Surveillance of antimicrobial resistance in Europe, 2022 data : executive summary.
Date: 2024-02-15
Institutions: European Centre for Disease Prevention and Control, World Health Organization
Subjects: activity report, antibiotic, antimicrobial resistance, data collection, health control, medical research, medicinal product, therapeutics

Surveillance of antimicrobial  
resistance in Europe, 2022 data
Executive summary

WHO European Region

This executive summary showcases results derived from 
2022 antimicrobial resistance (AMR) data, sourced from 
invasive  isolates  reported  to  both  the  Central  Asian 
and  European  Surveillance  of  Antimicrobial  Resistance 
(CAESAR)  network  and  the  European  Antimicrobial 
Resistance  Surveillance  Network 
(EARS-Net).  Of 
the  compiled  data,  CAESAR  received  reports  from 
17 countries, whereas EARS-Net amassed data from 30 
countries, encompassing all European Union/European 
Economic  Area  (EU/EEA)  nations.  Although  both  EARS-
Net  and  CAESAR  utilize  similar  methodologies  for  data 
gathering and analysis, the information originates from 
distinct surveillance systems across different countries. 
Given  that  each  country’s  surveillance  is  shaped  by 
unique  protocols  and  practices,  it  is  important  to 
exercise  caution  when  contrasting  AMR  patterns 
between them.

Epidemiology

in  bacterial  species  reported 
The  AMR  situation 
to  the  AMR  surveillance  networks 
in  2022  varied 
widely  depending  on  species,  antimicrobial  group 
and  geographical  region.  Within  the  WHO  European 
Region,  pronounced  disparities  are  evident,  echoing 
trends  highlighted 
reports.  A  notable 
in  past 
resistance gradient emerges, with a clear pattern from 

north-to-south  and  west-to-east.  The  northern  and 
western  regions  predominantly  show  lower  resistance 
rates,  while  the  eastern  and  southern  regions  tend  to 
register  higher  ones.  Resistance  to  third-generation 
cephalosporins  (3GC)  and  carbapenems  was  generally 
higher  in  Klebsiella  pneumoniae  (K.  pneumoniae)  than 
Escherichia  coli  (E.  coli).  While  carbapenem  resistance 
remained  rare  in  E.  coli  for  most  countries,  32% 
reported  resistance  percentages  of  25%  or  higher 
in  K.  pneumoniae.  Carbapenem  resistance  was  also 
common  in  Pseudomonas  aeruginosa  (P.  aeruginosa) 
and  Acinetobacter  species  (Acinetobacter  spp.)  and 
generally at a higher percentage than in K. pneumoniae.

Seven  (41%)  of  the  17  countries  that  reported  data  to 
CAESAR  reported  that  their  participating  laboratories 
had  an  estimated  population  coverage  of  over  two 
thirds of the overall population, including two countries 
reporting  having  an  estimated  population  coverage  of 
100%.  However,  six  countries  reported  an  estimated 
population coverage of less than half of their population. 
Four did not report data on population coverage.

representativeness, 

One  (6%)  of  the  17  countries  that  reported  data 
indicated  that  the  reported  data  had 
to  CAESAR 
three 
in 
a  high 
metrics:  geographical 
representativeness,  hospital 
representativeness  and  isolate  representativeness.  A 
further nine countries reported that representativeness 
was  high  for  two  of  these  three  metrics,  while  one 

terms  of 

reported  that  representativeness  was  medium  or  low 
for  two  of  these  three  metrics  and  four  reported  that 
the  representativeness  of  their  data  was  low  for  all 
three  metrics.  Two  countries  did  not  report  data  on 
these metrics.

44  countries  reported  resistance  percentages  below 
1%.  Fourteen  (32%)  countries  reported  percentages 
equal  to  or  above  25%,  eight  of  which  (18%  of  44 
countries)  reported  resistance  percentages  equal  to  or 
above 50%.

in  hospitals  served  by 
The  blood  culture  rate 
laboratories  participating 
in  2022  was 
in  CAESAR 
reported  by  12  countries.  For  the  single  country  that 
reported  a  high  representativeness  according  to  all 
three  metrics  listed  above,  no  data  was  available  on 
the blood culture rate. In the eight countries reporting 
high  representativeness  according  to  two  of  the  three 
metrics  listed  above  that  also  had  data  available  on 
blood  culture  rate,  the  median  rate  was  3.6  times 
higher  than  in  the  four  countries  reporting  medium  or 
low representativeness according to at least two of the 
three metrics that also had data available on the blood 
culture  rate  (16.0  versus  4.5  blood  culture  sets  per  
1000 patient-days, respectively).

Among  the  16  countries  that  provided  data  to  CAESAR 
in both 2021 and 2022, there was an increase in the total 
number  of  isolates  reported  in  2022  compared  with 
2021. This overall tendency was not always observed at 
country level.

Of the 17 countries submitting data to CAESAR in 2022, 
14 reported data for all eight bacterial species. Among 
these  17  countries  that  submitted  data  to  CAESAR 
in  2022,  the  majority  of  isolates  (72%)  consisted  of 
E.  coli  (39%),  Staphylococcus  aureus  (S.  aureus)  (18%) 
and K. pneumoniae (15%).

group 

Concerning  bacterial  species-specific  results 
from 
2022,  resistance  to  fluoroquinolones  in  E.  coli  was 
generally  lowest  in  the  northern  parts  of  the  WHO 
European Region and highest in the south. A resistance 
percentage  below  10%  was  observed  in  one  (2%)  of  
46 countries that reported data on this microorganism-
resistance 
antimicrobial 
percentage  of  25%  or  above  was  reported  in  21  (46%) 
countries. A resistance percentage of 50% or above was 
observed  in  four  (9%)  countries.  For  3GC  resistance  in 
E.  coli,  13  (28%)  of  47  countries  reported  percentages 
below 10%, whereas resistance percentages equal to or 
above 50% were observed in five countries (11%). Eight 
(17%)  of  46  countries  reported  carbapenem-resistant 
E. coli percentages of 1% or above.

combination.  A 

Since  2019,  over  40%  of  countries  have  consistently 
shown resistance percentages of 50% or higher for 3GC 
in K. pneumoniae. This trend is particularly pronounced 
in the southern and eastern parts of the WHO European 
Region, where this specific microorganism-antimicrobial 
combination  appears  to  be  increasingly  prevalent.  In 
2022  percentages  below  10%  were  observed  in  eight 
(18%) of 44 countries in the Region reporting data on this 
microorganism-antimicrobial group combination, while 
20 (45%), particularly in the southern and eastern parts 
of  the  Region,  reported  resistance  percentages  of  50% 
or above. Carbapenem resistance was more frequently 
reported  in  K.  pneumoniae  than  in  E.  coli:  12  (27%)  of  

2

Large  differences  were  observed  in  the  percentages 
of  carbapenem-resistant  P.  aeruginosa  in  the  WHO 
European  Region.  In  2022  resistance  percentages  of 
below 5% were observed in two (4%) of the 45 countries 
reporting  data  on  this  microorganism-antimicrobial 
group  combination,  whereas  six 
(13%)  countries 
reported percentages equal to or above 50%.

The percentages of carbapenem-resistant Acinetobacter 
spp. varied widely within the Region in 2022, from below 
5% in ten (25%) of the 40 countries that reported data on 
this  microorganism-antimicrobial  group  combination, 
to equal to or above 50% in 22 (55%) countries, mostly 
in southern and eastern Europe.

In  2022,  12  (27%)  of  45  countries  reporting  data  on 
S.  aureus  reported  methicillin-resistant  S.  aureus 
(MRSA) percentages below 5%. MRSA percentages equal 
to or above 25% were found in 11 (24%) of 45 countries.

of 

penicillin 

non-wild-type 
percentages 
The 
Streptococcus  pneumoniae 
(S.  pneumoniae)  varied 
markedly  across  the  Region.  Out  of  the  41  countries 
reporting  data  on  this  microorganism-antimicrobial 
group  combination,  five  (12%)  registered  percentages 
below  5%,  while  seven  (17%)  recorded  rates  of  25%  or 
higher.

Resistance  to  vancomycin 
in  Enterococcus  faecium 
(E. faecium) varied substantially among countries in the 
Region.  In  2022,  resistance  percentages  of  below  1% 
were  reported  by  five  (11%)  of  44  countries  reporting 
data  on 
this  microorganism-antimicrobial  group 
combination,  while  percentages  equal  to  or  above 
25%  were  found  in  19  (43%),  five  of  which  (11%  of  
44 countries) reported resistance percentages equal to 
or above 50%.

Country-specific information for each bacterial species, 
including information on patient age group and sex, are 
available on the WHO European Region website (1).

Discussion

The  results  from  CAESAR  and  EARS-Net  clearly  show 
that  AMR  remains  widespread  in  the  WHO  European 
Region.  Although  assessing  the  exact  magnitude  of 
AMR  is  challenging  and  the  interpretation  of  results 
should  be  made  with  caution,  the  presence  of  specific 
AMR  patterns  across  clinical  settings  covered  by  these 
surveillance networks is apparent. High percentages of 
resistance  to  3GC  and  carbapenems  in  K.  pneumoniae 
carbapenem-resistant 
and  high  percentages  of 
Acinetobacter  spp.  in  several  countries  are  of  serious 
concern.  They  suggest  the  dissemination  of  resistant 
clones  in  health-care  settings  and  indicate  that  many 
countries have serious limitations in treatment options 

2023Surveillance of antimicrobial resistance in Europe, 2022 data: executive summaryfor  gram-negative  bacteria 

for patients with infections caused by these pathogens. 
While  the  west-to-east  gradient  in  AMR  percentages 
is  evident 
(E.  coli, 
K.  pneumoniae,  P.  aeruginosa  and  Acinetobacter  spp.), 
it  is  less  obvious  for  gram-positive  bacteria  (S.  aureus, 
S. pneumoniae and E. faecium). The COVID-19 pandemic 
clearly illustrated that microorganisms know no borders 
or  regional  constraints.  These  findings  underscore  the 
imperative  need  to  address  AMR,  not  just  within  the 
WHO European Region, but globally. Hence, it becomes 
paramount  to  usher  in  a  new  era  of  international 
cooperation,  where  governments  unite  in  their  efforts 
to tackle shared health challenges head-on.

The  shift  away 
from  COVID-19  related  activities 
is  reflected  in  the  differing  AMR  data  from  many 
surveillance  systems.  A  large  number  of  countries  that 
provided AMR data to CAESAR reported a higher count of 
S. pneumoniae isolates in 2022 compared with 2021. This 
trend  could  be  attributed  to  the  increasing  circulation 
of  respiratory  pathogens  in  communities  following 
the  lifting  of  lockdowns.  Likewise,  typical  health-care-
associated  pathogens  such  as  Acinetobacter  spp.  and 
E. faecium were noted less often in 2022 compared with 
2021.

Overall, more and more laboratories have been reporting 
data to the European surveillance networks since both 
networks  were  initiated,  which  is  an  encouraging  step 
in  the  right  direction.  Nevertheless,  when  looking  at 
surveillance  capacity  in  the  WHO  European  Region, 
27%  (14/51)  of  countries  still  reported  that  they  only 
collect AMR data at local level or without a standardized 
approach. This highlights the ongoing need to strive for 
enhanced  standardization  of  surveillance  efforts  as 
systems and networks continue to grow and mature (2).

Antimicrobial consumption patterns across the EU/EEA 
countries  have  shown  notable  variations  in  adherence 
to  WHO  targets.  During  2022,  17  of  28  (61%)  EU/EEA 
countries reported, through the European Surveillance 
of  Antimicrobial  Consumption  Network  (ESAC-Net), 
data  for  both  the  community  and  the  hospital  sector 
that  meet  or  exceed  the  WHO  country-level  target  of 
60%  of  total  antibacterial  consumption  coming  from 
WHO’s  Access  category,  as  defined  in  the  Access, 
Watch,  Reserve  (AWaRe)  classification  list  (3,4).  In 
contrast,  only  two  out  of  10  countries  that  reported 
2021 consumption data to the WHO Regional Office for 
Europe  Antimicrobial  Medicines  Consumption  (AMC) 
Network achieved this target in 2021 (5).

Since  2011,  activities  to  contain  AMR  in  the  WHO 
European Region have been guided by the Global Action 
Plan  on  AMR  (6)  and  were  further  reinforced  by  the 
European Strategic Action Plan on Antibiotic Resistance 
that  concluded  in  2020.  By  2022  it  was  evident  that 
while  86%  (44/51)  of  the  countries  in  the  Region  had 
developed  their  National  Action  Plan  (NAP)  on  AMR,  a 
mere 18% (9/51) had factored in operational strategies 
and financial resources for its execution (2).

levels  and  ensuring  continued 

Addressing  this  critical  gap,  the  new  Roadmap  on 
antimicrobial  resistance  for  the  WHO  European  Region 
2023–2030  (7)  is  more  than  just  a  strategic  document. 
It is an innovative tool designed to support countries to 
assess national AMR capacity to implement action areas 
and  enablers,  facilitate  consensus  on  priorities,  set 
targets and guide implementation, and enable them to 
measure progress. With clear objectives of reducing the 
burden  and  impact  of  infectious  diseases,  controlling 
AMR 
treatment 
capabilities,  the  Roadmap  serves  as  a  compass  to 
provide  direction  for  action.  It  recognizes  not  just  the 
need  for  interventions  based  on  the  best  available 
evidence  but  also  understands  the  importance  of 
adaptability,  allowing  countries  to  tailor  their  efforts 
to local contexts. Additionally, the Roadmap highlights 
the  importance  of  leveraging  digital  transformations 
focus  on  environmental  and 
and  emphasizes  a 
social  determinants  of  AMR,  underscoring  its  holistic 
approach.  By 
interventions 
and  offering  tools  for  consensus  and  investment,  the 
Roadmap  aims  to  provide  a  robust  framework  for 
countries in their efforts to tackle AMR.

identifying 

impactful 

Public health implications

AMR  is  one  of  the  top  10  global  public  health  threats 
facing  humanity (8).  In  2022  the  European  Commission 
and  the  EU  Member  States  deemed  it  one  of  the  top 
three  priority  health  threats  (9).  Many  countries  in 
the  WHO  European  Region  have  responded  to  the 
global  call  (10,11)  to  develop  NAPs  on  AMR  and  are 
even  revising  them  for  the  next  phase  of  their  plans. 
However, some countries are still in the early stages of 
implementing effective interventions against AMR. The 
new  Roadmap  offers  a  structured  path  forward,  with 
the  aim  that  all  countries,  regardless  of  their  current 
stage,  have  a  comprehensive  and  adaptable  guide  to 
prioritizing  interventions  for  implementation  to  tackle 
AMR  effectively.  Surveillance  has  been  identified  as 
one  of  the  enabling  areas  in  the  Roadmap,  as  the 
successful  implementation  of  interventions  in  most 
action areas depends on the availability of high-quality 
data and information. Continued effort and investment 
are 
representativeness, 
comparability, quantity and quality of AMR surveillance 
data.  Current  trends,  such  as  the  high  percentages 
of  carbapenem-resistant  Acinetobacter  spp.  isolates, 
which  are  challenging  to  eliminate  once  endemic, 
highlight the imperative to bolster measures in infection 
prevention and control (IPC), ensuring timely detection 
to prevent the spread of these resistant organisms.

to  better 

required 

the 

for 

comprehensive 

There is still a lack of high-level support and sustained 
funding 
and 
interventions  on  IPC,  antimicrobial  stewardship  and 
surveillance.  Commitment  from  the  highest  level  of 
government continues to be crucial to advance the AMR 
agenda (10).

programmes 

Following  the  COVID-19  pandemic,  it  is  hoped  that 
addressing  AMR  will  be  given  a  higher  priority 

3

Surveillance of antimicrobial resistance in Europe, 2022 data: executive summary2023when  rebuilding  health  systems  and  taking  the 
interconnectedness  of  countries  and  continents 
into  account.  As  the  world  adjusts  to  the  effects 
of  this  pandemic  on  population  and  public  health, 
efforts  to  tackle  AMR  have  begun  to  find  a  balance 
after  the  repurposing  of  health-care  professionals  to 
support  the  COVID-19  response  throughout  the  WHO 
European  Region.  Across  the  globe,  governments  were 
confronted with a need for more coordinated action and 
collaboration,  and  this  has  paved  the  way  for  a  more 
united  front  against  current  and  future  health  threats, 
including AMR. It is hoped that such a front will enable 
more  effective  responses  to  the  threat  represented  by 
AMR in the coming years.

In  the  backdrop  of  global  health  priorities,  the  WHO 
European  Region  has  been  confronted  with  challenges 
in  strengthening  and  expanding  the  AMR  agenda. 
Ongoing  geopolitical  conflicts  and  natural  disasters 
disrupt  core  operations  such  as  data  collection 
and  training.  Subsequent  large-scale  migrations  of 
populations  place  additional  strain  on  already  taxed 
health-care and surveillance systems.

Despite  such  a  scenario,  particularly  in  Ukraine,  WHO 
has  been  unwavering  in  its  efforts  to  combat  AMR.  A 
testament  to  this  commitment  is  the  universal  and 
mandatory  adoption  of  the  European  Committee 
on  Antimicrobial  Susceptibility  Testing 
(EUCAST) 
methodology  across  the  whole  country.  Moreover, 
the  AMR  surveillance  network  in  Ukraine  has  seen  a 
substantial expansion, with the number of laboratories 
participating in CAESAR growing from 4 in 2018 to 48 in 
2022. Recognizing the unique health challenges arising 
from  the  war,  separate  data  collection  initiatives  have 
been implemented specifically for AMR among wounded 
patients,  reflecting  both  the  scale  and  significance  of 
the issue. Furthermore, in a bid to bolster the country’s 
response  capabilities,  WHO  has  made  significant 
investments,  channelling  over  US$  1  million  into  the 
procurement  of  state-of-the-art  equipment.  This  has 
resulted  in  an  increased  capacity  for  blood  culturing 
and  antimicrobial  susceptibility  testing,  therefore 
fortifying  the  country’s  defences  against  the  spread  of 
AMR.

These  challenges  hinder  activities  pertaining  to  the 
AMR agenda and highlight the increased relevance and 
urgency  of  public  health  initiatives.  Now,  more  than 
ever,  there  is  a  pressing  need  for  more  resilient  and 
collaborative public health strategies.

EU/EEA countries

Epidemiology

having  a  population  coverage  of  90.0%  or  more. 
However,  seven  countries  reported  data  for  less  than 
half of their population.

Of  the  30  participating  countries,  22  (73.3%)  indicated 
that  their  reported  data  had  high  representativeness 
in  terms  of  three  metrics:  geographical  areas  covered, 
acute  care  hospitals  included  and  the  microorganisms 
that  caused  invasive  infections  in  those  hospitals.  A 
further  three  countries  reported  representativeness 
that  was  high  for  two  of  the  three  metrics  and  one 
country reported that no data were available for two of 
the three metrics.

In  hospitals  served  by  the  laboratories  that  reported 
data  to  EARS-Net  in  2022,  the  blood  culture  rate 
was  reported  by  25  countries.  In  the  18  countries 
that  reported  a  high  representativeness  for  all  three 
representativeness  metrics  and  provided  a  blood 
culture rate, the average blood culture rate was 3.7 times 
higher  than  in  the  five  countries  reporting  medium, 
low  or  no  data  on  representativeness  for  at  least  two 
of  the  metrics  (84.8  versus  22.9  blood  culture  sets  per  
1000  patient-days,  respectively).  The  reported  blood 
culture rates were highest in Belgium, Denmark, Finland, 
Portugal  and  Spain  (>  100  sets  per  1000  patient-days) 
and  lowest  in  Bulgaria,  Hungary,  Latvia,  Liechtenstein 
and Lithuania (< 20 sets per 1000 patient-days).

All  but  one  country  reported  isolate  data  for  all 
eight  bacterial  species  under  EARS-Net  surveillance 
(E.  coli,  K.  pneumoniae,  P.  aeruginosa,  Acinetobacter 
spp.,  S.  pneumoniae,  S.  aureus,  Enterococcus  faecalis 
faecium),  while  one  country 
(E. 
faecalis)  and  E. 
(Liechtenstein)  reported 
for  E.  coli, 
S. pneumoniae and S. aureus only.

isolate  data 

The  number  of  laboratories  participating  in  EARS-Net 
has  increased  since  2018,  indicating  a  strengthening 
of  national  AMR  surveillance  systems  in  the  EU/EEA. 
In  2022,  1845  laboratories  reported  data,  942  of  which 
were  in  France.  Based  on  the  laboratory  identifiers 
provided by the countries, there were 692 laboratories 
identifiable as having reported data for each year during 
the period 2018–2022.

laboratories, 

Compared  with  2021,  the  total  number  of  reported 
isolates  increased  from  366 794  to  392 602  and  among 
continuously  reporting 
from  237 630 
to  246 944.  In  2022  the  most  commonly  reported 
bacterial  species 
laboratories 
were  E.  coli  (39.2%),  followed  by  S.  aureus  (22.1%), 
K. pneumoniae (12.3%), E. faecalis (8.2%), P. aeruginosa 
(6.1%),  E.  faecium  (5.9%),  S.  pneumoniae  (3.7%)  and 
Acinetobacter spp. (2.5%). This ranking was different to 
that  from  2021,  with  P.  aeruginosa  and  S.  pneumoniae 
both one rank higher in 2022.

from  all  reporting 

In  2023  all  EU  Member  States  and  EEA  countries 
reported  data  for  2022  to  EARS-Net.  Of  these  30 
countries,  20  (66.7%)  reported  that  their  participating 
laboratories had population coverage of over two thirds 
of the population, including 14 countries that reported 

Although  the  representativeness  of  EARS-Net  data 
is  high,  restricting  analysis  to  laboratories  known 
to  have 
throughout 
2018–2022  (a  so-called  “restricted  dataset”)  is  a  way 
of  further  confirming  trends.  As  the  years  2020  and 

reported  data  continuously 

4

2023Surveillance of antimicrobial resistance in Europe, 2022 data: executive summary2021  coincided  with  extreme  pressures  on  health-
care  associated  with  the  COVID-19  pandemic,  it  is  also 
informative  and  valid  to  compare  2022  data  with  data 
from 2019. To analyse changes in the reported number 
of  isolates  over  time,  two  countries  were  excluded 
from  the  restricted  dataset:  France,  due  to  changes 
to  its  national  surveillance  system,  and  Greece  for 
S.  pneumoniae,  as  this  country  only  started  reporting 
on S. pneumoniae with 2022 data. Within this restricted 
group  of  laboratories  and  when  comparing  2019  to 
2022,  the  largest  increases  in  the  number  of  reported 
isolates  were  for  Acinetobacter  spp.  (+35.2%;  3528  and 
4770,  respectively),  E.  faecium  (+33.2%;  10 584  and 
14 097,  respectively),  E.  faecalis  (+18.5%;  16 096  and 
19 075, respectively), P. aeruginosa (+12.5%; 12 711 and 
14 299, respectively) and K. pneumoniae (+11.8%; 26 836 
and 29 996, respectively), followed by S. aureus (+9.0%; 
49 064  and  53 467,  respectively).  There  was  a  decrease 
in  the  number  of  E.  coli  (-1.6%;  101 415  and  99 743, 
respectively)  and  S.  pneumoniae 
isolates  reported 
(-12.4%;  12 379  and  10 842,  respectively).  However, 
more  recently,  from  2021  to  2022,  a  different  pattern 
has  emerged:  S.  pneumoniae  has  increased  (+71.2%; 
6333  and  10 842,  respectively)  and  Acinetobacter  spp. 
has  decreased  (-29.0%;  6714  and  4770,  respectively). 
The  remaining  pathogens  saw  changes  of  ≤  6% 
(E.  faecium  and  E.  faecalis  decreasing;  P.  aeruginosa, 
E.  coli,  S.  aureus  and  K.  pneumoniae  increasing).  This 
more  recent  pattern  indicates  that  some  of  the  most 
pronounced changes in the number of isolates reported 
between  2019  and  2022  are  possibly  on  their  way  to 
being reversed.

The  AMR  outlook  reported  by  EU/EEA  countries  to 
EARS-Net for 2022 varied widely depending on bacterial 
species,  antimicrobial  group  and  geographical  region, 
as demonstrated by both the varying AMR percentages 
and the estimated incidences of bloodstream infections 
with  selected  pathogens  with  AMR.  Overall,  for  the 
EU/EEA (excluding the United Kingdom), most bacterial 
species–antimicrobial  combinations  showed  either  a 
significantly  decreasing  trend  or  no  significant  trend 
in  the  population-weighted  mean  AMR  percentage 
during  2018−2022.  The  exceptions  were  carbapenem 
resistance  in  K.  pneumoniae,  piperacillin-tazobactam 
resistance  in  P.  aeruginosa,  penicillin  non-wild-type 
and  macrolide  resistance  (including  a  combination  of 
these  two  types  of  resistance)  in  S.  pneumoniae  and 
vancomycin  resistance  in  E.  faecium,  for  which  there 
was a significant increase during the period 2018−2022.

In  2022  more  than  half  of  the  E.  coli  isolates  reported 
to  EARS-Net  and  almost  a  third  of  the  K.  pneumoniae 
isolates  were  resistant  to  at  least  one  antimicrobial 
group  under  surveillance  and  combined  resistance  to 
several antimicrobial groups was a frequent occurrence. 
With  one  notable  exception  −  carbapenem  resistance 
in  K.  pneumoniae  −  both  E.  coli  and  K.  pneumoniae 
saw  either  decreasing  trends  in  the  EU/EEA  (excluding 
the  United  Kingdom)  population-weighted  mean  AMR 
percentages  or  no  trend.  For  3GC-resistant  E.  coli, 
a  decreasing  trend  in  the  estimated  incidence  of 

bloodstream  infections  was  also  noted  from  2018  to 
2022  for  the  EU  with  a  16.8%  decrease  in  2022  against 
the  baseline  year  2019.  Among  antimicrobial  groups 
for  both  species,  EU/EEA  population-
monitored 
weighted mean AMR percentages were generally higher 
in K. pneumoniae than in E. coli.

Carbapenem  resistance  remained  rare 
in  E.  coli, 
but  almost  one  third  of  EU/EEA  countries  reported 
carbapenem  resistance  percentages  above  10%  in 
K. pneumoniae. It is noteworthy that the largest increase 
(+2.4%)  in  population-weighted  mean  AMR  percentage 
under EARS-Net surveillance during 2018−2022 occurred 
in  carbapenem-resistant  K.  pneumoniae,  resulting 
in  a  significantly  increasing  trend.  In  addition,  there 
was  a  significantly  increasing  trend  in  the  estimated 
incidence of bloodstream infections with carbapenem-
resistant  K.  pneumoniae  with  a  49.7%  increase  in  2022 
against the baseline year 2019. Carbapenem resistance 
was  also  common  in  P.  aeruginosa  and  Acinetobacter 
spp.,  with  a  higher  EU/EEA  population-weighted  mean 
percentage  than  in  K.  pneumoniae.  For  most  gram-
negative  bacteria  under  surveillance,  increases  in  the 
EU/EEA  (excluding  the  United  Kingdom)  population-
weighted  mean  AMR  percentages  between  2018  and 
2022  were  moderate.  However,  AMR  remained  at  high 
levels,  as  previously  reported.  It  is  also  worth  noting 
that,  compared  with  2021,  the  EU/EEA  population-
weighted  mean  AMR  percentages  in  Acinetobacter  spp. 
for 2022 showed decreases for all antimicrobial groups 
under surveillance.

For  S.  aureus,  a  significantly  decreasing  trend  in  the 
EU/EEA  (excluding  the  United  Kingdom)  population-
weighted mean percentage of MRSA isolates, as well as 
in the estimated EU incidence of bloodstream infections 
with MRSA, was reported during the period 2018−2022. 
Moreover,  in  2022,  there  was  a  12.2%  decrease  in 
the  estimated  incidence  against  the  baseline  year 
important 
2019.  Nevertheless,  MRSA  remains  an 
pathogen  in  the  EU/EEA,  with  levels  remaining  high  in 
several  countries  and  combined  resistance  to  another 
antimicrobial group quite common.

In  addition  to  the  increase  in  the  number  of  reported 
isolates  in  2022  compared  with  2021,  the  last  5  years 
have  seen  a  significantly  increasing  trend  for  the 
EU/EEA  (excluding  the  United  Kingdom)  population-
weighted mean percentage of macrolide resistance and 
penicillin non-wild-type, including combined resistance 
in S. pneumoniae.

One  development  of  particular  concern  was  the  fact 
that  the  significantly  increasing  trend  in  the  EU/EEA 
(excluding  the  United  Kingdom)  population-weighted 
mean  percentage  of  vancomycin-resistant  isolates  of 
E.  faecium  further  increased,  from  16.2%  in  2018  to 
17.6% in 2022.

The 
reported  AMR  percentages  and  estimated 
incidences  of  bloodstream  infections  with  resistant 
bacteria  varied  widely  among  EU/EEA  countries,  often 
with  a  north-to-south  and  west-to-east  gradient.  In 

5

Surveillance of antimicrobial resistance in Europe, 2022 data: executive summary2023general,  the  lowest  AMR  percentages  were  reported 
by countries in the north of Europe and the highest by 
countries in the south and east of Europe.

2022, highlighting the opportunities for significant AMR 
reduction  through  interventions  to  improve  IPC  and 
antimicrobial stewardship practices.

In addition to this executive summary, published jointly 
by  the  European  Centre  for  Disease  Prevention  and 
Control (ECDC) and the WHO Regional Office for Europe, 
an  Annual  Epidemiological  Report  on  Antimicrobial 
resistance in the EU/EEA (EARS-Net) using 2022 data has 
been  published  by  the  ECDC  (Antimicrobial  resistance 
in  the  EU/EEA  (EARS-Net):  Annual  Epidemiological 
Report 2022, in publication). For each bacterial species, 
country-specific information on the estimated incidence 
of  bloodstream  infections  (EU  recommended  targets), 
data  availability  and  age  group,  sex  and  intensive  care 
unit patient percentages is available in country profiles 
that  are  published  as  an  annex  to  the  Report.  Results 
by  age  group  and  sex  for  specific  AMR  phenotypes  are 
available  in  the  ECDC’s  Surveillance  Atlas  of  Infectious 
Diseases (12).

Discussion

For the first time, in 2022 all EU/EEA countries reported 
data  to  EARS-Net.  Representativeness  was  reported 
as  high  for  over  70%  of  countries.  This  indicates  that 
although  all  EU/EEA  countries  are  included  in  EARS-
Net,  work  still  needs  to  be  done  in  some  to  improve 
surveillance representativeness.

Overall,  the  EU/EEA  population-weighted  mean  AMR 
percentages  for  bacterial  species–antimicrobial  group 
combinations  under  surveillance  continued  to  be  high 
for the EU/EEA in 2022.

largest 

increase 

in  2022  the 

population-weighted  mean 

in  the 
Specifically, 
EU/EEA 
percentage 
AMR  from  2018,  excluding  the  United  Kingdom,  and 
compared with all other bacterial species antimicrobial 
in  carbapenem-resistant 
group  combinations,  was 
K.  pneumoniae.  The  continuing  increasing  trend  in  the 
percentage  when  also  considering  the  significantly 
increasing 
incidence  of 
bloodstream infections at EU level for the same period 
is  of  considerable  concern.  Similarly,  the  increase  in 
reports  of  E.  faecium  since  2019,  with  a  significantly 
increasing  trend  in  the  EU/EEA  population-weighted 
mean  vancomycin  resistance  percentage  since  2018 
indicates  that  AMR  remains  a  serious  challenge  in  the 
EU/EEA.

the  estimated 

trend 

in 

interventions  were 

Another  development  of  concern  in  2022  was  the  fact 
that,  following  a  decline  in  2020−2021  when  more 
in 
COVID-19  nonpharmaceutical 
place  in  the  EU/EEA  (13),  the  number  of  reports  of 
S.  pneumoniae  invasive  infections  showed  signs  of 
returning to a level similar to that for 2019. In addition, 
there  was  an  increasing  trend  in  EU/EEA  population-
weighted mean combined penicillin non-wild-type and 
macrolide resistance.

As in previous years, overall there was a large variability 
in  the  AMR  percentages  across  EU/EEA  countries  in 

6

resistance  percentages, 

Equally,  indications  of  potential  improvements  were 
seen.  The  previous  worsening  of  the  Acinetobacter 
spp.  situation  (14,15)  showed  signs  of  improving  in 
2022,  with  decreasing  numbers  of  isolates  and  EU/EEA 
population-weighted  mean  resistance  percentages 
reported  compared  with  2021.  This  suggests  a 
continued  requirement  for  Acinetobacter  spp.-specific 
control  interventions  in  affected  hospitals  (16),  while 
interventions  may  have  had  some 
indicating  that 
effect.  In  addition,  E.  coli  showed  either  no  trend  or 
a  decreasing  trend  in  EU/EEA  population-weighted 
mean 
further  supported 
by  a  decreasing  trend  in  the  estimated  incidence  of 
3GC-resistant E. coli bloodstream infections at EU level. 
S. aureus also displayed a declining trend in the EU/EEA 
population-weighted mean percentage of MRSA, as well 
as in the estimated EU incidence of MRSA bloodstream 
infections  from  2018  to  2022.  Nevertheless,  despite 
these  encouraging  developments,  AMR  percentages 
remain  high  in  EU/EEA  countries.  The  ECDC  estimated 
that  in  2020  alone,  the  number  of  infections  with 
antibiotic-resistant bacteria in the EU/EEA falling under 
EARS-Net surveillance was more than 800 000, resulting 
in over 35 000 deaths (17).

On  13  June  2023  the  Council  of  the  EU  adopted  a 
Council  Recommendation  on  stepping  up  EU  actions 
to  combat  antimicrobial  resistance  in  a  One  Health 
approach  (2023/C  220/01),  which  recommends  targets 
to  be  achieved  in  the  EU  by  2030  (18).  These  include 
three  AMR  targets  aimed  at  reducing  total  incidence 
of  bloodstream  infections  with  MRSA,  3GC-resistant 
E.  coli  and  carbapenem-resistant  K.  pneumoniae  by 
15%,  10%  and  5%,  respectively,  by  2030  compared 
with the baseline year (2019). Data for 2022 have shown 
favourable decreasing trends in the estimated incidence 
of bloodstream infections at EU level for the EU targets 
on MRSA and 3GC-resistant E. coli.

Data  relevant  to  the  third  EU  target  on  the  total 
incidence of bloodstream infections with carbapenem-
resistant K. pneumoniae, showed an increase of almost 
50%  during  the  period  2019−2022.  Therefore,  instead 
of  progressing  towards  the  5%  reduction  target  by 
2030,  the  situation  in  the  EU  has  worsened  since  2019. 
This  increase  indicates  the  need  to  rapidly  strengthen 
prevention  and  control  action  in  EU  Member  States, 
as  highlighted  in  the  EU  Council  recommendation 
(18).  The  widely  varying  estimated 
incidences  of 
bloodstream  infections  with  resistant  bacteria  and 
AMR  percentages  among  countries  suggest  that  there 
are further opportunities for reduction. For specifically 
carbapenem-resistant  K.  pneumoniae  and  other 
carbapenem-resistant  Enterobacterales  (CRE),  options 
for  action  are  highlighted  in  the  2019  update  of  the 
ECDC’s  rapid  risk  assessment  on  CRE,  including  timely 
and  appropriate  diagnosis,  high  standards  of  IPC  and 
antimicrobial stewardship (19).

2023Surveillance of antimicrobial resistance in Europe, 2022 data: executive summaryData for the years 2020 and 2021 coincided with the first 
years  of  the  COVID-19  pandemic.  Changes  to  human 
behaviour  through  2020−2021  aimed  at  control  of  the 
pandemic,  and  then  again  in  2022  as  the  number  of 
nonpharmaceutical  interventions  was  reduced,  may 
have  modified  the  risk  of  infection  by  pathogens  with 
AMR.  However,  unlike  antimicrobial  consumption  in 
the  EU/EEA  (Antimicrobial  consumption  in  the  EU/EEA 
(ESAC-Net):  Annual  Epidemiological  Report  2022,  in 
publication),  for  AMR  under  EARS-Net  surveillance 
there  was  no  uniform  pattern  across  surveillance 
data.  Some  bacterial  species  such  as  Acinetobacter 
spp.  and  S.  pneumoniae  showed  indications  of  having 
been  affected  by  the  COVID-19  pandemic  and  actions 
taken  during  this  time.  However,  these  two  species 
followed  different  patterns:  increases  and  decreases, 
respectively,  during  2020–2021  and  a  reversal  of 
these  changes  in  2022.  These  changes  indicate  the 
importance  of  IPC  in  health-care  settings,  as  well  as 
nonpharmaceutical interventions in the community.

The impact of the war in Ukraine on the data reported 
to EARS-Net is unclear. In 2022 there were reports from 
EU/EEA countries of the detection of multidrug-resistant 
organisms  in  patients  recently  hospitalized  in  Ukraine 
(20,21).  On  8  March  2022  the  ECDC  published  a  report 
entitled  Operational  public  health  considerations  for 
the prevention and control of infectious diseases in the 
context  of  Russia’s  aggression  towards  Ukraine  (22). 
This  report  recommended  that  hospitalized  patients 
in  the  EU/EEA  whether  transferred  from  hospitals  in 
Ukraine  or  with  a  history  of  hospitalization  in  Ukraine 
during  the  previous  12  months,  should  be  isolated 
pre-emptively  and  screened  for  carriage  of  multidrug-
resistant organisms.

The  results  in  this  summary  provide  an  overview 
of  the  AMR  situation  in  the  EU/EEA.  However,  when 
interpreting  EARS-Net  data,  it  is  important  to  be 
mindful  of  the  structure  of  the  surveillance  system 
itself,  including  the  large  variation  in  blood  culture 
rates, and changes in national surveillance systems and 
in  EARS-Net  over  time.  It  is  also  of  note  that  there  has 
not been a systematic assessment of the characteristics 
of, and AMR data provided by, the EU/EEA laboratories 
that do not report to EARS-Net. Nevertheless, EARS-Net 
surveillance data do reflect the overall AMR situation in 
the EU/EEA.

The European Health Union has been created to better 
protect  the  health  of  EU  citizens  (23).  This  includes 
strengthened  mandates  for  ECDC  and  the  European 
Medicines Agency, the creation of the European Health 
Emergency  preparedness  and  Response  Authority  and 
a  new  regulation  on  serious  cross-border  threats  to 
health adopted by the Council on 24 October 2022 (24). 
Additionally,  a  large  budget  has  been  made  available 
under  the  EU4Health  programme  (€5.3  billion  for  the 
period  2021–2027),  one  of  the  main  instruments  for 
the  European  Health  Union,  dedicated  to  wider  policy 
areas and including action on AMR. In line with this, the 
recently  adopted  Council  of  the  EU  Recommendation 

on  stepping  up  EU  actions  to  combat  antimicrobial 
resistance  in  a  One  Health  approach  not  only  includes 
AMR  and  antimicrobial  consumption  targets,  but  also 
encourages  Member  States  to  improve  surveillance 
where needed and develop NAPs against AMR, including 
implementation  and  regular  updates.  In  addition,  the 
Recommendation  highlights  the  need  for  Member 
States to provide the necessary resources to implement 
the  NAPs,  with  the  European  Commission  providing 
support for this where required.

Public health implications

Public  health  action  to  tackle  AMR  in  the  EU/EEA 
remains  insufficient,  despite  the  increased  awareness 
of AMR as a threat to public health and the availability 
of  evidence-based  guidance  for  IPC,  antimicrobial 
stewardship  and  adequate  microbiological  capacity. 
AMR will be an increasing concern unless governments 
respond more robustly to the threat. More specifically, 
there  is  a  concern  that  more  infections  with  bacteria 
resistant  to  antibiotics  will  be  harder  to  treat,  leading 
to an increase in suffering and deaths. Estimates based 
on  data  from  EARS-Net  show  that  in  2020,  more  than 
800 000  infections  in  the  EU/EEA  were  due  to  bacteria 
resistant to antibiotics and that more than 35 000 people 
died as a direct consequence of these infections (17).

Data from 2022 not only indicate the necessity for IPC in 
health-care  settings,  even  during  trying  circumstances 
such  as  a  pandemic,  but  also  the  potential  effects  of 
nonpharmaceutical  interventions.  Data  from  2022  also 
show  that  AMR  levels  remain  high  in  the  EU/EEA  and 
that  there  are  specific  AMR  issues  of  concern,  such 
as  the  continuing  increase  in  carbapenem-resistant 
K. pneumoniae and vancomycin-resistant E. faecium.

Further  investment  in  public  health  interventions  is 
urgently  needed  to  tackle  AMR.  This  would  have  a 
significant  positive  impact  on  population  health  and 
future  health-care  expenditure  in  the  EU/EEA.  These 
interventions  could  include  IPC  measures,  such  as 
in  health-care 
promotion  of  better  hand  hygiene 
to  prevent 
stewardship 
transmission;  antibiotic 
programmes,  such  as  rapid  testing  of  patients  to 
discriminate  viral  from  bacterial  infections  and  the 
promotion  of  prudent  antibiotic  usage  to  prevent 
bacteria 
from  developing  AMR;  and  mass  media 
campaigns,  to  raise  public  awareness  of  AMR.  In  2019 
for  Economic  Co-operation  and 
the  Organisation 
Development  estimated  that  a  mixed 
intervention 
package 
including  enhanced  hygiene,  antibiotic 
stewardship  programmes,  mass  media  campaigns 
and  the  use  of  rapid  diagnostic  tests  would  have  the 
potential  to  prevent  approximately  27 000  deaths  each 
year  in  the  EU/EEA.  In  addition  to  saving  lives,  such  a 
package could pay for itself within just 1 year and save 
around €1.4 billion per year in the EU/EEA (25).

7

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Suggested citation: WHO Regional Office for Europe and 
European Centre for Disease Prevention and Control. 
Surveillance of antimicrobial resistance in Europe, 2022 data: 
executive summary. Copenhagen: WHO Regional Office for 
Europe; 2023.

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2023Surveillance of antimicrobial resistance in Europe, 2022 data: executive summary