Country visit to Sweden to discuss antimicrobial resistance issues based on a One Health approach

The European Centre for Disease Prevention and Control (ECDC) and the European Commission’s Directorate General for Health and Food Safety jointly carried out this country visit to Sweden from 16 to 20 September 2024. The visit was at the invitation of the Swedish government, to assist in the review of their national strategy and plan for tackling antimicrobial resistance (AMR), based on a One Health approach. 

Sweden has among the lowest levels of AMR and antimicrobial consumption in Europe and has made a long-standing effort to prevent the emergence and spread of AMR through promoting appropriate use of antibiotics in both humans and animals. There have been longstanding, joint national activities in human and animal health and food, and more recently in the environmental sector, addressing the risk of AMR in a truly One Health fashion. The collaboration between different authorities and stakeholders on a national level is coordinated through the Intersectoral Coordinating Mechanism. Joint reporting and communication activities resulted in broad awareness among all the relevant actors and society about the risk of AMR and importance of maintaining the effectiveness of antibiotics. This, together with the political commitment of considering AMR as an issue of high priority, nationally and internationally, could be considered the key elements of success of Sweden in addressing AMR. 

The national One-Health strategy on AMR and the Swedish One-Health cross-sectoral action plan are coming to an end in 2025. As the review process has now started, this is an opportunity for finetuning the strategy and the plan, and this report includes many observations and considerations intended for their review. 

In the human health sector, long-standing activities promoting appropriate use of antibiotics through the unique Strama programme, wide use of treatment guidelines and point-of-care tests, and access to high-quality laboratory services, resulted in low antibiotic use and a favourable AMR situation compared to other EU/EEA countries, including low prevalence of multidrug-resistant organisms (MDROs). Infection prevention and control (IPC) is viewed as an essential requirement for safe patient care with designated infection control teams in the regions and IPC doctors and IPC nurses in healthcare settings. Comprehensive risk-based MDRO screening allows for the rapid control and prevention of outbreaks. However, the focus of IPC is mainly personal and environmental hygiene, as well as the use of PPE, with less emphasis on the implementation of prevention bundles such as for the proper use and management of indwelling devices. While there are good quality data on MDROs, there is a lack of systematically collected actionable surveillance data on hospital acquired infections. 

In the veterinary sector, the successful Swedish model based on the principle: ‘Healthy animals do not need antibiotics’ consists of: a) long-standing efforts by the authorities and stakeholders to eradicate and control various notifiable diseases, resulting in an exceptionally good animal health situation; b) comprehensive monitoring of AMR predating the European Union’s harmonised surveillance system; and c) collection of data on III antimicrobial consumption by the competent authorities and stakeholders; and d) national requirements for IPC in veterinary settings (a best practice model for other Member States to follow). There were, however, concerns about the availability of veterinarians, and some indication that additional training may be needed to ensure that all are fully familiar with the Swedish model and their obligations when prescribing antimicrobials. While the overall picture of compliance was positive, challenges were faced in implementing the official controls as planned, highlighting the need to redefine the risk criteria to streamline the selection of veterinarians and establishments to be inspected. 

In the environmental sector, there is a vast body of research, in particular in the role of wastewater in the occurrence of AMR. The first full-scale wastewater treatment plants utilising advanced treatment methods are now in operation. In 2025, the competent authorities will pilot financial incentives scheme promoting the sustainable production of pharmaceuticals. There is an important need to develop a framework for systematic surveillance of antimicrobials, AMR resistant bacteria and resistance genes in the environment.