European Antibiotic Awareness Day 2023: Key messages

About the antimicrobial resistance targets

• ECDC estimates that every year, over 35 000 people in the European Union (EU), Iceland and Norway die from infections resistant to antimicrobials - an estimate that has increased in recent years. The health burden of these infections is comparable to that for influenza, tuberculosis and HIV/AIDS combined.
• A Council Recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach was adopted on 13 June 2023. The document outlines five targets related to antimicrobial consumption and antimicrobial resistance to be reached by 2030, with 2019 as the baseline year.
• The recommended targets are an effective way of monitoring progress and achieving goals related to the prevention and reduction of antimicrobial resistance. They are concrete, measurable goals for the EU and for each EU Member State according to their individual situations.
• For the EU overall, the recommended targets to reach by 2030 are the following:
  • Reduce the total consumption of antibiotics in humans by 20%;
  • Ensure that at least 65% of the total consumption of antibiotics in humans comes from the ‘Access’ group of antibiotics as defined in the AWaRe classificationof the WHO;
  • Reduce the total incidence of bloodstream infections with meticillin-resistant Staphylococcus aureus (MRSA) by 15%;
  • Reduce the total incidence of bloodstream infections with third-generation cephalosporin-resistant Escherichia coli by 10%;
  • Reduce the total incidence of bloodstream infections with carbapenem-resistant Klebsiella pneumoniae by 5%.

Is the EU progressing towards the antimicrobial resistance targets?

• Even though there has been slow progress in certain areas, the latest data show that antimicrobial resistance remains a serious challenge in the EU/EEA, and that we need to continue to further reduce unnecessary antimicrobial usage and improve infection prevention and control practices to achieve all the targets by 2030.

Total consumption of antibiotics in humans (community and hospital sectors combined)

• By 2022, total consumption of antibiotics in humans (community and hospital sectors combined) had decreased by 2.5% against the baseline year 2019, indicating a slow progress towards the 20% target reduction for the EU by 2030.
• After unprecedented reductions during 2020 and 2021, antimicrobial consumption across the EU/EEA rebounded in 2022 with consumption rates overall, and individually for the community and the hospital sector, much closer to 2019 levels than to those in 2021. It is possible that factors related to the COVID-19 pandemic had an impact on consumption of antimicrobials in the previous years, such as the implementation of non-pharmaceutical interventions (e.g. lockdowns, teleworking, school closures, etc.) resulting in changes to communicable disease transmission, healthcare-seeking behaviour and antibiotic prescribing practices. With the COVID-19 pandemic having reached a phase of lower intensity, patterns of communicable diseases, social contacts, hygiene habits and antibiotic-prescribing practices may now be closer to what they were before the pandemic.
• Nevertheless, decreasing trends in antimicrobial consumption have been observed, in the community and in the hospital sector, throughout the EU/EEA over the past 10 years (2013−2022), with variations between sectors and countries. For the community, 11 countries reported a decreasing trend between 2013 and 2022, while one country reported an increasing trend. In the hospital sector, six countries reported a decreasing trend, while two countries reported an increasing trend.

Percentage of total consumption of antibiotics in humans belonging to the “Access” group of antibiotics

• Only nine EU Member States met or exceeded the target of at least 65% of antibiotic consumption being from the ‘Access’ group, as per WHO’s AWaRe classification of antibiotics, while 17 countries remained below this target. For the EU overall, this percentage was 59.8% in 2022.

Incidence of bloodstream infections with meticillin-resistant Staphylococcus aureus (MRSA)

• The total incidence of bloodstream infections with MRSA showed a decreasing trend at EU level, falling by 12.2% between 2019 and 2022.

Incidence of bloodstream infections withthird-generation cephalosporin-resistant Escherichia coli

• The total incidence of bloodstream infections with third-generation cephalosporin-resistant E. coli also showed a decreasing trend at EU level, dropping by 16.8% between 2019 and 2022. This means that, overall, the EU had already reached the 10% reduction target by 2022.

Incidence of bloodstream infections with carbapenem-resistant Klebsiella pneumoniae

• On the other hand, there was an increasing trend (of almost 50%) in the total incidence of bloodstream infections with carbapenem-resistant K. pneumoniae between 2019 and 2022 which means that, instead of progressing towards the 5% reduction target by 2030, the situation in the EU has worsened since 2019.
• This is a worrying trend, given that very few therapeutic options remain available for patients infected with carbapenem-resistant Klebsiella pneumoniae, and those that are available are often limited (e.g. new, recently- approved antibiotics or combinations, as well as older antibiotics such as colistin). This trend points towards the need for further efforts to improve infection prevention and control (IPC) and encourage prudent use of antimicrobials in healthcare settings.

Other key messages related to the latest data

• After an increase in 2020 and 2021, the number of reported Acinetobacter spp. invasive infections (mostly bloodstream infections) in the EU/EEA decreased in 2022 compared to 2021. Nevertheless, AMR percentages, including resistance to carbapenems, remained high. Although this does indicate that actions may have had a positive effect, there is a continued need for interventions to control Acinetobacter spp. in hospitals, particularly in intensive care units (ICUs). Acinetobacter spp. is especially problematic since it can persist in the healthcare environment for long periods and, once established, is notoriously difficult to eradicate.
• In 2022, the number of reported S. pneumoniae invasive infections in the EU/EEA showed signs of returning to a level similar to that for 2019, following a decline in 2020−2021. For S. pneumoniae, there was also an increasing trend for the percentage of macrolide resistance, penicillin non-wild-type (i.e. different from normal wild-type isolates which are susceptible to penicillins) and combined resistance, during the period 2018−2022. This may be an indication that non-pharmaceutical interventions, in place during the COVID-19 pandemic, could have modified the risk of infection for S. pneumoniae, including resistant strains.

• For most bacterial species–antimicrobial group combinations, the reported incidence rates and AMR percentages varied widely among countries, often with a north-to-south and west-to-east gradient. In general, the lowest AMR levels were reported by countries in the north of Europe, and the highest by countries in the south and east of Europe.

• Despite the increased awareness of antimicrobial resistance as a threat to public health, the availability of evidence-based guidance for infection prevention and control, antimicrobial stewardship and adequate microbiological capacity, public health action to tackle this issue remains insufficient. Stronger interventions and actions to address antimicrobial resistance are urgently needed, and these would have a significant positive impact on population health and future healthcare expenditure in the EU/EEA.

Infection prevention and control, and prudent use of antibiotics

• Good infection prevention and control practices in hospitals and healthcare settings are a must, starting with hand hygiene. Over 70% of the health burden of antimicrobial resistance in the EU/EEA is due to healthcare- associated infections with multidrug-resistant bacteria, half of which could be prevented through adequate infection prevention and control measures.
• In the community, many infections can be prevented through hand hygiene, vaccination and other measures such as respiratory etiquette and physical distancing, potentially resulting in a decreased need for antibiotics.
• Antibiotics are not effective against infections caused by viruses such as COVID-19, common colds or influenza. They should only be used to treat bacterial infections.
• Patients suffering from viral infections rarely develop bacterial infections as a complication, but if they do, they will require treatment with antibiotics. Antibiotics should be reserved for these situations and should not be taken without the advice of a medical doctor.
• Antibiotics do not work like painkillers and cannot relieve headaches, aches, pains or fevers. Taking antibiotics for the wrong reasons will not aid recovery, and may even cause side-effects such as diarrhoea, nausea or skin rashes.
• If symptoms persist, or if there are concerns about an individual’s health, it is important to seek medical advice.
• If a healthcare professional confirms that antibiotics are necessary, they should be taken responsibly - i.e. at the correct dosage and intervals, ensuring that the course is completed.

What is antimicrobial resistance and why is it an issue?

• Antimicrobial resistance is the ability of bacteria to combat the action of one or several antimicrobials. Humans and animals themselves do not become resistant to antimicrobials, but the bacteria they carry can do so
• Antimicrobials – mostly antibiotics – are commonly used in hospitals and long-term care facilities for the treatment or prevention of infections. Some of this use may be unnecessary, further contributing to the emergence and spread of antimicrobial resistance.
• The situation with antimicrobial resistance is deteriorating, and new bacterial strains are emerging that are resistant to several antibiotics at the same time (known as multidrug-resistant bacteria). A major antimicrobial resistance problem, especially in hospitals, is the emergence of bacteria that are resistant to last-line antimicrobials, which severely limits treatment options for infected patients. Such bacteria may eventually become resistant to all existing antimicrobials.
• Without effective antibiotics, we could return to the ‘pre-antibiotic era’, and it would be difficult, if not impossible, to safely perform organ transplants, cancer chemotherapy, intensive care or other medical procedures. Bacterial diseases which were once preventable would spread and it would no longer be possible to treat infections.

Information on specific bacteria

• Klebsiella pneumoniae (K. pneumoniae) is a common cause of urinary tract, respiratory tract and bloodstream infections and is a frequent cause of hospital outbreaks, if appropriate prevention and control measures are not taken. Very few therapeutic options remain available for patients infected with multidrug-resistant K. pneumoniae who have additional resistance to carbapenems. Options are often limited to new, recently-approved antibiotics or combinations, as well as older antibiotics such as colistin - an antibiotic from the polymyxins group.
• Escherichia coli (E. coli) is one of the most frequent causes of bloodstream infections and community- and healthcare-associated urinary tract infections worldwide.