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Swedish strategy to combat antibiotic resistance
Contents
Foreword................................................................................................................................3
Swedish strategy to combat antibiotic resistance...............................................5
Objective 1: Increased knowledge through enhanced surveillance ......................7
Objective 2: Continuous strong preventive measures...............................................8
Objective 3: Responsible use of antibiotics................................................................ 10
Objective 4: Increased knowledge for preventing and managing bacterial
infections and antibiotic resistance with new methods.................. 12
Objective 5: Improved awareness and understanding in society
about antibiotic resistance and countermeasures.......................... 14
Objective 6: Supporting structures and systems..................................................... 16
Objective 7: L
eadership within the EU and at
the international cooperation................................................................. 17
Past and present work in Sweden............................................................................ 20
Photo:
Jessica Gow/TT (cover),
Jessica Gow/TT (p 4, 13, 15)
Maskot/Folio (p 9),
John Sandlund/Folio (p 23).
The Government adopted this strategy on 21 April 2016
S2016/02971/FS Article no: S2016.007
Foreword
Antibiotic resistance is a problem of including low profitability, but also
global dimension that affects us all. the scientific difficulty of finding
The World Economic
The use of antibiotics is linked to new approaches. In view of the com-
both the emergence and the spread plexity of the problem, all of society Forum has identified
of resistance. must come together and work within antibiotic resistance as
a ‘One Health’ approach. The human a global risk beyond the
Genuine commitment and vigorous and animal health care sector must capacity of any organiza-
actions are needed to combat antibio- jointly ensure that antibiotics are used tion or nation to manage
tic resistance if future generations will in a responsible way, take preventive or mitigate alone.
have effective remedies to our most measures to limit the need for anti-
common infectious diseases. Antibio- biotics and minimise the spread of
tics must be considered as a global com- infections.
mon good and must be accessible to
anyone who needs them. Action is needed both from academic
research and industry if new antibio-
Resistant bacteria are of particular con- tics, vaccines and diagnostic methods
cern to the most vulnerable health are to be developed. Issues related to
care sectors: emergency and intensive environmental release of antibiotics
care units and neonatal units. Modern require the involvement of the en-
health care depends on antibiotics, vironmental sector. Resistant bacteria
particularly in connection to medical are spreading between people and
procedures that involve an increased animals, and in the environment.
risk of infection, e.g. cancer treatment, Surveillance of resistance is hence
transplantations and operations. Infec- needed at international, national and
tions caused by resistant bacteria can local levels.
have serious consequences, from pro-
tracted hospitalisation to increased All of society must be involved;
mortality. This means suffering for numerous relevant actors could be
patients and increased costs for health mentioned. To find global ways for-
and medical care. Similarly, infections ward, the issue must be raised to
involving resistant bacteria can cause Heads of States and Governments to
financial losses in the livestock indus- ensure a true One Health perspective.
try and animal suffering. Low-income Increased awareness among the gen-
countries are particularly severely af- eral public is important regarding the
fected; limited access to clean water consequences of widespread antibiotic
and sewage facilities, medicines and resistance, both for individuals and
health care can dramatically increase for society in general.
child mortality. Most deaths caused by
pneumonia among children under the In May 2015, WHO member states
age of five are due to a lack of access adopted a Global action plan on anti-
to effective antibiotics. microbial resistance, which provides
a basis for the continuous work on
Antibiotic resistance is a complex pro- antibiotic resistance. It is a top priority
blem. People, animals, food and other for Sweden that the action plan is put
goods cross borders every day, contri- into practice, all countries must take
buting to the spread of resistant bacte- responsibility for fighting the pro-
ria. An increasing number of bacteria blems of resistance. This problem
are developing resistance to existing cannot be solved by individual coun-
antibiotics, while the development of tries; it requires intense global efforts.
new classes of antibiotics has slowed
down. This is due to several factors,
Swedish strategy to combat antibiotic resistance 3
Working at the international level is To tackle the problems of resistance,
vital to achieving national goals on we need to make a concerted effort
preserving the possibility of treating and coordinate our activities. To this
infections in humans and animals. end, we are presenting this Swedish
strategy to combat antibiotic resistance.
There is a broad political consensus in The strategy points out the direction
Sweden on prioritising action against of Swedish efforts and is also intended
antibiotic resistance. We have a long for international actors wishing to
tradition of a broad and preventive benefit from Swedish knowledge and
approach and as a result we have a experience.
favourable resistance situation. Over
the years we have developed a high
level of expertise which is highly Gabriel Wikström,
recognised in international forums. Minister for Health Care,
This applies to policy issues, but also Public Health and Sport
to the research area, where Sweden
has been deeply involved for several Sven-Erik Bucht,
years, playing a role in the international Minister for Rural Affairs
Joint Programming Initiative on
Antimicrobial Resistance. Sweden Helene Hellmark Knutsson
will continue to engage in advocacy Minister for Higher Education
and set a good example. and Research
4 Swedish strategy to combat antibiotic resistance
Swedish strategy to combat
antibiotic resistance
Antibiotic-resistant bacteria are spread globally in the same way as This strategy is to form the basis of
other bacteria. This means they can be transferred between people, Sweden’s work to curb the develop-
animals and foodstuffs, and they can spread in our environment. ment and spread of antibiotic resis-
These links between the various sectors mean that efforts to combat tance and to deal with the situation
antibiotic resistance must be made from a broad perspective. we have today. The strategy is to high-
light areas and measures for effective
This is called a One Health approach. It is important that the term work to combat antibiotic resistance.
One Health is understood in a way that all significant factors must be Sweden’s work to combat antibiotic
covered, such as issues concerning the economy, education, research resistance must be long-term and sus-
and aid, in order to deal globally with the problems of resistance. tainable, and it must build on the good
international reputation Sweden has
Health care environments are particularly at risk for the emergence in this area.
and spread of antibiotic resistance. Infections caused by resistant
bacteria can have serious consequences, such as increased mortality The strategy, which covers work at the
and prolonged illnesses, and a reduced ability to protect patients national level, as well as within the
using antibiotics during a surgery and other medical procedures. EU and at the international level,
This results in suffering for patients and increased costs for health applies until 2020.
and medical care services, and the society as a whole.
The global commitments made
In addition, currently established treatment methods for diseases within the 2030 Agenda, as well as
such as cancer, as well as some areas of transplant surgery and other Sweden’s Policy for Global Develop-
advanced surgery, may need to be re-evaluated. This may, in time, ment, are key frameworks for
also apply to more common surgical procedures, such as prosthetics. Sweden’s continued leadership in
the international work.
In animal populations, resistant bacteria can spread quickly and
thus represent a reservoir of bacteria that can spread further to both The strategy is based on Sweden’s
people and animals. Animals can also get infections that are difficult current work to combat antibiotic
to treat as a result of resistant bacteria. This causes suffering for the resistance, the Global action plan
animals and economic losses. on antimicrobial resistance that was
adopted by WHO member states at
Important functions in society can also be affected by growing the World Health Assembly in May
antibiotic resistance. 2015, confirmed by FAO and OIE
resolutions, and relevant documenta-
tion, such as evaluations, action plans
and other strategies.
This strategy sets up an overarching
goal and seven strategic objectives
where the Government has identified
the important factors for achieving
these objectives. This strategy may be
supplemented with specific concrete
initiatives for various areas and sectors.
Swedish strategy to combat antibiotic resistance 5
Overarching goal Preserve the possibility of effective treatment of bacterial infections in people and animals 6 Swedish strategy to combat antibiotic resistance
Objective 1: Increased knowledge
through enhanced surveillance
This objective involves:
• improving access to data on resistance and the sale
and use of antibiotics and other antibacterial agents in
all sectors, as well as access to data on the spread of
antibiotics into the environment; and
• evaluating the success and cost-effectiveness of
various measures, using continuous data collection.
It is necessary to continuously collect ence how well treatment recommen- • possibilities to systematically moni-
data on the occurrence of resistant dations are used by prescribers (e.g. tor the long-term trends concerning
bacteria and use of antibiotics. This doctors and veterinarians). We have resistance, sales and use of antibio-
enables us to analyse trends over a long tradition in Sweden and high tics, and human and animal infec-
time, see important changes that level of expertise in surveillance, but tions to be maintained and further
could indicate a spread of resistant the systems used need to be improved developed;
bacteria, quickly detect such a spread, and further developed to become more
communicate findings and take mea- effective and efficient, and to be adap- • data about the reasons for prescrip-
sures at an early stage. Surveillance ted to new challenges. tion and compliance with treatment
also makes it possible for us to moni- recommendations to be available
tor the effects of measures taken and The Government expects: in all sectors and the results fed
to evaluate them. • appropriate data to be collected back into relevant services.
from relevant sectors and fed back
Using comparable resistance data from where relevant at local, regional
various sectors, we can map out path- and national level, as well as at EU
ways of spread and the significance of and international level;
different sources for the resistance
problem. It is also important to be able • efficient systems for early detection,
to link an antibiotic prescription to a compilation, analysis and reporting
diagnosis so as to monitor and influ- of information to be in place;
90 n Sweden
n Denmark
80 n Netherlands
n Spain
n Germany
70
Figure 1. Proportion of resistant 60
indicator bacteria (Escherichia coli)
in broilers 2014, an international 50
comparison.
40
Source: The European Food Safety
30
Authority and the European Centre
for Disease Prevention and Control
20
2016, The European Union sum-
mary report on antimicrobial 10
resistance in zoonotic and indica-
tor bacteria from humans, animals 0
and food in 2014. Ampicillin Quinolones Tetracycline Cefotaxime
Swedish strategy to combat antibiotic resistance 7Objective 2: Continuous strong
preventive measures
This objective involves:
• identifying and implementing preventive measures
in relevant sectors so that spread can be prevented,
detected and avoided as early as possible;
• minimising the spread of multiresistant bacteria.
The favourable resistance situation use and partly because of the spread
in Sweden does not mean we can be of bacteria to patients more suscepti- An important success
complacent. Resistance is growing ble to infections. This, in turn, means factor for effective natio-
here as well, albeit more slowly than a greater risk of serious complications nal work against antibiotic
elsewhere. We must remain vigilant for these patients.
resistance has been close
and realise the importance of preven-
tive measures so that the situation The need for antibiotics in animals cooperation between the
does not deteriorate. Infection preven- is reduced through efficient disease local and national levels
tion measures will reduce the need for control, good farm management, in the health care sector,
antibiotics. People and animals that biosecurity, and sound animal hus- and also between central
are healthy or that receive good treat- bandry systems. Safe international government and the live-
ment or care will be less in need of trade in both living animals and stock industry.
antibiotics. animal products is particularly impor-
tant. This also reduces the risk of
The national vaccination programmes resistant bacteria spreading to other
and measures to maintain good hygie- animals, to foodstuffs and to people.
nic standards in health care settings
are fundamental as infection preven- Releasing antibiotics and other anti-
tion measures. Healthcare-associated bacterial agents into the environment
infections are the most common can give rise to resistance. Although
adverse event in health care settings, our knowledge about how antibiotics
and a number of these infections are and other antibacterial agents can
caused by bacteria that have acquired select for antibiotic-resistant bacteria
various resistance mechanisms. in the environment is incomplete,
Health care settings are particularly there is data to indicate that this is an
sensitive for the development and important factor.
spread of antibiotic resistance, partly
because of the high level of antibiotic
8 Swedish strategy to combat antibiotic resistanceThe Government expects: control regarding infectious
• a high level of compliance with vac- diseases in order to ensure good Responsible and sustain-
cination and health programmes to animal health and safe foodstuffs; able breeding practices
be maintained to keep people and in animal husbandry are
animals as healthy as possible, thus • antibiotic resistance, infection pre-
prerequisites for healthy
reducing the need for antibiotics; vention and control/hygiene to be
included in relevant education and animals, in need of less
• relevant staff to have knowledge training programmes; antibiotics.
about antibiotic resistance, the
spread of infectious diseases and • a high level of vigilance, rapid dia-
the importance of a high degree gnoses, and established routines
of compliance with basic hygiene and guidelines to prevent, detect
routines and other infection pre- and stop the spread of infectious
vention measures, as well as know- disease;
ledge about the seriousness and
complexity of the issue from a • technology for the cleaning of
global perspective; pharmaceutical residues and other
substances that are difficult to
• county councils and municipalities treat in water treatment plants to
to have access to expertise regar- be tested and evaluated by 2018;
ding basic hygiene in health care
settings so that good hygiene • the development of rules on good
standards can be maintained; manufacturing practice and criteria
in support of the county councils’
• relevant actors in animal produc- procurement processes so as to
tion, veterinary medicine, and the move towards minimising releases
food chain to have access to exper- of antibiotics into the environment
tise on hygiene and efficient disease during pharmaceutical production.
Swedish strategy to combat antibiotic resistance 9Objective 3: Responsible use
of antibiotics
This objective involves:
• using and handling antibiotics and other anti-
bacterial agents in a wise and responsible manner.
Increased use of antibiotics leads to an plications arise due to insufficient
increased risk of development of resis- treatment. Sweden has the lowest
tance. Equally, the risk of resistance level of antibiotic use in
increases if antibiotics are used incor- Recommended first-choice drugs food-producing animals
rectly, for example in inappropriate that are available in other EU Member
in the EU.
doses or using antibiotics with an un- States are not always available in
justifiably broad antibacterial spectrum. Sweden. This could pose a risk that
It is therefore important that antibiotics more expensive second-choice drugs The use of antibiotics
and other antibacterial agents are only are prescribed, alternatively pharma- as growth promoters for
used when they are needed, that the ceuticals with negative side effects or animals was prohibited in
right type of antibiotic is used and that are worse from a resistance point of Sweden in 1986 and in
treatment recommendations are deve- view. Hence, it is therefore important
the EU in 2006.
loped and followed. To reduce the risk that access to recommended first-
of development of resistance, it is im- choice drugs is guaranteed. More
portant that drugs of particular impor- knowledge is also needed on how the
tance for human medicine are not used efficacy of older antibiotics can be
for animals. optimised and preserved.
Data on compliance to treatment There is a risk that the widespread
recommendations must be fed back – and in many cases unnecessary – use
to the prescribers to ensure that pre- of antibacterial agents in everyday pro-
scribing are made in the correct way. ducts could be a contributing factor
It is also important to be able to moni- to the emergence and spread of resis-
tor that antibiotic prescribing do not tant bacteria.
decrease to such an extent that com-
10 Swedish strategy to combat antibiotic resistanceBelgium
Bulgaria
Cyprus
Denmark
Estonia
Finland
France
Ireland
Italy
Latvia
Lithuania
Luxembourg
The Netherlands
Poland
Portugal
Slovakia
Slovenia
Spain
United Kingdom
Sweden
Czech Republic
Germany
Hungary
Austria
0 50 100 150 200 250 300 350 400 450
Figure 2. Sales of veterinary antimicrobial agents for food-producing animals in the EU. Expressed as mg of
active substance per Population Correction Unit (PCU). PCU corresponds to the total weight of live animals
within a country, expressed in kilograms. The measure is not exact and should therefore be interpreted with
caution. Source: Fifth ESVAC report 2013, European Medicines Agency.
The Government expects:
• antibiotics to, continuingly, only be cines used for treating animals, • antibiotics of particular importance
used following a prescription from especially as regards production to continue to be given to animals
professionals that are authorised to animals, in order to facilitate con- only when there are exceptional
prescribe antibiotics; trols regarding compliance with grounds for doing so;
treatment recommendations;
• recommendations to be drawn up • environmental data to make up
at the relevant level (local, regional • the regular use of quality-assured part of the basis of the approval
or national) concerning the diag- microbiological diagnostics with process of antibiotics and to be
nosis and handling of common in- as short response times as possible, made available to government
fections within both human health so that unnecessary and incorrect agencies and other relevant stake-
care and veterinary care, and that treatment can be avoided; holders for the assessment of
those recommendations will be har- environmental risks;
monised as far as possible and used • access to both new and older anti-
in day-to-day work; biotics to be guaranteed on the • discarded antibiotics to be dealt
Swedish market; with in an environmentally sound
• data on compliance with treatment way;
recommendations to be accessible • increased knowledge about how the
for prescribers, service managers, availability and use of new antibio- • antibacterial agents to be used in a
government agencies and the pub- tics and older antibiotics – where prudent, responsible and evidence-
lic, in both human and veterinary national availability is inadequate based way in various types of con-
medicine; – can be guaranteed, while at the sumer products.
same time the risk of developing
• data to be available regarding resistance is minimised and the
reasons for prescription of medi- best possible care is provided;
Swedish strategy to combat antibiotic resistance 11Objective 4: Increased knowledge for
preventing and managing bacterial
infections and antibiotic resistance
with new methods
This objective involves:
• increasing knowledge about basic bacterial infection
mechanisms so that new diagnostic methods, vaccines
and treatment options can be developed;
• increasing knowledge about the emergence and spread
of resistance so that the use of new and existing antibio-
tics can be optimised and the extent of the resistance
problem can be prevented and limited.
One contributing factor to the serious- biotic resistance for the health sector.
ness of the resistance problem is that The effects of actions taken must be Antimicrobial resistance
the development of new antibiotics measurable as well as the economic refers to resistance among
and other treatment options has slow- consequences of resistance. The costs bacteria, viruses and other
ed down. This is due to several fac- and benefits of antibiotic use and resis-
microorganisms, whereas
tors, including low profitability, but tance in animal production must be
also the scientific difficulty of finding possible to estimate to justify further antibacterial resistance
new approaches. To enable the deve- improvements at national and inter- (antibiotic resistance) ref-
lopment of new treatment strategies national levels. Increased knowledge ers only to resistance in
and preventive measures, research is is also needed about how the structure bacteria.
necessary into how bacteria give rise of health and medical care systems,
to infections and what other factors animal production, global trade and
affect which individuals are infected tourism affects the spread of antimi-
and how severely they are affected. crobial resistance between bacteria,
Equally, research is needed to be able people, animals and the environment.
to optimise and preserve the efficacy
of existing treatments for as long as These challenges cannot be solved
possible. The development of cost- by individual nations; they require
effective methods for better infection coordinated international cooperation
diagnostics and sensitivity tests could spanning many sectors. The EU is an
reduce the incorrect use of antibiotics important platform for the work to
in health care, veterinary medicine be carried out by Sweden.
and animal husbandry.
Moreover, there is a need for new
knowledge to be able to estimate the
burden of disease and costs of anti-
12 Swedish strategy to combat antibiotic resistanceThe Government expects: • Sweden to take part in international
• research to be carried out in the research cooperation in the area of
area of antibiotic resistance, inclu- antibiotic resistance and related
ding research into how resistance areas;
develops and spreads, into how
existing and new antibiotics can • universities and other higher edu-
be optimally used to prevent the cation institutions, government
emergence of resistance, into com- agencies, health and medical care
municable disease control and institutions and the industry to col-
preventive measures, and into the laborate at national level, within
consequences of antibiotic resis- the EU and at international level to
tance – for the economy, for health identify and bridge knowledge gaps;
and for society in general;
• Sweden to contribute to the deve-
• research to be carried out into basic lopment of knowledge about new
bacterial infection mechanisms; business models and financial in-
centives to stimulate the develop-
• research to be carried out into how ment of new antibiotics and other
new strategies and other knowledge treatment options.
can best be implemented in relevant
activities;
• measures to be taken to bridge the
gap between basic research and
the commercialisation of research
findings;
Swedish strategy to combat antibiotic resistance 13Objective 5: Improved awareness
and understanding in society
about antibiotic resistance and
countermeasures
This objective involves:
• knowledge, competence and increased awareness
among all relevant parties – including the general
public – about measures to prevent the spread of
infections and about the risks of resistance develop-
ment through the use of antibiotics.
Antibiotics are only available on pre- important that information is co-
scription in Sweden, prescribers have ordinated within each sector and The responsible use of
the full responsibility to use them between sectors so that the general antibiotics, infection pre-
wisely. However, the public’s know- public will have the same message vention and a high level of
ledge and expectations can influence from all actors. Collaboration makes
knowledge among health
decisions about prescribing antibiotics. it easier to produce information tailor-
Therefore, a high level of awareness ed to specific needs. care staff are prerequisites
about why it is important that anti- for preventing healthcare-
biotics are only used when they are The Government expects: associated infections.
needed is essential for building a • people working in health care and
sustainable approach in the society to social services, dental care, with
antibiotics. Equally, a high level of animals and with food production
awareness about the importance of to have good knowledge of the
good hygiene and preventive measu- One Health concept, antibiotics,
res are important to reducing the antibacterial agents, general
spread of infectious diseases and thus hygiene, hygiene in health care
the need for antibiotics. It is also im- settings and infection control;
portant that consumers are given the
opportunity to make well informed • patients and animal keepers to
decisions. For example, labelling of have good knowledge about the
the origin of meat can help consu- importance of using antibiotics
mers choose meat from countries as prescribed;
with prudent use of antibiotics in
animal production. • national, regional and other rele-
vant parties to collaborate to prod-
Many actors in Sweden are currently uce and disseminate tailored and
working to disseminate information coordinated information about
and knowledge about antibiotic resis- antibiotics and antibiotic resistance,
tance and preventive measures via general hygiene and other preven-
their channels and networks. This is tive measures.
a strength but at the same time, it is
14 Swedish strategy to combat antibiotic resistanceSwedish strategy to combat antibiotic resistance 15
Objective 6: Supporting structures
and systems
This objective involves:
• conducting work related to antibiotic resistance in a
coherent, efficient and strategic manner on the basis
of the roles of different stakeholders;
• this work being followed up and lessons learned.
Work to prevent and handle antibiotic The Government expects:
resistance spans across several sectors • the Government Office to be well- The Public Health Agency
and actors. Clear systems and struc- coordinated in its work on issues of Sweden and the Swedish
tures for collaboration are needed to concerning antibiotic resistance; Board of Agriculture have
make use of the accumulated know- been tasked by the govern-
ledge that exists among the different • a national coordination function
ment to jointly coordinate
stakeholders and to identify know- with relevant government agencies
ledge gaps. Coordination enables re- and other stakeholders to coordi- the work against antibiotic
sources to be used more efficiently nate overall national work; resistance and healthcare-
and helps to avoid duplication of work associated infections in
and to communicate coordinated • the Swedish strategic programme Sweden.
messages. against antibiotic resistance
(Strama) to lead national work and
Successful work to contain antibiotic to coordinate the county councils’
resistance builds on support for the Strama groups, that support and
implementation of measures targeting monitor activities in work on the
both individuals and targeting the prudent and responsible use of anti-
development of supporting structures biotics for humans. Within the
in the organisations. For example, animal and food sector, Strama
established systems related to the VL (for the veterinary and food
follow-up of antibiotic use and com- sectors) continues to provide know-
pliance with treatment recommenda- ledge support to various stake-
tions can influence how and when holders);
antibiotics are prescribed.
• knowledge to be developed and
used regarding how organisational
factors should support the work on
antibiotic resistance.
16 Swedish strategy to combat antibiotic resistanceObjective 7: Leadership within the EU
and in international cooperation
This objective involves:
• Sweden showing leadership in efforts to combat antibiotic
resistance and to work for the prudent and responsible
use of antibiotics globally in multilateral processes, work
at EU level and in bilateral contacts and cooperation;
• global commitments made as part of the 2030 Agenda,
as well as Sweden’s Policy for Global Development,
being key frameworks.
Antibiotic resistance is a global pro- Sweden has currently a favourable
blem that requires many countries situation, with regard to resistance, The Swedish strategic
contributing to the solution. The but this can change quickly as a result work has a long tradition
major international organisations of travel and trade and depending on of collaboration between
WHO, FAO and OIE are platforms how resistance develops and spreads all relevant sectors and
for this work. The political will to act internationally. This is why Sweden
disciplines such as the
on the threat of resistance has grown needs to contribute to work so that
throughout the world in recent years. the resistance status of other countries human, animal, food and
The fact that in 2015, WHO members is also improved. Sweden’s relatively the environment sectors.
adopted the Global action plan on good situation is a result of long and
antimicrobial resistance to gives con- laborious work, which has led to a
crete form to and speeds up efforts is very high level of expertise on anti-
proof of this. In light of this, it is also biotic resistance that is asked for inter-
important to stress that the global nationally. Different countries have
action plan is based on a clear One different situations when it comes to
Health approach, where measures tackling the resistance problem. For
have also been identified in the area example, there may not be sufficient
of agriculture and are supported by data for new treatment recommen-
both the FAO and OIE. These orga- dations. Equally, many countries lack
nisations adopted at the same time health and medical care systems and
resolutions to support the global veterinary agencies that have the
action plan in their areas of expertise. capacity to implement these recom-
However, international pressure is mendations.
still needed to move the issue high up
on the agenda in all countries and to Healthy animals are the overall objec-
increase awareness in all relevant tive in animal husbandry in Sweden.
sectors. Strategies based on improving animal
health result in a reduced spread of
infectious diseases and a reduced use
Swedish strategy to combat antibiotic resistance 17of antibiotics. Preventive animal tend not to reach the poorest people.
health measures and low levels of anti- The problems of antibiotic resistance Every year, the Public
biotic use in animal production result are also present in the area of sexual Health Agency of Sweden
in a favourable resistance situation. and reproductive health and rights. and the National Veterinary
However, the resistance problem is Maternal and child mortality, infec- Institute publish a joint
not tied to national borders; for ex- tions in new-borns and resistant
report giving an overview
ample, resistance can spread via the gonorrhoea are some of the areas that
international trade of animals. To get risk being hit hardest by antibiotic of the resistance status
to grips with the resistance problem resistance. Efforts to combat anti- and antibiotic use.
in animal production, it is therefore biotic resistance in developing coun-
necessary for other EU Member tries have traditionally focused on the
States to take similar measures to health sector. However, the nature of
those already implemented in Sweden. the resistance problem means that
This is also important from a com- a broader approach is desirable,
petitiveness perspective, so that the including preventive measures that
animal keepers who continuously cover the environmental sector and
work to reduce antibiotic use are not animal production, as well as the
disadvantaged. Sweden must there- health sector.
fore try to influence the other EU
Member States to continue to work Knowledge about how antibiotic use
with strategies based on improving and resistance affect economic and
animal health and using antibiotics social aspects is generally poor glo-
in a more responsible way in animal bally. By producing such knowledge,
production. analyses and models, we can influence
understanding of this problem to a
The fact that many international higher degree. For example, the
initiatives are under way to manage OECD has shown through a study
antibiotic resistance is good news. financed by Sweden that the costs of
However, resources are required to ceasing to use antibiotics as growth
follow and coordinate various initi- promotors in animal production are
atives and to actively participate in relatively low in wealthy nations
them. By channelling resources in the world. More such studies are
through the EU, the large internatio- needed to monitor development and
nal organisations and the cooperation as incentives for change.
between the Nordic countries, we can
improve the leverage of our resources. The Government expects:
Sweden also has bilateral agreements • Sweden to support the WHO,
with certain countries where we can FAO and OIE in efforts to combat
focus on special initiatives. antibiotic resistance, also within
the framework of the EU and
Antibiotic resistance risks under- Nordic cooperation. It is particu-
mining a series of advances that have larly important to support the im-
been made through the Millennium plementation of the Global action
Development Goals, as infections plan on antimicrobial resistance.
caused by resistant bacteria occur to The focus of Sweden’s engagement
a disproportionately high degree in should be on building up a global
developing countries. Lack of access surveillance system for antibiotic
to water, sanitation, health and med- resistance. In the long term,
ical care and relevant antibiotics are Sweden should work for integrated
some of the causes. Moreover, mea- global surveillance systems for
sures to reduce antibiotic resistance antibiotic resistance and antibiotic
18 Swedish strategy to combat antibiotic resistance• use in humans and animals and, broad approach that also includes,
where appropriate, also in food- in addition to the health sector, for
stuffs, in cooperation with the example the environmental and
WHO, FAO, OIE and the Codex agricultural sectors. Sweden should
Alimentarius; also, in the international coopera-
tion, make use of experiences from
• Sweden to continue building allian- other countries and learn from
ces with other countries in order to others;
advance the antibiotic resistance
issue at a high political level, e.g. • Sweden to cooperate with other
through a high-level UN meeting EU Member States, the European
in 2016. The purpose is to raise Commission and the EU agencies
important overarching issues that on the implementation of the EU
cannot be solved by the health Action Plan against the Rising
sector and the agricultural sector Threats from Antimicrobial
alone. This concerns issues such Resistance. In working on a new
as access to and the correct use EU action plan, Sweden should
of new and old antibiotics, and argue for concrete and clear
diagnostic methods and other treat- objectives;
ment methods. These are impor-
tant issues for ensuring that the • Sweden to be a driving force in
problem with resistance will not negotiations concerning new
increase and the new antibiotics do regulatory frameworks, recom-
not quickly become ineffective; mendations and guidelines in the
EU to work towards the respon-
• Sweden to continue pushing for sible use of antibiotics in animal
the OECD to develop economic production;
analyses about the consequences
of antibiotic resistance in both the • Sweden to continue its involvement
agricultural sector and the human in the EU Joint Programming
health sector; Initiative on Antimicrobial
Resistance;
• Sweden to continue working as
one of the leading countries in the • Sweden to work to ensure that
action package for antimicrobial increased environmental conside-
resistance under the Global Health ration is taken into account in the
Security Agenda (GHSA); EU pharmaceuticals legislation
and internationally, for example
• Sweden to work for a global phase- should a regulation on minimum
out of the use of antibiotics as a requirements for production
growth promoter in animal pro- conditions be considered;
duction and of other routine use
of antibiotics in animals, and for a • Sweden to promote issues related
transition to sustainable produc- to antibiotic resistance through
tion systems; bilateral agreements with other
countries.
• Sweden to share knowledge and
experiences with other countries,
considering in particular the needs
of low-income countries. In this
work, Sweden should argue for a
Swedish strategy to combat antibiotic resistance 19Past and present work in Sweden
The basic idea behind the Swedish Today there is a strong consensus Sweden is a result of regulated sales
work against antibiotic resistance is amongst the country’s animal health of antibiotics both on the animal and
that an overall low infection rate in organizations, veterinary personnel the human side, and sound surveil-
the society leads to a healthy popula- and professional animal keepers on lance of the prescription of antibiotics.
tion and healthy animals with lesser restrictive and responsible antibiotic Treatment recommendations for
need of antibiotics. This in turn leads use. Sweden has a long tradition of infections, both the within health
to a reduced selection of resistant bac- preventive work to keep the animals care and dental care, are produced
teria. Prevention control practices healthy, and healthy animals need and updated by the Medical Products
may include anything from vaccina- little antibiotics. Agency and the Public Health Agency.
tions, good diagnostics, good hygiene, Corresponding work regarding vet-
active animal health work and good We carry out continuous resistance erinary medicine has been performed
animal husbandry, to public health surveillance in Sweden and are well for the major domestic animal species
interventions against lifestyle diseases informed about the current resistance by the Medical Products Agency and
directed towards the profession as situation. Samples are often collected by the Swedish Veterinary Associa-
well as the general public. from patients within the health care tion. Furthermore, the Swedish Board
system which provides us with data of Agriculture has adopted regulations
Significant attention has been paid, at for surveillance. Sweden has also in- on antibiotics that should not be given
an early stage, to antibiotic resistance vested in well-functioning standardi- to animals.
in Sweden, and measures were taken zed laboratories. The systems for sur-
to prevent the spread of resistant bac- veillance of antibiotic resistance are In order to further support optimized
teria and to limit the unnecessary use based on voluntary participation of use of antibiotics through surveillance,
of antibiotics. Due to close collabora- laboratories complementing the not- analysis and feedback on compliance
tion between government agencies ifications made in accordance with to treatment recommendations, data
and interested parties representing the Communicable Diseases Act. is needed that links prescription with
animal husbandry, Sweden was the The Public Health Agency analyses, diagnosis.
first country within the European compiles and provides feedback of
Union to prohibit antibiotic additives national data of antibiotic resistance Antibiotic resistance has been a prio-
as growth promoters in animal feed- and antibiotic use, and the incidence ritised research topic in Sweden for
stuff. This was already in place 1986. of health care associated infections. many years. The latest research and
innovation government bill included
The favourable situation, from an Sweden also has a programme for a focus on antibiotics and infection,
international perspective, as regards monitoring of antibiotic resistant bac- resulting in graduate schools and re-
antibiotic resistance in humans and teria in food producing animals and search grants within this area. Sweden
animals is a result of early awareness food. The Swedish National Veteri- was also – along with Italy – the initi-
of the problem. One example is the nary Institute is responsible for this ator of the international research col-
low prevalence of methicillin resistant monitoring, regarding food this work laboration that was initiated in the
Staphylococcus aureus (MRSA) (see is conducted in collaboration with the field of antibiotic resistance in 2010,
figure 3, page 21). Also, this bacteri- National Food Agency. Through Joint Programming Initiative on
um has yet not become established in yearly surveillance of antibiotic resi- Antimicrobial Resistance. Today the
our Swedish pig population. From an dues in meat, samples are taken in collaboration includes 22 countries,
international perspective, Sweden has order to ensure that animals used for of which several are non-European.
a relatively low use of antibiotics per food production will not be treated Sweden had the presidency for the
capita (see figure 4, page 22). Pres- with antibiotics prior to slaughter. first six years and the secretariat is
cription of antibiotics has decreased located at the Swedish Research Coun-
since the middle of the 1990s, we have The results from the surveillance cil. JPIAMR has developed a strategic
seen a total decline with over 40 per- of resistance and antibiotic use in research agenda, which has formed
cent. For animals the use of antibio- humans and animals are presented the basis for several countries’ national
tics is the lowest within the EU. The annually in a joint report by the agendas.
total amount of antibiotics given to ani- Swedish National Veterinary Institute
mals in Sweden has decreased by 60 and the Public Health Agency.
percent since the middle of the 1980s. The relatively good situation in
20 Swedish strategy to combat antibiotic resistanceFigure 3. Staphylococcus aureus. Percentage (%) of invasive isolates with
resistance to meticillin (MRSA), by country, EU/EEA countries, 2014
< 1% 25% to < 50% Non-visible countries
1% to ≤ 5% > 50% Liechtenstein
5% to < 10% No data reported or less than 10 isolates Luxembourg
10% to < 25% Not included Malta
Swedish strategy to combat antibiotic resistance 21In order to coordinate the work of The county councils and the regions’ The Strama group for dental care
the national government agencies, local Strama groups can disseminate develops and supports the implemen-
a national intersectoral coordinating knowledge on treatment recommen- tation of treatment recommendations
mechanism was established in 2012 dations and give feedback on indivi- as 0well as disseminates knowledge
for antibiotic resistance and health dual prescription data and resistance on antibiotics within Swedish dental
care associated infections. The Public level to prescribers. Today the Strama care. Strama VL (veterinary and food
Health Agency and the Swedish Board groups are a part of the Swedish stuff) is a network where a broad
of Agriculture are jointly responsible Association of Local Authorities and group of interested parties participa-
for this function, 21 government Regions where they have established tes. The Swedish National Veterinary
agencies participate in this mechanism. the Strama Programme Council. Institute has been mandated to sup-
Close contact and good collaboration port this collaboration and therefore
Other success factors is the regional between national government agencies hosts a Strama VL secretariat. The
and local work within the Swedish and the regions, county councils and secretariat shall promote coordination,
Strategic programme against antibiotic local authorities will first and fore- be a point of contact and a centre of
resistance (Strama), the clinical micro- most guarantee strong implementa- knowledge.
biological laboratories, the infection tion of knowledge and evidence-
control units, the communicable dis- based action.
ease control units and the drug thera-
peutic committees.
Figure 4. Consumption of Antibacterials For Systemic Use (ATC group J01)
in the community (primary care sector) in Europe, reporting year 2014
35
30
DDD per 1000 inhabitants and per day
25
20
15
10
5
0
ce nia* nce ium Italy rus urg alta land land pain atia aria akia om ugal land blic land gary ania way ark any enia stria den tvia onia nds
ee a g p o M re S Cro ulg lov ingd ort Ice epu Fin un thu Nor enm erm lov Au we La Est erla
Gr oma Fr Bel Cy emb I Po B S K P H Li S S
R x d hR D G
Ne
th
L u ite ec
Un Cz
*Country provided only total care data.
*Country provided only total care data.
22 Swedish strategy to combat antibiotic resistance”For animals the use of antibiotics is the lowest within the EU”
Swedish strategy to combat antibiotic resistance 23Ministry of Health and Social Affairs 103 33 Stockholm government.se
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