COMMISSION STAFF WORKING DOCUMENT Accompanying the document Proposal for a COUNCIL RECOMMENDATION on stepping up EU actions to combat antimicrobial resistance in a One Health approach
Date: 2023-04-26
Institutions: Directorate-General for Health and Food Safety, European Commission
Subjects: animal disease, antibiotic, antimicrobial resistance, drug surveillance, environmental protection, infectious disease, innovation, public health, research and development, veterinary medicinal product

EN 

  EN 

   EUROPEAN COMMISSION  Brussels, 26.4.2023  SWD(2023) 190 final  COMMISSION STAFF WORKING DOCUMENT    Accompanying the document Proposal for a COUNCIL RECOMMENDATION on stepping up EU actions to combat antimicrobial resistance in a One Health approach {COM(2023) 191 final}  
 
 
Table of Contents  

1. 

INTRODUCTION .................................................................................................................................1 

2.  METHODOLOGY.................................................................................................................................4 

3.  ACHIEVEMENTS OF THE 2017 AMR ACTION PLAN AND GAPS ...............................................6 

3.1  PILLAR 1: MAKING THE EU A BEST PRACTICE AREA ...............................................................6 

3.2  PILLAR 2: BOOSTING RESEARCH, DEVELOPMENT AND INNOVATION .............................. 10 

3.3  PILLAR 3: SHAPING THE GLOBAL AGENDA .............................................................................. 14 

4. 

5. 

FUTURE-PROOFING ANALYSIS AND CHALLENGES ................................................................ 15 

RECOMMENDATIONS ON HOW TO ADDRESS THE CHALLENGES ....................................... 21 

5.1  FURTHER DEVELOP MEMBER STATE NATIONAL ACTION PLANS ...................................... 21 

5.2 

IMPROVING AMR SURVEILLANCE AND MONITORING .......................................................... 22 

5.3 

IMPROVING  PATIENT  SAFETY  AND  SUPPORTING  INFECTION  PREVENTION  AND 
CONTROL ........................................................................................................................................... 22 

5.4  STRENGTHENING RESEARCH, DEVELOPMENT AND ACCESS OF ANTIMICROBIALS ..... 23 

5.5  REINFORCING EU ACTION AT GLOBAL LEVEL ....................................................................... 23 

5.6  STRENGTHENING AWARENESS, EDUCATION AND TRAINING ABOUT AMR ................... 24 

5.7  PROMOTING PRUDENT USE OF ANTIMICROBIALS ................................................................. 24 

5.8  FURTHER INTEGRATE THE ENVIRONMENT IN AMR POLICY ............................................... 25 

5.9  CONTINUE TO SUPPORT MEMBER STATES AND FACILITATE COOPERATION ................ 25 

5.10  STRENGTHEN  THE  FRAMEWORK  FOR  ACTION  THROUGH  TARGETS  AND 

INDICATORS ..................................................................................................................................... 25 

6. 

CONCLUSION .................................................................................................................................... 26 

 
 
 
 
 
 
 
 
 
 
 
 
 
Glossary 

Term or acronym 

Meaning or definition 

AMC 

AMR 

BTSF 

CAP 

ECDC 

ECRAID 

EEA 

EMA 

ESAC-Net 

ESVAC 

Antimicrobial consumption 

Antimicrobial resistance 

Better Training for Safer Food 

Common Agricultural Policy 

European Centre for Disease Prevention and Control 

European Clinical Research Alliance on Infectious 
Diseases 

European Economic Area 

European Medicines Agency 

European Antimicrobial Resistance Surveillance 
Network 

European Surveillance of Veterinary Antimicrobial 
Consumption  

EU 

European Union 

EU-JAMRAI 

Joint Action on Antimicrobial Resistance and 
Healthcare-Associated Infections 

EXPH 

FAO 

H2020 

HERA 

Expert Panel on effective ways of investing in health 

The Food and Agriculture Organization 

EU’s Research Funding Programme Horizon 2020  

The Commission’s Health Emergency preparedness and 
Response Authority 

 
 
ICMs 

IMI 

NAPs 

Intersectoral Coordination Mechanisms 

Innovative Medicines Initiative 

National Action Plans 

ND4BB Programme 

New Drugs 4 Bad Bugs Programme 

OH EJP 

The One Health European Joint Programme 

OIE/ WOAH (new name 
replacing OIE) 

World Organisation for Animal Health 

PAHO 

R&D 

R&D&I 

TAFTAR 

TB  

UN 

UNEP 

WHO 

Pan American Health Organization 

Research and Development 

Research, Development and Innovation 

Transatlantic Taskforce on AMR 

Tuberculosis 

United Nations 

United Nations Environment Programme 

World Health Organization 

 
 
1. 

INTRODUCTION 

The purpose of this staff working document is to provide evidence in support of the proposal 
for a Council Recommendation on stepping up EU actions to combat antimicrobial resistance 
in  a  One  Health  approach.  The  proposed  Recommendation  aims  at  strengthening  and 
complementing  the  2017  European  One  Health  Action  Plan  against  Antimicrobial 
Resistance1  (AMR)  (hereafter  referred  to  as  ‘2017  AMR  Action  Plan’)  by  setting  concrete 
objectives and activities to support the Commission’s and the Member States’ actions against 
AMR.  It  thus  aims  at  complementing  and  extending  the  actions  implemented  at  European 
Union  (EU)  level,  maximising  synergies  to  attain  a  strong  and  effective  response  against 
AMR across the EU. 

i.a. 

the  ability 

threatening, 

increasingly 

to  perform  surgery, 

AMR  means  the  ability  of  a  micro-organism  to  survive  or  to  grow  in  the  presence  of  a 
concentration  of  an  antimicrobial  agent  which  is  usually  sufficient  to  inhibit  or  kill  that 
micro-organism. AMR is leading to infections being difficult or even impossible to treat and 
treatment  of 
is 
immunocompromised  patients  and  organ  transplantation,  and  constitutes  a  threat  for  cancer 
therapy.  AMR  is  a  One Health2,  cross-border  and  cross-cutting  issue,  and  is  described  as  a 
“slow  tsunami”  by  the  World  Health  Organization  (WHO)3  -  a  slowly  developing  but 
potentially  devastating  global  pandemic.  AMR  is  a  growing  global  burden  and  it  marks  a 
grave societal and economic challenge with cost of inaction projected to result in 10 million 
deaths globally each year and costs up to 100 trillion USD to the world economy by 20504. In 
the EU, AMR  is estimated to  be  responsible for  over 35,000 deaths  per  year5  and annually 
costs  about  1.1  billion  euros  to  the  health  care  systems  of  EU/  European  Economic  Area 
(EEA) countries6.  

the 

Already in 2001, the EU identified the importance of tackling AMR with the adoption of the 
2001  Community  strategy  against  AMR7.  As  from  2006,  in  the  EU,  antibiotics  are  not 
allowed as additives in animal feed (Regulation (EC) No 1831/2003)8. The EU AMR policy 
was  reinforced  by  the  2011-2016  Commission  Action  Plan9  meant  to  foster  action  among 
Member  States.  Following  the  evaluation  of  the  action  plan10,  the  Commission  adopted  the 
2017 AMR Action Plan, as requested in 2016 by the EU Member States11. The 2017 AMR 

1 A European One Health Action Plan against Antimicrobial Resistance (AMR)  
2 “One Health” is an integrated, unifying approach that aims to sustainably balance and optimize the health of 
people, animals, and ecosystems. It recognizes the health of humans, domestic and wild animals, plants, and the 
wider environment (including ecosystems) are closely linked and interdependent. 
3 WHO Director-General opening remarks at the AMR Action Fund Launch 
4 For the period 2014-2050 - see Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations, 
The Review on Antimicrobial Resistance Chaired by Jim O’Neill. December 2014 
5 Assessing the health burden of infections with antibiotic-resistant bacteria in the EU/EEA, 2016-2020  
6 Antimicrobial Resistance: Tackling the Burden in the European Union, Briefing note  
for EU/EEA countries, OECD 2019  
7 Communication from the Commission on a Community Strategy against antimicrobial resistance  
8  Regulation  (EC)  No  1831/2003  of  the  European  Parliament  and  of  the  Council  of  22  September  2003  on 
additives for use in animal nutrition (OJ L 268, 18.10.2003, p. 29–43).  
9  Communication  from  the  Commission  to  the  European  parliament  and  the  Council  Action  plan  against  the 
rising threats from Antimicrobial Resistance COM/2011/748 
10  Commission  Staff  Working  Document  on  the  evaluation  of  the  Action  Plan  against  the  rising  threats  from 
antimicrobial resistance (2016) 347 final 
11 Council conclusions on the next steps under a One Health approach to combat antimicrobial resistance  

1 

 
 
 
                                                           
Action Plan is structured around three overarching pillars and fifteen specific objectives12 and 
is motivated by the need for the EU to play a leading role in the fight against AMR and to add 
value  to  Member  States’  actions.  It  provides  a  framework  for  continued,  more  extensive 
action to  reduce the emergence  and spread of AMR.  Its  overarching goal  is  to preserve the 
possibility  of  effective  treatment  of  infections  in  humans  and  animals,  by  ensuring  the 
development and access to effective antimicrobials inside and outside the EU. 

The three pillars on which the 2017 AMR Action Plan is built are:  

1.  Making  the  EU  a  best  practice  region  in  terms  of  better  evidence,  coordination, 

surveillance and control measures;  

2.  Boosting  research,  development  and  innovation  by  closing  current  knowledge 
gaps, providing novel solutions and tools to prevent and treat infectious diseases and 
improving diagnosis in order to control the spread of AMR;  

3.  Intensifying EU efforts worldwide to shape the global agenda on AMR and address 

the related risks in an increasingly interconnected world.  

Under each of these three pillars, concrete  activities relating to  the  specific objectives  were 
set.  Progress  reports  on  the  2017  AMR  Action  Plan  are  published  regularly;  the  latest 
progress report was published in March 202213.  

Since the adoption of the 2017 AMR Action Plan, important policy actions have contributed 
to further strengthen the EU’s response to AMR, such as: 

- 
- 

the adoption of the Strategic Approach to Pharmaceuticals in the Environment14; 
the adoption of the Farm-to-Fork Strategy15, the Biodiversity Strategy16 and the Zero 
Pollution  Action  Plan17,  which  all  include  a  target  to  reduce  overall  EU  sales  of 
antimicrobials for farmed animals and in aquaculture by 50% by 2030; 

12 (1) Better evidence and awareness of the challenges of AMR, (2) Better coordination and implementation of 
EU  rules  to  tackle  AMR,  (3)  Better  prevention  and  control  of  AMR,  (4)  Better  addressing  the  role  of  the 
environment,  (5)  A  stronger  partnership  against  AMR  and  better  availability  of  antimicrobials,  (6)  Improve 
knowledge  on  detection,  effective  infection  control  and  surveillance,  (7)  Develop  new  therapeutics  and 
alternatives, (8) Develop new preventive vaccines, (9) Develop novel diagnostics, (10) Develop new economic 
models  and  incentives,  (11)  Close  knowledge  gaps  on  AMR  in  the  environment  and  on  how  to  prevent 
transmission, (12) A stronger EU global presence, (13) Stronger bilateral partnerships for stronger cooperation, 
(14) Cooperating with developing countries, (15) Developing a global research agenda.   
13 Progress reports on the 2017 AMR Action Plan  
14 Communication from the Commission to the European Parliament, the Council and the European Economic 
and  Social  Committee  -  European  Union  Strategic  Approach  to  Pharmaceuticals  in  the  Environment  –  COM 
(2019) 128 final 
15 Communication from the Commission to the European Parliament, the Council, the European Economic and 
Social  Committee  and  the  Committee  of  the  Regions  -  A  Farm  to  Fork  Strategy  for  a  fair,  healthy  and 
environmentally-friendly food system - COM 2020 (381 final) 
16 Communication from the Commission to the European Parliament, the Council, the European Economic and 
Social Committee and the Committee of the Regions – EU Biodiversity Strategy for 2030 – COM 2020 (380) 
final 
17 Communication from the Commission to the European Parliament, the Council, the European Economic and 
Social Committee and the Committee of the Regions - EU Action Plan: 'Towards Zero Pollution for Air, Water 
and Soil' – COM 2021(400)final 

2 

 
 
                                                           
- 

- 
- 
- 

- 

- 
- 
- 
- 

the  adoption  and  implementation  of  the  Regulation  on  Veterinary  Medicinal 
Products18, the Regulation on Medicated Feed19, and relating tertiary legislation20; 
the EU4Health programme21; 
the Horizon Europe programme22; 
the reinforcement of the EU health security framework, notably through the adoption 
of  the  Regulation  on  serious  cross-border  threats  to  health23  and  the  reinforced 
mandates of the European Centre for Disease Prevention and Control (ECDC)24 and 
the European Medicines Agency (EMA)25; 
the  new  Commission  Implementing  Decision  on  the  monitoring  and  reporting  of 
AMR in zoonotic and commensal bacteria26;  
the building of the European Health Union27; 
the creation of the Health Emergency Response Authority (HERA)28; 
the adoption of the Pharmaceutical Strategy for Europe29; 
the adoption of the EU Global Health Strategy30. 

18 Regulation (EU) 2019/6 of the European Parliament and of the Council of 11 December 2018 on veterinary 
medicinal products and repealing Directive 2001/82/EC (OJ L 4, 7.1.2019, p. 43–167) 
19  Regulation  (EU)  2019/4  of  the  European  Parliament  and  of  the  Council  of  11  December  2018  on  the 
manufacture, placing on the market and use of medicated feed, amending Regulation (EC) No 183/2005 of the 
European Parliament and of the Council and repealing Council Directive 90/167/EEC (OJ L 4, 7.1.2019, p. 1–
23). 
20 Implementation of Regulation (EU) 2019/6 on veterinary medicinal products and Regulation (EU) 2019/4 on 
medicated feed 
21 Regulation (EU) 2021/522 of the  European parliament and of the Council of 24 March 2021 establishing a 
Programme for the Union’s actions in the field of health (‘EU4Health Programme’) for the period 2021-2027, 
and repealing Regulation (EU) No282/2014 (OJ L 107, 26.3.2021,p.1). 
22  Regulation  (EU)  2021/695  of  the  European  Parliament  and  of  the  Council  of  28  April  2021  establishing 
Horizon  Europe  –  the  Framework  Programme  for  Research  and  Innovation,  laying  down  its  rules  for 
participation and dissemination, and repealing Regulations (EU) No 1290/2013 and (EU) No 1291/2013 (OJ L 
170, 12.5.2021, p. 1–68) 
23 Regulation (EU) 2022/2371 of the European Parliament and of the Council of 23 November 2022 on serious 
cross-border threats to health and repealing Decision No 1082/2013/EU 
24 Regulation (EU) 2022/2370 of the European Parliament and of the Council of 23 November 2022 amending 
Regulation (EC) No 851/2004 establishing a European centre for disease prevention and control 
25 Regulation (EU) 2022/123 of the European Parliament and of the Council of 25 January 2022 on a reinforced 
role  for  the  European  Medicines  Agency  in  crisis  preparedness  and  management  for  medicinal  products  and 
medical devices 
26 Commission Implementing Decision (EU) 2020/1729 of 17 November 2020 on the monitoring and reporting 
of  antimicrobial  resistance  in  zoonotic  and  commensal  bacteria  and  repealing  Implementing  Decision 
2013/652/EU (OJ L 387, 19.11.2020, p. 8–21) 
27 Communication from the Communication to the European Parliament, the Council, the European Economic 
and Social Committee and the Committee of the Regions - Building a European Health Union: Reinforcing the 
EU’s resilience for cross-border health threats - COM(2020) 724 final  
28  Commission  Decision  of  16  September  2021  establishing  a  Health  Emergency  Preparedness  and  Response 
Authority - C(2021) 6712 final   
29 Communication from the Commission to the European Parliament, the Council, the European Economic and 
Social  Committee  and  the  Committee  of  the  Regions  -  Pharmaceutical  Strategy  for  Europe  -  COM/2020/761 
final 
30 EU Global Health Strategy: Better Health for All in a Changing World  

3 

 
 
                                                           
Member States have also put in place new policy initiatives that could help to boost the fight 
against AMR  in  the EU, notably those  policy initiatives  brought  about  by COVID-19 (e.g., 
joint  procurement  and  diagnostics).  In  the  meantime,  progress  in  research,  innovation  and 
technology is expected to positively influence the fight against AMR, for example the phage 
therapy31 clinical trials. Behavioural and societal changes are also shaping a new context for 
AMR as shown by the 2022 Special Eurobarometer on AMR32. Although some progress has 
been achieved since the last Eurobarometer in 201833, reducing the misuse of antimicrobials 
remains a challenge. 

In light of these developments, there was a need to assess the progress in the implementation 
and outcomes of the 2017 AMR Action Plan, to review its relevance and coherence against 
the  new  challenges  and  opportunities  brought  by  recent  and  potential  future  developments 
and to  prioritize the most impactful activities in  order to  reach concrete  outcomes reducing 
the development and spread of AMR. 

2.  METHODOLOGY 

future  scientific, 

To  achieve  a  solid  base  for  the  proposed  Council  Recommendation,  the  Commission 
launched a study on a future-proofing analysis of the EU AMR Action Plan34. The aim of this 
study  was  to  assess  the  outcomes  of  the  2017  AMR  Action  Plan  to  date  and  to  identify 
priorities to inform improvements for the future. In particular, the study identified recent and 
potential 
technological,  environmental,  agricultural  and  societal 
developments influencing AMR and analysed the relevance of the 2017 AMR Action Plan in 
the light of those developments. In the assessment of the 2017 AMR Action Plan, the study 
considered the fifteen specific objectives under the three pillars and assessed to which extent 
the activities have been effective in  reaching the objectives.  For  several specific objectives, 
gaps have been identified between the implemented actions and the  Action Plan objectives. 
This is outlined in section 3 of this staff working document “Achievements of the 2017 AMR 
Action Plan and Gaps”. In its section 4, the impacts of current  and future developments on 
AMR  as  well  as  how  EU  action  can  be  strengthened  are  considered.  Finally,  section  5 
outlines the recommendations on how the identified gaps and challenges can be addressed.  

The study used a mixed methodology involving (1) a document review complemented by an 
in-depth  review  of  28  selected  activities  within  the  2017  AMR  Action  Plan;  (2)  the 
development  of  future  scenarios;  and  (3)  consultations  with  stakeholders  through  a  call  for 
evidence, interviews, a targeted survey and a future scenarios workshop.  A synopsis report, 
summarizing the results of the stakeholder consultations, is provided in Annex 8 of the study 
on  a  future-proofing  analysis  of  the  2017  AMR  action  plan.  The  documents  reviewed 
captured  information  on  how  factors  relating  to  AMR  may  develop  over  the  next  10  years 
within  thematic  areas  (science  and  technology,  society,  human  health,  animal  health  and 
agriculture,  and  the  environment).  A  public  call  for  evidence  on  a  “recommendation  for 

31 A bacteriophage (or phage) is a virus that infects bacteria. The phage therapy uses bacterial viruses (phages) 
to treat bacterial infections. 
32 Eurobarometer 2022, Antimicrobial Resistance. 
33 Special Eurobarometer 478: Antimicrobial Resistance (in the EU) 
34 European Commission, Directorate-General for Health and Food Safety, Study on a future-proofing analysis 
of  the  2017  AMR  action  plan  :  final  report,  Publications  Office  of  the  European  Union,  2023 
https://data.europa.eu/doi/10.2875/636347 

4 

 
 
                                                           
greater  action  on  antimicrobial  resistance”35  was  launched  on  24  February  2022,  which 
received  161  qualitative  feedbacks  and  28  relevant  documents  in  4  weeks.  Apart  from  the 
document  reviews  and  the  call  for  evidence,  the  study  work  consisted  of  a  targeted  survey 
which received  149 responses,  40 targeted interviews,  a  future scenario  workshops with  28 
multisectoral  stakeholders,  in-depth  activity  review  and  triangulation  of  evidence  and 
analysis.  

Beyond the future-proofing analysis study, the Commission also took into consideration the 
following  published  reports  and  initiatives  launched  to  prevent  and  tackle  development  of 
AMR: 

-  The  subgroup  of  the  AMR  One  Health  Network36  composed  of  Member  States 
representatives  was  tasked  to  provide  technical  expertise  and  opinions  on  concrete 
objectives and  activities to  strengthen EU  and Member States’  action against  AMR. 
They  considered, in  particular, the One Health approach covering the area of public 
health, animal health, plant health and the environment, taking into account the latest 
policy developments.  

-  The Commission performed a review of the Member States existing National Action 
Plans37 (NAPs). The review was a systematic check to ascertain the extent to which 
Member States have developed NAPs, including how the One Health dimension and 
governance mechanisms are reflected therein as well as policy objectives per area.  
-  The Expert Panel on effective ways of investing in health (EXPH)38 was requested to 
provide  a  policy-oriented  opinion  with  analysis  and  recommendations  on  the  One 
Health  dimension  of  AMR,  the  impact  of  new  technologies,  existing  AMR  policies 
and concrete strategies to tackle AMR in the future.  

-  The  latest  EU-JAMRAI  report39  and  the  case  study  report  on  AMR40  from  the 
evaluation  study41  of  the  European  Framework  Programmes  for  Research  and 
Innovation were also reviewed.  

-  The  Commission  launched  a  Eurobarometer  on  AMR42.  It  comprised  a  series  of 
surveys among the general public to monitor their levels of knowledge and usage of 

35 Antimicrobial resistance – recommendation for greater action  
36  Final  report  -  Subgroup  established  under  the  EU  AMR  One  Health  Network  to  formulate  suggestions  for 
AMR Actions  
37 Overview report on the review  of Member States’ One Health National  Action Plans against  Antimicrobial 
Resistance. Globally, countries committed to the framework set out in the Global Action Plan (GAP) 2015 on 
AMR  during  the  2015  World  Health  Assembly  and  committed  to  the  development  and  implementation  of 
multisectoral  national  action  plans.  To  ensure  global  progress,  countries  need  to  ensure  costing  and 
implementation of national action plans across sectors to ensure sustainable progress. 
38 Expert Panel on Effective Ways of Investing in Health, Managing antimicrobial  
resistance across the health system, 26 October 2022  
39  European  Joint  Action  on  Antimicrobial  Resistance  and  Healthcare-Associated  Infections  (EU-JAMRAI), 
LAYMAN REPORT  
40 This case study analysed a portfolio of 188 AMR actions funded under H2020. These actions were directly 
related to AMR R&D and were a part of a larger portfolio of projects that addressed infectious diseases and that 
directly and indirectly will also contribute to advancements in AMR R&D. 
41 [Publication forthcoming] 
42  Eurobarometer  2022,  Antimicrobial  Resistance.  This  survey  was  carried  out  by  the  Kantar  Public  Brussels 
network  in  the  27  EU  Member  States  between  21  February  and  21  March  2022.  In  total,  26,511  respondents 
from different social and demographic groups were interviewed face-to-face at home in their mother tongue. 

5 

 
 
                                                           
antibiotics. The 2022 survey represents the fourth in the series of surveys and tracks 
progress on public use of and knowledge about antibiotics. 

On the basis of the results of the future-proofing analysis study and the review of the above- 
mentioned  reports,  a  review  of  the  achievements  and  remaining  gaps  of  the  2017  AMR 
Action Plan is presented below. Factors that influence how AMR may develop in the future 
are also considered to inform recommendations on how actions can be strengthened.  

3.  ACHIEVEMENTS OF THE 2017 AMR ACTION PLAN AND GAPS 

The following sections outline the implementation and outcomes of key activities of the 2017 
AMR Action Plan. Gaps between implemented activities and the objectives are also reported 
as  identified  notably  by  the  study  on  the  future-  proofing  analysis  of  the  EU  AMR  Action 
Plan. 

3.1 

Pillar 1: Making the EU a best practice area 

Achievements 

To achieve the specific objective 1.1 of better evidence and awareness of the challenges of 
AMR,  different  actions  took  place  to  strengthen  One  Health  surveillance  and  reporting  of 
AMR  and  antimicrobial  use,  benefit  from  the  best  evidence-based  analysis  and  data,  and 
increase awareness and understanding of AMR, including: 

- 

- 

- 

the  adoption  of  a  new  EU  implementing  decision  on  monitoring  and  reporting  of 
AMR  in  zoonotic  and  commensal  bacteria  and  on  the  communicable  diseases  and 
related special health issues to be covered by epidemiological surveillance as well as 
relevant case definitions43; 
the  adoption  of  outcome  indicators  for  the  surveillance  of  AMR  and  antimicrobial 
consumption in humans and food-producing animals44; and 
the  support  to  Member  States  in  their  awareness-raising  efforts  through  the  annual 
European Antibiotic Awareness Day45 and the outputs produced by ECDC, including 
the  ECDC  annual  updates  on  AMR  and  antibiotic  consumption  surveillance  from 
EU/EEA countries46. 

Moreover,  the  Commission  has  made  proposals  for  the  harmonised  monitoring  of  AMR  in 
the environment. The Commission proposal for a recast of the Urban Waste Water Treatment 
Directive47 includes the requirement to establish the mandatory surveillance of AMR, at least 
twice a year, at the inlets and outlets of urban wastewater treatment plants for agglomerations 
of 100 000 population equivalent and above and, when relevant, in the collecting systems. To 
that  end,  the  Commission  is  empowered  to  adopt  an  implementing  act  to  establish  a 
harmonised  methodology  for  measuring  AMR  in  urban  wastewaters.  In  the  Commission 

43  Commission  implementing  Decision  (EU)  2018/945  of  22  June  2018  on  the  communicable  diseases  and 
related special health issues to be covered by epidemiological surveillance as well as relevant case definitions 
44  ECDC,  EFSA  and  EMA  Joint  Scientiﬁc  Opinion  on  a  list  of  outcome  indicators  as  regards  surveillance  of 
antimicrobial resistance and antimicrobial consumption in humans and food-producing animals 
45 European Antibiotic Awareness Day (EAAD) 2022  
46 European Centre for Disease Prevention and Control, Annual surveillance reports on antimicrobial resistance.  
47 Proposal for a revised Urban Wastewater Treatment Directive – COM(2022) 541 final 

6 

 
 
                                                           
proposal  reviewing  the  water  legislation48,  microorganisms,  genes  or  genetic  material 
reflecting  the  presence  of  microorganisms  resistant  to  antimicrobial  agents,  in  particular 
microorganisms pathogenic to humans or livestock, have been included in the indicative list 
of main pollutants49. Moreover, the Commission  intends to  include  AMR genes in  the next 
watch  list  under  the  Environmental  Quality  Standards  Directive50,  after  the  Directive’s 
proposed revision. The Commission proposal reviewing the water legislation also includes a 
number of antimicrobial substances in the priority substances list under the Water Framework 
Directive  and  sets  quality  standards  for  those  substances  both  in  groundwater  and  surface 
water.  

To  achieve  a  better  coordination  and  implementation  of  EU  rules  to  tackle  AMR 
(specific objective 1.2) several initiatives were put in place. In particular, the EU launched a 
joint action to tackle AMR and healthcare-associated infections (EU-JAMRAI)51, co-funded 
by  the  Third  EU  Health  Programme52,  to  support  collaborative  activities  and  policy 
development by Member States. The EU-JAMRAI conducted a wide range of activities, e.g., 
producing work packages on the implementation of One Health national strategies and NAPs 
for AMR, on infection prevention and control and antimicrobial stewardship, contributing to 
better coordination, better knowledge and increased sharing of information. Additionally, the 
EU  supported  the  implementation  of  national  One  Health  action  plans  through  joint 
Commission/ ECDC visits to Member States upon their request.  

To reach the specific objective 1.3 of better prevention and control of AMR, the WHO and 
ECDC have carried out annual infection prevention and control trainings from 2018-2021. In 
2018,  2019  and  2020, the  training  was  attended  by  senior  healthcare  professionals  from  13 
countries  in  the  WHO  European  region.  The  workshops  focussed  on  a  different  aspect  of 
infection prevention and control support each year, starting with the infection prevention and 
control core concepts, and moving on to their implementation and the development of action 
plans  at  national  level.  Regarding  better  prevention,  Member  States  used  the  2015  EU 
guidelines  for  the  prudent  use  of  antimicrobials  for  veterinary  medicine53  to  inform  the 
understanding  of  best  practices  and  develop  guidelines  at  national  level;  the  Commission 
monitored Member States’ efforts to encourage this prudent use54. Similarly, Member States 
used  the  2017  EU  guidelines  for  the  prudent  use  of  antimicrobials  in  human  health55  to 

48  Proposal  for  a  Directive  amending  the  Water  Framework  Directive,  the  Groundwater  Directive  and  the 
Environmental Quality Standards Directive  
49  Annex  VIII  to  Directive  2000/60/EC  of  the  European  Parliament  and  of  the  Council  of  23  October  2000 
establishing a framework for Community action in the field of water policy 
50  Directive  2008/105/EC  of  the  European  Parliament  and  of  the  Council  of  16  December  2008  on 
environmental  quality  standards  in  the  field  of  water  policy,  amending  and  subsequently  repealing  Council 
Directives  82/176/EEC,  83/513/EEC,  84/156/EEC,  84/491/EEC,  86/280/EEC  and  amending  Directive 
2000/60/EC of the European Parliament and of the Council 
51 The Joint Action ‘EU-JAMRAI’ was launched in 2017, bringing together 44 participating partners (National 
Competent Authorities, National Institutes of public health, National veterinary Institutes and universities) and 
over 45 stakeholders across Member States (in the form of a Stakeholder Forum), including representatives from 
international organisations, industry, healthcare professional associations and patient associations. 
52 EU Health Programme  
53 Guidelines for the prudent use of antimicrobials in veterinary medicine. (2015/C 299/04)   
54 Overview Report - Measures to tackle Antimicrobial Resistance through the Prudent Use of Antimicrobials in 
Animals 
55 EU Guidelines for the prudent use of antimicrobials in human health (2017/C 212/01) 

7 

 
 
                                                           
develop AMR NAPs and implement measures to promote the prudent use of antimicrobials in 
humans.  In  addition,  Regulation  (EU)  2019/6  on  Veterinary  Medicinal  Products56  and 
Regulation  2019/4  on  Medicated  Feed57  provide  since  2022  a  stronger  mechanism  for 
promoting  prudent  and  responsible  use  of  antimicrobials  in  all  animal  species,  including 
companion animals, by means of concrete legal obligations. In line with the requirements of 
Regulation  (EU)  2019/6  on  Veterinary  Medicinal  Products,  Member  States  have  to  collect 
relevant  and  comparable  data  on  the  volume  of  sales  and  on  the  use  of  antimicrobial 
medicinal  products  used  in  animals.  Furthermore,  Regulation  (EU)  2022/2371  on  serious 
cross-border threats to health covers AMR which is defined as one of the serious cross-border 
threats  to  health  of  biological  origin.  Application  and  implementation  of  this  Regulation 
allows to  reinforce  collection of comparable  and compatible data and information on AMR 
and antimicrobial consumption (AMC), in particular through the designation of one or more 
EU  reference  laboratories  specifically  on  AMR  and  the  adoption  of  tertiary  legislation 
focusing on AMR and AMC.  

To  better  address  the  role  of  the  environment  (specific  objective  1.4),  the  Commission 
identified  actions  in  the  2019  EU  Strategic  Approach  on  Pharmaceuticals  in  the 
Environment58 to be taken or further investigated at EU and/or Member State level to address 
the risks from and contribution of pharmaceutical residues in the environment to AMR. The 
Strategic  Approach  also  aims  to  encourage  action  in  third  countries  where  pharmaceutical 
emissions from manufacturing and other sources are suspected of contributing to the global 
spread of AMR. There has been some international cooperation on this matter through WHO 
and  United  Nations  (UN)  work,  and  especially  through  the  Strategic  Approach  to 
International  Chemicals  Management59.  This  has  provided  frameworks  for  cooperation  and 
action in third countries. The Strategic Approach also seeks to facilitate the exchange of best 
practices on the environmentally safe disposal of medicinal products and clinical waste, and 
the collection of pharmaceutical residues. For this, an ad-hoc working group was established 
under  the  Pharmaceutical  committee  to  focus  on  the  above  actions  of  the  EU  Strategic 
Approach on Pharmaceuticals  in  the Environment. Further progress  has been made through 
the  publication  of  EFSA’s  scientific  opinion  on  the  role  played  by  the  environment  in  the 
emergence and spread of AMR through the food chain60.  

As  described  in  the  2022  Progress  Report  on  the  EU  AMR  Action  Plan61,  four  concrete 
activities have been undertaken to achieve a stronger partnership against AMR and better 
availability of antimicrobials (specific objective 1.5): (1) The EU has supported work with 
stakeholders to ensure the availability of human and veterinary antimicrobials and continued 

56   Regulation (EU) 2019/6 of the European Parliament and of the Council of 11 December 2018 on veterinary 
medicinal products and repealing Directive 2001/82/EC (OJ L 4, 7.1.2019, p. 43–167) 
57  Regulation  (EU)  2019/4  of  the  European  Parliament  and  of  the  Council  of  11  December  2018  on  the 
manufacture, placing on the market and use of medicated feed, amending Regulation (EC) No 183/2005 of the 
European Parliament and of the Council and repealing Council Directive 90/167/EEC (OJ L 4, 7.1.2019, p. 1–
23) 
58 Communication from the Commission to the European Parliament, the Council and the European Economic 
and  Social  Committee  on  the  European  Union  Strategic  Approach  to  Pharmaceuticals  in  the  Environment, 
COM(2019) 128 final 
59 Strategic Approach to International Chemicals Management  
60  European  Food  Safety  Authority  2021,  Role  played  by  the  environment  in  the  emergence  and  spread  of 
antimicrobial resistance (AMR) through the food chain.  
61 Progress Report on the 2017 EU AMR Action Plan, Q2 2022  

8 

 
 
                                                           
access  to  established  antimicrobials,  as  well  as  the  provision  of  incentives  to  increase  the 
uptake of diagnostics, antimicrobial alternatives and vaccines. A completed action to support 
this  specific  objective  is  the  discussion  in  the  In  Vitro  Diagnostic  Technical  Group  (IVD 
TG)62.  (2)  In  addition,  the  EU  has  engaged  with  and  supported  collaboration  among  key 
stakeholders  in  the  human  health,  animal  health,  food,  water  and  environmental  sectors  to 
encourage  the  responsible  use  of  antimicrobials  and  appropriate  handling  of  waste  material 
through  “Better  Training  for  Safer  Food”  (BTSF)  training  activities,  discussions  in  the 
plenary  of  the  advisory  group  of  the  food  chain  and  animal  and  plant  health  and  an  EMA 
information session on AMR. (3) The EU has also assisted Member States and stakeholders 
in the successful implementation of the safety features (unique identifier) to reduce the scope 
for falsified medicines and (4) discussed the availability of veterinary antimicrobials to tackle 
AMR in the Veterinary Pharmaceutical Committee.  

Identified gaps  

Monitoring  systems  for  AMR  are  not  operational  in  all  Member  States  which  hampers 
achieving  better  evidence  and  awareness  of  the  challenges  of  AMR.  In  particular, 
harmonised  outcome  indicators  for  evaluating  progress  made  at  national  level  are  not  in 
place.  While  a  target  on  the  reduction  of  the  overall  EU  sales  of  antimicrobials  for  farmed 
animals and in aquaculture by 2030 has been included in the Farm to Fork Strategy, there is 
currently no AMR target in the human health sector.  Generally, differences across Member 
States continue to exist in both areas, mostly due to varying degrees of resources  available, 
traditional views and national methods of working. Therefore, progress is less than expected, 
especially in countries with fewer resources. Indeed, according to the EXPH, although most 
EU Member States have NAPs in place, too few are fully implemented. Furthermore, in its 
overview  report  of  17  November  202263,  the  Commission  found  that  the  NAPs  vary 
considerably  in  content,  detail  and  core  components.  For  instance,  the  operational, 
monitoring  and  evaluation  parts,  are  generally  not  well  developed,  nor  available  in  other 
documents cross-linked to NAPs. Finally, awareness-raising efforts among stakeholders and 
the  general  public  are  not  sufficiently  tailored  to  respond  to  specific  national  needs  and 
country settings.  

Activities  and  actions  to  better  address  the  role  of  the  environment  are  still  largely 
ongoing  and  have  overall  been  less  developed  than  in  other  dimensions  of  the  One  Health 
approach.  A  relevant  gap  is  a  persistent  lack  of  communication  around  research  on 
environmental issues. This may be because relevant knowledge is not widely communicated 
with  relevant  stakeholders,  and  AMR  discourse  may  not  include  researchers  working  on 
AMR and environment64. In addition, there is insufficient awareness of the existing body of 
evidence emerging on the role of the natural environment in AMR.  

62 Register of Commission Expert Groups and Other Similar Entities, In Vitro Diagnostic Technical Group 
63 Overview report on the review of Member States’ One  Health National  Action Plans against  Antimicrobial 
Resistance   
64 European Commission, Directorate-General for Health and Food Safety, Study on a future-proofing analysis 
of  the  2017  AMR  action  plan  :  final  report,  Publications  Office  of  the  European  Union,  2023, 
https://data.europa.eu/doi/10.2875/636347  

9 

 
 
                                                           
Regarding  the  availability  of  existing  antimicrobials,  the  EU-JAMRAI65  identified 
shortages  of  existing  antibiotics  in  EU  Member  States  and  third  countries  as  a  serious 
problem.  Due  to  antibiotic  resistance  patterns  and  prescribing  habits,  the  markets  of  some 
essential  antibiotics  are  small,  including  those  for  children.  Those  shortages  of  older  and 
newer  generic  antibiotics  lead  to  more  broad-spectrum  use  of  antibiotics  which  in  turn 
increases the risk of AMR. One major barrier to continued access is insufficient transparency 
of  where  active  pharmaceutical  ingredients  are  manufactured.  National  medicines  agencies 
and procurers lack the tools to work proactively to avoid antibiotic shortages. In addition, the 
world supply of active pharmaceutical ingredients is highly concentrated in a few countries, 
outside of the EU/EEA.  

3.2 

Pillar 2: Boosting research, development and innovation 

Achievements 

To improve knowledge on detection, effective infection control and surveillance (specific 
objective  2.1),  the  activities  supported  by  the  Commission  include  research  into  the 
development and testing of interventions that prevent the development  and spread of AMR, 
improve  the  understanding  of  the  epidemiology  of  AMR,  support  the  development  of  new 
tools  for  early  (real-time)  detection  of  resistant  pathogens  in  humans  and  animals,  and 
support new eHealth solutions. The activities have produced promising outputs, especially in 
terms  of  developing  stewardship  tools  to  combat  AMR  (i.e.,  a  digital  antimicrobial 
stewardship smartphone application to combat AMR, the AB-Assistant project66) as well as 
new methods to advance research for AMR detection (i.e., WORLDCOM project67).  

Research  was  also  supported  for  the  development  of  new  antimicrobials  and  alternative 
products for humans and animals as well as the repurposing of existing antimicrobials or on 
the  development  of  new  combination  therapies  (specific  objective  2.2).  In  particular,  12 
relevant  projects  have  been  funded  in  2018  through  the  EU’s  research  funding  programme 
Horizon  2020  (H2020)68.  Furthermore,  reporting  activities  referring  to  many  projects  have 
been  completed  or  are  currently  ongoing,  including  reporting  activities  on  eight  projects 
funded  in  the  context  of  the  EU’s  two  public-private  partnerships,  i.e.  the  Innovative 
Medicines Initiative69 (IMI) (funded under the 7th Framework Programme for Research and 
Innovation) and the IMI2 (funded under H2020). These EU-funded initiatives have supported 
the  New  Drugs  for  Bad  Bugs  (ND4BB)70  Programme  and  the  Antimicrobial  resistance 

65  European  Joint  Action  on  Antimicrobial  Resistance  and  Healthcare-Associated  Infections  (EU-JAMRAI), 
Incentivizing antibiotic access and innovation. 
66 A digital antimicrobial stewardship smartphone application to combat AMR: the AB-assistant (AB-assistant) 
67  WORLDCOM:  Development  of  new  tools  for  real-time  detection  of  zoonotic  bacteria  and  antimicrobial 
resistance in  veterinary, human and environmental sources. The WORLDCOM project,  supported by  the  One 
Health European Joint Programme (OH EJP), developed new methods and tools for detection of AMR zoonotic 
pathogens in agriculture and environmental settings.   
68  Horizon  2020  Call  topics  SC1-BHC-14-2019  on  stratified  host-directed  approaches  to  improve  prevention, 
treatment  and/or  cure  of  infectious  diseases;  and  Horizon  2020  Call  topics  SC2-SFS-11-2018-2019  on 
antimicrobials and animal production. 
69 https://www.imi.europa.eu/about-imi  
70  https://www.imi.europa.eu/projects-results/project-factsheets/nd4bb.  The  ND4BB  had  multiple  streams, 
including  ENABLE  ,  which  aimed  to  develop  attractive  antimicrobial  candidates  for  extensive  preclinical 
studies  and  First-in-Human  clinical  trials,  as  well  as  TRANSLOCATION  focused  on  drug  discovery, 

10 

 
 
                                                           
 
Accelerator71 (AMR accelerator). Two specific projects, DRIVE-AB72 (funded under the IMI 
ND4BB)  and  Phagovet73  (funded  under  H2020),  have  produced  outputs  contributing  to 
increased  knowledge,  including  at  the  international  level,  and  understanding  of  limitations 
and  possibilities  in  the  context  of  the  development  of  new  therapeutics  and  alternatives  to 
antibiotics. In particular, DRIVE-AB outputs have enabled the development of pilots on pull 
incentives  across  Europe  and  internationally,  while  Phagovet  contributed  to  advancing 
research in  the area of phage-based products  as  alternatives to  antibiotics. Furthermore, the 
Commission  has  been  supporting  different  research  projects  for  the  establishment  of  a 
European-wide  sustainable  clinical  research  network  for  infectious  diseases  (ECRAID)74  to 
efficiently  generate  evidence  to  improve  the  diagnosis,  prevention  and  treatment  of 
infections.  

The EU has also provided continued support and funding for research into the development 
of  new  preventive  vaccines  for  humans  and  for  animals  (specific  objective  2.3).  Several 
projects have been funded for this activity under H2020, including the SAPHIR75 project on 
novel vaccine strategies for animal production and the TBVAC202076  project on advancing 
novel and promising tuberculosis (TB) vaccine candidates from discovery to preclinical and 
early  clinical  development.  The  outputs  produced  by  TBVAC2020  and  SAPHIR  are  being 
used  by  actors  involved  in  the  development  of  new  vaccines,  including  by  academic 
institutes, research laboratories and pharmaceutical companies. 

In  addition,  the  EU  has  supported  research  into  the  development  of  novel  diagnostics 
(specific objective 2.4), in particular on-site tests in humans and animals. Seven projects were 
initiated in the context of the One Health European Joint Programme (OH EJP) including on 
new  diagnostics  tools  on  AMR.  Furthermore,  two  projects  that  have  been  funded  under 

COMBACTE  focused  on  drug  development  for  gram  positive  bacteria,  and  COMBACTE-CARE, 
COMBACTE-MAGNET, and iABC focused on drug development for gram-negative bacteria. 
71 https://www.imi.europa.eu/projects-results/project-factsheets/amr-accelerator  
72 The project DRIVE-AB conducted research on specific bottlenecks affecting the development of antibiotics 
and evaluated possible solutions: Driving re-investment in R&D and responsible antibiotic use (DRIVE-AB). 
73 The project Phagovet has been conducting research on alternatives to antibiotics in poultry production and is 
producing  promising  initial  results  in  terms  of  proving  safety  and  efficacy  of  phage-based  products:  A  cost-
effective solution for controlling Salmonella and Escherichia coli in poultry production (Phagovet). 
74 https://www.ecraid.eu/. One of the outputs consisted of a Business Plan serving as the implementation basis 
for  a  coordinated,  permanent,  and  pan-European  infrastructure  for  clinical  research  on  infectious  diseases, 
ECRAID74.  This  infrastructure,  that  builds  upon  the  COMBACTE  programmes,  has  now  been  established,  it 
provides  a  platform,  first  of  its  kind  in  Europe,  to  offer  a  single  point  of  access  to  a  pan-European  clinical 
research network for infectious diseases.  
75 Strengthening  Animal Production and Health through the  Immune Response (SAPHIR). The outputs of the 
SAPHIR  project  include  six  laboratory-tested,  promising  candidate  vaccines  to  protect  against  six  major 
pathogen strains affecting cattle, pigs and poultry, with one already licensed to a pharmaceutical company for 
commercial development and other companies interested in two others. 
76  Advancing  novel  and  promising  TB  vaccine  candidates  from  discovery  to  preclinical  and  early  clinical 
development (TBVAC2020). The project TBVAC2020 identified 13 promising new TB vaccines candidates and 
established a unique global platform for TB biomarker research and development resulting in a rich pipeline of 
biomarkers, while also contributing to better knowledge sharing and exchange with more than 120 publications 
in scientific journals. 

11 

 
 
                                                                                                                                                                                     
H2020 have produced significant outputs: the FAPIC77 project on developing a fast assay for 
pathogen  identification  and  characterization  and  the  PoC-ID78  project  on  Point-of-Care 
diagnostics  for  infectious  diseases.  In  addition,  projects  of  H2020  contributed  to  advancing 
the AMR research and innovation field by bringing diagnostic tools and alternative therapies 
for infection treatment closer to the market.  

Under specific objective 2.5 to  develop new economic  models  and incentives, actions  are 
ongoing  to  increase  the  evidence  base  for  understanding  the  societal  costs  and  benefits  of 
different  strategies for  fighting AMR,  and to  support research into the development  of new 
economic models, exploring and analyzing  financial incentives to boost the development of 
new  therapeutics,  alternatives,  vaccines  and  diagnostics.  Different  research  projects  have 
been  funded  under  these  activities,  including  the  DRIVE-AB  project  funded  under  the  IMI 
ND4BB Programme described in specific objective 2.2. The reporting activity related to this 
project was conducted in the context of the 2017 AMR Action Plan and completed in 2018. 
The DRIVE-AB project significantly contributed to advancing research into the development 
of new economic models to boost the development of new antibiotics. It produced significant 
results  as  it  has  researched  and  assessed  economic  incentives  gathered  from  different 
industries and identified incentives applicable to the antibiotic development.   

Continued efforts have led to progress in terms of closing knowledge gaps on AMR in the 
environment and on how to prevent AMR evolution and transmission (specific objective 
2.6). The Commission has supported research into knowledge gaps on the release of resistant 
microorganisms and antimicrobials into the environment and their spread. Many actions have 
been  taken  to  further  develop  knowledge  on  AMR  in  the  environment,  including  the 
NEREUS79  action  which,  amongst  other,  conducted  a  multinational  survey  of  cefotaxime-
resistant  coliforms  in  urban  wastewater  treatment  plants,  a  reflection  paper  from  EMA80 
which reviewed currently available data on antimicrobials in the environment and their role 
in  the  transmission  of  antimicrobial  resistance  genes,  and  the  PREMIER81  project  which 
seeks to develop a database with environmental information on pharmaceuticals and a novel 
information and assessment guiding system to support regulators, water managers and other 
stakeholders  in  identifying  and  managing  any  potential  environmental  risks  associated  with 
the  patient  use  of  medicines.  Another  action  described  in  the  2022  Progress  Report  on  the 
2017  AMR  Action  Plan  is  the  development  of  technologies  that  enable  efficient  and  rapid 
degradation  of  antimicrobials  in  wastewater  and  the  environment  and  reduce  the  spread  of 
AMR.  Actions  taken  to  further  develop  such  technologies  include  the  LIFE  Programme82 

77  Fast  Assay  for  Pathogen  Identification  and  Characterization  (FAPIC).  The  FAPIC  project  developed  two 
automated instruments based on specifications and assay protocols, one of which has been clinically validated. 
The  tools  provide  a  better  understanding  of  the  genetic  mechanisms  that  bacterial  pathogens  use  to  evade  an 
antibiotic therapy. 
78 Platform for ultra-sensitive Point-of-Care diagnostics for Infectious Diseases (PoC-ID). The PoC-ID project 
produced  new  microelectronic  based  sensors  in  a  point-of-care  in  vitro  diagnostic  (PoC-ID)  benchtop  device 
which provides accurate analysis results in only approximately 6 minutes. Such novel devices can be applied in 
diagnosis, monitoring of therapeutic responses research of pathogen-host interaction and personalised medicine 
and represent a significant step towards low cost and fast detection of specific biomarkers. 
79 NEREUS Cost Action  
80  Reflection  paper  on  antimicrobial  resistance  in  the  environment:  considerations  for  current  and  future  risk 
assessment of veterinary medicinal products, EMA 
81 PREMIER: Prioritisation and risk evaluation of medicines in the environment, Innovative Medicines Initiative 
82 LIFE Programme, European Climate Infrastructure and Environment Executive Agency. 

12 

 
 
                                                           
which helped develop and promote methods to address pharmaceuticals and other emerging 
contaminants in Wastewater treatment plants, and NEREUS83 which i.a. sought to understand 
the contribution of biological processes to antibiotic resistance spread into the environment. 
Such research actions provide strong knowledge bases to develop needed technology in the 
area. The activities show that progress has been achieved in terms of closing knowledge gaps 
on AMR in the environment and on how to prevent transmission.  

Identified gaps 

In  its  2019  special  report84  on  AMR,  the  European  Court  of  Auditors  noted  that  despite 
providing  a  strategy  for  the  Commission  to  support  research,  the  2017  AMR  Action  Plan 
does  not  address  some  specific  challenges  for  AMR  research  in  the  development  of  new 
antibiotics, given in particular the long timelines required for R&D, as well as challenges in 
integrating  long  term  research  priorities  and  sustaining  activities  across  programming 
periods. The EU-JAMRAI report85 also identified gaps, pointing at a lack of research in the 
environmental  field,  food  safety  area,  infection  prevention  and  control  and  on  how  to 
improve clinical trials for antimicrobials.  

In  addition,  incentives  may  not  be  sufficient  to  encourage  innovation  and  investment  in 
antimicrobials,  medical  countermeasures  against  AMR,  and  innovation  in  wastewater 
management such that they are brought to the market. Fragmentation of the type and target of 
incentives across Member States makes it difficult for incentives to be effective.  

None  of  the  innovative  solutions  to  stimulate  the  development  of  novel  antibiotics  (i.e., 
economic incentives in the context of the DRIVE-AB project) have been implemented at EU 
or at national level. Furthermore, limited access to new and pre-existing antibiotics is driving 
resistance  development  because  of  prolonged  infections,  greater  use  of  broader  spectrum 
antibiotics, and the creation of market opportunities for substandard and falsified antibiotics. 
Thus,  there  is  still  room  for  push  and  pull  incentives  to  encourage  the  development  of 
innovative  novels  antimicrobials,  as  well  as  the  access  to  antimicrobials  (new  and  existing 
ones),  medical  countermeasures  such  as  preventive  vaccines  against  certain  resistant 
pathogens,  a  stronger  focus  on  public-private  partnerships  and  greater  attention  to  the 
development of novel diagnostics.  

The EU-JAMRAI report86 identified gaps with regards to EU infection prevention and control 
programmes, in particular a lack of active involvement of hospital administrators and clinical 
department  heads,  insufficient  cooperation  between  hospital  administrators,  infection 
prevention  and  control  teams  and  public  health  authorities,  and  a  lack  of  human  and 
budgetary resources.  

83 NEREUS Cost Action ES1403. 2018. Deliverable 15 Harmonized protocols for effect-based in vitro biotests 
(bioassays) able to serve as routine tools for analysis and evaluation of the efficiency of the various treatment 
technologies to remove toxicological hazards and evaluate the quality of the wastewater to be reused. 
84 Special report No 21/2019: Addressing antimicrobial resistance: progress in the animal sector, but this health 
threat remains a challenge for the EU  
85  European  Joint  Action  on  Antimicrobial  Resistance  and  Healthcare-Associated  Infections  (EU-JAMRAI), 
LAYMAN REPORT   
86  European  Joint  Action  on  Antimicrobial  Resistance  and  Healthcare-Associated  Infections  (EU-JAMRAI), 
LAYMAN REPORT  

13 

 
 
                                                           
Furthermore,  the  current  European  monitoring  system  does  not  cover  AMR  surveillance  in 
sick animals, as pointed out in the EU-JAMRAI report. This is of limited help to veterinary 
practitioners  and  policymakers  seeking  to  improve  antimicrobial  prudent  use  in  animal 
health. 

3.3 

Pillar 3: Shaping the global agenda 

Achievements 

To promote a stronger EU global presence (specific objective 3.1), the EU has played an 
active  role  in  collaborating  with  international  organisations.  The  Commission  has  been 
contributing to the normative work of the WHO, the World Organisation for Animal Health 
(WOAH),  the  Food  and  Agriculture  Organisation  of  the  United  Nations  (FAO)  and  Codex 
Alimentarius  on  the  development  of  ambitious  international  frameworks  and  standards, 
norms,  guidelines  and  methodologies  related  to  AMR.  The  Commission  has  also  been 
working  towards  continued  high-level  political  attention  and  commitment  to  AMR  action, 
including in UN forums, the G7 and G20, and collaborating with the United States, Canada, 
Norway and the United Kingdom within the Transatlantic Taskforce on AMR87 (TAFTAR). 
Combatting AMR in the context of the One Health approach has also been included in the EU 
Global Health Strategy as a priority88, highlighting that international cooperation is needed to 
ensure a coordinated response to AMR from the global community. 

Activities relating to the specific objective  3.2 of forming stronger bilateral partnerships 
for  stronger  cooperation  include  the  EU-JAMRAI  which  successfully  created  bilateral 
partnerships  across  EU  Member  States  focusing  on  AMR,  as  well  as  the  engagement  with 
major global players and strategic countries (e.g., Brazil, China and India) towards achieving 
the  objectives  of  the  WHO  global  action  plan  on  AMR89.  The  EU  has  been  working  to 
develop  stronger  partnerships  with  third  countries  and  has  delivered  initiatives  to  increase 
networking and collaboration to address the global issue of AMR. Actions undertaken in the 
context  of  this  activity  include  events90  with  India  on  AMR  in  veterinary  medicine,  animal 
health  and  the  environment  (in  2017  and  2021),  which  created  opportunities  to  enhance 
cooperation  between  the  EU  and  India,  as  well  as  the  publication  of  a  report91  regarding 
national  policies  and  measures  against  AMR  in  third  countries  (2018),  and  the  ongoing 
quadripartite  collaboration  project  between  FAO,  WOAH,  PAHO/WHO  and  UNEP 
“Working  together  to  fight  Antimicrobial  Resistance  (2019-2023)”92.  This  collaboration 
supports  the  implementation  of  national  action  plans  in  seven  South  American  countries 
(Argentina, Brazil, Chile, Colombia, Paraguay, Peru and Uruguay). 

The  Commission  is  cooperating  with  developing  countries  (specific  objective  3.3)  on  the 
development of AMR strategies in the area of food safety and animal health through regional 

87 Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) 
88 EU Global Health Strategy: Better Health for All in a Changing World 
89 Global action plan on antimicrobial resistance, WHO 2016  
90 EU-India Dialogue Seminar on the Use of Veterinary Medicine and AMR 
91  Non-EU  Countries’  National  Policies  and  Measures  on  Antimicrobial  Resistance  Report  (2018).  As  part  of 
the report, a questionnaire was sent to 128 EU delegations in non-EU countries. Amongst the 77 countries that 
replied to the questionnaire, 13 were form East Asia and Pacific and 19 from Latin America & Caribbean. 
92  The  Quadripartite  Collaboration  Project  (FAO,  OIE,  PAHO/WHO,  UNEP)  “Working  together  to  fight 
Antimicrobial Resistance (2019-2023)” 

14 

 
 
                                                           
training  workshops  on  AMR.  Third  countries  participate  in  an  AMR  One  Health  training 
within the BTSF programme93. Additionally, between 2017 and 2022, DG INTPA supported 
two projects94 with  the WHO to  pilot  a package of activities to  foster the development  and 
implementation  of  antimicrobial  stewardship  (AMS)  programs  in  hospitals  in  Sub-Saharan 
African  countries  and  to  conduct  surveys  to  identify  the  frequency  of  substandard  and 
falsified  (SF)  antimicrobial  medicines  to  inform  the  development  of  tools  to  support  future 
SF surveillance programs in low resources countries. 

By providing essential information on the status of research, including research developments 
and existing initiatives and opportunities, the EU is contributing to a global research agenda 
(specific objective 3.4). The EU further supports research facilities working on AMR around 
the world, facilitating research coordination, knowledge exchange and capacity development.  

Identified gaps 

Support  to  low  and  middle-income  countries  in  implementing  their  actions  against  AMR 
remains  insufficient  concerning  the  strengthening  of  the  knowledge  and  evidence  base, 
infection  prevention  and  control,  quality  and  use  of  antimicrobials,  as  well  as  sharing  best 
practices from the EU such as antimicrobial stewardship teams.  

4.  FUTURE-PROOFING ANALYSIS AND CHALLENGES 

This  section  assesses  how  current  and  future  developments  might  influence  AMR,  to  what 
extent  the  2017  AMR  Action  Plan  is  relevant  and  coherent  in  light  of  these  developments, 
and how it can be complemented to better address future challenges.  

4.1 

Science, technology and innovation 

While  knowledge  of  AMR  has  improved  over  time,  there  are  still  areas  where  basic  and 
applied  research  may  significantly  change  our  understanding  of  the  threats  posed  by  AMR 
and  the  ways  to  address  them  in  the  future.  Basic  research  has  led  to  knowledge  of  the 
connections  between  animal,  human  and  environmental  health,  but  it  has  not  yet  led  to  a 
precise  understanding  of  how  AMR  is  transferred  between  the  environment,  humans  and 
animals. New discoveries made through basic research in the next ten years could shape how 
well  the  mechanisms  by  which  resistance  is  transferred  are  understood  and  what  policy 
actions  can  be  taken  to  address  it.  Future  research  into  AMR  with  a  One  Health  approach 
which  is  at  the  heart  of  the  2017  AMR  Action  Plan  will  continue  to  be  relevant,  as  new 
evidence  will  emerge  on  how  One  Health  domains  are  linked  and  regarding  the  important 
role of the environment in transfer of resistance. Further areas of research where discoveries 
may be relevant are for example genetic and microbiome factors associated with AMR. 

Similarly,  technological  advancements  may  change  how  AMR  is  addressed.  Advancements 
in  laboratory  techniques  over  the  next  ten  years  may  allow  for  more  rapid  identification  of 

93 BTSF Academy, Courses One Health, Antimicrobial Resistance  
94  PP-AP/2017/387-116  and  P-AP/2018/402-050  Pilot  Projects  “Mapping  the  Global  Threat  posed  by 
Antimicrobial Resistance". 

15 

 
 
                                                           
pathogens,  resistance  and  virulence,  which  could  help  avoid  spread  of  resistant  pathogens, 
reduce the need for antimicrobials and better target their use when necessary95.  

The  slow  progress  in  developing  new  antimicrobials  for  human  health,  in  particular  due  to 
scientific challenges  and high  risk of failed R&D efforts, is  a key issue  in  the fight  against 
AMR  and  there  are  very  few  novel  antimicrobials  currently  in  pharmaceutical  pipelines. 
Since  2017,  only  11  antibiotics  have  been  approved  (by  either  the  Commission  or  the  US 
Food and  Drug Administration or both).  With some exceptions,  the newly  approved agents 
have  limited  clinical  benefit  over  existing  treatment,  as  over  80%  are  from  existing  classes 
where  resistance  mechanisms  are  well  established  and  rapid  emergence  of  resistance  is 
foreseen96. Currently 43 antibiotics and combinations with a new therapeutic entity are in the 
clinical antibacterial pipeline, but only few of them meet at least one of the WHO innovation 
criteria (absence of known cross-resistance, new binding site, mode of  action and/or class). 
The development and availability of novel antimicrobials and other medical countermeasures 
(e.g., vaccines, phage therapy and alternative treatments) for both human and animal health in 
the next ten years will be pivotal in combating AMR. 

How can EU activities be strengthened? 

There  is  a  need  to  further  strengthen  research,  development  and  innovation  (R&D&I) 
activities,  also  around  specific  mechanisms  by  which  resistance  is  transferred  between  the 
One Health dimensions (human, animal and environment). Furthermore, given the emergence 
of resistant strains, there is a need for a new generation of safe and effective antimicrobials, 
alongside  alternative  treatments  and  vaccines  to  mitigate  the  spread  of  AMR.  Therefore, 
continued  support  and  increased  funding  to  R&D&I  to  support  technological  developments 
needs to be strengthened. This should also include further financial and technical support, as 
well as coordination and infrastructure such as universities and clinical research networks. 

To  strengthen  the  One  Health  approach,  there  is  a  need  for  additional  evidence  from  basic 
and applied research (e.g., in genetics, transfer of resistance and the role of the environment) 
clarifying how the One Health approach should be understood and applied in practice. More 
cross-disciplines research, including social sciences, and collaboration can further encourage 
the uptake of the One Health approach. Part of this includes the need for integrated, joined up 
surveillance of AMR as it relates to human health, animal health and the environment.   

4.2 

Society, awareness and education 

Although  many  Europeans  are  aware  of  the  risks  related  to  AMR97,  evidence  points  to  the 
need for continued educational efforts, especially in relation to awareness of AMR among the 
public  and  key  stakeholders  (e.g.,  healthcare  providers,  farmers,  veterinarians).  The  2022 

95 Bassetti, M., Poulakou, G., Ruppe, E. et al. (2017). Antimicrobial resistance in the next 30 years, humankind, 
bugs and drugs: a visionary approach. Intensive Care Med 43, 1464–1475. https://doi.org/10.1007/s00134-017-
4878-x  
96  World  Health  Organisation  2021,  2020  Antibacterial  agents  in  clinical  and  preclinical  development:  an 
Overview and Analysis 
97  Elena-Alexandra  Alexa  (Oniciuc),  Eleni  Likotrafiti,  Alberto  Garre,  Lorena  Ruiz,  Miguel  Prieto,  Avelino 
Alvarez-Ordóñez,  A  European  questionnaire-based  study  on  population  awareness  and  risk  perception  of 
antimicrobial  resistance,  FEMS  Microbiology  Letters,  Volume  366,  Issue  17,  September  2019,  fnz221, 
https://doi.org/10.1093/femsle/fnz221  

16 

 
 
                                                           
Eurobarometer98  showed  that  Europeans’  knowledge  about  antibiotics  leaves  room  for 
improvement. Only half of those questioned are aware that antibiotics are ineffective against 
viruses,  and  there  are  still  great  differences  between  citizens  awareness  among  Member 
States. In addition, almost one in ten Europeans are taking antibiotics without prescription. A 
large majority (79%) of Europeans say they would like further information on antibiotics, a 
sharp  increase  compared  to  2018.  Close  to  one  in  three  mention  wanting  more  information 
regarding  the  medical  conditions  for  which  antibiotics  are  used  and  a  large  majority  of 
Europeans  do  not  remember  getting  any  information  in  the  last  year  about  not  taking 
antibiotics unnecessarily. 

Political will and public awareness of AMR may also be challenging, particularly in light of 
trends  around  misinformation  and  distrust,  and  due  to  competing  priorities  during  times  of 
crisis  and  economic  downturn.  As  human  health  is  largely  a  national  competence,  political 
will among policy makers at Member State level will likely impact how AMR is dealt with. 
Programmes aimed at raising awareness and educating the public and key stakeholders about 
AMR  may  influence  AMR-related  behaviours  into  the  future99.  The  EU-JAMRAI  report61 
also  stresses  that  promoting  behaviour  change  is  the  biggest  challenge  in  the  fight  against 
AMR. 

How can EU activities be strengthened? 

The  results  of  the  2022  Special  Eurobarometer  on  AMR  demonstrate  the  need  to  improve 
awareness-raising  activities  on  AMR  at  all  levels  to  increase  knowledge  and  influence 
behavioural  change.  Although  awareness  raising  and  education  are  primarily 
the 
responsibilities  of  Member  States,  the  2017  AMR  Action  Plan  could  be  strengthened  by 
supporting  national  and  local  efforts  to  educate  all  the  relevant  stakeholders,  including  the 
public,  healthcare  providers,  veterinarians  and  farmers,  about  AMR.  For  example,  this  can 
include supporting Member States in creating and distributing information to the public about 
not  requesting  antimicrobials  for  common  colds  and  how  to  appropriately  dispose 
antimicrobials. For the healthcare providers it is important  to  provide better information  on 
appropriate  diagnosis  for  human  health  and  to  ensure  core  competencies  for  infection 
prevention and control. Education efforts should also include veterinarians and farmers, and 
material about basic hygiene, wastewater treatment and environmental aspects of AMR. It is 
also  important  to  promote  continuous  dialogue  and  collaboration  between  the  human, 
veterinarian and environmental sectors.  

4.3  Human health 

The  use  of  antimicrobials,  vaccines,  diagnostics  and  other  medical  countermeasures  may 
differ  between  Member  States  (e.g.,  due  to  differences  in  capacities  within  healthcare 
systems).  Future  disease  trends  (e.g.,  more  or  fewer  outbreaks  or  pandemics  in  the  future) 
may also influence AMR and the amount of antimicrobials used over the next ten years. 

98 Eurobarometer 2022, Antimicrobial Resistance. 
99 Charani, E., Mendelson, M., Ashiru-Oredope, D., Hutchinson, E., Kaur, M., McKee, M., Mpundu, M., Price, 
J. R., Shafiq, N., & Holmes, A. (2021). Navigating sociocultural disparities in relation to infection and antibiotic 
resistance,  3(4),  dlab123. 
resistance-the  need 
https://doi.org/10.1093/jacamr/dlab123 

intersectional  approach. 

JAC-antimicrobial 

for  an 

17 

 
 
                                                           
Surveillance  of  resistance  in  humans  and  monitoring  of  the  use  of  antimicrobials  in  human 
health will remain a key priority to be dealt with in the future. The ability to collect consistent 
data across geographies is crucial to understand how pathogens and resistance spreads among 
human  populations,  to  assess  the  severity  of  AMR-related  threats  and  to  create  timely  and 
targeted responses to  outbreaks.  The  2017 AMR  Action Plan supports existing surveillance 
and  monitoring  systems,  which  remain  relevant  despite  challenges  with  implementation.  
Currently  the  capacities  to  conduct  surveillance  of  antimicrobial  use  and  AMR  in  humans 
differ between Member States, hampering EU and global efforts around surveillance.  

The  COVID-19  pandemic  presents  challenges  and  opportunities,  and  the  future  will  be 
influenced by the degree to which we are able to build on lessons and progress made during 
the  pandemic.  This  includes  joint  procurement,  wastewater  surveillance,  the  use  of 
diagnostics  in  clinical  care,  breakthroughs  in  the  development  of  vaccines  and  the  use  of 
genomic monitoring as a tool to understand the epidemiology underlying the global and local 
emergence, selection and transmission of AMR.  

How can EU activities be strengthened? 

Although human health is largely a Member State competence, there may be areas where the 
EU is well positioned to increase coherence across Member States. Potential areas that could 
be  strengthened  include  the  support  for  Member  States  to  encourage  antimicrobial 
stewardship,  the  uptake  of  vaccines,  diagnostics  and  other  medical  countermeasures,  and 
infection prevention and control measures, particularly where capacity is lacking. In order to 
improve  access  to  existing  antibiotics,  diversifying  manufacturing  capacity,  greater 
intelligence  gathering  and  surveillance  across  the  supply-chain,  stockpiling,  and  joint 
procurement efforts need to be supported at EU level. 

Supporting Member States in shifting healthcare systems towards prevention is important in 
the  fight  against  AMR,  to  prevent  individual  infections  and  prevent  the  spread  of  AMR  in 
healthcare settings, in particular in long-term care facilities.  

There  is  a  need  for  joined  approaches  to  monitoring  and  surveillance  that  link  AMR  in 
humans, animals and the environment. This would provide further insight into the One Health 
approach and can provide more information to decision makers. In order for this approach to 
be  successful,  Member  States  need  to  collaborate  when  reviewing  integrated  data  and 
incorporating  insights  into  policy  and  practice.  Furthermore,  integrated  systems  for 
surveillance  and monitoring of  AMR  and AMC  at  all levels  (e.g.,  hospitals,  long-term care 
facilities,  community/  primary  care  level)  to  support  the  prudent  use  of  antimicrobials  in 
human health are needed. Setting clear targets at EU and national level on the consumption of 
antimicrobials  in  humans  and  the  spread  of  AMR,  in  particular  regarding  critical  resistant 
pathogens  that  pose  the  highest  burden  and  threat  to  public  health  in  the  EU,  would  bring 
clarity on the necessary level of effort, allow for targeted support where necessary and allow 
monitoring  the  process  made  in  the  coming  years.  Targeted  support  may  be  needed  in 
particular  for  Member  States  that  lack  capacity  to  effectively  perform  surveillance  and 
monitoring.  The  Commission  can  play  a  role  in  encouraging  Member  States  to  support  the 
uptake of best practices with respect to surveillance and monitoring, e.g., complying with the 

18 

 
 
protocols established by ECDC100 to report Member State data to the European Antimicrobial 
Resistance Surveillance Network (EARS-Net)101. 

4.4 

Animal health and welfare 

Poor  animal  welfare  has  an  impact  on  animal  health  and  is  associated  with  higher 
antimicrobial  use  in  animals102.  The  over-use  of  broad-spectrum  antimicrobials  in  animals 
and the lack of good diagnostic techniques and vaccines for animals could worsen AMR in 
the future.  

Improving  animal  welfare  of  food-producing  animals  may  contribute  to  decrease  the 
occurrence and transmission of infectious diseases in farming, contributing to a reduction of 
antimicrobial use. The degree to which the Farm to Fork Strategy’s target of decreasing EU 
antimicrobial sales for farmed animals and aquaculture by 2030 is successful will also likely 
influence AMR. 

However, progress has also been made in the EU with respect to animal and agricultural use 
of antimicrobials and medical countermeasures, which will have a positive impact on AMR, 
such as the list of antimicrobials reserved for human use103 and the Regulations on Veterinary 
Medicinal Products and Medicated Feed which restrict antimicrobial use in animals to what 
corresponds  to  prudent  and  responsible  use  and  requires  Member  States  to  gather  data  on 
antimicrobial  sales  and  use  of  antimicrobials  in  animals.  Acknowledging  the  international 
dimension  of  AMR,  the  Regulation  on  Veterinary  Medicinal  Products  also  requires  that 
operators  in  third  countries  do  not  use  (i)  antimicrobials  in  animals  for  the  purpose  of 
promoting growth or to increase yield and (ii) antimicrobials from the list of those reserved 
for  human  use,  for  animals  and  animal  products  intended  for  human  consumption  to  be 
exported  to  Union.  The  latest  annual  report104  on  European  Surveillance  of  Veterinary 
Antimicrobial  Consumption  (ESVAC)  shows  that,  since  2011,  European  countries  have 
substantially  reduced  sales  of  veterinary  antibiotics  in  animals.  According  to  data  from  25 
countries  that  continuously  provided  input  for  the  full  2011-2021  period,  overall  sales  of 
veterinary  antibiotics  decreased  by  47%  in  this  interval,  reaching  the  lowest  value  ever 
reported. Despite those advances in Europe, global consumption of antimicrobials from food 
are estimated to increase by 67% between the years 2010 and 2030105.  

Furthermore,  surveillance  and  monitoring  of  AMR  in  animals  and  the  food  chain  has 
progressed  in  recent  years,  e.g.,  with  the  publication  of  annual  EU  Summary  reports  on 
zoonotic infections, food-borne outbreaks and AMR produced by EFSA in cooperation with 
ECDC,  and  the  EFSA  baseline  survey  reports  on  the  prevalence  of  AMR  in  the  EU  in 

100  European  Centre  for  Disease  Prevention  and  Control,  Surveillance  and  disease  data  for  antimicrobial 
resistance. 
101 European Antimicrobial Resistance Surveillance Network (EARS-Net). 
102 Rodrigues da Costa, M., & Diana, A. (2022). A Systematic Review on the Link between Animal Welfare and 
Antimicrobial Use in Captive Animals. Animals, 12(8), 1025. MDPI AG. https://doi.org/10.3390/ani12081025  
103 Commission Implementing Regulation (EU) 2022/1255 of 19 July 2022 designating antimicrobials or groups 
of  antimicrobials  reserved  for  treatment  of  certain  infections  in  humans,  in  accordance  with  Regulation  (EU) 
2019/6 of the European Parliament and of the Council  
104  European  Medicines  Agency,  Sales  on  veterinary  antimicrobial  agents  in  31  European  countries  in  2021, 
Trends from 2010 to 2021, Twelfth ESVAC report 
105 Bloomer, E. and McKee, M. (2018). Policy options for reducing antibiotics and antibiotic-resistant genes in 
the environment.  Public Health Pol. 39, p389-406. https://doi.org/10.1057/s41271-018-0144-x  

19 

 
 
                                                           
specific  animal  populations106.  Moreover,  in  the  context  of  the  Regulation  on  Veterinary 
Medicinal Products, tertiary legislation has been adopted to define specific requirements for 
the  collection  of  data  on  the  sales  of  veterinary  antimicrobials  and  on  the  use  of 
antimicrobials  per  animal  species.  The  implementation  of  this  legislation  aims  to  allow  for 
improved  data  quality  and  comparability  with  a  view  to  set  up  targeted  measures  to  tackle 
AMR.  However,  there  remain  differences  in  how  Member  States  conduct  surveillance  and 
monitoring  that  may  create  challenges  in  integrated  surveillance  which  may  impact 
harmonisation at EU-level in the future. 

How can EU activities be strengthened? 

Access  to  information,  as  well  as  resources  and  funding  to  support  good  practice,  will  be 
influential in how AMR is dealt within the animal health and agricultural sector in the future. 
The  2017  AMR  Action  Plan  may  be  strengthened  by  implementing  ways  to  promote 
prevention of infections in animals, rather than focusing only on treatment. Ensuring higher 
standards for animal welfare leads to improved animal health, which helps decrease antibiotic 
use.   

Although  EU  legislation  regarding  AMR  surveillance  in  animals  already  exists  with  the 
Veterinary  Medicinal  Products  and  Medicated  Feed  Regulations  and  the  new  Commission 
Implementing Decision on the monitoring and reporting of AMR in zoonotic and commensal 
bacteria,  addressing  variation  between  Member  States  in  how  antimicrobials  are  used  and 
AMR in animals is monitored would be useful in the fight against AMR. For example, there 
may be opportunities to ensure that all Member States implement consistent monitoring and 
surveillance  systems  (e.g.,  consistent  methods  and  inclusion  of  the  same  species  and 
pathogens)107. As mentioned in relation to human health, there is also a need for surveillance 
and monitoring systems that link human health, animal health and the environment.  

4.5 

Environment 

Climate  change  may  create  an  environment  more  conducive  to  AMR,  as  increase  in 
temperature  correlates  with  an  increase  in  AMR  infections  in  humans108  and  periods  of 
drought can also contribute to poor water sanitation and increased risks of AMR109. Climate 
change may also shift the disease burden in Europe by increasing zoonotic transmission and 
vector-borne diseases, which may affect demand for antimicrobials. Likewise, the loss of soil 
biodiversity  may  facilitate  the  transmission  of  AMR  even  though  more  study  is  needed  to 
understand this interrelation better110. 

106 European Food Safety Authority, Antimicrobial resistance.  
107 Mesa Varona, O., Chaintarli, K., Muller-Pebody, B., Anjum, M. F., Eckmanns, T., Norström, M., Boone, I., 
& Tenhagen, B. A. (2020). Monitoring Antimicrobial Resistance and Drug Usage in the Human and Livestock 
Sector and Foodborne Antimicrobial Resistance in  Six European Countries. Infection and drug resistance, 13, 
957–993. https://doi.org/10.2147/IDR.S237038  
108 McGough, S. F., MacFadden, D. R., Hattab, M. W., Mølbak, K. and, Santillana, M. (2020). Rates of increase 
of  antibiotic  resistance  and  ambient  temperature  in  Europe:  a  cross-national  analysis  of  28  countries  between 
2000 and 2016. Euro Surveill. 25 (45), pii=1900414. https://doi.org/10.2807/1560-7917.ES.2020.25.45.1900414 
109 Burnham J. P. (2021). Climate change and antibiotic resistance: a deadly combination. Therapeutic advances 
in infectious disease, 8, 2049936121991374. https://doi.org/10.1177/2049936121991374  
110 TU Dresden, Chair of Limnology: ANTIVERSA. 

20 

 
 
                                                           
The  release  of  effluents  (medical,  industry,  agricultural  and  urban  wastewater  treatment 
facilities etc.) and waste into the environment can impact genetic material and antimicrobial 
compounds in water and soils pathways, which in turn can contribute to the development of 
resistance. This is a global issue, as there are different standards in the EU and third countries 
where  manufacturing  takes  place.  Furthermore,  advances  in  statistical  forecasting  and 
wastewater  surveillance  will  improve  the  surveillance  of  AMR  in  the  environment  in  the 
future. 

In  the  context  of  plant  production,  some  pesticides  are  used  as  antimicrobial  substances, 
namely antibiotics used against bacterial diseases and fungicides used against fungal diseases. 
There is growing concern that some of those plant protection products select for AMR among 
pathogens important to plant, human and animal health111. 

How can EU activities be strengthened? 

Despite  wastewater  treatment  and  the  partial  elimination  of  antimicrobial  residues,  final 
treated effluents, even after disinfection, can contain antimicrobials112. Therefore, along with 
the prudent use of plant protection products or biocidal products, a shift towards prevention 
(reducing antimicrobials in the environment) could change how AMR in the environment is 
dealt  with  and  eventually  reduce  the  risk  of  environmental  transmission  to  humans  and 
animals.  

Furthermore,  as  outlined  by  the  AMR  One  Health  Network  subgroup,  strengthened  data 
collection and surveillance systems  of the  environment  and in  wastewater  will improve our 
understanding of the role of the environment in the spread of AMR. There is also a need to 
harmonised  methods  to  conduct  environmental  and  wastewater  monitoring  to  ensure  that 
Member States provide comparable results. Supporting Member States to monitor AMR more 
effectively in  the environment (through environmental  and wastewater  surveillance) will be 
useful to ensure that practices are similar across all Member States.  

5.  RECOMMENDATIONS ON HOW TO ADDRESS THE CHALLENGES  

The  2017  AMR  Action  Plan  has  been  central  to  tackling  AMR  in  the  EU  and  beyond.  It 
should be continued and strengthened to address the future challenges likely to be posed by 
this complex public health issue.  

5.1 

Further develop Member State National Action Plans 

NAPs to tackle AMR should continue to be in place in all Member States and  should focus 
more on the One Health dimension of AMR, particularly on the environment. As shown by 
the review of Member States’ NAPs, the environment is currently included in only half of the 
One  Health  NAPs113.  Although  research  on  AMR  and  international  collaborative  work  are 
already covered in most NAPs, more could be done to raise the profile of work to improve 

111 FAO 2020, Antimicrobial Resistance (AMR) in relation to pesticide use in plant production. 
112 Célia M. Manaia (2022) Framework for establishing regulatory guidelines to control antibiotic resistance in 
treated 
Technology,  DOI: 
10.1080/10643389.2022.2085956  
113 Overview report on the review of Member States’ One Health National Action Plans against Antimicrobial 
Resistance   

effluents,  Critical  Reviews 

Environmental 

Science 

and 

in 

21 

 
 
                                                           
the  knowledge  on  the  role  of  the  environment  for  AMR.  Member  State  NAPs  should 
therefore  include  measures  to  prevent,  monitor  and  reduce  the  spread  of  AMR  in  the 
environment.  

Furthermore, NAPs should well describe the intersectoral coordination mechanisms (ICMs), 
including  a  clear  composition  and  mandate  of  the  ICMs  since  they  are  essential  for  the 
development and implementation of One Health NAPs. 

To  ensure  effective  implementation  of  NAPs,  Member  States  should  implement  specific 
measures to achieve overarching measurable goals and indicators, and regularly evaluate the 
outcomes and progress towards achieving these goals. As outlined in the review of Member 
States’  NAPs,  efforts  to  improve  data  collection  and  integration  across  sectors  are  key  to 
strengthen  knowledge  and  to  achieve  targets.  In  addition,  Member  States  should  provide 
sufficient human and financial resources. This would address concerns about the sustainable 
implementation of NAPs and the arrangements in place in Member States to ensure that the 
strategic objectives are achieved effectively114.  

5.2 

Improving AMR surveillance and monitoring 

Environmental and wastewater surveillance and monitoring should be improved to facilitate 
the understanding of the evolution,  dissemination and transmission of AMR  within, to,  and 
from the environment to enable more informed decision-making for mitigation strategies to 
address  the  spread  of  AMR.  In  addition,  the  capacity  of  Member  States  to  comply  with 
existing  AMR  surveillance  and  monitoring  activities  should  be  enhanced,  especially  where 
capacity  is  insufficient  or  lacking.  The  EU  could  create  mechanisms  to  share  data  across 
relevant  functions  (e.g.,  human  health,  the  environment,  wastewater  and  animal  health), 
which  will  be  facilitated  by  the  establishment  of  aligned  approaches  to  data  collection  and 
indicators. One of the recommendations of EU-JAMRAI115 relates to action on surveillance: 
in  order  to  achieve  real  time  surveillance,  the  EU-JAMRAI  identifies  as  priorities 
institutional support, unified coordination of microbiological and antimicrobial consumption 
data  sources,  more  homogeneous  indicators,  dedicated  human  resources  and  modern  and 
integrated  IT  systems.  The  subgroup  established  under  the  AMR  One  Health  Network  also 
highlighted the strengthening of data collection and AMR surveillance as a priority. 

5.3 

Improving patient safety and supporting infection prevention and control  

With over 70% of the AMR burden linked to healthcare-associated infections, it is important 
to strengthen the standards for infection prevention and control in healthcare and community 
settings and long-term care facilities at national level to reinforce patient safety. This is also 
highlighted  in  the  EU-JAMRAI  recommendations116  which  underline  the  urgent  need  to 
foster  research  on  infection  prevention  and  control  to  improve  health  security.  Further 
research in the area of patient environment  and behavioural science will have wide-ranging 
benefits  including  lowering  the  number  of  hospitalised  patients,  hindering  antibiotic 

114 Overview report on the review of Member States’ One Health National Action Plans against Antimicrobial 
Resistance   
115  European  Joint  Action  on  Antimicrobial  Resistance  and  Healthcare-Associated  Infections  (EU-JAMRAI), 
LAYMAN REPORT 
116  European  Joint  Action  on  Antimicrobial  Resistance  and  Healthcare-Associated  Infections  (EU-JAMRAI), 
LAYMAN REPORT 

22 

 
 
                                                           
resistance, and strengthening global health preparedness for future pandemics. Core elements 
for a common infection prevention and control framework at EU level need to be developed. 
Infection prevention and control also needs to be strengthened in animal health, including in 
aquaculture. There is a need to improve the health and welfare of food-producing animals to 
decrease the occurrence and spread of infectious diseases in farming and thereby reduce the 
need for antimicrobial use in animals.  

5.4 

Strengthening research, development and access of antimicrobials 

To  further  support  AMR  research,  development  of  and  access  to  antimicrobials,  there  is 
scope  for  coordination,  joint  procurement  for  the  stockpiling  of  antimicrobials  and  AMR 
medical  countermeasures,  push  incentives  to  research  and  innovation,  support  to  European 
and  Member  State  research  infrastructure  (e.g.  data  infrastructures,  clinical  and  research 
networks), greater support for the identification of innovative business models  and strategic 
pooling of incentives at EU level. The EU may consider opportunities to pool resources and 
take  collective  EU  action,  while  respecting  Member  State  competence,  to  create  a 
harmonised, multi-country pull incentive scheme in form of revenue guarantee, market entry 
rewards  or  milestone  payments 
to 
incentivize 
antimicrobials,  complementary  to  the  regulatory  framework  applicable  to  the  medicinal 
products  for  human  use.  Member  States  and  the  Commission  should  regularly  review  the 
scheme  implemented  and  the  impact  on  the  development  and  accessibility.  This  would 
contribute  to  strengthening  the  EU’s  role  in  establishing  best  practices  on  incentives. 
Increased  direct  funding  of  AMR-relevant  R&D  and  support  to  Member  State  R&D 
infrastructure (e.g., data infrastructure, R&D networks and partnerships) are crucial aspects. 
The  approach  should  be  considered  not  only  for  novel  antimicrobials,  but  also  for  existing 
ones  on  the  market  including  recently  authorized  antimicrobials,  as  well  as  off-patent 
antimicrobials,  and  potentially  other  relevant  medical  countermeasures  relevant  to  combat 
AMR.   

the  development  and  access117 

to 

In the opinion on managing antimicrobial resistance across the health system of the EXPH, it 
is  recommended  that  Member  States  should  focus  research  on  understanding  why  policies 
and practices on their territories continue to create risks of AMR and the Commission should 
support exchange of the knowledge thus generated. 

5.5 

Reinforcing EU action at global level  

As  AMR  is  a  global  issue,  actions  beyond  the  EU-level  have  also  to  be  continued  and 
strengthened. The EU should continue to participate in and lead global initiatives to address 
issues  such  as  inappropriate  antimicrobial  use  in  human  and  animal  health,  AMR-related 
surveillance, and prescription practices, particularly in low- and middle-income countries. To 
support  this,  the  EU  should  support  the  development  and  implementation  of  standards  by 
international  bodies  (e.g.,  WHO,  WOAH).  In  particular,  the  EU  should  work  towards  the 
inclusion  of  concrete  provisions  on  AMR  following  a  One  Health  approach  in  the  future 
WHO international agreement on pandemic prevention, preparedness and response118. More 
broadly,  technical  capacity  as  well  as  human  and  financial  resources  may  also  need  to  be 

117  European  Joint  Action  on  Antimicrobial  Resistance  and  Healthcare-Associated  Infections  (EU-JAMRAI), 
Policy Brief Improving Access to Essential Antibiotics  
118 World Health Organization 2022, Pandemic prevention, preparedness and response accord  

23 

 
 
                                                           
strengthened at various levels and Member States should report data on AMR and AMC to 
the Global Antimicrobial Resistance and Use Surveillance System (GLASS). 

5.6 

Strengthening awareness, education and training about AMR 

The  report  on  Member  States’  NAPs  showed  that  awareness  campaigns  are  included  in  all 
NAPs and good examples of collaborative awareness campaigns were identified. The need to 
adjust  the  narrative  to  convey  the  urgency  and  importance  of  AMR  is  reflected  in  actions 
targeting  communication  strategies  and  education  and  continuous  professional  development 
in a One Health approach, covering all the relevant professional groups in place in Member 
States.  

Nevertheless, more can be done to ensure that knowledge produced is used effectively and is 
communicated across disciplines and sectors, remaining aware that specific stakeholders will 
require  different  ways  of  communicating  such  knowledge.  Awareness  campaigns  for  the 
public  and  health  professionals  should  focus  amongst  others  on  the  collection  and  safe 
disposal  of  unused,  expired  and  leftover  antimicrobials,  as  well  as  on  the  release  of 
antimicrobials  into  the  environment  and  its  role  in  the  emergence  of  more  resistant  strains. 
The EU should continue to support collaboration and coordination among Member States, for 
example  by  building  on  EU-JAMRAI.  At  the  same  time,  the  EU  should  also  offer  more 
specialised  support  to  countries  with  fewer  resources  through  trainings,  networking  events, 
and ad-hoc mutual learning activities. Such actions should be designed as to embed the One 
Health  approach, bringing together stakeholders from across sectors as much as possible to 
engage in a meaningful and comprehensive way regarding AMR. The EU could also create 
resources to support evidence-based behaviour change initiatives in Member States aimed at 
the  general  public  and  key  stakeholders  (e.g.,  healthcare  professionals  and  providers, 
veterinarians, farmers). Similarly, the EU should continue supporting countries to ensure that 
communication and education is a corner stone of their NAP on AMR. At the same time, the 
EU  should  continue  training  and  awareness  raising  activities  following  the  One  Health 
approach in the context of the BTSF initiative. 

5.7 

Promoting prudent use of antimicrobials 

Overuse  and  misuse  of  antibiotics  remain  a  challenge.  Improving  public  awareness  on  the 
role of antibiotics and of AMR is crucial to the achievement of these objectives. Some of the 
key findings of the 2022 Eurobarometer119 highlight in particular that fewer Europeans have 
reportedly  taken  antibiotics  in  the  last  year  than  in  the  2018  survey120.  This  trend  is  also 
reflected in data from ECDC, showing show a decrease in the total antibiotic consumption in 
humans  by  more  than  15%  between  2019  and  2020121.  There  has  also  been  a  small 
improvement  in  Europeans’  knowledge  of  antibiotics  since  2018.  However,  the  EU  should 
further  promote  a  widespread  adoption  of  best  practices  in  antimicrobial  stewardship.  This 
can include the development of EU guidelines for the treatment of major common infections 
and the choice of appropriate antibiotics, including the need to ensure their most optimal and 
prudent use.  

119 Eurobarometer 2022, Antimicrobial Resistance 
120 Special Eurobarometer 478: Antimicrobial Resistance (in the EU) 
121  European  Centre  for  Disease  Prevention  and  Control  2021,  Reported  decrease  in  antibiotic  consumption 
across EU/EEA during COVID-19 pandemic. 

24 

 
 
                                                           
5.8 

Further integrate the environment in AMR policy 

Other types of monitoring and surveillance are needed to understand how AMR develops in 
the environment in the presence of antimicrobial  residues and/or what risks AMR pollution 
poses  to  human  and  animal  transmission  risk  through  crop  irrigation,  drinking  water  or 
recreational use of natural waters.  

It  is  important  to  synthesize and review evidence on the environmental dimension of AMR 
and create opportunities to translate this evidence into policy and practice across sectors and 
different  types  of  stakeholders.  The  subgroup  of  the  AMR  One  Health  Network122 
recommends  developing  EU  guidelines  and  regulations  to  control  through  harmonized 
surveillance and manage environmental pollution, notably from wastewater treatment plants 
and manufacturing sites. The subgroup also concludes that there is a need to strengthen data 
collection and surveillance systems of the environment. In line with the One Health approach, 
environmental  monitoring  of  AMR  in  freshwater  and  wastewater  is  essential  to  further 
understand  the  role  that  the  environment  plays  in  the  emergence  and  spread  of  AMR,  the 
levels  of  environmental  contamination  and  the  risks  posed  to  human  health.  Monitoring  is 
also  essential  to  complement  clinical  data  by  providing  sampling  material  from  a  large 
population.  Actions  in  relation  to  the  environment,  notably  concerning  research  and 
monitoring, as well as specific measures on soil and manure management should be included 
in Member State NAPs.  

5.9 

Continue to support Member States and facilitate cooperation 

The  EU  is  already  using  a  range  of  tools  at  its  disposal  to  support  Member  States  in 
addressing  AMR  at  national  level;  these  support  mechanisms  should  continue.  Still,  some 
Member States lack the knowledge and resources to sufficiently tackle the problem. The EU 
should  consider  whether  there  are  further  instruments,  including  financial  and  technical 
support  that  can  be  leveraged  to  strengthen  capacity  within  Member  States  (e.g.,  mutual 
learning  and  best  practice  exchange  between  Member  States).  The  EU-JAMRAI 
recommendations123 further point to the need to enhance cooperation between Member States, 
highlighting  that  an  extended  and  strengthened  AMR  One  Health  Network  as  well  as 
cooperation  with  AMR  stakeholders  and  relevant  agencies  (e.g.,  EFSA,  EMA,  ECDC,  and 
EEA) is crucial to achieve this purpose and make Europe a best practice region. 

5.10  Strengthen the framework for action through targets and indicators 

The  importance  of  introducing  EU  indicators  and  targets  is  reflected  in  the  EU-JAMRAI 
recommendations and in the opinion of the EXPH, which underlines the need to prioritise the 
development of a comprehensive set of indicators and structured data to measure progress on 
tackling  AMR,  ensuring  that  they  are  integrated  with  relevant  regulatory  data  collection 
requirements. The development of indicators and targets would provide clarity and alignment 
on goals and objectives and, through future monitoring and evaluation, help to identify where 
additional  support  is  most  needed.  This  will  also  contribute  to  a  more  robust  evaluation  of 

122 Final report  -  Subgroup established  under the EU  AMR  One  Health Network to  formulate  suggestions for 
AMR Actions 
123  European  Joint  Action  on  Antimicrobial  Resistance  and  Healthcare-Associated  Infections  (EU-JAMRAI), 
LAYMAN REPORT  

25 

 
 
                                                           
future  AMR  Action  Plans,  including  of  cost-effectiveness,  by  providing  a  clear  framework 
for analysis and supporting data obtained through regular monitoring.  

While  an  aspirational  target  for  the  reduction  of  the  overall  EU  sales  of  antimicrobials  for 
farmed animals and in aquaculture by 2030 has been included in the Farm to Fork Strategy 
and the contribution of Common Agriculture Policy (CAP) support measures to the reduced 
use of antimicrobials in  farmed animals should be monitored124, there is currently no AMR 
related  target  in  the  human  health  sector  at  EU  level.  Therefore,  the  Commission,  in 
cooperation with the ECDC, should introduce concrete targets both at EU and Member States 
level to reduce the unnecessary use of antimicrobials.   

Furthermore, AMR action should be strengthened through specific and measurable EU-level 
targets on AMC and AMR and linked to related indicators that define progress, with efforts 
focused  on  those  countries  with  the  greatest  challenges  in  meeting  those  targets.  The 
recommended  targets  at  Union  level  can  be  complemented  by  national  targets  that  cover 
other AMR-related aspects such as IPC, antimicrobial stewardship, prescription practices and 
training. 

6.  CONCLUSION 

Since  its  adoption  and  until  now,  the  2017  AMR  Action  Plan  has  made  progress  towards 
achieving its main objectives and, based on the reports reviewed and feedback gathered, has 
had  an  overall  positive  effect  in  making  the  EU  a  best  practice  region,  boosting  research, 
development and innovation by closing current knowledge gaps, and intensifying EU efforts 
worldwide  to  shape  the  global  agenda  on  AMR.  To  date,  experience  shows  that  the  2017 
AMR Action Plan is still overall fit for purpose.  

Notwithstanding this, the future-proofing analysis drawing on scientific literature and reports 
and  outcome  assessment  of  the  2017  AMR  Action  Plan,  which  includes  numerous 
consultations of all relevant parties, has led to identification of aspects that deserve particular 
attention in the short term. While much progress has been achieved in the veterinary sector, it 
is  now  crucial  to  further  integrate  the  One  Health  approach,  better  address  human  health, 
support  Member  States  in  their  efforts  against  AMR  and  increase  actions  in  the 
environmental and global domains. The activities implemented under the 2017 AMR Action 
Plan  need  to  be  extended  and  complemented  to  maximize  synergies  to  attain  a  stronger 
response to AMR across the EU and beyond. Based on this assessment, further support is put 
forward in the proposal for a Council recommendation, which focuses on specific topics, i.e., 
(1)  NAPs  against  AMR,  (2)  surveillance  and  monitoring  of  AMR  and  AMC,  (3)  infection 
prevention and control, (4) antimicrobial stewardship and prudent use of antimicrobials,  (5) 
recommended targets for AMC and AMR, (6) awareness, education and training, (7) research 
and  development;  incentives  for  innovation  and  access  to  antimicrobials  and  other  AMR 
medical countermeasures, (8) cooperation and (9) global action.  

124 On the basis of result indicator R.43 (share of livestock units concerned by supported actions to limit the use 
of  antimicrobials)  of  the  CAP  Strategic  Plan  Regulation  (Regulation  (EU)  2021/2115  of  the  European 
Parliament and of the Council of 2 December 2021 establishing rules on support for strategic plans to be drawn 
up  by  Member  States  under  the  common  agricultural  policy  (CAP  Strategic  Plans)  and  financed  by  the 
European Agricultural Guarantee Fund (EAGF) and by the European Agricultural Fund for Rural Development 
(EAFRD) and repealing Regulations (EU) No 1305/2013 and (EU) No 1307/2013 (OJ L 435, 6.12.2021, p. 1-
186). 

26