Antimicrobial resistance (AMR) occurs when bacteria develop the ability to survive the effects of antimicrobial drugs, rendering them ineffective. Although AMR is a natural process, human activities – such as the misuse of antibiotics and inadequate infection control in healthcare settings, especially hospitals – significantly accelerate its development. AMR constitutes a major public health threat in Europe and at a global level (OECD, 2023[1]). Estimates indicate that over 800 000 antibiotic-resistant infections occur annually in the EU, Iceland and Norway, with more than 70% being healthcare‑associated, resulting in approximately 35 000 deaths every year. AMR’s economic impact is equally significant, with direct costs of treating resistant infections estimated at EUR 6.6 billion annually (ECDC, 2023[2]).
Measuring AMR is complex due to the diversity of micro‑organisms and antibiotics involved and the difficulty of establishing comprehensive surveillance. An effective approach measures the prevalence of resistance for specific pathogen-antibiotic combinations selected on the basis of their clinical importance and public health impact. The ECDC’s Composite AMR Index, combining data on five key bacteria‑antibiotic pairs, provides a comprehensive overview of AMR in European hospitals. Data from 2022‑23 indicate that, overall, 32% of reported bacterial isolates were resistant to first-level AMR markers, a proportion consistent with levels observed in 2016‑17. However, this EU/EEA average masks significant cross-country variations and trends, with Northwestern European countries generally reporting significantly lower AMR rates than southeastern ones. Malta, Sweden and Finland demonstrated the lowest AMR index scores (<12%), while in Romania, Greece, Cyprus and Bulgaria over 50% of isolates exhibited resistance. Between 2016‑17 and 2022‑23, Cyprus, Lithuania and Estonia experienced the largest increases in their AMR index scores, while Malta, Ireland and Portugal reported the most significant reductions (Figure 8.5).
Antibiotic consumption in the community, accounting for nearly 90% of total antibiotic consumption in the EU/EEA, is a key driver of AMR. In 2022, average antibiotic consumption stood at 17 defined daily doses (DDD) per 1 000 inhabitants per day, 20% higher than during the first two years of the COVID‑19 pandemic, when containment measures led to reduced transmission of respiratory pathogens and fewer antibiotic prescriptions in the community (OECD, 2023[1]). Despite this recent increase, the average consumption level in 2022 still represented a significant decrease of approximately 10% over the past decade. Half of the EU countries reported consumption levels between 13.5 and 21.5 DDD per 1 000 inhabitants per day, ranging from 8.3 DDD per 1 000 inhabitants per day in the Netherlands to in excess of 30 in Greece. While consumption levels alone do not indicate prescribing appropriateness, the wide cross-country variation suggests factors beyond infection prevalence influence antibiotic use, highlighting opportunities for improved antimicrobial prescribing and stewardship in several countries.
In addition to consumption volumes, examining the ratio of broad-spectrum to narrow-spectrum antibiotic use across countries provides valuable insights into the appropriateness of prescribing practices and their contribution to AMR. In 2022, the average EU/EEA ratio stood at 4:1, an increase from the relatively stable pre‑pandemic ratio of approximately 3.2:1. Variation was significant, with half of the EU countries reporting ratios ranging from 1.2 to 5.5. In addition to below-average consumption levels, Nordic countries reported ratios below 0.5, reflecting strong antibiotic stewardship. In contrast, Malta, the Slovak Republic and Hungary reported the highest broad-spectrum to narrow-spectrum antibiotic consumption ratios, indicating a pattern of usage that potentially increases the risk of accelerating the emergence and spread of antibiotic-resistant bacterial strains (Figure 8.6). In June 2023, the Council of the European Union adopted a recommendation on stepping up EU actions to combat AMR under a One Health approach, which includes five AMR reduction targets to be achieved by 2030 (European Council, 2023[3]).
