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 SEC(2010)399
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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EUROPEAN COMMISSION 

Brussels, 9.4.2010 
COM(2010) 141 final 

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 

SEC(2010)399 

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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 

(Text with EEA relevance) 

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TABLE OF CONTENTS 

1. 

2. 

3. 

4. 

INTRODUCTION..........................................................................................................  

SUMMARY OF MAIN ACTIONS AT MEMBER STATE LEVEL ...........................  

SUMMARY OF MAIN ACTIONS AT EUROPEAN UNION LEVEL.......................  

CONCLUSIONS............................................................................................................  

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1. 

INTRODUCTION 

In  November  2001  the  Council  adopted  a  Recommendation  on  the  prudent  use  of 
antimicrobial  agents  in  human  medicine  (2002/77/EC),  hereinafter  referred  to  as  the 
Recommendation.  This  Recommendation  asks  Member  States  and  EEA  countries  to  put  in 
place specific strategies for the prudent use of antimicrobial agents with a view to containing 
antimicrobial resistance. These strategies should include measures relating to the surveillance 
of antimicrobial resistance and antimicrobial use, control and preventive measures, education 
and training, and research. The Recommendation invites the Commission: to facilitate mutual 
information,  consultation,  cooperation  and  action;  to  keep  matters  covered  by  this 
Recommendation under review; and to submit reports on the basis of Member States’ reports.  

Within  two  years  of  its  adoption  the  Commission  summarised  the  main  actions  taken  at 
Member State and European Union level in a report to the Council on the implementation of 
the Recommendation (COM (2005)684 final)1. The Report indicated that most Member States 
had  taken  a  variety  of  actions  as  requested  by  the  Recommendation.  However,  it  also 
highlighted  numerous  areas  of  the  Recommendation  where  only  limited  actions  had  been 
undertaken and identified others where further attention was needed: 

•  implementation of national strategies and national action plans; 

•  setting up of an appropriate intersectoral mechanism with a proper mandate and adequate 

means; 

•  collaboration between the human and animal health sectors; 

•  education of the general public on the proper use of antimicrobial treatments; 

•  setting  up  of  measures  to  enforce  prescription-only  use  of  systemic  antimicrobials  or 

antibiotics; 

•  appropriate infection control; 

•  nationally accepted guidelines recommending appropriate antibiotic treatment. 

Following  this  first  report  on  the  implementation  of  the  Recommendation,  in  August  2008 
Member States were asked to report to the Commission on the state of implementation as a 
contribution to the follow up of the Recommendation. The Commission received replies from 
all Member States and from one of the three EEA/EFTA countries. 

Based on the replies this second Report summarises the main actions taken at Member State 
and European Union level and compares the situation in 2008 with the situation in 2004 when 
the data for the previous report was collected. This report placed a strong emphasis on the use 
of  indicators  to  follow  up  implementation  of  the  action  plan.  It  also  highlights  in  its 
conclusion the areas of the Recommendation needing further attention. It is accompanied by a 
Commission Staff Working Paper providing a more detailed technical analysis of the Member 
States’ replies. 

1 

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

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2. 

SUMMARY OF MAIN ACTIONS AT MEMBER STATE LEVEL 

The  Recommendation  asks  Member  States  to  put  in  place  specific  strategies  on  the  prudent 
use of antimicrobial agents with a view to containing antimicrobial resistance. By the end of 
2008, sixteen countries had a national strategy in place and eight Member States were in the 
process of preparing such a strategy. Four Member States had no strategy to report nor were 
they in the process of preparing one. 

Strategies should pursue the following main objectives: 

(a) 

To establish or strengthen surveillance systems on antimicrobial resistance and 
use of antimicrobial agents. 

All reporting countries had implemented a surveillance system for antimicrobial resistance. In 
18  countries  there  was  a  surveillance  system  in  addition  to  participation  in  the  European 
Antimicrobial  Resistance Surveillance System (EARSS) that  covers antimicrobial  resistance 
both in the community and in hospitals.  

In  a  significant  number  of  Member  States  and  EEA  countries  there  was  an  operational  link 
between  antimicrobial 
in  charge  of  outbreak 
investigation/disease control, as well as collaboration with veterinary surveillance. However, 
only a few countries had established links with the environment.  

resistance  surveillance  and 

those 

Most of the countries had published a national report on antimicrobial resistance and the data 
were also publicly available. 

Health  authorities  had  access  to  antimicrobial  resistance  surveillance  data  in  all  but  two 
countries. However, there were still obstacles to obtaining rapid and easy access to detailed 
data owing to  problems that were already flagged up in the first report — legal status, data 
ownership, budget shortage, and poor information and technology support. 

Regarding  the  structure  of  the  surveillance  system,  the  publication  of  national  reports,  and 
operational  links  with  antimicrobial  resistance  surveillance  in  animals,  progress  appeared  to 
be  limited  when  compared  with  the  achievements  already  reported  in  2003.  Nevertheless, 
there had been progress as regards access to surveillance data, with fewer countries reporting 
obstacles to access data in 2008 than in 2003. 

Almost  all  respondents  had  national  systems  for  the  surveillance  of  antimicrobial  use  and 
antibiotic  consumption  and  all  countries  participate  in  the  European  Surveillance  of 
Antimicrobial  Consumption  Project  (ESAC).  Comparisons  with  the  achievements  identified 
in 2003 indicate that progress had been made since the first report. The obstacles to obtaining 
antimicrobial  consumption  data  had  been  overcome.  The  collection  of  categorised  data  and 
links  between  antimicrobial  resistance  data  and  antibiotic  consumption  data  improved. 
However, in most countries the data were not detailed enough to allow appropriate feedback 
for prescribers. The obstacles were the same as those involved in resistance surveillance per 
se. In addition, in only half the responding countries consumption data could be broken down 
by  indication  and  linked  to  the  resistance  data.  The  collection  of  more  useful  data  on 
antimicrobial  consumption  and  prescribing  practices  seemed  to  be  undermined  by  the  weak 
legal  status  of  data,  including  its  ownership,  and  problems  with  information  technology 
systems.  In  addition,  indicators  for  the  monitoring  of  prescribing  practices  were  still 
underdeveloped in several countries 

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(b) 

To  implement  control  and  preventive  measures  to  support  the  prudent  use  of 
antimicrobial  agents  and  contribute  to  limit  the  spread  of  communicable 
diseases 

Since the previous report many countries have taken positive action regarding the selling of 
antimicrobial agents without a prescription. While only one country was able to provide data 
in  2003,  in  2008  all  respondents  provided  estimates  of  the  extent  of  such  sales.  Eighteen 
countries reported that this phenomenon was not a significant source of misuse of antibiotics 
in their country. However, it should be noted that from those countries in which the estimated 
percentage of antibiotics sold without prescription was from 1 % to more than 15 % four did 
not indicate taking measures to enforce the law on prescription-only use for antibiotics. Such 
measures  are  provided  by  the  European  Union  pharmaceutical  legislation  on  medicinal 
products for human use (Directive 2001/83/EC as amended by Directive 2004/27/EC).  

Most  countries  had  in  2008  nationally  endorsed  guidelines  on  the  appropriate  use  of 
antimicrobials covering the most common infections in the community, such as otitis media, 
sinusitis,  tonsillopharyngitis,  community  acquired  pneumonia,  urinary  tract  infections  and 
meningitis.  However  hospital  guidelines  were  less  frequent  and  exist  in  only  half  of  the 
countries.  In  addition,  the  assessment  of  compliance  with  guidelines  and  the  evaluation  of 
their impact were still rare, although there had been progress in this respect since 2003.  

Twenty-two countries had in place a national programme for hospital hygiene and infection 
control. In twenty countries it was mandatory for every hospital to have an infection control 
committee.  However,  in  only  three  countries  did  this  requirement  apply  to  nursing  homes. 
More than half of the respondent countries had legal requirements or recommendations for the 
number of infection-control nurses needed in hospitals, but none of the countries had similar 
requirements  for  nursing  homes.  Guidelines  for  the  prevention  and  control  of  healthcare 
associated infections were available in all but three countries. The most commonly addressed 
topic in the guidelines was Methicillin-resistant Staphylococcus aureus (MRSA). Guidelines 
on  multidrug-resistant  bacteria  in  general  were  always  in  addition  to  specific  guidelines  on 
MRSA.  Guidelines  were  less  frequent  in  nursing  homes  than  in  hospitals.  Most  responding 
countries  also  had  recommendations  on  vaccination  against  Streptococcus  pneumoniae 
infections in both adults and children.  

(c) 

To promote the education and training of health professionals on the problem 
of  antimicrobial  resistance  and  to  inform  the  general  public  about  the 
importance of the prudent use of antimicrobial agents. 

Most  countries  reported  that  curricula  for  health  professionals  included  issues  related  to 
antimicrobial resistance, hygiene and infection control, appropriate use of antimicrobials, and 
vaccination  programmes.  Fifteen  countries  had  in  place  requirements  for  non-sponsored 
continuous  education  for  healthcare  professionals,  mainly  covering  hygiene  and  infection 
control measures. However, this did not cover all healthcare professions, nor did it solve the 
problem of the inappropriate use of antimicrobials in every country.  

Sixteen countries had implemented awareness-raising campaigns for healthcare professionals 
on  antimicrobial  resistance,  mainly  for  medical  doctors,  and  in  some  also  for  pharmacists, 
nurses, and vets. 

During  the  last  two  years,  seventeen  countries  have  targeted  the  general  public  with 
awareness-raising campaigns on antimicrobial resistance, inappropriate use of antimicrobials, 

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vaccination  programmes  and  their  role,  and  general  hygiene  measures.  Progress  since  2003 
has  been  very  slow.  These  campaigns  targeted  the  general  public  rather  than  a  specific 
audience, such as patient associations or patients. 

In  2002  the  Council  recommended  that  each  Member  State  should  rapidly  establish  an 
appropriate intersectoral mechanism to coordinate the implementation of the above strategies 
at national level. As well as from national coordination this mechanism should participate in 
information exchange and coordination between the Commission and other Member States.  

Nineteen countries said they had an intersectoral coordinating mechanism (ICM) in place and 
seven  countries  were  in  the  process  of  developing  such  a  mechanism,  which  they  were 
planning to complete between the end of 2008 and 2010. Two Member States had no plans to 
establish an ICM. The main improvement since the previous report is the legal status of the 
ICM. In 2008 the ICM were created by governmental decision in eight countries and in six by 
regulation. In addition, three countries indicated that their ICM was created by decision of the 
National  Chief  Medical  Officer  or  was  considered  to  be  an  official  working  group.  In  most 
countries the ICM was truly intersectoral with the link between the human and animal health 
sectors well established through the ICM in almost all cases. It should be noted, however, that 
ministries  of  employment,  environment,  research,  and  education  were  seldom  represented, 
and  there  had  been  little  improvement  in  the  involvement  of  patient  groups  since  the  first 
report.  Nurses  and  institutions  for  long-term  care  were  represented  in  less  than  half  of  the 
ICMs,  even  though  they  were  important  in  containing  the  development  and  transfer  of 
antimicrobial resistance. 

As  we  are  now  moving  from  the  strategy  development  phase  to  implementation,  the 
questionnaire raises the issue of indicators as tools to follow up the implementation. Twelve 
countries reported having indicators in place for monitoring purposes. In most cases outcome 
indicators  were  used  (for  antimicrobial  resistance,  antimicrobial  use,  prescription,  and 
healthcare  associated  infections).  Five  countries  indicated  the  use  of  structure  and  process 
indicators  at  local  and  national  level  (such  as  the  volume  of  alcohol  gel  used  for  hand 
disinfection,  implementation  of  antibiotic  management  teams,  evaluation  of  compliance, 
control of sales of antimicrobial agents and number of research projects). 

3. 

SUMMARY OF MAIN ACTIONS AT EUROPEAN UNION LEVEL 

Antimicrobial  resistance  continues  to  be  a  key  priority  for  the  Commission,  which  is 
undertaking and promoting a wide range of activities at European Union level.  

to  address  also 

the  first  report’s  recommendation 

Given 
the  spread  of  resistant 
microorganisms  in  health  care  settings  and  following  a  proposal  from  the  Commission,  in 
June 2009 the Council adopted a Recommendation on patient safety, including the prevention 
and  control  of  healthcare  associated  infections2.  The  Recommendation  aims  to  ensure  that 
Member  States  have  proper  and  adequate  strategies  to  improve  patient  safety  in  their 
healthcare systems, including specific proposals to prevent and control healthcare associated 
infections.  

2 

Council Recommendation 2009/C 151/01of 9 June 2009 on patient safety, including the prevention and 
control of healthcare associated infections, OJ C 151, 3.7.2009. 

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Since  the  rise  of  antimicrobial  resistance  has  been  traced  to  the  use  of  antibiotics  in  both 
human  and  veterinary  medicine,  the  Commission  has  been  working  since  the  first  report 
towards the development of initiatives which would be relevant for both sectors.  

Thus,  the  Directorate-General  for  Health  and  Consumers  has  established  a  technical  intra-
service platform to exchange information and enhance the coordination of activities between 
public health and animal health. The work of this group aims to encourage a joint approach to 
monitoring AMR in humans and animals with support from the European Centre for Disease 
Prevention and Control (ECDC), the European Medicines Agency (EMA), and the European 
Food  Safety  Authority  (EFSA).  As  result  of  these  activities,  in  November  2009  the 
Commission  published  a  Staff  Working  Paper  on  antimicrobial  resistance3.  The  purpose  of 
this  paper  is  to  inform  the  Parliament  and  the  Council  on  the  progress  made  by  the 
Commission in monitoring and controlling antimicrobial resistance in human and veterinary 
medicine  and  to  start  an  exchange  of  views  on  follow-up  and  possible  further  actions.  This 
joint approach has been strengthened by the establishment of closer cooperation between the 
different EU Agencies working on antimicrobial resistance. Following a joint request by the 
Commission  departments,  the  ECDC,  EFSA,  EMA  and  the  Scientific  Committee  on 
Emerging and Newly Identified Health Risks worked together to provide a common state of 
play on antimicrobial resistance4.  

In addition to these initiatives, the Commission has been addressing antimicrobial resistance 
through  the  funding  of  several  European-wide  projects  within  the  framework  of  the  Public 
Health Programme 2003-2007: 

EARSS — the European Antimicrobial Resistance Surveillance System (2003-2006) aims to 
maintain  a  surveillance  and  information  system  that  links  national  networks  as  well  as  to 
monitor health threats caused by AMR in Europe www.earss.rivm.nl. EARSS is in the process 
of being integrated into ECDC activities.  

ESAC  —  the  European  Surveillance  of  Antimicrobial  Consumption  (2004-2007)  aims  to 
consolidate  the  collection  of  antibiotic  consumption  data.  Moreover,  in-depth  consumption 
data for ambulatory care, hospital care, and nursing homes were investigated and a pharmaco-
economic evaluation was carried out. Some data derived from this project could be assessed 
in relation to resistance patterns and incidence of disease and could also be used as guidelines 
for  treatment  http://www.esac.ua.ac.be  .  ESAC  is  in  the  process  of  being  integrated  into 
ECDC activities.  

EUCAST  —  the  European  Committee  on  Antimicrobial Susceptibility Testing (2004-2007) 
establishes  the  surveillance  of  pathogens  resistant  to  antimicrobial  agents  by  defining 
common  reference  methods  which  permit  comparison  of  results,  thus  providing  a  common 
basis  for  interpreting  AMR  data  across  Europe.  This  project  has  established  a  standing 
committee for European susceptibility testing and breakpoint setting. http://www.eucast.org.  

BURDEN — Burden of Resistance and Disease in European Nations (2007-2010) is a project 
which aims to provide comparable information on the burden of disease and resistance across 
Europe and to generate awareness and understanding among policy-makers and communities 

3 
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Reference to be included 
Reference to be included 

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at  large.  This  project  will  also  include  a  case  study  of  MRSA  in  intensive  care  units  and 
general wards in hospitals www.eu-burden.info. 

E-BUG  PACK  —  Development  &  Dissemination  of  an  Antibiotic  &  Hygiene  Education 
Pack (2006-2009) for schools, based on a successful UK project. Targeted at 9-16 year-olds, 
this project aims: 1. to increase awareness of the benefits of antibiotics as well as prudent use; 
2.  to  teach  how  inappropriate  use  can  have  adverse  effects  on  ‘good  bugs’  and  on 
antimicrobial resistance; 3. to improve hand and respiratory hygiene, thus reducing the spread 
of respiratory, gastrointestinal and skin infections and decreasing the demand for antibiotics. 

ABS  International  —  implements  Antibiotic  Strategies  (ABS)  for  Appropriate  Use  of 
Antibiotics in Hospitals in Member States of the European Union (2006-2008). Implemented 
in 9 Member States, it aimed to prepare a training programme for national ABS experts and to 
develop standard organisational tools for hospitals to ensure appropriate antibiotic use. 

IPSE/HELICS — is an international network for the collection, analysis and dissemination 
of  valid  data  on  the  risks  of  nosocomial  infections  in  European  hospitals.  HELICS’  routine 
data collection continues to be supported in Work Package 4 of the project. 

Through  its  Sixth  and  Seventh  Framework  Programmes  for  Research  and  Technological 
Development, the Commission supports a broad range of research projects of major relevance 
to the prudent use of antimicrobials in human medicine. Several European-wide projects have 
been  funded,  focusing  on  areas  such  as  the  development  of  evidence-based  patient 
management,  guidelines  for  respiratory  infections  and  the  control  of  healthcare  associated 
infections. In the latest call, the impact of antibiotic therapy on the human host was addressed 
in  several  of  the  selected  proposals  as  well  as  the  clinical  validation  of  diagnostic  tests.  In 
addition  to  the  Framework  Programmes,  other  related  initiatives,  such  as  European 
Technology Platforms, consider the issue of AMR. Moreover, the Joint Technology Initiative 
on Innovative Medicines provides an instrument for a public-private partnership that can play 
a role in tackling the AMR issue. 

European  Union  actions  against  antimicrobial  resistance,  which  promote  the  prudent  use  of 
antimicrobial agents in human medicine, have been further strengthened since the first report 
with the creation in 2005 of the ECDC.  

In  order  to  assess  and  monitor  the  antimicrobial  resistance  risk,  the  epidemiological 
surveillance  activities  in  this  field  envisaged  under  Decision  2119/98/EC5  and  Decision 
2000/96/EC6  have  continued,  with  the  added  value  of  the  ECDC,  which  is  now  responsible 
for  the  running  of  the  surveillance  networks.  Every  year  the  ECDC  publishes  data  on 
antimicrobial resistance and antimicrobial use in the EU in its Annual Epidemiological Report 
on communicable diseases.  

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Decision  No  2119/98/EC  of  the  Parliament  and  of  the  Council  of  24  September  1998  setting  up  a 
network for the epidemiological surveillance and control of communicable diseases in the Community, 
OJ L 268, 3.10.1998 
Commission  Decision  2000/96/EC  of  22  December  1999  on  the  communicable  diseases  to  be 
progressively covered by the Community network under decision No 2119/98/EC of the Parliament and 
of the Council, OJ L 28, 3.2.2000 

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In addition the ECDC has set up a network of antimicrobial resistance National Focal Points 
from Member States and EFTA-EEA7 countries aimed at strengthening EU collaboration on 
this  issue.  It  is  also  implementing  a  specific  programme  on  antimicrobial  resistance  and 
healthcare  associated  infections  in  cooperation  with  the  Commission,  the  other  European 
Union Agencies and the Member States. As a result, the ECDC will help the Commission to 
foster best practice on the prevention and control of healthcare associated infections, promote 
training  opportunities  and  assist  Member  States  to  develop  infection-control  training  and 
curricula for infection-control staff and healthcare workers. 

In  order  to  ensure  a  coordinated  and  balanced  approach  between  veterinary  and  human 
medicine,  cooperation  has  been  established  with  EFSA  on  antimicrobial  resistance 
surveillance  in  the  field  of  EFSA’s  competencies.  Cooperation  with  other  EU  agencies 
includes the publication of a joint ECDC/EMA study on the need for new antibacterial drugs8 
and  a  joint  ECDC/EFSA/EMA/SCENIHR  study  on  the  state  of  play  of  antimicrobial 
resistance in the EU9.  

As part of the drive to increase awareness among the general public and improve education of 
healthcare  professionals,  in  2008  the  European  Antibiotic  Awareness  Day  (EAAD)  was 
initiated  as  a  European  public  health  initiative  coordinated  by  the  European  Centre  for 
Disease  Prevention  and  Control.  This  annual  event  aims  to  raise  awareness  about  the  risks 
associated with the inappropriate use of antibiotics and how to take antibiotics responsibly. 

4. 

CONCLUSIONS 

Significant progress has been achieved since the publication of the first report. Most Member 
States  have  taken  a  variety  of  actions,  as  requested  by  the  Recommendation  and  further 
underlined in the first implementation report. However, there are still numerous areas of the 
Recommendation where only limited improvement has been attained. It is important that all 
the Recommendation’s provisions are adhered to by the Member States. Based on the findings 
identified in this report, the areas on which future work could be focused include: 

•  Improving  the  enforcement  by  the  Member  States  of  the  Council  Recommendation, 

addressing current concerns: 

•  Rapid  development  and  efficient  implementation  of  national  strategies  and 
national action  plans in all Member States  and  associated  countries taking into 
account the Council Recommendation on patient safety, including the prevention 
and control of healthcare associated infections. 

•  Greater involvement of nursing homes and representatives of institutions for long-
term  care  when  setting  up  action  plans  and  guidelines  regarding  antimicrobial 
resistance and healthcare associated infections. 

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study, 

European Free Trade Association — European Economic Area countries 
ECDC/EMA 
http://ecdc.europa.eu/en/publications/Publications/0909_TER_The_Bacterial_Challenge_Time_to_Rea
ct.pdf. 
Reference to be included 

‘The  Bacterial  Challenge: 

September 

react’, 

time 

to 

2009, 

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•  Collaboration  between  the  human  and  animal  health  sectors  on  antibiotic 
resistance and antibiotic use at national and European Union level, particularly in 
all those countries where this has not yet been established. 

•  External assessment of national programmes. 

•  Actions  to  ensure  that  each  Member  State  has  an  appropriate  intersectoral 
mechanism in place with a suitable mandate and the means to coordinate the 
implementation  of  the  strategies  foreseen  in  the  Recommendation.  It  would  be 
useful to evaluate the functioning of the various intersectoral mechanisms. 

•  Fostering monitoring and evaluation at Member State level 

•  Develop  and  use  indicators  to  monitor  the  implementation  of  the  Council 
Recommendation and assess the impact of national action plans and the efficiency 
of measures. 

•  Develop mechanisms and indicators to assess the impact of national guidelines.  

•  Strengthen surveillance networks on antimicrobial resistance and antibiotic use in 
order  to  improve  access  to  the  surveillance  systems’  data  on  antimicrobial 
resistance and the use of antimicrobial agents by policy makers, professionals and 
the public. 

•  Improve the collection of comprehensive data on antimicrobial consumption and 

prescription practices. 

•  Develop a feedback mechanism on prescription practices and the use of antibiotics 

for prescribers and decision makers.  

•  Promote  the  use  of  indicators  to  monitor  the  implementation  and  efficiency  of 

measures and to disseminate relevant information to the public. 

•  Improving  at  Member  State  level  education  of  healthcare  professionals  and  the  general 

public 

•  Involve  patient  groups  in  the  implementation  of  the  strategies  and  action  plans 

being planned.  

•  Improve non-sponsored continuing education for all healthcare professionals in all 
countries.  Educational  programmes  should  cover  all  aspects  of  antimicrobial 
resistance (hygiene, appropriate use, etc.). 

•  Raise awareness among all healthcare workers and the general public. 

•  Optimise European Antibiotic Awareness Day. 

•  Cooperation at EU level and European Union actions 

•  Strengthen  cooperation  on  the  links  between  antimicrobial  resistance  in  humans 

and in animals and food. 

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•  Address  the  global  dimension  of  antimicrobial  resistance.  Action  cannot  be 
limited  to  the  EU  level  and  links  with  international  partners  and  EU  external 
actions are vital (ie. strengthening pharmaceutical policies and health systems in 
developing countries). 

•  Monitor the environmental impact of the use of antimicrobials. 

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