 
project (ESAC). In addition, another system for 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  reports  on  antimicrobial  use;  the  date  of  last 

publication was 2008 in most countries where information was provided. 

•  Hospitals  collected  antimicrobial  consumption  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 Northern Ireland, health authorities do not have 
access  to  individual  hospital  data.  The  obstacles  mentioned  were  weak  legal  status 
(mentioned  in  4  countries),  private  ownership  (in  4  countries)  and  poor  information 
technology support (in 1 country). Other limits mentioned included the poor quality of data 
(expressed in cost (CZ), not representative and not in a standardised format (AT)) and the 
fact that hospitals are the owners of the data (NL). In addition, France mentioned that the 
weak  legal  status  and  insufficient  information  technology  support  prevented  health 
authorities from having detailed and comprehensive data. 

•  In 20 countries, prescription data in the community were available for prescribers (data not 
available in BG, CZ, EE, EL, HU, IT, MT, missing data for PT). Access was possible at 
national level in general. Individual 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  legal  status,  ownership,  information  technology, 
resources,  and  concern  over  data  security.  Even  countries  where  data  could  be  accessed 
reported  difficulties.  Norway  specified  that  health  authorities  could  not  access  individual 
but  only  anonymous  data.  In  addition,  France  stated  that  information  technology  support 
did not allow access to individual data by health authorities. 

•  Data  on  antimicrobial  consumption  could  be  broken  down  by  indication  in  13  countries 
(including  the  UK,  except  Scotland),  mainly  for  ambulatory  care  (12  including  the  UK, 
except Scotland) and less often for hospitals (seven and Wales). In half of the cases, this 
was carried out by research projects (five countries and Wales) and on a continuous basis 
in only seven countries, England and Northern Ireland.  

•  Hospital data on antimicrobial consumption could be broken down to hospital level in most 
countries:  18  and  in  England,  Wales,  and  Northern  Ireland.  They  could  be  accessed  at 
speciality  or  ward  level  in  12  countries  and  in  Wales.  This  surveillance  in  hospitals  was 
carried  out  by  research  projects  in  seven  countries,  was  continuous  in  9,  and  England, 
Wales, and Northern Ireland, and mixed in two (DE, ES). 

EN 

   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 continuous in seven countries and 
in Wales (along with research projects in four countries and Wales). A regional level for 
this analysis was mentioned by AT, FI and Wales. 

•  Prescription practice indicators existed in 15 countries and Wales, mainly for hospitals (12 
and Wales). Measures to improve prescription practices were carried out in most countries 
(19/28) and they addressed both community and 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  national  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 continuous basis, to break 
down data to individual level, to hospital ward, or by indication. 

•  Countries reported that the collection 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 with information technology systems. 

•  Indicators to monitor prescribing practices were still underdeveloped in several countries. 

Progress made since the first report 

The following improvements can be noted: 

•  Obstacles to obtain antimicrobial consumption data, in particular financial ones, have been 

largely overcome ;  

•  Improved collection of broken-down data by indication, hospital ward and speciality; 

•  Improved links of antimicrobial resistance data to antibiotic consumption data: no country 

had a sustainable system in place for this purpose in 2003; 

•  The use of indicators to monitor prescribing practices doubled from 2003 to 2008.  

4. 

CONTROL 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 

   EN 

 
 
IT, NL and UK) reported that such sales might contribute to less than 1 % of total sales of 
antibiotics. This gave 18 countries where sales without prescription were not considered as 
a  significant  source  of  misuse  of  antibiotics.  The  percentage  of  antibiotics  sold  without 
prescription  was  assumed to be  between 1 and 5 percent in five countries  (BG, CY,  LV, 
LT, PL), between 5 and 10 percent in three countries (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 taking measures to enforce the 
law on prescription-only use for antibiotics. 

•  Topical antibiotic marketing authorisation had been assessed in five countries. Regarding 
regulations  on  advertising,  only  Wales  mentioned  a  national  regulation  that  goes  further 
than European rules. 

Guidelines on the appropriate use of antimicrobials6 

•  All  but  four  countries  (CY,  EE,  LV  and  ES)  and  Wales  had  national  guidelines  on  the 
appropriate  use  of  antimicrobials.  Spain  responded  that  guidelines  had  been  issued  by 
several  medical  societies  (e.g.  infectious  disease  specialists,  paediatricians,  general 
practitioners). Four countries and Northern Ireland had guidelines only in the community 
and two other countries only in hospitals. 

•  The  most  common  guidelines  were  for  community-acquired  pneumonia,  which  were 
issued in 20 countries, England and Scotland. Guidelines for otitis media, acute bronchitis, 
tonsillopharyngitis,  acute  exacerbation  of  chronic  bronchitis,  and  urinary  tract  infections 
were  issued  in  more  than  half  of  the  countries.  Seven  countries  and  Scotland  had 
guidelines  on  each  type  of  infection  listed.  Some  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  comprehensive  set  of  guidelines  —  for  each  type  of 
infection  listed.  Other  hospitals  guidelines  were  for  the  treatment  of  endocarditis, 
meningitis and, in some countries, a variety of infections. 

•  Countries  reported  that  it  was  common  practice  to  have  guidelines  endorsed  by  national 

health authorities.  

•  It was still rare to assess whether prescribing doctors comply with national guidelines, or 
the impact of  guidance  on  prescription  practices. 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  industry  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  account  and  not  additional  guidelines  developed  by 
different Belgian scientific organisations, often sponsored by the pharmaceutical industry. 

EN 

   EN 

 
 
                                                 
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Figure 4: Number and status of guidelines (N=25 incl. 4 responses for the UK) 

Ambulatory care

Hospital care

Guidelines for hand hygiene 

•  All responding countries (27) except two had guidelines for hand hygiene. The compliance 
of  healthcare  workers  with  these  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 infection 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 infection 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 infection 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 survey 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 networks. In  DK,  the only network was regional. 
Most  of  the  existing  networks  monitored  bloodstream  infections.  Nine  countries  had  a 
network  to  survey  surgical  site  infections  (SSI),  infections  in  intensive  care  units  (ICU), 
bloodstream  infections,  and  hospital  wide  surveillance.  In  addition,  three  countries  had  a 
network  to  monitor  SSI,  infections  in  ICU,  and  bloodstream  infections.  This  could  be 

7 

Despite a definition in the questionnaire, characteristics of nursing homes may vary among countries. 

EN 

   EN 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
interpreted as 12 countries having relatively comprehensive 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 Ireland). 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  (hospitals  and  nursing  homes),  and  in  RO  for 
nursing homes (no data for Spain). 

•  More  than  half  of  the  respondent  countries  (15  countries  and  Wales)  had  legal 
requirements  or  national  recommendations  for  the  numbers  of  infection  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 healthcare associated infections were available 
in  all  but  three  responding  countries  (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  guidelines  on  MRSA  and  frequently  in  addition  to 
guidelines on gram-negatives. 

•  Guidelines  were  half  as  frequent  in  nursing  homes  as  in  hospitals.  The  most  frequent 
guidelines in nursing homes are for healthcare-associated infections in general and MRSA. 
Prevention  and  control  of  C.  difficile  infections  in  nursing  homes  was  addressed  in  six 
countries. 

Hospitals

Nursing homes

25

20

15

10

5

0

HCAI (in
general)

MDR bacteria
(in general)

 MRSA

Clostridium
difficile

VRE

MDR gram
negatives 

MDR-TB and
XDR-TB

EN 

   EN 

 
 
 
Figure 5: Number of guidelines for the prevention and control of healthcare-associated 
infections (HCAI) and microorganisms (N= 27 responses, 4 responses for UK) 

Streptococcus pneumoniae  

Most  countries  issued  recommendations  on  vaccination  against  Streptococcus  pneumoniae 
infections,  addressing  both  children  and  the  elderly  in  most  cases.  The  trends  of  invasive 
pneumococcal infections were monitored in most countries. 

Comments 

•  In  nine  countries,  sales  of  systemic  antimicrobials  without  prescription  were  assumed  to 
represent  a  potential  source  of  misuse.  Whatever  their  situation,  most  countries  were 
implementing measures to better enforce European regulations on prescription-only use of 
systemic antimicrobials. 

•  National  scientific  guidelines  on  the  appropriate  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  the  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 committees 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  healthcare-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  assessed  guidelines  for  appropriate  use  of 

antimicrobials (12 countries and Scotland versus 6 in 2003). 

•  National  programmes  and  requirements  regarding  infection  control  committees 
and  infection  control  nurses  in  hospital  existed  for  most  countries  in  2003. 
However, in 2008 two countries, (CZ and HU) lacked a national programme and 
requirements  for  hospital  hygiene.  Malta  and  Poland  reported  having  a  national 
programme for infection control/hospital hygiene in 2003 and not in 2008. 

5. 

EDUCATION AND TRAINING OF HEALTH PROFESSIONALS 

Main findings 

EN 

   EN 

 
 
•  In all but two countries, the curriculum of healthcare professionals 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 pharmacy. 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 hygiene and infection control more often than 
any other issues. In NO, continuing medical education was mandatory for specialists only. 
PL  indicated  that  they  were  working  on  a  proposal  to  include  infection  control  topics  in 
post-graduate training in medicine, dentistry and nursing. ES reported that the Ministry of 
Health had provided funding to autonomous regions for training on rational use of drugs, 
including antibiotics. 

•  More  than  half  of  the  countries  (16/28,)  implemented  awareness  raising  campaigns  on 
antimicrobial  resistance  for  healthcare  professionals  in  2006/2007.  In  most  countries,  the 
campaigns targeted medical doctors (in all countries 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 undergraduate training for healthcare professionals on 

issues related to antimicrobial resistance. 

•  Non-sponsored continuing education was required in 15 countries but did not concern all 
healthcare professions nor did it cover the problem of inappropriate use of antimicrobials 
in every country. 

Progress made since the first report  

•  In 2003, almost all countries reported that initial 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. 

INFORMATION FOR THE PUBLIC 

Main findings 

•  Reports  on  the  public’s  knowledge  and/or  perception  of  antimicrobial  resistance, 
inappropriate use of antimicrobials, 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  implemented  awareness  raising  campaigns  on 
antimicrobial resistance, inappropriate use of antimicrobials, vaccination programmes and 
their  role  in  preventing  infections,  and  the  importance of hygiene.  They were  targeted to 

EN 

   EN 

 
 
the  general  public  rather  than  to  a  specific  audience,  such  as  patient  associations  or 
patients.  Only  Sweden  reported  that  it  had  implemented  campaigns  specifically  targeting 
patient associations (vaccinations) and patients (vaccinations and hygiene).  

•  Topics  addressed  in  public  campaigns  were  vaccination  programmes  (regardless  of  the 
target), followed by the importance of hygiene and 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  antimicrobials.  Most  campaigns  included  messages  on 
hygiene and vaccination.  

Progress made since the first report  

•  While  12  countries  reported  having  implemented  awareness  raising  campaigns  in  2003, 
they were seventeen countries in 2008. As in 2003 the most common topic addressed was 
vaccinations in 2008.  

7. 

NATIONAL 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), reference 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  national  projects  to  fulfil  the  recommendation 
regarding  information  and  communication  on  national  research  initiatives  in  the  field  of 
antimicrobial resistance. 

Progress made since the first report:  

•  As replies to the question regarding research varied greatly, comparisons are not relevant. 

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8. 

USE  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 and control of antimicrobial resistance.  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 information 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 antimicrobial resistance. Six countries followed-up 
the requirement regarding the number of infection control nurses in hospitals (BG, CY, FR, 
LU, PL, and SI). 

The year of data collection for indicators reflecting the situation at the time of the first report 
varied from 1999 (IE) to 2005 (and even 2006 for Wales). Indicators reflecting the situation at 
the time of the survey were based on data from 2006 (FR and SK) or later. Many countries 
found  questions  regarding  the  value  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 shows 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. 

Number of  national guidelines on appropriate use
of  antimicrobials

% of  systemic antibiotics sold w ithout prescription

Antimicrobial consumption expressed in daily
def ined doses (DDD)/ 100 patient-days (hospitals)
% hospitals reporting annual data on antimicrobial
consumption
Data expressed in def ined daily doses per 1,000
inhabitants per day (DID) in outpatients

% MRSA f rom clinical isolates in hospitals

% of  participating laboratories to AMR surveillance
system

% of  hospitals meeting requirements f or the
number of  inf ection control nurses per bed 

Information at the time of the first
report 

Information at the time of the
second report 

0

5

10

15

20

25

Num ber of countries  with the inform ation

Figure 6: Number of countries reporting a value for the listed indicators 

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DISCUSSION  

Despite the short timeframe to respond, most countries returned their questionnaires on time. 
Some of the questions left room for different interpretations, which can hamper the 
comparability of answers. This questionnaire was a self-assessment exercise rather than an 
external evaluation, hence natural variations between countries regarding the practical 
implementation of recommendations and the effectiveness of measures implemented could 
not be addressed. Nevertheless, these results give a relatively clear picture of the state of 
implementation of the Council Recommendation and 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 instance) regarding existing systems 
for developing indicators, implementing data collection, 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  work  must  encompass  the  impact  of  these 
developments and the need to involve and inform the public and patients. 

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