Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035

2 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 3 Content Introduction 6 International commitments underscore Sweden’s work in AMR 7 Focus and scope limitations of this Strategy 8 A long-term strategy for 2026–2035 8 Gender equality and equity 9 Target groups for the Strategy 9 Other relevant strategies 9 Vision 11 Overall objectives during the Strategy period 11 Target area 1 15 Safeguard structures for coordinating the work to curb AMR to enable long-term management of a cross-sectoral problem 15 Target area 2 18 Communication and increased knowledge about antibiotic resistance and counter-measures that lead to behavioural changes throughout society 18 Target area 3 20 Working actively and proactively to ensure that antimicrobial resistance is recognised and managed through global cooperation 20

4 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Target area 4 25 Continuous, effective surveillance of antimicrobial resistance 25 Target area 5 29 Continued responsible use of antibiotics and good monitoring of their use 29 Target area 6 33 Reduced development and spread of infections including healthcare-associated infections among humans 33 Target area 7 36 Healthy animals and safe food through preventive measures 36 Target area 8 38 Strengthened preventive measures to limit discharges into the environment 38 Target area 9 41 Ensure reliable access to antibiotics and effective diagnostic tests 41 Target area 10 44 Research and innovation that helps to curb antimicrobial resistance 44 Background information 46 A description of how this strategy was developed 46 List of terms and abbreviations 47 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 5 Cross-environmental Antibiotics interactions in anti- microbial resistance e Us a g Us ag e Animals Humans Health and Antibiotic social care resistance can be selected for Spread Spread Antibiotic resistance Antibiotic resistance can be selected can be selected Antibiotic Spread Sp ad An re leakage re e ag tib ad Sp ak io ic le le t tic ak io ag t ib e An Antibiotic resistance can be selected Environment Introduction Antimicrobial resistance (AMR), in particular antibiotic resistance, poses one of the biggest global threats to health and food production in our time. When bacteria and other microorganisms develop resist- ance to antimicrobials, the possibility of effectively treating infections in both humans and animals is reduced, leading to higher morbidi- ty and mortality rates1 with substantial consequences for the econo- my. Antibiotic resistance threatens to undermine all of modern health- care, as it means that even routine operations, neonatal care, cancer treatments and advanced intensive care become associated with mortal danger if we do not have functioning antibiotics. Discharges of antibiotics and other antimicrobials, and solid waste from their manufacturing as well as resistant bacteria into the environ- ment can lead to an increased burden of resistant bacteria in humans, animals and plants. Infections and resistance can spread between an- imals, humans and the environment through direct contact, food or wastewater for example. Working strategically to curb AMR is vital so that we can continue to have access to effective treatments, but also to equip Sweden for peace- time crisis situations, a heightened state of alert, and war. Effective work in this area therefore requires collective action, but also an understand- ing of the different starting points and conditions that prevail in each sector. Antimicrobial resistance is thus not just a public health issue, but also a security and supply issue, with implications for the whole of society. 1 Naghavi, Mohsen et al, 2024, Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050, The Lancet.

6 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Animals Humans One health Environment International commitments underscore Sweden’s work in AMR The UN recommends that all countries develop a National Action Plan on Antimicrobial Resistance.2 Sweden has long followed this rec- ommendation by working with a whole-of-society Strategy, decided by the Swedish Government, and a National Action Plan developed by Swedish government agencies. International declarations, recommendations and guides are devel- oped and updated regularly. The term One Health is often used in de- scribing the interaction between animals, humans and the environ- ment in this area. This Strategy is based on sector-specific as well as One Health-oriented objectives, and recommendations adopted by the United Nations (UN), the European Union (EU) and the Nor- dic Council of Ministers, all of which entail commitments for Sweden. They include the Political Declaration of the High-Level Meeting on Antimicrobial Resistance adopted at the 79th session of the UN Gen- eral Assembly in 20243, the EU’s Council recommendation on step- ping up EU actions to curb antimicrobial resistance in a One Health approach,4 and the Nordic Council of Ministers’ declaration regarding work to curb AMR.5 Other internationally accepted documents, guide- lines and recommendations also underscore this work in Sweden.6 This Strategy also contributes to the implementation of the 2030 Agenda. 2 Global action plan on antimicrobial resistance, WHA, 2015. 3 Political Declaration of the High-Level Meeting on Antimicrobial Resistance, UNGA, 2024. 4 Council recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach, 2023. 5 One Health – Strengthened Nordic Cooperation on Antimicrobial Resistance, Nordic Council of Ministers, 2024. 6  For example, the WHO AWaRe (Access, Watch, Reserve) antibiotic book published by the World Health Organization, the European Food Safety Authority (EFSA) in- dicators, the World Organisation for Animal Health (WOAH) standards, the WHO’s Global Strategy on Infection Prevention and Control and its infection control and prevention initiatives, the UN Food and Agriculture Organisation (FAO) guidelines and resolutions, and the Codex Alimentarius standards on AMR, etc. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 7 Focus and scope limitations of this Strategy Resistance is an evolutionary, natural phenomenon in microorganisms and increases when the microorganisms are exposed to antimicrobials. Strategic management of the development of AMR in human and an- imal health, and food production and the environment is needed, and it needs to be sustainable over the long term. Effective prevention in relevant sectors are also essential. Long term means here delaying and inhibiting the development of AMR as far as possible while ensuring access to effective treatment options. Sweden has long been a pioneer in work to reduce AMR, but the new challenges that keep arising re- quire ongoing, concerted and strategic work. This Strategy therefore deals with the work to curb antimicrobial resistance (AMR) in a broad sense, where although antibiotic resistance (ABR) is the main chal- lenge, other forms of resistance must also be taken into account. For example, fungal infections that have become resistant to antimycotic drugs (antifungal agents) are a growing problem in Sweden. With this Strategy, the Government aims to bring together Sweden’s work and commitments in relation to the terms and concepts used in the Nordic region, the EU, and globally. Since antibiotic resistance is the biggest threat, it remains the focus of this work, both in Sweden and abroad. This explains why some of the Strategy’s objectives are limited to ABR and do not relate to the entire AMR area. By clarifying objectives and targets, how they are monitored and which actors are involved, in this new Strategy the Government’s aim is to reinforce and strengthen the efforts already being made. Key areas of development in relation to the previous strategy 7 include: • clear objectives and targets with clear timeframes; • infection prevention and control efforts, including healthcare hy- giene; • a society that is well prepared to cope with peacetime crisis situa- tions, a heightened state of alert and even war; • a cross-sectoral approach involving many actors but also sector-spe- cific target areas • access to effective antibiotics and diagnostic tests. A long-term strategy for 2026–2035 The Strategy has a 10-year horizon for predictability and sustainability in this work moving forward. The Strategy will be supplemented with a National Action Plan that relevant government agencies have been commissioned to develop in collaboration with other actors. The Na- tional Action Plan will include activities for the implementation of the targets set out in this Strategy. In 2029, a new High-Level Meeting of the UN General Assembly will be held on the theme of AMR, and by 2030 the EU’s Council Recommendation8 will have been implement- ed in the Member States. Following this Meetings, it is reasonable that 7 Swedish Strategy to Curb Antibiotic Resistance, 2024–2025. 8 Council recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach, 2023.

8 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 consideration should be given to whether or not Sweden’s Strategy needs adjustment. Therefore, and based on data from relevant govern- ment agencies working together to curb AMR, the Government in- tends to continuously monitor the implementation of the Strategy and the National Action Plan and to make any adjustments as needed. To- wards the end of the period covered by the Strategy, a more compre- hensive follow-up and evaluation should be carried out to determine the design of the work to curb AMR in Sweden moving forward. Gender equality and equity The Strategy is based on the right to health, including the supply of and access to medicinal products, as expressed in Article 12 of the In- ternational Covenant on Economic, Social and Cultural Rights.9 AMR often affects the most vulnerable and those with the greatest burden of disease, both in Sweden and globally. Furthermore, the World Health ­Organization (WHO) states that gender is associated with major differ- ences in diagnosis and treatment. Overall, women are almost 30% more likely to receive antibiotics during their lifetime than men.10 A Gender equality and equity dimension therefore needs to permeate the work to curb AMR and equity, where possible and appropriate, gender-disaggre- gated statistics should be reported. In work at the global level, low and middle-income countries are particularly vulnerable to AMR. Target groups for the Strategy Sweden’s Strategy to Curb Antimicrobial Resistance has been devel- oped and adopted by the Swedish Government, but is being imple- mented within the framework of a number of relevant government agencies’ tasks and areas of activity. A number of other actors at differ- ent levels are also important for the successful implementation of the Strategy, such as healthcare staff, social services, and activities carried out pursuant to the Act Concerning Support and Service for Persons with Certain Functional Impairments (hereinafter ‘LSS activities’), municipalities and regions, veterinary healthcare staff, actors in ani- mal husbandry and the food chain, researchers, companies, civil soci- ety, organisations, the education sector, higher education institutions, and others. Indirectly, both government agencies and these actors also help to raise awareness and bring about behavioural changes among the general public, patients and animal owners. Collaboration between these actors is crucial to curb AMR. It is vital to establish the basis for long-term prioritisations and the conditions that are essential to the work to curb AMR. Other relevant strategies Sweden’s Strategy to Curb Antimicrobial Resistance focuses on a sin- 9 International Covenant on Economic, Social and Cultural Rights (ICESCR) Gen- eral Assembly, 1966. 10 Addressing gender inequalities in national action plans on antimicrobial resist- ance – Guidance to complement the people-centred approach, WHO 2024. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 9 gle issue, but is entirely dependent on a cross-sectoral approach. In 2024 and 2025, the Government has decided on a number of assign- ments and strategic documents in which antibiotic use, antibiotic re- sistance or antimicrobial resistance are specifically mentioned as part of the assignment, such as: • Development assistance for a new era – freedom, empowerment and sustainable growth • Research and Innovation Bill 2024 • A concerted effort for long-term excellence, competitiveness and increased patient benefit – new objectives for Sweden’s national life sciences strategy • Food Strategy 2.0 • National Pharmaceutical Strategy 2024–2026 • National Security Strategy • Strategy for Sweden’s development cooperation for health and sexual and reproductive health and rights, 2025–2029 • Strategy for sustainable growth, the green transition and educa- tion 2025–2029. Furthermore, the National Board of Health and Welfare has been as- signed by the Government to develop a national action plan for patient safety in Sweden – a plan that applies for the period 2025–2030.11 11 Act for safer healthcare. National Action Plan for Increased Patient Safety 2025–2030, National Board of Health and Welfare. Sweden – a pioneering country Sweden boasts among the lowest levels of use of antibiotics in the EU for both humans and animals. This is largely a result of Sweden’s early start in working in a structured and long-term way to curb an- tibiotic resistance, which has enjoyed both political and legislative support. Sweden was the first country in the world to ban antibiotic growth promoters for animals in 1986. Another key factor in Sweden’s work in this area has been local, regional and national collaboration, within and between sectors. Swedish actors in relevant sectors from politics, government agen- cies, industry and civil society have all banded together to work constructively towards a common objective, which has created a strong foundation for good results. In the animal and food sector, prevention has been of key impor- tance based on the slogan “Healthy animals don’t need antibiotics”. Since 1995, the profession-driven Strama model (Strama is Swe- den’s strategic programme to curb antibiotic resistance) has been working locally, regionally and nationally and in various sectors to promote the responsible use of antibiotics and has been important for Sweden’s good position today. In Sweden, there is good access to data that can guide actions and their follow-up, which is essential for being able to determine wheth- er we are in a good position and are managing new challenges.

10 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 10 target areas Safeguard structures for coordinating the work to curb AMR to enable long- term management of a cross-sectoral problem Communication and in- creased knowledge about antibiotic resistance and counter-measures that lead to behavioural changes throughout society Working actively and proactively to ensure that antimicrobial resistance is recognised and managed through global cooperation Continuous, effective sur- veillance of antimicrobial resistance Vision Continued responsible use of antibiotics and good A society in which access to treatment with antimi- monitoring of their use crobials is maintained through cross-sectoral and Reduced development and sector-specific initiatives to prevent infection and limit spread of infections includ- the development, spread and consequences of resi- ing healthcare-associated stant microorganisms. infections among humans Healthy animals and safe food through preventive Overall objectives during the measures Strategy period Strengthened preventive Overall objectives are defined in the introduction to the Strategy and measures to limit discharg- aim to measure its effect over the long term. Following these, a num- es into the environment ber of targets divided into 10 target areas are described. There is no in- ternal ranking among these. Ensure reliable access to antibiotics and effective With this Strategy, Sweden aims to contribute to achieving the objec- diagnostic tests tives decided within the EU and the UN, including the global goal of reducing the global deaths caused by bacterial antimicrobial resistance Research and innovation by 10%.12 Some of the Strategy’s overall objectives have the end year that helps to curb antimi- 2030 if they are based on international commitments, while others end crobial resistance in 2035. 12 Political Declaration of the High-Level Meeting on Antimicrobial Resistance, UNGA 2024. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 11 Sweden’s objectives for the level of AMR Sweden’s objectives for antibiotic use • The rate of increase in the incidence of blood- • The total use of antibiotics (outpatient and inpa- stream infections with methicillin-resistant tient care) has decreased by 3% by 2030 com- Staphylococcus aureus (MRSA) for the period pared to baseline year 2019, measured in Defined 2026–2030 does not exceed the rate of increase Daily Dose (DDD) per 1000 inhabitants per day. in the period 2009–2018. • A maximum of 250 prescriptions per 1000 inhab- • The rate of increase in the incidence of blood- itants per year (outpatient) in all regions up to and stream infections with extended spectrum including 2035. β-lactamase (ESBL) producing Escherichia coli for • Prescriptions for people from a specific category the period 2026–2030 does not exceed the rate of antibiotics with a narrower spectrum (accord- of increase in the period 2009–2018. ing to the international AWaRe standard) contin- • In 2030, the incidence of bloodstream infections ues to exceed 75% in 2035. with carbapenem-resistant Klebsiella pneumoni- • The consumption of antibiotics in Sweden’s ae does not exceed that of baseline year 2019.13 livestock production in relation to total consump- • The proportion of Escherichia coli in randomly tion is to be on par with consumption during the sampled healthy pigs and chickens for slaughter period 2016–2025. sensitive to all tested substances in the EU proto- • The proportion of antibiotics for group treatment col for harmonised monitoring of AMR is not less in food-producing livestock does not exceed the than 70% on two consecutive testing occasions proportion during the period 2016–2025. for each species. • The proportion of penicillin in the total consump- • Reliable data on AMR in animal pathogens are tion used for animals is not less than the propor- available to ensure good monitoring of AMR. tion for the period 2016–2025. 13 Council recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health ap- proach, 2023.

12 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 12 Sweden’s objectives for prevention Sweden’s objectives for access to antibiotics • Vaccination coverage rates for children should not fall below the current level of 95% and, in accord- • Shortages of antibiotics and other antimicrobials ance with WHO recommendations, Sweden aims are to be reduced by 2035 compared to baseline to have good vaccination coverage against influ- year 2025 levels. enza and COVID-19 in high-risk groups. • The best conceivable treatment for the WHO’s list • The capacity to maintain a good animal health of ‘bacterial priority pathogens’ should be sup- status has been maintained. plied on the Swedish market and accessible. • The healthcare hygiene and infection prevention and control work in veterinary healthcare, and in human healthcare, social services and LSS activ- ities in the human sector, has reduced the risk of cross-infection and healthcare-associated infec- tions (also called nosocomial infections). The environment remains a key part of the work to curb AMR, with harmonised and binding legislation within the EU. By maintaining low levels of resistance Sweden’s objective for healthcare-associ- and prescribing of antimicrobials, and minimising ated infections: discharges to the environment, Sweden contributes to the overall objectives and to making the Strate- gy’s vision a reality. Consequently, there is currently • The average proportion of healthcare-associated no need for measurable targets in the environmen- infections in humans (according to the European tal area. Centre for Disease Prevention and Control’s defi- nition) between 2026 and 2035 has decreased by one third compared to the data for baseline year 2023 from the ECDC’s point prevalence survey conducted in Sweden. Sweden’s Strategy Sweden’s to Curb Strategy Antimicrobial to Curb Resistance Antimicrobial 2026–2035 Resistance 13 13 2026–2035

14 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Target area 1 Safeguard structures for coordinating the work to curb AMR to enable long-term management of a cross-sectoral problem Background Efforts to prevent and manage AMR span multiple sectors and ac- tors. The term One Health is being used more and more frequently to clarify the interaction between animals, humans and the environment. Through coordination between sectors, resources can be used more efficiently, duplication of work can be avoided, and common messag- ing can be communicated. This target area entails Between 2012 and 2025, there has been a government assignment an increased focus on in place for a national intersectoral coordinating mechanism (ICM) cross-sectoral interven- against antibiotic resistance, currently coordinated by the Public Health tions throughout the Agency of Sweden and the Swedish Board of Agriculture, in which whole of society as wells as government agencies and actors have worked together to develop a cross-sectoral collaboration multi-year National Action Plan. Other actors, such as professional or- to limit AMR through One ganisations, civil society actors and the Swedish Association of Local Health approaches in the Authorities and Regions (SALAR), have also participated in this work. area. Supporting structures These actors have also been responsible for the sector-wide communi- and systems are further cation platform “Skydda antibiotikan” (Safeguard antibiotics). developed and monitoring is improved. To ensure that knowledge in this area has the best possible condi- tions for being well used and well supported, close contact and good collaboration is needed between the relevant actors such as govern- ment agencies, regions, and municipalities as well as actors operating in animal husbandry and the food chain. For this knowledge to be put Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 15 into practice, well-functioning structures and activities such as Strama groups, microbiology laboratories, healthcare hygiene units, infectious disease control units, and medicinal products committees are needed. In Sweden, the regions and municipalities are responsible for struc- turing their own work to curb AMR in the human sectors. There are multiple groups that are relevant to this work within the regions’ na- tional systems for knowledge management in healthcare and dental care, such as national programme areas (NPO) and national working groups (NAG or NSG).14 For the animal sector, there are groups with similar objectives such as Strama VL (Veterinary and Food) and the Veterinär Vårdhygienförening (Veterinary Infection Prevention and Con- trol Association). The long-term impact of the work to curb AMR can also be helped by broader efforts to involve actors at all levels of society, which is in line with current public health policy on good and equitable health in the population. It is also about creating the conditions for people to be able to live and work anywhere in the country and to assure competi- tive and sustainable food production. Civil society, associations, representatives of the research community, companies, government agencies, municipalities, regions and other ac- tors need forums where they can be afforded opportunities to contrib- ute to the implementation of Sweden’s Strategy to Curb Antimicrobial Resistance in a coordinated way. 14 For example, NAG Vårdhygien (Healthcare hygiene), NSG Patient Safety, NAG Strama, NPO Infectious diseases, and others.

16 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets • Sweden has a National Action Plan to curb AMR and it is reg- ularly monitored, evaluated and updated. • Sweden has well-functioning, cross-sectoral collaboration at the national level to curb AMR that brings together relevant government agencies and actors. • Sweden has structures and working models for knowledge transfer between central government, the regions and the municipalities and to provide support for the implementation of the Strategy and National Action Plan. • Through management systems and established procedures, the responsible authorities/entities and managements for healthcare and dental care, in both the public and private sectors, have created the foundations for work within in- fection prevention and control, healthcare hygiene, clinical microbiology and patient safety, as well as for the responsi- ble use of antibiotics with the support of NAG Strama (the Strama national working group) and regional Strama groups. • Through management systems and established procedures, the responsible authorities/entities and managements of social services and LSS activities have created the founda- tions for work with infection prevention measures and basic hygiene in their respective activities. • The responsible authorities/entities and managements with- in veterinary healthcare have created the foundations for the responsible use of antibiotics, good infection prevention and control and good healthcare hygiene. • Working models have been further developed to implement the work to curb antibiotic resistance in dental care, and to ensure regional representation in Tandvårdsstrama (the den- tal care Strama group). • Forums have been established to inform and engage societal actors at all levels in the implementation of the Strategy. • The business community and organisations recognise anti- microbial resistance, in particular antibiotic resistance, as a future threat to economic growth and health, and contribute within their spheres of activity to the implementation of the Strategy. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 17 Target area 2 Communication and increased knowledge about antibiotic resistance and counter- measures that lead to behavioural changes throughout society Background In Sweden, where antibiotics are prescription-only drugs, prescribers have a great responsibility for the responsible use of antibiotics. How- ever, the expectations of the general public and their level of knowl- edge may influence prescribers’ decisions to prescribe antibiotics, or influence individuals’ decisions to procure antibiotics without a pre- scription, for example via the Internet, from acquaintances, or through importing them from other countries. A high level of awareness about why it is important that antibiotics are only used when they are bene- This target area means that ficial, in the right way, and when prescribed by an authorised prescrib- good knowledge and aware- er is fundamental to establishing a sustainable attitude to antibiotics in ness of measures to prevent the wider community. the development and spread of infections in humans and Similarly, a high level of awareness of the importance of preventive animals should be available measures is key to reducing the number of infections that require to all concerned, including the treatment and thus the need for antibiotics. The knowledge that vacci- general public. Furthermore, nations can help reduce antibiotic use, and thus the development of anti- knowledge of the risks asso- biotic resistance, may need to be enhanced at the wider community level. ciated with the development and spread of resistance It is important that this information is communicated in a coordinat- when antibiotics are used ed way, within each sector and between sectors, so that the public re- should increase in the com- ceives targeted and analogous messaging from relevant actors in a way munity. This knowledge is to that is easy for them to comprehend. translate into behaviours that lead to reducing the develop- Municipalities and regions along with professionals in healthcare, ment and spread of infections pharmacy, social services, LSS activities, dental care, and actors in vet- and antibiotic resistance. The erinary healthcare, animal husbandry and the food chain, all have a level of knowledge of staff clear role to play in facilitating the implementation of the Strategy. It working in healthcare, dental is decisive that practitioners in these professions have sufficient basic care, social services, LSS activ- training and access to continuing professional development training, ities, and animal health, and but also access to specialist training so that the Strategy can be imple- staff working for other actors mented. The knowledge communicated should preferably be analo- in animal husbandry and the gous, regardless of the higher education institution, region, municipali- food chain, must be sufficient ty or activity in which the person works. to enable them to contribute positively to the work to curb In order to achieve sustainable behavioural changes and for the imple- antibiotic resistance. mentation of interventions to be effective, it is important to make use of knowledge and methods derived from the social and behavioural sciences.

18 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets • The general public is knowledgeable about how infections, and the spread of infections, can be prevented and con- trolled in humans and animals and how common infections can be managed. Members of the general public comply with the prescriptions of doctors and veterinarians, do not pro- cure antibiotics without a prescription, and return leftover antibiotics to pharmacies. • With the current governing documents for schools as the starting point, areas such as cross-infection and antibiotic resistance are taught in the classroom. • Consumers continue to be well placed to make conscious choices for their food and other products from an AMR point of view, including placing a higher value on production that contributes to good animal health and responsible antibiotic use. • Relevant professions have good, nationally equivalent, knowl- edge about antibiotic resistance, the spread of infectious dis- eases, immunisation, working methods to prevent infections, healthcare-associated infections, healthcare hygiene and the responsible prescribing of antibiotics. Knowledge that is put into practice and leads to behavioural changes. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 19 Target area 3 Working actively and proactively to ensure that antimicrobial resistance is recognised and managed through global cooperation Background Antimicrobial resistance, in particular antibiotic resistance, is a global problem that requires global coordination. All nations need to contrib- ute to the solutions. From an international perspective, Sweden has a favourable AMR situation, but this can quickly change given how re- sistance develops and spreads globally through travel and trade, among other things. Countries have differing conditions which affect their ca- This target area means that pacity to curb the problem of AMR. In low- and middle-income coun- Sweden will continue to show tries, lower-standard living conditions such as limited access to clean clear and strong leadership in water and sanitation, healthcare and antibiotics, and the incidence of the work to curb AMR, with a ineffective and substandard antibiotic treatment, often represent great- particular focus on antibiotic er challenges than the actual problem of resistance itself. resistance, at the global, Eu- ropean and Nordic levels and In some parts of the world, poor public health and animal husband- to contribute with Sweden’s ry also create a greater need for antibiotics. Often, there is insufficient experiences in the area. data in these countries to obtain an overview of the resistance situa-

20 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 tion and thus decide on what measures are required. This is further complicated by insufficient laboratory infrastructure and inadequate systems for the collection, reporting and analysis of resistance data. In addition, demand for food of animal origin is rising, both per capita and in an increasing number of countries. As a result, many countries are making the switch from extensive small-scale animal husbandry to more intensive, large-scale production. Antibiotic resistance risks undermining a great deal of progress made through the Sustainable Development Goals and the 2030 Agenda. Work on updating the global cross-sectoral action plan15 of 2015 began in 2025 under the leadership of the Quadripartite collabora- tion which involves WHO,16 FAO,17 WOAH,18 and UNEP19. Two high-level meetings on antimicrobial resistance have taken place in the UN General Assembly, resulting in political declarations in 2016 and 2024, respectively.20 A third follow-up high-level meeting has been decided by the General Assembly for 2029. In order to keep the issue high on the global agenda, raise awareness in all relevant sectors, and monitor the implementation of commitments made, biennial ministe- rial conferences on antimicrobial resistance are to be held in accord- ance with the 2024 Political Declaration. The Global Leaders Group on AMR is currently an important high-level group in the global infra- structure. Sweden is actively engaged in this group at the highest level. Global commitments within the UN system and the 2030 Agenda, as well as the Government’s Reform agenda for development assistance21, are central frameworks for Sweden’s international work on AMR. It is positive and absolutely imperative that the threat of AMR is being given more attention internationally. Sweden can also work to disseminate knowledge about the relationship between AMR and sepsis internationally, and draw attention to the need for preventive measures and how to treat sepsis. Sweden’s relatively good AMR situation is the result of long-term, sys- tematic work in both the animal and human sectors. This has laid the foundations for Sweden being respected internationally for its work in the AMR area, where its expertise is highly appreciated international- ly. Sweden is to contribute to other countries’ efforts to reduce the de- velopment of AMR and prevent AMR spreading in both the animal and human sectors, as well as in the environmental and climate areas. Sweden should also continue to work towards ending the use of anti- biotic growth promoters in animals globally, as well as the routine use 15 Global Action Plan on Antimicrobial Resistance, World Health Organization; 2015. 16 World Health Organization 17 Food and Agriculture Organization of the United Nations 18 World Organisation for Animal Health 19 United Nations Environment Programme 20 Political Declaration of the High-Level Meeting of the General Assembly on An- timicrobial Resistance, UNGA, 2016 and 2024. 21 Development assistance for a new era – freedom, empowerment and sustain- able growth, Swedish Government, 2023. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 21 of preventive antibiotics in herds of animals. Swedish actors also have a good understanding of the role of the environment in the develop- ment and spread of AMR, and what consequences this can have in the environment. This is knowledge that can be disseminated internation- ally. Outside the EU, antibiotics are sometimes used for plants and crops. Within the EU, such use is prohibited, but it is possible to apply for an exemption in special cases. As rising temperatures may increase the need for antibiotic use in the EU as well, it is important to ensure that such use does not contribute to the development and spread of AMR. Formal cooperation, such as the Quadripartite collaboration, is a plat- form for global work with this issue. Through coordination between relevant UN bodies, great progress has been made in this work inter- nationally. In June 2023, during Sweden’s Presidency of the EU, the Council of the European Union adopted a recommendation on stepping up EU actions to curb the development and spread of antimicrobial resist- ance.22 The Council recommendation complements the 2017 EU One Health Action Plan against AMR and, in addition to objectives for the EU’s own work, it includes an objective to increase cooperation to im- prove global actions. Furthermore, Sweden has actively contributed to strengthening col- laboration on AMR through the adoption of a One Health declaration concerning AMR within the Nordic Council of Ministers.23 In situations of peacetime crisis and war, the risk of AMR spreading and shortages of antibiotics is often especially manifest. In Ukraine, for example, resistant bacteria and healthcare-associated infections have increased exponentially among military personnel and the civil- ian population since the start of the full-scale invasion. Identifying an effective treatment for infections thus becomes a serious challenge. It is beneficial to the economy to work with curbing anti-microbial resistance.24 By allocating resources to the relevant UN agencies and other multilateral international organisations, the EU, and the Nordic countries’ cooperation, our resources can be utilised more effectively. Sweden’s international work is to be proactive in multilateral processes as well as within the EU and Nordic co-operation, as well as in bilater- al contacts and partnerships, including those at regional level and with civil society actors and higher education institutions. 22 Council recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach, 2023. 23 One Health – Strengthened Nordic Cooperation on Antimicrobial Resistance, Nordic Council of Ministers, 2024. 24 Embracing a One Health Framework to Fight Antimicrobial Resistance, OECD, 2023.

22 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets in this area.27 • Sweden works to strengthen countries’ • Sweden has contributed to the international capacity-building based on their needs and work in this area under the Political Declara- circumstances, and has created international tion of the High-Level Meeting on Antimicro- networks at the professional level to further bial Resistance25 adopted at the 79th session develop work to curb antimicrobial resistance of the UN General Assembly, and participated at the national and international levels. in the work of international high-level groups • Sweden works to strengthen and support (such as the Global Leaders Group and the countries that are experiencing crisis and Alliance of Champions on AMR). It has also conflict in their work to limit antimicrobial pushed for more binding commitments resistance, for example in Ukraine. globally regarding work to curb antimicrobial resistance. • Sweden is working to facilitate a global shift towards sustainable animal husbandry and • Sweden has supported and participated in food production by lobbying for the use of the work of the Quadripartite collaboration.26 all antibiotic growth promoters to cease in • Sweden has worked to ensure that the EU is accordance with the guidelines from Codex pursuing issues relevant to the work to curb Alimentarius and WOAH, and for preventive AMR, including work on joint stockpiling and antibiotics not to be used routinely. This work medical safeguards in preparedness for crisis also includes promoting preventive measures within the EU and at global level, based on the for good animal health and welfare. EU’s Council recommendation on stepping • Sweden works to ensure that the recommen- up EU actions to curb antimicrobial resist- dations and guidelines within Codex Alimenta- ance, the EU’s One Health Action Plan against rius and from WOAH that concern antimicro- Antimicrobial Resistance, and the EU Global bial resistance are applied by more countries, Health Strategy. including those parts that concern plants and • Within the framework of the EU’s free trade crops. agreements, Sweden has effective coopera- • Sweden has worked to ensure that the WHO’s tion on the responsible use of antimicrobials guidance on the management of wastewater in veterinary medicine and food production to and solid waste in the manufacture of antibi- curb antimicrobial resistance. otics28 is followed. • Swedish actors have been actively involved in the implementation of the Nordic Declaration 27 One Health – Strengthened Nordic Cooperation on Antimicrobial Resistance, Nordic Council of Ministers, 25 Political Declaration of the High-Level Meeting on 2024. Antimicrobial Resistance, UNGA, 2024. 28 Guidance on wastewater and solid waste manage- 26 UNEP, WOAH, WHO, FAO. ment for manufacturing of antibiotics, WHO, 2024. Sweden’s Strategy Sweden’s to Curb Strategy Antimicrobial to Curb Resistance Antimicrobial 2026–2035 Resistance 23 2026–2035 23

24 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Target area 4 Continuous, effective surveillance of antimicrobial resistance Background In Sweden, there is a long tradition and a high level of knowledge and skills in the area of surveillance, but the systems used need to be con- tinuously improved and developed further towards greater integration and utilising fewer resources. They also need to be adaptable to new challenges and expectations with regard to international reporting that is required pursuant to recommendations and declarations that Sweden has publicly supported.29 Work to ensure access to quality-assured data This target area means that on AMR in the community – in humans and in animals and in the en- data on the presence of vironment, including wastewater – needs to continue and to contin- resistant microorganisms ue to develop. The purpose of surveillance is to be able to take action will continue to be collect- quickly. ed and analysed in order to detect AMR at an early stage, For surveillance of AMR to be effective, a good structure and knowl- limit cross-infection, or take edge and skills in diagnostics are needed, along with reference labora- necessary countermeasures. tories for humans and animals. Fundamentally, Sweden has a service- Sweden needs to continue able structure in the area with good access to microbiology services at to ensure sufficient capacity, activity level, as well as national, Nordic and international cooperation structures and technology for on antimicrobial susceptibility testing and surveillance methodology. surveillance in this area within different sectors, contribute Resistance data for the surveillance of AMR in humans are collected to international reporting, from specimens provided by patients for testing in the healthcare sys- and communicate results to tem. Ensuring good follow-up and sustainable access to relevant and relevant target groups. representative data requires digital infrastructure that functions well along with greater interoperability. This work needs to relate to and take advantage of the digitalisation processes occurring in the health- care system. 29 For example, through Regulation (EU) 2022/2371 of the European Parliament and of the Council of 23 November 2022 on serious cross-border threats to health; Political Declaration of the High-level Meeting on Antimicrobial Resist- ance, UNGA 2024; Council recommendation on stepping up EU actions to curb antimicrobial resistance in a One Health approach, 2023; Codex guidelines on integrated monitoring and surveillance of food-borne antimicrobial resistance, 2021; WOAH Terrestrial Animal Health Code, Chapter 6.8, Harmonisation of Na- tional Antimicrobial Resistance Surveillance and Monitoring Programmes. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 25 Sweden has developed several national systems for AMR surveillance, including the Swedish national database for AMR surveillance (SVE- BAR), and SmiNet, a system for communicable diseases surveillance, which is used for reporting notifiable antibiotic resistance. This sur- veillance also includes monitoring for antibiotic residues in foodstuffs. In the case of animals and foodstuffs, part of the surveillance is man- datory under EU Regulations.30 It includes regular testing for bacte- ria from animals and in food, as well as targeted baseline studies that focus on bacteria and resistance types relevant to human health. This is supplemented by monitoring of resistance in animal pathogens, where the results are currently based on diagnostics from the Swedish Veterinary Agency. In the environmental area, surveillance is carried out to implement the EU directive on urban wastewater treatment 31. Sweden contributes with data on the AMR resistance situation in the country to various international organisations32 whose publications and reports clarify Sweden’s AMR situation in relation to other coun- tries. Sweden’s surveillance system needs to be continuously adapted to meet new EU requirements and international standards in order to contribute to global efforts and ensure good quality reporting. Sweden’s relatively good AMR situation is the result of systematic sur- veillance with a long-term focus. This contributes to Sweden’s very high standing in terms of credibility internationally, where Sweden’s expertise is in high demand. This has resulted in two WHO collabo- rating centres for the surveillance of AMR in humans being located in Sweden: one in Region Kronoberg and another at the Public Health Agency of Sweden. The results of the surveillance sometimes need to be shared with, and used by, different types of target groups, from the general public to professionals and decision-makers. Comparisons with others can make it easier for various actors to develop their own action plans and take necessary measures. 30 Directive 2003/99/EC of the European Parliament and of the Council of 17 No- vember 2003 on the monitoring of zoonoses and zoonotic agents, and Com- mission Implementing Decision (EU) 2020/1729 of 17 November 2020 on the monitoring and reporting of antimicrobial resistance in zoonotic and commen- sal bacteria and repealing Implementing Decision 2013/652/EU. 31 Directive 2024/3019 of the European Parliament and of the Council of 27 No- vember 2024 concerning urban wastewater treatment. 32 For example, to the ECDC’s surveillance network and to the WHO’s surveillance system, the European Medicines Agency (EMA), the European Food Safety Au- thority (EFSA). Sweden also contributes to global surveillance by submitting reports to the World Organisation for Animal Health’s (WOAH) digital database ANIMUSE. Via the Swedish Environmental Protection Agency, Sweden will also report to the European Commission on the incidence of AMR in wastewater.

26 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets • There are well-functioning systems with sufficient capacity for the early detection, compilation, analysis and reporting of AMR, for example through the cooperation via SVEBAR between Sweden’s clinical microbiology laboratories and the Public Health Agency of Sweden. • There is well-functioning surveillance in humans where data on the incidence of AMR in different types of infections have been produced, for example the incidence of AMR in blood- stream healthcare-associated infections. • There is quality-assured data available on AMR in animals, humans and foodstuffs. • Relevant actors prioritise the continuous development of methods, for example through the use of full genome se- quencing for diagnostics and surveillance. • Suitable AMR surveillance data is collected and used for continuous improvement at the local, regional and national levels. • Sweden participates in European and international surveil- lance programmes. • The sharing of information within and between sectors is functioning well, which includes endeavouring to use stand- ardised and consistent terminology. • Surveillance results and comparisons between different regions or countries can be communicated in a simple, clear way to relevant target groups at different levels. • Sweden is using needs-based surveillance in the environ- ment in accordance with relevant EU legislation, including the Wastewater Directive and the Water Framework Directive. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 27

28 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Target area 5 Continued responsible use of antibiotics and good monitoring of their use Background Effective regulation of the sale of antibiotics for both animals and hu- mans supports responsible antibiotic use. Antibiotics that are used cor- rectly give Sweden good preparedness, reduce suffering, save people’s and animals’ lives, and safeguard food production. If antibiotics are used incorrectly, the development of resistance is accelerated unnecessarily. This target area means that Information and advice to patients both prior to prescribing and when antibiotics are to be used these medicines are dispensed creates an understanding of how and responsibly. Healthcare pro- why antibiotics can be used. Here, the healthcare system, dental care, fessionals must have good and animal health, but also pharmacy staff, have a great responsibility. knowledge of what respon- Pharmacists already assist through reinforcing and explaining treat- sible use and prescribing ment information leaflets to patients and animal owners in connection mean, and that prescribing is with dispensing antibiotics at the pharmacy. based on the latest treatment recommendations. Antibiotics Treatment recommendations, which are developed in dialogue with should only be used as pre- multiple key actors, therefore need to be regularly updated, communi- scribed by a doctor, dentist or cated and used. This applies in healthcare, dental care and veterinary veterinarian. Quality-assured care. There are still large regional differences in prescribing antibiot- sales data and data on the ics and adherence to treatment guidelines in the healthcare system. use of antibiotics in animals The number of prescriptions for antibiotics in the healthcare system in and humans (including, where 2024 was approximately 270 per 1000 inhabitants.33 applicable, other antimicro- bials), is to be compiled and Today, the rate of antibiotic prescription in Sweden’s healthcare and communicated in a compre- dental care systems is one of the lowest in the world, but there are hensible manner to relevant large geographical differences, differences between private and pub- target groups so that trends lic actors, and different levels of use of broad-spectrum antibiotics, can be monitored over time which tends to accelerate resistance. Differences need to be reported and contribute to internation- in a suitable way, and analysed and communicated to different target al comparisons. groups. This can then provide support to actors in how to ensure re- sponsible prescribing of antibiotics. 33 www.folkhälsomyndigheten.se, 30 June 2025. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 29 Information in the form of prescribing statistics on doctors’, den- tists’ and veterinarians’ compliance with treatment recommendations should be systematically fed back into these activities in order to facili- tate ongoing, responsible prescribing of antibiotics. Here, for example, the regional Strama groups, NAG Strama, Tandvårdsstrama (dental Strama group) and Strama VL (veterinary and food) can provide assis- tance. It is also important to be able to monitor antibiotic prescribing to ensure that it does not decrease to the extent that complications in- crease as a result of untreated or incorrectly treated infections. There is a need for increased knowledge about how the efficacy of older antibiotics, for example through clinical studies, can be opti- mised and preserved. The connection to the Government’s Life Sci- ence strategy is particularly important here. In 2023, the European Council adopted a recommendation which means that EU Member States should reduce the use of antibiotics in humans and that a high proportion of prescriptions should come from a certain category of antibiotics with a narrower spectrum. On the vet- erinary side, EU legislation and the Swedish Board of Agriculture’s Number of antibi- regulations govern the use of antibiotics in animals. otic prescriptions Multiple different data sources, individually or in combination, cur- per 1,000 inhabit- rently provide information on the use, prescribing and sales of antibi- otics for humans. A national development project is under way to aug- ants/year ment the collection of data on medicinal products used in healthcare for storage in national health data registers with the aim of being able to monitor the use of medicinal products in inpatient care. This should 481 also create opportunities to compare treatments linked to diagnoses given in outpatient care.34 Since 2024, Sweden has been unable to re- port certain antibiotic sales statistics to the ECDC through the Euro- pean Surveillance of Antimicrobial Consumption Network (SAC-Net) system, as there is currently no legal basis for this reporting. The Council recommendation also confirms the EU target of reduc- ing overall sales of antimicrobials for use in animals in agriculture and aquaculture by 50% between 2018 and 2030. The objective is set at EU 271 level and will be followed up by the Commission with a report to the Council in 2027. For Sweden, which already has the lowest rate of use in the EU, it is not a question of halving this use further, but of main- taining our low level while safeguarding animal health and welfare, in order to support the achievement of the objective at EU level. 1998 2024 34 Fortsatt utveckling av en nation ell läkemedelslista– en del i en ny nationell in- frastruktur för datadelning (SOU 2025:71) (Ongoing development of a national list of medicinal products – part of a new national infrastructure for data shar- ing), and Ett nytt regelverk för hälsodataregister (SOU 2024:57) (New regulatory Source: The Public Health Agency of Sweden framework for health data registers - summary available in English).

30 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets • Sweden has contributed to the EU’s target of reducing the total sales of antimicrobials for food-producing animals in ag- riculture and aquaculture within the EU by 50% by 2030 and is continuing to contribute to international data collection. • Sweden reports data to the WHO and the European Cen- tre for Disease Prevention and Control (ECDC) on antibiotic sales/use in humans to enable international comparisons. • Sweden regularly updates its recommendations on the diag- nosis, treatment and management of common infections in humans and animals. • Where necessary, Sweden’s treatment recommendations are harmonised with those in other Nordic countries, for exam- ple, and are used routinely in both healthcare and dental care. • The conditions for reporting antibiotic sales and the use of antibiotics in animals nationwide are good. • Data on prescribers’ compliance with treatment recommen- dations and prescribing patterns, including information on the reason for the prescription, are used to support contin- uous improvement in healthcare, dental care and veterinary healthcare. • Sweden’s use of antibiotics in healthcare and dental care is consistent and responsible and unjustified use has been reduced, as well as unjustified differences in use for example, between different regions and providers. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 31

32 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Target area 6 Reduced development and spread of infections including healthcare-associated infections among humans Background The most common harm arising from healthcare in Sweden is a healthcare-associated infection. With proper management, avoidable healthcare-associated infections can be reduced. A number of these in- fections are caused by resistant bacteria. The number of healthcare-as- sociated infections in Swedish hospitals is too high according to the latest available national data.35 The cost of prolonged hospital stays This target area means that linked to avoidable healthcare-associated infections is estimated at over preventive work in different SEK 1 billion per year.36 sectors contributes to good and equitable health in the Healthcare environments, including those where interventions are car- entire population and to ried out in the form of home care services, healthcare in the home, fewer infections, including and especially residential care for older people and LSS activities, pose through national vaccination particular risks for the development and spread of antimicrobial re- programmes and vaccina- sistance: in part due to high rates of antibiotic use; in part because of tions offered by the regions. the spread of infections to patients and users of these services with a In healthcare, social services, heightened susceptibility to infection; and in part due to the concen- LSS activities and dental care, tration of vulnerable individuals and infections in the one place. The prevention is used to limit the trend indicates that people being cared for in inpatient care in the fu- development and spread of ture will be older and have multiple and more complex pathologi- healthcare-associated infec- cal conditions, while more people will need care and support in their tions, and to contribute to safe homes, which requires efforts on the part of the responsible authori- healthcare and good quality ties, healthcare providers and providers of social services and LSS ac- interventions for patients, in- tivities to prevent healthcare-associated infections and cross-infection cluding through good health- in such environments. Healthcare-associated infections can be pre- care hygiene procedures. Inci- vented by applying systematic healthcare hygiene procedures and skills dence, interventions, actions at all levels, sufficient access to beds in inpatient care, increased adher- and outcomes are continuous- ence to medical standards, good patient safety procedures, collabora- ly monitored. Development tion between regional and municipal healthcare, and reflective learn- work is needed to be able to ing across boundaries between regions and between activities when utilise and further develop automated and standardised 35 Point prevalence survey of healthcare-associated infections and antimicrobial digital tools for measuring and use in European acute care hospitals – 2022–2023, ECDC, 2024. preventing healthcare-associ- 36  Uppdrag om nationell uppföljning inom området vårdhygien och vårdrelat- ated infections. erade infektioner- förslag som ger förutsättningar till data av hög kvalitet (Remit concerning national monitoring in the area of healthcare hygiene and health- care-associated infections – proposals providing the basis for high-quality data) National Board of Health and Welfare and Public Health Agency of Sweden, 2025. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 33 outbreaks of bacterial resistance have occurred in healthcare environ- ments. International and national guidelines and support have been developed to facilitate implementation. Many regions have systems for monitoring healthcare-associated infec- tions and risk factors for such infections, and carry out measurements of basic hygiene practices, but there are no national systems, and the systems are usually not automated either.37 The work of the munic- ipalities is also monitored through regular measurements in HALT (healthcare-associated infections and antimicrobial use in long-term care facilities). By strengthening people’s health while working to prevent infections, for example through good healthcare hygiene knowledge and skills among managers and staff in healthcare, social services, LSS activities and dental care, testing for the presence of microbes, contact tracing when an infection is detected, vaccination programmes and the pre- vention of communicable diseases, the use of antimicrobial drugs and the consequences of AMR development can be reduced. In recent times, opportunities to vaccinate against or otherwise pre- vent certain diseases that may eventually lead to an infection risk, and the need for antibiotic treatment, have also improved.38 Both national and regional vaccination programmes are greatly important in prevent- ing infections in the population and in particular in high-risk groups, thereby reducing the need for the use of antibiotics.39 37  Uppdrag om nationell uppföljning inom området vårdhygien och vårdrelat- erade infektioner – förslag som ger förutsättningar till data av hög kvalitet (Remit concerning national monitoring in the area of healthcare hygiene and healthcare-associated infections – Proposals providing the basis for high-quali- ty data) National Board of Health and Welfare, 2025. 38 These include vaccination against HPV and cervical cancer, tuberculosis, and vaccines that are being developed that can prevent non-communicable diseas- es. 39 Ansvaret för hälso- och sjukvården (Responsibility for healthcare) (SOU 2025:62) and Ett samordnat Vaccinationsarbete (Coordination of vaccination efforts) (SOU 2024:2).

34 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets • Vaccine acceptance is generally good among Sweden’s pop- ulation. Sweden also has a high and equitable vaccination coverage through its combined public vaccination efforts and high adherence to national vaccination programmes, which can be monitored via national registers. • In Sweden, work with healthcare hygiene as well as infection prevention and control is developed in line with recommen- dations in the area from WHO.40 • The responsible authorities and activities within the health- care system work in accordance with the current national guidelines for work with healthcare hygiene developed as part of knowledge management for healthcare. These guide- lines clarify the current regulations, and can also be used in social services, LSS activities and dental care. • Government agencies, municipalities and regions have jointly identified and developed an effective and preferably auto- mated/digitalised way of monitoring compliance with basic hygiene practices, the presence of risk factors, and the inci- dence of healthcare-associated infections in order to identify areas for improvement in the activity and to contribute to monitoring at the national level. • Sweden participates in European comparisons and reports relevant data. • Managers and staff work in compliance with the current regulations concerning risks in the work environment 41, basic hygiene42 and infection prevention and control measures 43 in order to strengthen work with infection prevention and control and hygiene in healthcare, dental care, social services and LSS activities. • Healthcare hygiene and the work to curb healthcare-associ- ated infections and AMR are part of systematic patient safety work and included in all regions’ and municipalities’ action plans for improving patient safety or included in some other suitable way. • The authorities responsible for the supervision of healthcare, social services, LSS activities and dental care take healthcare hygiene, healthcare-associated infections and AMR into ac- count when carrying out their supervision tasks. 40 Global strategy on infection prevention and control, WHO, 2023. 41 Swedish Work Environment Authority’s regulations and general advice on risks in the work environment (AFS 2023:10). 42 National Board of Health and Welfare’s regulations on basic hygiene in healthcare and social care (SOSFS 2015:10). 43 National Board of Health and Welfare’s regulations and general advice on infection prevention and control in certain activities pursuant to the Social Services Act (SoL) and the Act Concerning Support and Service for Persons with Certain Functional Impairments (LSS) (HSLF-FS 2022:44). Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 35 Target area 7 Healthy animals and safe food through preventive measures Background In Sweden, antibiotics are used in animals to treat infections. The re- sistance situation among Swedish production animals is currently rela- tively good, internationally. Vaccination, infection prevention and con- trol programmes, along with good animal welfare, are fundamental to preventing the spread of diseases. The need for antibiotics for animals This target area means that is reduced with good infection prevention and control, a good ani- preventive work will continue mal husbandry environment, and good livestock care. Sanitary trade in to remain in focus for reduc- both live animals and animal products is particularly important. This ing the burden of infection reduces the risk of spreading resistant bacteria between animals, as and the need for antibiotics in well as to food, the environment and humans. animal husbandry. Strength- ening biosecurity, infection In order to ensure that animal health in Sweden continues to be good, prevention and control, and preventive measures must be maintained and safeguarded. The need healthcare hygiene create the for this is clearly apparent in light of the growing challenges arising conditions for good animal from new diseases, the increased movement of animals, people, food health, a high level of animal and other products, climactical stress, and other external factors. welfare and safe food produc- tion. This is based on good In addition to the risks associated with the introduction of new infec- practices, high levels of knowl- tious diseases, there is also a challenge in remaining free from previ- edge and skills, and access to ously eradicated diseases and endemic diseases that lead to poor ani- expert support. In sustainable mal health and secondary infections. Another aspect is that Sweden’s production systems, the need work with infection prevention and control and animal health is based for antibiotic treatment is on close cooperation between central government and the agricultural minimised without compro- sector, and for initiatives to be fully effective, agricultural enterprises mising on appropriate care must also have the resources to invest in development. for sick animals, including treatment with antibiotics if necessary.

36 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets • Preventive work in the area of animal health and infectious disease control is maintained, including through voluntary adherence to animal health and infectious disease control programmes, and high rates of compliance with relevant vaccination, control and animal health programmes. • Veterinary healthcare services and staff have and apply knowledge about antibiotic resistance, cross-infection and healthcare hygiene. • Relevant actors in animal husbandry, veterinary healthcare and the food chain have access to expertise and have their own basic knowledge and skills in hygiene and infection pre- vention and control in order to maintain good animal health and safe food. • Effective and risk-based supervision of antibiotic use, infec- tious diseases control, healthcare hygiene and infection-pre- venting hygiene practices is in place and maintained for animal husbandry and veterinary healthcare activities. • Good biosecurity, good infectious diseases control, and safe food are ensured through measures which aim to prevent infections from entering and spreading between livestock herds, between animals and humans, and into the environ- ment, including measures to ensure sanitary trade in live animals and animal products. • Veterinary healthcare staff have access to continuing pro- fessional development and skills development in antibiotic management, infection prevention and control, biosafety and healthcare hygiene in order to support sustainable antibiotic use. • Veterinary healthcare staff and other relevant parties con- tribute to increasing knowledge among animal keepers about regulations governing the handling of medicinal products, and about safe practices for the storage, use and handling of medicinal products. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 37 Target area 8 Strengthened preventive measures to limit discharges into the environment Background The discharge of antibiotics and other antimicrobials into the environ- ment can result in increased resistance among microorganisms that inhab- it animals and plants. Although knowledge about the incidence and spread of antibiotic resistance in the environment is incomplete, there is currently sufficient knowledge to take action. Cooperation on actions is needed na- tionally, within the Nordic region and the EU, as well as globally. Actors that handle antibiotics (e.g. hospitals and veterinary clinics) as well as consumers and animal keepers must handle unused or leftover This target area means that antibiotics in accordance with Sweden’s waste legislation. Pharmacies are discharges of antimicrobials obliged to accept leftover medicinal products for human use from pri- and pharmaceutical residues vate households provided that they do not constitute hazardous waste. into the environment and Advanced wastewater treatment is one way to reduce the spread of me- their spread in the environ- dicinal products, pharmaceutical residues, antibiotics or other anti- ment are minimised, and that microbials and resistant bacteria into the environment. Between 2018 antibiotics and other antimi- and 2024, the Swedish Government provided investment grants for crobials are used and handled the purposes of installing advanced wastewater treatment facilities to in a responsible and environ- remove pharmaceutical residues. The EU’s Wastewater Directive of ment-friendly way. 2025 requires the gradual expansion (from 2033–2045) of such treat- ment in all major wastewater treatment plants and in small and medi- um-sized plants following a risk assessment. Minimising discharges from the production of antibiotics and other antimicrobials can also help to reduce their spread to the environment. Most of the antibiotics used in Sweden are now produced in other countries. It is important when approving medicinal products, in the procurement of medicinal products, and in the purchase of medicinal products, that requirements are imposed regarding good and ethical production that provide a good level of protection for the environment and health. There are guidelines developed by the WHO on how to limit the discharge of antibiotics from their manufacturing.44 Antibiotic resistance is a priority area for the Swedish Knowledge Cen- tre on pharmaceuticals in the environment which is part of the Swed- ish Medical Products Agency. Sweden has investigated the possibility of adding an environmental premium to the pharmaceutical benefits system.45 44 Guidance on wastewater and solid waste management for manufacturing of antibiotics, WHO, 2024. 45 Uppdrag att fortsätta utveckla försöksverksamhet för en miljöpremie i läkeme- delsförmånssystemet (Remit to continue to develop a pilot project for an envi- ronmental premium in the pharmaceuticals benefits system), TLV, 2023.

38 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets • Sweden has a milestone target under its environmental qual- ity objective A Non-toxic Environment, which aims to mini- mise pharmaceutical residues, including antibiotics, in the environment. In line with this milestone target, regulations and other measures to minimise these negative environmen- tal effects must be in place in Sweden, in the EU or interna- tionally by 2030. • The established structures and systems for handing in left- over antimicrobials for the human sector have been main- tained. • Sweden assists in stimulating antibiotic manufacturers glob- ally to contribute to reducing the presence of pharmaceutical residues in the environment, for example, by implementing an environmental premium as a pilot. • Environmental data form part of the documentation required in the processes for approving antibiotics and other antimi- crobials. These data are made available to government agen- cies and other relevant stakeholders based on the applicable legislation. • Sweden contributes to the development of rules, guidelines, procurement and other relevant tools and measures that steer development towards reducing the levels of antibiot- ics discharged to the environment in their manufacturing, through actions in Sweden, the EU and globally. • Sweden is implementing the requirements for the intro- duction of advanced treatment of effluent from wastewater treatment plants to remove pharmaceutical substances in accordance with the EU Wastewater Directive. • The Swedish Knowledge Centre on pharmaceuticals in the environment within the Swedish Medical Products Agency collects and communicates information about the develop- ment and spread of AMR in the environment. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 39

40 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Target area 9 Ensure reliable access to antibiotics and effective diagnostic tests Background Access to rapid tests and diagnostics to establish a diagnosis and pos- sible cause of an infection is fundamental to being able to treat an in- fection with the right type of antibiotic when needed and avoid unnec- essary antibiotic treatment. This may range from simple rapid tests at a healthcare clinic, veterinary clinic or in a stable, to more advanced equipment for identifying the bacterium and susceptibility testing. Access to effective antibiotics is fundamental to providing modern This target area means that human healthcare that saves lives, and veterinary healthcare that ena- access to diagnostics as well bles sustainable livestock production and animal husbandry. It is also as old, new and novel antibiot- crucial for protecting the health of Sweden’s population and maintain- ics is to be ensured in routine ing critical societal functions, which is an objective set out in Sweden’s work, as well as in prepared- National Security Strategy. It is not only about treating relatively com- ness for and during peacetime mon infections such as urinary tract infections and pneumonia, but crisis situations, a heightened also less common and life-threatening infections such as sepsis and state of alert and war. This meningitis. Antibiotics are also used as a complement to and to pre- requires an up-to-date logis- vent infections in, for example, surgery, cancer treatment, organ trans- tics and information system plantation, and neonatal care. that functions well, and the capability to identify the Strengthened and reliable access to antibiotics is part of the work car- cause of the infection (to diag- ried out within Sweden’s National Pharmaceutical Strategy 2024–2026, nose). Cross-sectoral collabo- and in the implementation of Sweden’s Life Science Strategy, in which ration is needed to enable the innovation and collaboration are key components for meeting future development of and access health challenges. to new and older antibiotics throughout the country, and A circumstance that makes this more difficult is that Sweden is a rel- to contribute to innovation in atively small market and its rate of antibiotic use is low compared to the field. It is also important other countries, which means that market forces are often not enough to have access to relevant to ensure access. This is especially true for narrow-spectrum antibiot- first-line antibiotics for treat- ics and older antibiotics. Shortage notifications and shortage situations ing animals so that antibiotics are common for antibiotics, there are insufficient incentives for the de- with as narrow a spectrum as velopment of new and novel antibiotics, and global production is often possible can be used. concentrated to a few places. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 41 Sweden has been working for a long time to investigate the needs, gaps and challenges that must be addressed in order to ensure access to antibiotics. The Government has taken a number of actions to en- sure access to both new and older antibiotics in Sweden, for example by enabling the state-owned enterprise Apotek Produktion & Labora- torier (APL) to buy a factory with the capacity to manufacture antibi- otics. Other initiatives include a model for guaranteed compensation decoupled from profit to companies that supply certain antibiotics to the Swedish market, a model currently managed by the Public Health Agency of Sweden. Knowledge in the area has increased, especially as a result of coordi- nated efforts between multiple actors and analyses in the medicinal products area, but since the antibiotic market is highly dynamic, inno- vation is also needed in terms of actions and implementation. Novel and innovative antibiotics are medicines based on new princi- ples and entirely new mechanisms of action. The WHO classifies the development of such drugs as a critical priority.46 The incentives for conducting research to produce novel antibiotics (or novel combina- tions that have the same effect) need to be strengthened. The same ap- plies to the development of more rapid diagnostic methods, including susceptibility testing. Different types of business models have been developed in Sweden to stimulate development and access to antibiotics. This is work that needs to continue. During its Presidency of the Council of the Euro- pean Union in 2023, and during its Presidency of the Nordic Council of Ministers in 2024, Sweden focused on development needs and mod- els to ensure access to antibiotics and incentives for the development of novel antibiotics – from early research right up to the product being available in pharmacies or hospitals.47 At EU level, this work is ongo- ing through regulatory processes as well as other initiatives. 46 List of Medically Important Antimicrobials, WHO, 2024. 47 Often referred to as push and pull factors and an end-to-end perspective.

42 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets • Quality-assured, cost-effective and suitable diagnostics are available with as short a time as possible to get the result in public and private activities. • Information on shortage notifications and shortages con- cerning antibiotics and other antimicrobials for both humans and animals is available and up-to-date, and efforts have been made to prevent and reduce these shortages. • Collaboration between industry, government agencies and academia has contributed to effective measures having been introduced that cover the entire life-cycle of the ´medicinal product, and which have ensured access to effective antibiot- ics in Sweden. • Access to antibiotics has been strengthened by taking antibi- otic resistance into account in Sweden’s emergency prepar- edness planning. • Access to new and older antibiotics for humans and animals has been ensured in the Swedish market through strategic and supplementary measures nationally or, if necessary, in collaboration with other countries, for example in the Nordic region.48 • The production capacity for antibiotics in Sweden, the Nordic countries and the EU has been strengthened. • Sweden has assisted in stimulating the development of novel antibiotics (or combinations that have the same effect), business models and other measures for ensuring access to antibiotics and other treatment options. 48 For example, through new models, control systems, joint procurement, price adjustments, information initiatives and regulatory flexibility. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 43 Target area 10 Research and innovation that helps to curb antimicrobial resistance Background Today, very few new antibiotics are being developed, and new treat- ment options are not becoming available in pace with bacteria exhibit- ing resistance to the antimicrobials that we have. This is due to multi- ple factors, including the difficulty of making a profit, but also because it is scientifically difficult to find new angles of attack. Bacteria that are resistant to antibiotics are rapidly increasing worldwide and pose a particular threat to health and food production. To enable the devel- This target area means that opment of new treatment strategies and preventive measures, research research and innovation is that is both interdisciplinary and multidisciplinary is required. Re- to contribute to the devel- search and development that supports identified needs should be pri- opment or optimisation of oritised, and focus on continuing to be able to treat infectious diseas- antimicrobials and other es successfully. Broad, cross-sectoral research is needed, for example, treatment options, diagnos- in the development and spread of AMR in the external environment, tic methods and vaccines to prevention, diagnostics, management of infectious diseases, health- curb antimicrobial resistance. care hygiene, the use of antibiotics, and access to effective antibiot- Furthermore, research and ics. Research is also needed into how attitudes and behaviours can be innovation is to help ensure modified to promote responsible antibiotic use, as well as how bacte- that knowledge about imple- ria give rise to infections, their epidemiology and disease course. In mentation, behaviours and order to continue to have access to effective antibiotics, active work to communication optimises curb AMR utilising a cross-sectoral One Health approach is of para- preventive measures such mount importance. Close collaboration between many different actors as infection prevention and is needed. control, healthcare hygiene and continuous improvement The challenges of AMR cannot be solved by a single country, but re- cross-sectorally. quire coordinated international cooperation across many sectors and must also include low-income countries and their specific circum- stances. For Sweden, the EU is an important platform in internation- al research cooperation. Through the Swedish Research Council’s co- ordination of the European Partnership on One Health AMR (EUP OHAMR), Sweden is leading and contributing to research, innovation, capacity-building in the research system, and the utilisation of research results for better products, practices and policy. A prerequisite for ensuring good results is that the research can be pursued long-term, has sufficient resources at its disposal, and that both basic research and more practice-oriented research continue.

44 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 Targets • Sweden carries out research relevant to AMR from a broad perspective and makes long-term investments in research within the framework of the National research programme within antibiotic resistance. • The gap between basic research and commercialisation or some other type of application of research results has nar- rowed. • Communication about research relevant to AMR has a great- er impact in the community. • New and existing microbiology diagnostics and treatments have been developed and optimised in line with the needs and priorities of the activities, in Sweden and in the global context. • Clinical trials conducted in Sweden, individually or in combi- nation with other countries, form the basis for updated treat- ment recommendations and have enhanced the responsible use of antibiotics in Sweden and the Nordic region. • Sweden participates in and has leading roles in EU and inter- national research collaborations on AMR and related areas. • Higher education institutions, government agencies, health- care and industry are all working together nationally, at EU level and globally to identify and address knowledge gaps from an interdisciplinary and cross-sectoral One Health per- spective. • The health data registers of the healthcare system and Swed- ish government agencies are used extensively for research work relevant to AMR. Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 45 Background information A description of how this strategy was developed Sweden has had several strategies to curb and limit In June 2024, the Government commissioned the antibiotic resistance over the years. The most recent Swedish Agency for Public Management to ana- one was in force from 2020–2023 and was then ex- lyse and develop proposals on how national work to tended without updates until 2025.49 In connection curb antibiotic resistance in Sweden could be devel- with that extension, the Government decided to oped after 2025. The analysis was to include pro- initiate a process to conduct a wider review of the posals for improvements in national work in the strategy by gathering views and suggestions from a AMR area in terms of initiatives, structures and range of different actors. areas, and an international perspective with expe- riences from a selection of comparable countries. The Government invited the European Centre for In February 2025, the Swedish Agency for Public Disease Prevention and Control (ECDC) and the Management submitted its final report on the com- European Commission’s Directorate-General for mission.53 Health and Food Safety to a country visit in 2024. The visit included study visits, dialogues and pres- All of the above documents and reports have been entations from a One Health AMR perspective and taken into account in the work on this new Strate- resulted in a report with observations and propos- gy. Furthermore, in 2024 and 2025 the Government als for development work.50 In 2024, a country visit conducted dialogues with organisations and rep- was also carried out under the aegis of the EU Reg- resentatives of industry, civil society, the research ulation on serious cross-border threats to health. community, government agencies, professions, mu- Recommendations in the area of antibiotic resist- nicipalities and regions through the stakeholder col- ance were also included in the Commission’s con- laboration forum (Aktörssamverkan) and through the clusions from the visit.51 healthcare directors network for the regions. This, too, has been useful for the Government in its work In May 2024, the Government commissioned the to develop the Strategy and to secure broad-based Public Health Agency of Sweden and the Swedish support for the work to curb AMR in Sweden mov- Board of Agriculture to produce a report compris- ing forward. ing an evaluation of the national intersectoral coor- dinating mechanism (ICM) against antibiotic resist- The overall objectives of the Strategy were devel- ance in terms of its composition, working methods oped in dialogue with the relevant government and results; and describing development needs and agencies and are based on international objectives improvement proposals.52 adapted to Swedish conditions. 49 Swedish Strategy to Curb Antibiotic Resistance, 2024– 2025. 50 European Centre for Disease Prevention and Control. Country report: Country visit Sweden AMR. Final Joint Report in respect of a One Health country visit on Anti- microbial Resistance carried out in Sweden from 16 to 20 September 2024. 51 European Centre for Disease Prevention and Control. Country report: ECDC Public Health Emergency Prepar- edness Assessment for Sweden, 2024 – Under Article 8 of the Regulation (EU) 2022/2371. Stockholm: ECDC; 2025. 53  Sveriges modell för arbetet mot antibiotikaresistens – 52 Report on government assignment. Changes to the ICM Analys och förslag (Sweden’s model for the work against and action plan for the work to curb antibiotic resistance, antibiotic resistance – analysis and proposals), Swedish Public Health Agency of Sweden, 2025. Agency for Public Management, 2025.

46 Sweden’s Strategy to Curb Antimicrobial Resistance 2026–2035 46 List of terms and abbreviations AMR is the abbreviation for antimicrobial resistance, NAP, National Action Plan on Antimicrobial Resist- which is a collective term for resistance in bacteria, ance, refers to countries’ national strategies and viruses, fungi and single-cell parasites to substances action plans to help reduce antimicrobial resistance. contained in medicinal products intended for treat- They contribute to the WHO’s Global Action Plan ment of infection with these microbes. The term on AMR (GAP) which has been adopted by the UN. AMR is widely used in international contexts. Resist- ance spreads when resistant microorganisms are One Health is used to describe the importance of transferred between humans, animals, foodstuffs taking a holistic approach to the health of humans, and the environment, or when resistance genes are domestic animals and wild animals, plants and the spread between microorganisms. surrounding environment, including its ecosystems, as these are interconnected and interdependent. ABR is the abbreviation for antibiotic resistance, which means specifically the resistance of bacteria Strama is a multi-profession association that to substances intended to kill them or inhibit their promotes responsible antibiotic use by providing growth. ABR is part of AMR. Antibiotic resistance treatment guidelines and training, as well as feed- is the biggest threat to human and animal health. back to prescribers on how their prescribing relates to established recommendations and objectives, Biosecurity means management and physical for example. The Strama model has strong local measures designed to reduce the risk of the intro- support and is a cornerstone of Sweden’s work to duction, development and spread of diseases to, curb antimicrobial resistance, especially antibiot- from and within: (a) an animal population, or (b) an ic resistance. The National Working Group (NAG) establishment, zone, compartment, means of trans- Strama directs and coordinates the work of the 21 port or any other facilities, premises or location. local Strama groups in all of Sweden’s healthcare regions. There is also an independent network (the Broad-spectrum antibiotics work against many Strama Network) of the chairs of the regional Strama different types of bacteria, and thus have a higher groups. There is a Strama group for dental care and risk of developing resistance to them than nar- another for veterinary and food, which work with row-spectrum antibiotics. They are often used in antibiotic issues in their respective areas, but are the initial treatment of serious bacterial infections not organisationally linked to NAG Strama. before it is clear which bacterium is causing the infection. They have a major impact on the body’s Healthcare-associated infection means an in- normal bacterial flora. fection that is contracted by a person during inpa- tient care or as a result of measures in the form of Narrow-spectrum antibiotics target a few diagnostics, treatment or nursing in other forms of specific bacteria. The advantage is a lower risk of care, or that staff working in healthcare and social resistance developing than with broad-spectrum care suffer as a consequence of practising their antibiotics and less impact on the body’s normal occupations.54 The equivalent applies in veterinary bacterial flora. healthcare. Quadripartite collaboration is the name given to Healthcare hygiene aims to prevent the develop- a collaboration between the World Health Organi- ment and spread of healthcare-associated infections zation (WHO), the UN Food and Agriculture Organ- in healthcare and veterinary healthcare. Healthcare isation (FAO), United Nations Environmental Pro- hygiene units work with monitoring and support as gramme (UNEP) and World Organisation for Animal well as providing training and advice to healthcare Health (WOAH). and social care activities for a good standard of hygiene. 54 Termbank of the National Board of Health and Welfare,

30 June 2025. Sweden’s Strategy Sweden’s to Curb Strategy Antimicrobial to Curb Resistance Antimicrobial 2026–2035 Resistance 47 47 2026–2035 Government Offices of Sweden Switchboard: +46 8 405 10 00 www.government.se