Swedish Strategy to Combat Antibiotic Resistance 2024-2025

2 Swedish Strategy to Combat Antibiotic Resistance Overarching goal Preserve the possibility of effective treatment of bacterial infections in humans and animals. Swedish Strategy to Combat Antibiotic Resistance 3 Introduction Bacteria that are resistant to antibiotics pose an increasing threat to health and food production across the world. Like other bacteria, resistant This strategy is intended to form the basis of Swedish bacteria can be transmitted between people, efforts to curb the development and spread of anti- animals and foods, and be spread in our environ- biotic resistance and to prevent and manage its ment. This means that multiple sectors, such consequences. Swedish efforts to combat antibiotic as human and animal health, the environment, resistance at the national, EU and international levels research, education, trade and international deve- need to be long-term and sustainable and be based lopment cooperation must be involved to combat on effective initiatives in all relevant areas. antibiotic resistance in what is known as a One Health approach. Sweden should continue to show leadership in inter- Resistance to antimicrobial agents in general, national efforts, in line with the Swedish Policy for which include antibiotics, is a global problem. Global Development, global commitments made Antibiotic resistance is particularly challenging, under the 2030 Agenda for Sustainable Development however, as bacterial infections are very common and EU activities. among humans and animals world-wide. Further- more, in the Swedish context, infections treated The strategy is based on ongoing Swedish efforts to with antimicrobial agents other than antibiotics combat antibiotic resistance, on the global action plan are more uncommon in relative terms. on antimicrobial resistance adopted by the WHO1 Infectious diseases caused by resistant bacteria Member States, the FAO2 action plan, the OIE3 bring suffering to those affected. Their consequ- strategy and on other relevant plans and strategies ences can be serious, including increased morta- such as the EU Action Plan against Antimicrobial lity, prolonged illness and a reduced ability to use Resistance, the IACG4 recommendations and the antibiotics to protect patients in surgery or other joint work plan of the Tripartite5. medical treatments, such as cancer therapy. Ani- mals can also contract infections that are difficult The present strategy is an update of the previous to treat due to resistant bacteria, which causes Swedish strategy (2016–2019). The update has been suffering, loss of production and reduced profita- made in line with how circumstances for efforts to bility in the agricultural sector. This poses a threat combat antibiotic resistance have changed in recent to food safety and to food security world-wide. years in Sweden, in the EU and at the international Resistant bacteria can spread quickly in animal level. It is based on developments in several areas, in populations, which can pose a risk of further particular internationally with increased engagement spread to both humans and animals. Antibiotic within the UN system. The strategy applies until the resistance leads to increased costs in the health- end of 2025 and maintains the long-term focus, its care system and in society at large. overarching goal continuing to be to preserve the Few new antibiotics are currently being developed, possibility of effective treatment of bacterial infec- and treatment options are failing to keep pace tions in humans and animals. It comprises the same with the increasing bacterial resistance to existing seven objectives as previously, in which the Govern- drugs. However, even developing new antibiotics ment has identified important factors in attaining the to a greater extent would not be sufficient to keep overarching goal. up with the development of resistance as it looks today. If the overarching goal of the strategy is to be attained, a long-term, sustainable approach to preventive efforts, the management of infectious 1. World Health Organisation diseases and the use of antibiotics is therefore 2. UN Food and Agriculture Organisation needed. 3. World Organisation for Animal Health 4. UN Inter-Agency Coordination Group on Antimicrobial Resistance 5. WHO, OIE and FAO

4 Swedish Strategy to Combat Antibiotic Resistance Objective 1: Increased knowledge through enhanced surveillance This objective signifies that • access to data on antibiotic resistance and the sale and use of antibiotics and other antimicrobial agents in all sectors, as well as data on healthcare-associated i­nfections and the emission of antibiotics to the ­environment is improved • the outcome and cost-effectiveness of various measures is evaluated, using continuous data collection. It is necessary to continuously ­recommendations by prescribers • possibilities for exchange of ­collect data on the occurrence of (for example doctors and veterinar- information between IT sys- resistant bacteria and use of anti- ians). There is a long tradition and tems and analytical tools to be biotics. This makes it possible to a high level of expertise in surveil- developed further to increase analyse trends over time, identify lance in Sweden, but the current the benefit of existing data significant changes indicating systems should be improved and sources spread of resistant bacteria, developed further to become more ­communicate findings and take integrated and resource-efficient, • relevant IT systems to make action at an early stage. Changes and to be ­capable of adaptation to data available on reasons for in patterns of resistance may new ­challenges. prescribing, and compliance prompt updates to treatment with treatment recommenda- ­recommendations. Surveillance The Government expects tions in all sectors and the also allows the monitoring and • appropriate data to be collected results to be fed back to rele- evaluation of measures taken, as from relevant sectors that guide vant organisations. part of systematic efforts for the work at local, regional and improvement. Using comparable national levels, as well as in the resistance data from different EU and globally Access to high-quality data ­sectors, makes it possible to map enables organisations to make transmission routes and identify • Sweden to employ effective improvements pertaining to risk factors that are of significance ­systems for early detection, antibiotic resistance. to the problem of resistance. ­collation, analysis and reporting of antibiotic resistance and More efficient use of existing data healthcare-associated infections sources necessitates improved technical means for the exchange • the ability to systematically and sharing of information. It is monitor the long-term trends important, for example, to be able regarding infections in humans to link an antibiotic prescription and animals, the resistance to the preceding diagnosis in ­situation and sale and use of order to monitor and influence antibiotics to be maintained, the compliance of treatment coordinated and developed Swedish Strategy to Combat Antibiotic Resistance 5 Objective 2: Continued strong preventive measures This objective signifies that • effective measures are taken to prevent infections and infection transmission and to minimise the spread of multi-resistant bacteria • emissions of antibiotics and antimicrobial substances to the environment are minimised. The favourable resistance situa- serious complications. Infection knowledge of the development tion in Sweden in international prevention and control measures and spread of antibiotic resistance terms does not permit compla- and practices are fundamental in in the environment is incomplete, cency. Resistance is growing here curbing infections and spread of there is sufficient knowledge as well, albeit more slowly than infection in health and social care today for action to be taken. elsewhere. We must continue to and in veterinary care. Advanced treatment of waste­water be acutely aware of the impor- is one way of reducing the disper- tance of preventive measures so The resistance situation in Swedish sal of antibiotics, resistant bacteria that the situation does not deteri- food producing animals is rela- and other antimicrobial agents to orate. Humans and animals that tively good from an international the environment. Minimising are healthy or receive good quality point of view, and bacteria with emissions from the manufactur- care have less of a need for anti­ notifiable resistance are generally ing of antibiotics and other anti- biotics. Preventive efforts such as uncommon in Swedish animals. microbial agents can also contrib- vaccination programmes and pre- Vaccination, control and monitor- ute to reduced dispersal to the vention of sexually transmitted ing programmes are of funda­ environment. infections, reduce both the use of mental importance in preventing antibiotics and the consequences infections. The need for antibiot- The Government expects of the development of resistance. ics in animals is reduced through • a high level of compliance with efficient disease control, good vaccination, monitoring and Healthcare-associated infections farm management, biosecurity health programmes to be main- are the most common type of and sound animal husbandry. Safe tained to promote human and medical adverse event, and a num- international trade in both living animal health and consequently ber of these infections are caused animals and animal products is reduce the need for antibiotics by resistant bacteria. Health and particularly important. This also social care settings are particularly reduces the risk of resistant bacte- • personnel in relevant organisa- conducive to the development and ria spreading to other animals, to tions to have and apply knowl- spread of antibiotic resistance, foods, to the environment and to edge of antibiotic resistance, both because of the high level humans. infection transmission and the of antibiotic use and because of importance of a high level of transmission to patients with The emission of antibiotics and compliance with basic hygiene increased susceptibility to infec- other antimicrobial agents to the practices as part of systematic tion. This, in turn, means that environment can contribute to and evidence-based infection these patients are at greater risk of increased resistance. Although prevention efforts

6 Swedish Strategy to Combat Antibiotic Resistance • regions and municipalities to • personnel in relevant organisa- • public procurement to be used have access to expertise on tions to observe a high level of as a strategic tool to attain the hygiene in healthcare settings vigilance, use rapid diagnostic goals of the strategy, for exam- so that good hygiene standards techniques and apply estab- ple by setting requirements for can be maintained lished procedures and guide- animal welfare, responsible use lines to prevent, detect and halt of antibiotics and reduced envi- • relevant actors in animal pro- the spread of infectious disease ronmental impact of antibiotics. duction, veterinary medicine and the food chain to have • technology to be installed in access to expertise on hygiene wastewater treatment plants for and infection prevention and the treatment of pharmaceutical control in order to ensure good residues and other persistent animal health and safe food substances Swedish Strategy to Combat Antibiotic Resistance 7 Objective 3: Responsible use of antibiotics This objective signifies that • antibiotics and other antimicrobial agents are used and managed in a responsible and environmentally friendly manner. Antibiotics are one of our most important classes of medicines, which if used correctly save many lives and safeguard food produc- tion. Increased use of antibiotics, however, leads to increased devel- opment of resistance. If antibiotics are used incorrectly, for example when they are not needed, at an inappropriate dosage, or if anti­ biotics with an unjustifiably broad antibacterial spectrum are used, the development of resistance is promoted unnecessarily. It is therefore important that antibiot- ics and other antimicrobial agents are used only when they are of benefit, that the right type of anti- that complications increase as a needed on how the efficacy of biotic is used and that treatment result of untreated or mistreated older antibiotics can be optimised recommendations are developed, infections. and preserved. The increasing kept up to date and followed. To activity of online sales of pharma- reduce the growth of resistance, Shortages in the availability of ceuticals poses challenges in guar- antibiotics must also be used antibiotics in the short and long anteeing the same safety and responsibly in animal husbandry. term may pose serious obstacles ­quality as in sale at a physical The Swedish Board of Agriculture to the responsible use of anti­ pharmacy. Diagnosis, treatment regulations govern the use in ani- biotics. This is a problem that and contact tracing of infectious mals of drugs that are particularly also exists in wealthier countries, diseases must attain the same high important for the treatment of including Sweden. If there is a level of quality in both physical humans. shortage of recommended first- and digital healthcare consulta- line drugs, there is a risk of alter- tions. Data on compliance with treat- natives being prescribed that are ment recommendations must be more expensive, have more There is a risk that the widespread, fed back to healthcare organisa- adverse side effects or are worse and in many cases unnecessary, tions to ensure that antibiotics are from the point of view of resist- use of antimicrobial agents in prescribed responsibly. It is also ance development. It is therefore everyday products could contrib- important to be able to monitor important that access to recom- ute to the emergence and spread that antibiotic prescription does mended first-line drugs is guaran- of resistant bacteria. not decrease to such an extent teed. More knowledge is also

8 Swedish Strategy to Combat Antibiotic Resistance The Government expects necessary and incorrect treat- • antibiotics to continue only to ment and to enable follow-up Responsible manufacturing be used after being prescribed and use of antibiotics and by professionals who are • data on compliance with treat- other antimicrobial agents, authorised to prescribe anti­ ment recommendations to be as well as correct waste management, reduce the risk biotics used by relevant staff, for exam- of antibiotic resistance deve- ple prescribers, managers in loping and spreading in the • recommendations on diagnostics healthcare organisations and environment. and management of common purchasers, to support improve- infections to be kept up-to-date ment efforts both in the health- and harmonised as far as possi- care system and in veterinary • antimicrobial agents to be used ble and applied in day-to-day care in a responsible and evidence-­ work in the healthcare system based manner in different types and in veterinary care • access to both new and older of consumer products antibiotics to be guaranteed on • quality-assured and adequate the Swedish market • data to be available regarding diagnostics with the shortest reasons for prescribing of medi- response time possible to • antibiotics that are not used to cines in veterinary medicine in underlie the prescribing of anti- be returned to pharmacies and order to enable checking or biotics, regardless of the form disposed of in an environmen- supervision of compliance with of care, in order to avoid un­­ tally correct manner treatment recommendations. Number of prescriptions filled 481 472 500 463 469 450 437 436 444 423 418 426 392 390 385 400 374 343 328 323 318 309 296 285 300 200 Prescriptions/1000 inhabitants/year 100 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Figure 1. Number of out patient care antibiotic prescriptions filled in Sweden 1998–2019. Systemic use J01 excl. methenamine. Source: The Swedish eHealth Agency Swedish Strategy to Combat Antibiotic Resistance 9 Objective 4: Increased knowledge for pre- venting and managing bacterial i­nfections and antibiotic resistance with new methods This objective signifies that • greater knowledge of infectious diseases contributes to new antibiotics, other treatment options, diagnostic methods and vaccines being developed • increased knowledge about the emergence and spread of resistance contributes to the optimised use of new and existing antibiotics and to the problem of resistance being prevented and limited. A contributory cause of the seri- of resistance-related health and platform in international research ousness of the problem of resist- social care. Estimates of the costs cooperation for Sweden. ance is that the development of and benefits of antibiotic use and new antibiotics and other treat- resistance in both animal produc- The Government expects ment options has slowed. Many tion and healthcare should be • research concerned with anti­ pharmaceutical companies have used to justify further improve- biotic resistance to be pursued closed down their development of ments at the national and interna- and long-term research initia- antibiotics. This is due to several tional levels. It is very important tives to be taken under the factors, including low profitability, to be able to measure the effects National Research Programme but also the scientific difficulty of of actions taken and calculate the on Antibiotic Resistance finding new angles of attack. To economic consequences of resist- enable the development of new ance. There is also a need for • initiatives to be taken to bridge treatments and preventive meas- greater knowledge of how atti- the gap between basic research ures, research is required into how tudes and behaviour can be and the commercialisation or bacteria cause infections and into i­nfluenced to promote responsible other application of research their epidemiology and the course use of antibiotics and of how the findings of disease. Equally, research is organisation of healthcare sys- needed to be able to optimise and tems, animal production, global • existing diagnostics and treat- preserve the effectiveness of exist- trade and tourism affect the ments to be developed and ing antibiotics for as long as possi- spread of antibiotic resistance ­optimised in line with the needs ble. The development of cost-­ between bacteria, humans, ani- and priorities of healthcare effective methods for better diag- mals and the environment. organisations nostics and determination of resistance could reduce the incor- These challenges cannot be solved • Sweden to take part in interna- rect use of anti­biotics in health- by individual nations; they require tional research cooperation in care and veterinary care. coordinated international cooper- the field of antibiotic resistance ation spanning multiple sectors, and related areas There is furthermore a need for also including low-income coun- new knowledge to be able to esti- tries and their particular circum- • universities, government agen- mate the disease burden and costs stances. The EU is an important cies, the healthcare sector and

10 Swedish Strategy to Combat Antibiotic Resistance trade and industry to collabo- • Sweden to contribute to the the availability of antibiotics rate at the national, EU and development of knowledge on and encourage the development international levels to identify new business models and finan- of new antibiotics and other and eliminate knowledge gaps cial control systems to improve treatment options. SEK millions 778 800 700 600 414 500 400 278 300 200 100 0 2020 2030 2050 Figure 2. Estimated cost for health care and loss of production due to notifiable antibiotic resistance. Source: Public Health Agency of Sweden Swedish Strategy to Combat Antibiotic Resistance 11 Objective 5: Improved awareness and ­understanding in society of antibiotic ­resistance and countermeasures This objective signifies that • good knowledge and awareness exist among all relevant parties, including the general public, of measures to prevent the spread of infections and of the risks of ­resistance development due to the use of antibiotics • the knowledge is implemented as behaviour that ­promotes containment of antibiotic resistance. In Sweden, where antibiotics are nate knowledge about antibiotic in their sectors with the aim of available on prescription only, pre- resistance and preventive meas- counteracting increasing anti­ scribers have a heavy responsibil- ures through their channels and biotic resistance ity for responsible use. Public networks. At the same time, it is knowledge and expectations may, important that the information is • patients and animal keepers to however, influence decisions on coordinated in each sector and have good knowledge of the prescribing antibiotics. Acute between the sectors, so that the importance of using antibiotics awareness of why it is important general public receive the same as prescribed following contact that antibiotics are used only message from all parties involved with the healthcare system or a when they are of benefit, used and that the communication leads veterinarian correctly and used after being to the desired behaviour. ­prescribed by an authorised pre- • consumers to be aware that scriber is therefore essential in The Government expects food from producers who work building a sustainable approach • the general public to have good to achieve good animal health to antibiotics in society. Likewise, knowledge of approaches that and use antibiotics only when reducing the spread of infectious can prevent the spread of infec- they are really needed contrib- diseases and consequently the tion and promote responsible utes to counteracting the spread need for antibiotics relies on acute use of antibiotics of resistant bacteria in society awareness of the importance of good hygiene and preventive • staff in health and social care, • relevant parties to collaborate measures. It is also important that dentistry and the animal and to develop and disseminate consumers are given the opportu- food sector to have good updated and tailored informa- nity to make informed and con- knowledge of the issue of resist- tion about antibiotics and scious choices. For example, ance, antibiotics and antimicro- ­antibiotic resistance, general ­origin labelling on certain foods bial agents, infection prevention hygiene and other preventive can contribute to enabling and control practices and the measures ­consumers to choose meat from One Health concept countries with responsible use of • antibiotic resistance, infection antibiotics in animal production. • management of relevant organi- prevention and control and sations and other decision-mak- healthcare hygiene to be It is beneficial that many parties ers to have good knowledge of included in relevant basic educa- in Sweden are working to dissemi- possible initiatives to be taken tion and professional training.

12 Swedish Strategy to Combat Antibiotic Resistance Swedish Strategy to Combat Antibiotic Resistance 13 Objective 6: Supporting structures and systems This objective signifies that • supporting structures and systems are in place and in use, as well as that activities regarding antibiotic resistance are followed up and the lessons learnt are acted upon • efforts are carried out in a coherent, efficient and strategic manner on the basis of the roles of the various parties involved. Efforts to prevent and manage antibiotic resistance in the Gov- • Strama, a national working antibiotic resistance spans several ernment Offices of Sweden. The group within the Swedish sectors and parties. Distinct sys- National Research Programme for national system for knowledge tems and structures for support Antibiotic Resistance is another management in healthcare, to and collaboration are important, supporting structure that contrib- support national efforts of the for example to utilize the accumu- utes to coordinating research and entities responsible for health- lated knowledge that exists among increasing the dissemination and care and to coordinate the the various stakeholders involved impact of research results. regional Strama groups in and to identify knowledge gaps. ­working towards prudent and Such processes can facilitate the Successful efforts to combat anti- responsible use of antibiotics evidence-based approach in biotic resistance build on initia- healthcare organisations and also, tives targeting individuals and on • Strama VL (Veterinary and where necessary, generate new the development of supporting Food) to continue to provide ­evidence. Coordination enables structures in healthcare organisa- knowledge-based support to resources to be used more effi- tions. For example, established various stakeholders in the ciently, duplication of work to be systems for the follow-up of anti- ­veterinary and food sectors avoided and coordinated messages biotic use and compliance with to be communicated. Several treatment recommendations can • regional health authorities, groupings involved with efforts to influence how and when anti­ healthcare providers and man- combat antibiotic resistance have biotics are prescribed. This also agement of relevant organiza- been formed within the Swedish applies to veterinary medicine. tions to create the necessary national system for knowledge The long-term impact of efforts conditions for responsible use management in healthcare, such to tackle antibiotic resistance can of antibiotics and reduced as the national working groups for also be promoted by broader spread of infection Strama6 and for infection preven- approaches to involve stakeholders tion and control. For the animal at all levels of society, in accord- • the Knowledge Centre for sector there are groupings with ance with current public health Pharmaceuticals in the Envi- similar objectives such as Strama policy. ronment at the Medical Prod- VL (Veterinary and Food) and the ucts Agency to collate and Swedish Veterinary Association The Government expects ­disseminate knowledge on the for Infection Prevention and Con- • a national collaborative func- development and spread of anti- trol. There is an interdepartmental tion with relevant government biotic resistance in the environ- working group on the issue of agencies and other stakeholders ment, as well as the risks to the to coordinate overarching environment and to human and national efforts animal health. 6. Swedish Strategic Programme Against Antibiotic Resistance

14 Swedish Strategy to Combat Antibiotic Resistance Objective 7: Leadership within the EU and international cooperation This objective signifies that • Sweden continues to show international leadership in efforts to tackle antimicrobial resistance and urges responsible use of antimicrobial agents around the world. Antibiotic resistance and other The high-level meeting on AMR antimicrobial resistance (AMR) is at the UN General Assembly in Antibiotic resistance and other a global problem that requires all 2016 led to the formation of the antimicrobial resistance are countries to contribute to its solu- UN Interagency Coordination a global and cross-sectoral tion. Large international organ- Group on AMR (IACG), which in threat to health that necessi­ isations such as WHO7, FAO8, 2019 presented recommendations tates input from the whole international community. OIE9 and UNEP10 are platforms to the Secretary-General of the for these efforts. The political UN on measures that need to be will to address the threat posed taken for a more effective global by AMR has increased in recent response to AMR. Sweden has preparing Council conclusions on years in more and more countries, been promoting these efforts in AMR. and substantial progress has been several ways, for instance through made in international efforts. the alliance of health ministers The Nordic region leads the way The global action plan adopted known as the Alliance of Champi- in several aspects of the issue of by the WHO Member States in ons. Despite considerable pro- antibiotic resistance, and the use 2015 emphasises the importance gress, international lobbying is of antibiotics here is low in com- of having an explicit One Health still needed to keep the issue high parison with other countries. As perspective in tackling AMR. on the international agenda and well as cooperation in the EU, FAO has developed its own action raise awareness in all sectors joint Nordic efforts take place plan to support the food and agri- ­concerned. through the Nordic Council of culture sectors in particular in Ministers. implementing the global action Progress is also being made in the plan. OIE has prepared a strategy EU in efforts to tackle antibiotic Sweden currently has a favoura- to support Member Countries on resistance. In 2017 the European ble situation with regard to anti- AMR related efforts and responsi- Commission adopted a cross-­ biotic resistance in international ble use of antimicrobial agents in sectoral action plan with the terms, but this can change quickly animal production. Other inter- objectives that the EU should due to the way resistance devel- national organisations such as become a best practise region in ops and spreads internationally, UNICEF11 are also active in the activities to tackle AMR, to boost through travel and trade. Circum- field of AMR. research, development and inno- stances differ between countries vation and further shape the with regard to tackling the prob- global agenda in the context of lem of resistance, and inadequate AMR. Sweden has been proactive access to antibiotics is perhaps the 7. World Health Organisation 8. UN Food and Agriculture Organisation in the negotiations ahead of the most pressing problem in low-in- 9. World Organisation for Animal Health 10. UN Environment Programme recent EU Regulation on Veteri- come countries. Lack of sufficient 11. UN Children’s Fund nary Medicinal Products and in data often impedes an overview of Swedish Strategy to Combat Antibiotic Resistance 15 the resistance situation and conse- health and animal welfare lead to ­coordinate, drive and take part in quently of what initiatives need reduced spread of infectious dis- various initiatives. By channelling to be taken. There is a risk of eases, reduced use of antibiotics resources through the large inter- ­antibiotic resistance undermin- and greater profitability. Preven- national organisations, the EU ing some of the progress that has tive animal health measures and and the cooperation between the been made through the Sustaina- low levels of antibiotic use in Nordic countries, we can improve ble Development Goals, as infec- ­animal production result in a the impact of our resources. The tious diseases are more common favourable resistance situation. importance of international coop- in low-income countries. Worse It is also important from the point eration and coordination in the living conditions such as lack of view of competition that other area of research is highlighted of access to clean water, sanita- countries take similar measures to under Objective 4 in the present tion, healthcare and antibiotics those already implemented in strategy. Swedish international are some of the causes. In addi- Sweden, so that animal producers efforts should be made in multi- tion, measures to reduce anti­ who make continuous efforts to lateral processes, in the EU and in biotic resistance tend not to reach keep their use of antibiotics down bilateral contacts and cooperation. the poorest people. The conse- are not put at a disadvantage. The global commitments made quences of antibiotic resistance under the UN system and under also make their presence felt in Knowledge of the economic and the 2030 Agenda, as well as the the area of sexual and reproduc- social impact of antibiotic use and Swedish Policy for Global Devel- tive health and rights, which is antibiotic resistance is increasing opment, represent key frame- a priority for Swedish develop- globally. Analyses, models and works. ment cooperation. Maternal and knowledge raise the level of child mortality, infections in new- understanding of the problem The Government expects born infants and gonorrhoea are and are needed as an incentive for • Sweden to continue to support some of the problem areas at risk change. For example, in a study WHO, FAO, OIE and UNEP of being exacerbated by increased funded by Sweden, the OECD in efforts to tackle AMR, in anti­biotic resistance. Agriculture is has shown that the costs of accordance with the global relatively more important in low-­ ­phasing out the use of antibiotics action plan on AMR and income countries than in high-in- as growth promoters in livestock ­equivalent documents in the come countries. Adverse effects of are relatively low in high-income agriculture and food sectors antibiotic resistance in food pro- countries. duction therefore pose a threat to • Sweden to press for the expan- the goal of abolishing hunger and Knowledge of the role of the sion, development and use of several other goals in the 2030 ­environment in the development harmonised global surveillance Agenda for Sustainable Develop- and spread of antibiotic resistance systems for antibiotic resistance ment. and what effects can occur in the and antibiotic use in humans environment is also increasing. and animals and, where appro- Sweden should contribute to other To prevent emissions of antibiotic priate, also for foods and the countries’ efforts on reducing the residues to the environment, there environment. This can take development of resistance and is a need for emissions from manu­ place in cooperation with curbing spread. Sweden’s relatively facturing to be minimised, for WHO, FAO, OIE, Codex good resistance situation is due in people throughout the world to ­A limentarius12 and UNEP, part to assiduous work over a long have access to clean water and san- among others period of time, which has gener- itation and for discarded antibiotics ated a high level of expertise on to be collected and managed in an • Sweden actively to push the antibiotic resistance in demand environmentally sound way. issue of antibiotic resistance in internationally. the EU and to cooperate with It is positive and entirely neces- other EU Member States, the Antibiotic resistance can spread sary that increasing attention is across borders through interna- paid to the threat of resistance 12. Codex, or Codex Alimentarius Commission tional trade with animals. Healthy internationally. It is economically (CAC), is a programme for food standards formed in the early 1960s by the UN bodies FAO and animals are an overarching goal in favourable to address the prob- WHO for the purpose of drafting international Swedish animal production. Strat- lems of resistance, but resources rules – standards – for food safety, fair practices in food handling and free trade in food at a global egies based on improving animal are also required to monitor, level.

16 Swedish Strategy to Combat Antibiotic Resistance European Commission and the tainable agriculture and produc- • Sweden to push for environ- EU agencies on the implemen- tion systems, and to support a mental data to form part of the tation of the EU Action Plan global phase-out of the use of basis for the approval process of against AMR; Sweden to be a antibiotics as growth promoters antibiotics and be made availa- driving force in relevant nego­ in animal production and of ble to governmental agencies tiations on new EU regulations, other routine use of antibiotics and other relevant stakeholders. recommendations and guide- in groups of animals The data should be used for the lines linked to AMR and assessment of environmental reduced environmental impact; • Sweden to urge effective coop- risks of development and spread Sweden to urge the EU to eration on responsible use of of antibiotic resistance ­pursue issues relevant to AMR antibiotics in animal production at the global level under EU free trade agreements • Sweden to push for the develop- to counteract antibiotic resist- ment of regulations to steer • Sweden to continue to build ance towards minimised emissions of alliances with other countries to antibiotics to the environment pursue the AMR issue at a high • Sweden to share knowledge and in pharmaceutical production political level with the aim of experience with other countries highlighting important over­ from a One Health perspective, • Sweden to continue to address arching issues from a One paying particular attention to issues relating to antibiotic Health perspective; Sweden to the needs of low-income coun- resistance in international take part in Nordic cooperation tries; Sweden also to make use forums such as the OECD and on AMR of experience from other coun- the Global Health Security tries in international coopera- Agenda, as well as through • Sweden to contribute to a tion and learn from how others bilateral agreements with other movement towards more sus- operate countries. mg active substance/PKU 500 400 300 200 100 0 Belgium Bulgaria Denmark Estonia Finland France Grekece Ireland Iceland Germany Hungary Austria Italy Croatia Latvia Lithuania Malta Netherlands Polen Portugal Rumania Sweden Cyprus Luxembourg Czech Republic Switzerland Slovakia Spain Norway Slovenia UK Figure 3. Sales of antibiotics for food-producing animals 2017 expressed as mg of active substance per Population Correction Unit (PCU). PCU corresponds approximately to the total weight of live animals within a country, expressed in kilograms. Source: European Medicines Agency Swedish Strategy to Combat Antibiotic Resistance 17

18 Swedish Strategy to Combat Antibiotic Resistance Sweden as a model Preventive measures measures against antibiotic resist- ­Particular communication initia- Swedish preventive efforts to ance and is the basis for recom- tives are also carried out through combat antibiotic resistance are mendations on the treatment of other channels. In the European based on the idea that low infec- infectious diseases. Diagnostics Eurobarometer survey in 2018, tion pressure in society leads to a with routine taking of samples the Swedish public scored highly healthy population and healthy forms the basis of surveillance for knowledge concerning anti­ animals needing less antibiotics. in the Swedish healthcare system. biotics and antibiotic resistance. Lower consumption of antibiotics This, combined with automated, in turn leads to reduced develop- daily collation of laboratory results, Sweden has been proactive in the ment of antibiotic resistance. produces clinically relevant resist- development of global surveillance Effective infection prevention and ance data. of antibiotic resistance. The Pub- control programmes such as good lic Health Agency of Sweden sup- healthcare hygiene and other pre- Sweden also has a programme for ports the expansion of the Global ventive measures, reduce the surveillance of antibiotic resist- Antimicrobial Resistance Surveil- spread of infectious diseases in ance in bacteria from animals and lance System through its WHO society and in health and social in food. The Swedish National Collaborating Centre. care. Two examples are the Swed- Veterinary Institute and the Pub- ish child vaccination programme, lic Health Agency of Sweden are The antibiotic resistance situation one of the most successful of its tasked with monitoring antibiotic in Sweden is relatively favourable kind, and the regulations on basic resistance, which is done in col- in international terms, largely due hygiene routines applicable to all laboration with the Swedish Board to consistent and purposeful health and social care staff. A cor- of Agriculture and the Swedish efforts having been pursued over responding approach with vacci- National Food Agency. Samples a long period of time in relevant nation programmes, infection pre- are also taken through the annual sectors. Resistance to first-line vention and control programmes residue control program to detect treatment of urinary tract infec- and rules for hygiene procedures antibiotic residues in food produc- tions is uncommon, and the rate is used to keep animals healthy in ing animals that may have entered of methicillin-resistant Staphylo- Sweden. the food chain before the with- coccus aureus (MRSA) is among drawal period has expired. the lowest in the EU. The serious Surveillance of antibiotic type of resistance ESBL-CARBA, ­resistance and use A high level of awareness of the for which few treatment options Microbiological diagnostics and problem of antibiotic resistance remain, has not yet been detected surveillance were expanded at an among relevant professions and in animals in Sweden, and the early stage in Sweden, which was industries, managements of number of cases in humans is very important in drawing attention to healthcare organisations, the low. In general, however, antibiotic the problem of antibiotic resistance. ­general public and decision-­ resistance in health and social care The discovery of rapidly increasing makers is an important element is also on the rise here, indicating resistance among pneumococci had in efforts towards responsible use a need for strong countermeasures a great impact, leading to initiatives of antibiotics. The results from to continue in accordance with being taken to prevent the spread surveillance of resistance and anti- this Strategy. of resistance and limit unnecessary biotic use in humans and animals use of antibiotics. are presented annually in a joint Responsible use of antibiotics report by the Swedish National The use of antibiotics in Sweden Surveillance is essential in order Veterinary Institute and the Pub- is low by international compari- to draw up and evaluate relevant lic Health Agency of Sweden. son, and in addition consists Swedish Strategy to Combat Antibiotic Resistance 19 largely of narrow-spectrum below 300. As a result, the num- developed regulations on the use drugs that are less likely to drive ber of antibiotic prescriptions of antibiotics in animals. ­resistance. The interdisciplinary filled annually fell by around one ­organization Strama has pro- million between 2009 and 2017, Many different measures are moted responsible use of anti­ without any adverse health conse- required to deal with emissions biotics since it was formed in quences being observed. of antibiotics to the environment. 1995. The Strama model is based In addition to work in progress to on peer-to-peer feedback to pre- Sales of antibiotics for animals promote responsible use of anti­ scribers, in particular how their have decreased steadily in Swe- biotics, the Government in 2018 prescribing relates to established den over the past 30 years. In launched a three-year programme treatment recommendations and 2018 a total of 10,042 kilograms to install advanced wastewater set targets. The model is well of active substance of differ- treatment. The aim is to reduce established locally and represents ent antibiotics for veterinary use emissions of pharmaceutical resi- a cornerstone in Swedish efforts were sold, representing a decrease dues, including antibiotics, from to tackle antibiotic resistance. The of around 70% since the start of wastewater treatment plants. The Public Health Agency of Sweden the 1980s. The resistance situa- Government has also set up a is tasked with working to ensure tion among animals in Sweden is Knowledge Centre for Pharma- that the possibility of using anti­ favourable, and some resistance ceuticals in the Environment at biotics effectively in humans with relevance for human health the Medical Products Agency. and animals is maintained. The is decreasing. ESBL resistance National Veterinary Institute among broiler chickens, for exam- Cross-sectoral collaboration l­ikewise has a remit to take action ple, dropped sharply from 34% and research to ensure responsible use of anti­ in 2017 to 17% in 2018. Notifia- The Swedish Strategy to Combat biotics in the veterinary and food ble resistant bacteria are generally Antibiotic Resistance points the ­sector through Strama VL. uncommon in Swedish animals. way for activities in the area and facilitates coordination of Swedish Evidence-based national treat- Effectively regulated sale of anti- stakeholders to maximize contri- ment recommendations provide biotics both for veterinary and butions in the same direction. important support to physicians human use fosters responsible use and veterinarians as well as a of antibiotics. As a result of close A national collaborative function ­reference point to follow up pre- cooperation between government currently comprising 25 govern- scription. Prescribing targets that agencies and the livestock indus- ment agencies and other organisa- are developed in consideration try, Sweden became the first coun- tions coordinates national efforts of current treatment recommen- try in the world to prohibit the against antibiotic resistance since dations and the possibility of use of antibiotics for growth-pro- 2012. This collaborative function ­follow-up can be a useful tool in moting purposes in 1986. Sweden operates according to a national efforts to combat antibiotic resist- also contributed strongly to the action plan based on the Swedish ance. An example is the national introduction of a corresponding Strategy. The Public Health ‘250 target’ in primary care (fewer ban in the EU in 2006. Today Agency of Sweden and the Swed- than 250 antibiotic prescriptions there is broad consensus among ish Board of Agriculture chair the issued per 1,000 inhabitants per Swedish animal health organisa- collaborative function, which year), which was introduced in tions, animal health professionals hosts the sector-wide communica- 2009. Two regions achieved the and animal keepers on responsible tion platform ‘Save Antibiotics’, target in 2018, and the national use of antibiotics. In addition, the and an annual Antibiotics Forum, average fell in the same year to Swedish Board of Agriculture has in which a broad group of stake-

20 Swedish Strategy to Combat Antibiotic Resistance holders meet. One Health has of new knowledge depend on applied research. Sweden was also long been an established approach well-functioning organisations, one of the initiators of the inter- in Sweden, and the first national such as Strama groups, clinical national research cooperation action plan against antibiotic microbiology laboratories, infec- Joint Programming Initiative on resistance in 2000 was already tion prevention and control units Antimicrobial Resistance cross-sectoral. and pharmaceutical committees. (JPIAMR) that was launched in 2010. Ever since, Sweden has There is close contact and good Antibiotic resistance has been a played a leading role in this coop- collaboration in the efforts done priority research issue in Sweden eration, in part through the secre- at national government agencies for many years. In the 2016 tariat being located at the Swedish and at the level of regions, county Research Bill, the Government Research Council. Sweden is also councils and local authorities, launched a National Research a member of the Global AMR ensuring endorsement and the Programme on Antibiotic Resist- R&D Hub, a collaboration plat- best possible conditions for appro- ance. The research programme form for research policy issues in priate use of knowledge and evi- takes a broad, interdisciplinary the area of resistance. dence-based initiatives. Both the and cross-sectoral perspective and acquisition and implementation is focused on both basic and mg active substance/PKU 50 Use for growth promotion Group treatment 40 Individual treatment 30 20 10 0 1980 1984 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 Year Figure 4. Sales of antibiotics for food-producing animals in Sweden expressed as mg of active substance per Population Correction Unit (PCU). PCU corresponds approximately to the total weight of live animals within a country, expressed in kilograms. Data for 2010–2015 is not complete due to drop out. Source: Swedres-Svarm 2018 Article number S2020/002 Ministry of Health and Social Affairs +46-8-405 10 00 SE-103 33 Stockholm