Prioritising antimicrobial resistance interventions from a One Health perspective: lessons and applied tools for diverse contexts

IntroductionAlthough antimicrobial resistance (AMR) threatens the entire world, it disproportionately affects Low- and Middle-Income countries. The animal sector is a contributor to AMR and interventions for reducing AMR in this sector exist. However, in sub-Saharan Africa, there is limited information on AMR interventions targeting livestock.MethodsA systematic review was conducted following the PRISMA checklist to evaluate the existing evidence on AMR interventions, outcomes, motivators and barriers to adoption, and the strengths and weaknesses, with a focus on farmers and animal health professionals. The databases Web of Science, Scopus, and PubMed were searched. The articles were categorised into seven groups based on outcome measures: change in antimicrobial use (AMU) practices; change in AMR level; change in antimicrobial stewardship (AMS) practices; change in attitudes and perceptions concerning AMU, AMR, and AMS; change in knowledge concerning AMU, AMR, and AMS; change in surveillance strategies; and other.Results and discussionA total of 546 articles were considered and, in the end, only five articles were eligible. The reported interventions focused on change in knowledge (3/5), change in AMS practices (2/5), surveillance (AMR and AMU) (2/5), and change in development of AMR (1/5). The motivators for adoption of interventions included social desirability and the barriers included lack of finance and lack of perceived sustainability of the interventions. The observed strengths of the reviewed studies included the use of One Health approaches, collaboration between researchers and the community, and involvement of a diverse study population. The observed weaknesses included self-reporting of outcome measures and lack of clarity in reporting. The financial impact and societal impact were not documented in any of the reported interventions. However, organisation culture was highlighted as having a positive impact on adoption of interventions in one study. The quality of the study designs was generally considered low.ConclusionThe findings revealed there is limited evidence on AMR interventions in the animal sector in Africa especially those focussed on change in AMU and change in development and/or spread of AMR. This gap suggests a need for well-designed and robust studies that assess and evaluate the impact of interventions and target animal health professionals and farmers in Africa.

Background: Antimicrobial resistance (AMR) is a global health challenge that has escalated due to the inappropriate use of antimicrobials in humans, animals, and the environment. Developing and implementing strategies to reduce and combat AMR is critical. Purpose: This study aimed to highlight some global strategies that can be implemented to address AMR using a One Health approach. Methods: This study employed a narrative review design that included studies published from January 2002 to July 2023. The study searched for literature on AMR and antimicrobial stewardship (AMS) in PubMed and Google Scholar using the 2020 PRISMA guidelines. Results: This study reveals that AMR remains a significant global public health problem. Its severity has been markedly exacerbated by inappropriate use of antimicrobials in humans, animals, and the broader ecological environment. Several strategies have been developed to address AMR, including the Global Action Plan (GAP), National Action Plans (NAPs), AMS programs, and implementation of the AWaRe classification of antimicrobials. These strategies also involve strengthening surveillance of antimicrobial consumption and resistance, encouraging the development of new antimicrobials, and enhancing regulations around antimicrobial prescribing, dispensing, and usage. Additional measures include promoting global partnerships, combating substandard and falsified antimicrobials, advocating for vaccinations, sanitation, hygiene and biosecurity, as well as exploring alternatives to antimicrobials. However, the implementation of these strategies faces various challenges. These challenges include low awareness and knowledge of AMR, a shortage of human resources and capacity building for AMR and AMS, in adequate funding for AMR and AMS initiatives, limited laboratory capacities for surveillance, behavioural change issues, and ineffective leadership and multidisciplinary teams. Conclusion: In conclusion, this study established that AMR is prevalent among humans, animals, and the environment. Successfully addressing AMR calls for a collaborative, multifaceted One Health approach. Despite this, some gaps remain effectively implementing strategies currently recommended to combat AMR. As a result, it is essential to reinforce the strategies that are deployed to counter AMR across the human, animal, and environmental sectors.

Animals are considered key contributors to the development and spread of antimicrobial resistance (AMR). However, little is known about the existing AMR interventions in the animal sector. This scoping review examines the existing evidence on AMR interventions aimed at livestock, animal health professionals (AHPs), and farmers, while reviewing their impact, limitations, gaps, and lessons for future use. The scoping review was conducted following guidelines from the PRISMA-ScR checklist. The databases, Web of Science, Scopus, PubMed, and international organisations' websites (WHO, FAO, WOAH) were searched for articles reporting interventions targeting livestock, farmers, and AHPs. Interventions were categorised based on seven pre-defined primary measures including: change in antimicrobial use (AMU) practices; change in the uptake of antimicrobial stewardship (AMS); change in development of AMR; change in knowledge of appropriate AMU practices, AMR, and AMS; change in attitudes and perceptions concerning AMU, AMR, and AMS; and surveillance strategies. In total, ninety three sources were included: 66 studies, 20 reports, and 7 webpages. The reviewed interventions focused mostly on AMU practices (22/90), AMS uptake (8/90), and reduction of bacterial or resistant strains (30/90). Changes in knowledge (14/90) and attitude (1/90) were less frequently assessed and were often implicit. Most interventions were conducted within a select country (83/90) and 7/90 were at a global level. Only 19% (16/83) of interventions were implemented in low- and middle-income countries (LMICs) and most were at herd level with many self-reporting changes. Most of the interventions that focused on surveillance strategies (30/83) were implemented in high-income countries (62/83). Only one study investigated the financial implications of the intervention. The study findings provide an overview of existing AMR interventions and insights into the gaps which can be addressed to guide future interventions and research. A focus on developing, implementing and evaluating interventions in LMICs coupled with the use of objective outcome measures (e.g., measurable outcomes vs. self-reporting) will improve our understanding of the impact of interventions in these settings. Finally, assessing the financial benefits of interventions is necessary to inform feasibility and to encourage uptake of interventions aimed at reducing AMR in the animal health sector.

AHHME: A model for estimating the holistic cost-effectiveness of antimicrobial resistance interventions in food animal production

The pandemic legacy of antimicrobial resistance in the USA

Despite the escalating burden of antimicrobial resistance (AMR), the global response has not sufficiently matched the scale and scope of the issue, especially in low- and middle-income countries (LMICs). While many countries have adopted national action plans to combat AMR, their implementation has lagged due to resource constraints, dysfunctional multisectoral coordination mechanisms and, importantly, an under-recognized lack of technical capacity to adapt evidence-based AMR mitigation interventions to local contexts. AMR interventions should be tailored, context-specific, cost-effective and sustainable. The implementation and subsequent scale-up of these interventions require multidisciplinary intervention-implementation research (IIR). IIR involves both quantitative and qualitative approaches, occurs across a three-phase continuum (proof of concept, proof of implementation and informing scale-up), and across four context domains (inner setting, outer setting, stakeholders and the implementation process). We describe the theoretical underpinnings of implementation research (IR), its various components, and how to construct different IR strategies to facilitate sustainable uptake of AMR interventions. Additionally, we provide real-world examples of AMR strategies and interventions to demonstrate these principles in practice. IR provides a practical framework to implement evidence-based and sustainable AMR mitigation interventions.

BackgroundAntimicrobial resistance is a global problem and involve pathogens which have the potential to move between food producing animals and humans by direct exposure or through the food chain or the environment. The objective of this study was to determine the performance in addressing antimicrobial resistance in Kenya, Tanzania, Uganda and Zambia. Desk review and in-depth interviews were employed for data collection. Interviews were conducted with national antimicrobial resistance focal officials.ResultsThe findings indicate that in the four countries there was minimal capacity to conduct AMR surveillance. There were few well-established laboratories in tertiary hospitals, both private and public hospitals. The animal, environment and agricultural sectors in all countries had limited capacity in conducting antimicrobial resistance surveillance. There is limited data on antimicrobial resistance in all the four countries, and regional data sharing was limited. In all the four countries, data from research institutions were not linked using standardized system making difficult to compile the national database. The capacity for microbiological culture, identification and antimicrobial sensitivity testing using standardized protocols was available in the four countries. The interventions adopted by the countries included development of National Action Plans on antimicrobial resistance and setting up of multi-sectoral national coordinating structures.ConclusionsBased on this findings, the countries need improved National Integrated Antimicrobial Resistance Surveillance systems to include community settings, involving antimicrobial use and resistance in human, animal, food, and environment sectors. In addition, the region requires clear antimicrobial resistance data sharing protocol for quick comparability of the data across the region. This is important in driving antimicrobial resistance agendas at regional level, which will eventually trigger collective actions.

Antimicrobial resistance (AMR) and interventions to mitigate it are multisectoral, exhibiting super-wicked features that require intersectoral collaboration and synergy. Although AMR and mitigation strategies are pressing issues, their solutions are complex, ethically challenging, multilayered and often conflict at various levels and among diverse stakeholders. The main objective of this study was to identify the values and potential contributions of stakeholder analysis related to AMR and potential interventions from a case study that is being undertaken in Nepal using a 'One Health' approach. A total of 33 representatives from human, animal, agricultural and environmental sectors attended a stakeholder meeting in Kathmandu to discuss AMR, its ethical and practical challenges, opportunities and potential interventions. Using a five-pillar framework for stakeholder analysis, we demonstrate its relevance for addressing AMR and propose practical considerations for implementing effective interventions in Nepal. Beyond the practical discussions on AMR and its interventions at the policy, implementation and practice levels, this study underscores the critical value of its methodological reflections for informing ongoing interventions both within Nepal and in similar contexts globally.

Antimicrobial resistance (AMR) is a complex, inter-sectoral and international problem. Economic evaluation (EE) methods offer systematic, evidence-driven approaches to inform policy decisions about which AMR interventions to fund. EE of AMR interventions is complicated owing to diffuse effects, complex mechanics of the problem and high levels of uncertainty. Current AMR EE literature restricts the analytical scope, potentially resulting in omissions of effects that may limit the utility of EE to inform policy decisions. We aimed to systemise the key evolutionary and ecological processes of AMR to elucidate the paths through which AMR interventions impact population health and healthcare costs to support EE design and to support decision makers in understanding the limitations of EE evidence for decision-making. A conceptual map and a corresponding tool were developed on the basis of a literature review in consultation with experts across the relevant disciplines of molecular biology, infectious disease modelling, health economics and ecology. The AMR development map: (1) distils the key AMR processes and process drivers behind AMR development and maps the available types of AMR interventions to AMR process drivers; (2) proposes a way to conceptualise the spatial scope of analysis through considering the connectivity of the wider ecosystem and (3) outlines the key dimensions that AMR burden and intervention effects could be measured across. An AMR development map tool was developed to support conceptual modelling, with the focus on the choice of scope in the EE of AMR interventions, and an illustrative case study was provided. This work summarises the key underlying biological principles of AMR development to provide mechanistical grounding for considering the scope of effects of AMR interventions and the appropriate system of analysis to support conceptual modelling in EE of AMR interventions. In addition, this map can facilitate the identification of effects that cannot be considered or quantified, thus enabling transparency about these omissions within decision-making.

Antimicrobial resistance (AMR) poses a global health threat, with lower-middle-income countries bearing a disproportionate burden. Surveillance of AMR under a One Health framework is needed to elucidate the associations among clinical, animal, and environmental AMR. This review aimed to describe the state of AMR in Ghana, focusing on One Health. This review utilized the PRISMA guidelines and major databases to systematically search and analyze AMR in Ghana published from 1 January 2014 to 1 May 2023. Out of the 48 articles that met the inclusion criteria, 28 studies were conducted on humans, 14 studies involved animals, and 6 studies focused on the environment. A total of 48 different pathogens were identified across the human, animal, and environmental sectors, with the most common being Escherichia coli (67%, n = 32), Klebsiella spp. (52%, n = 25), Pseudomonas spp. (40%, n = 19), and Salmonella spp. (38%, n = 18). Generally, a high prevalence of antibiotic resistance was observed among various bacterial species across the sectors. These bacteria exhibited resistance to commonly used antibiotics, with resistance to ampicillin and tetracycline exceeding 80%, and multidrug resistance (MDR) ranging from 17.6% in Shigella spp. to 100% in Acinetobacter spp. This review reaffirms the significant challenge of AMR in Ghana, with a high prevalence observed in the human, animal, and environmental sectors. Key pathogens (e.g., Staphylococcus aureus and Escherichia coli) found across the sectors emphasize the urgent need for a One Health approach to tackle AMR in Ghana.

The global rise in antimicrobial resistance (AMR) is claiming the lives of more than 1.2 million people each year. According to the World Health Organization (WHO) this global health crisis is particularly acute in Africa, largely due to fragile and underfunded health systems. Efforts to combat this public health threat have led to the implementation of health system interventions worldwide aimed at managing and containing the spread of AMR. However, the literature on the real time impacts and the barriers that hinder the implementation of these interventions in the African context is limited. The objective of this scoping review was to identify AMR interventions in African health systems, their impact, and the challenges of the implementation. Drawing on Muka and colleague’s 24 step approach for scoping reviews, two major public health databases (PubMed and Global Health) were searched for articles in accordance with the PRISMA guidelines resulting in 4,783 records. Screening and retrieval of articles was done using Rayyan software based on specified inclusion criteria and 36 articles included in the final list. These articles were synthesized after extracting specific data on AMR interventions and their impact on African health systems. The review identified four broad impacts of AMR interventions including 1. Reduction in antibiotics use, 2. Increased adherence to guidelines and protocols, 3. Enhanced laboratory-based AMR surveillance, 4. Development of antimicrobial stewardship (AMS) Action Plans and Teams. However, challenges such as poor laboratory infrastructure, logistical challenges, poor financial commitment and inadequate education and training were identified as challenges impeding the successful implementation of AMR interventions in Africa. Our findings reveal a range of successful AMR interventions in African health systems although infrastructural and financial challenges remain. Better standardization and reporting of AMR diagnosis while leveraging the available information is needed to improve the optimization of treatment guidelines across Africa.

Background Antimicrobial resistance (AMR) is a pressing global public health challenge that requires coordinated multisectoral responses. In line with the Global Action Plan (GAP) on AMR, Jordan developed its first National Action Plan (NAP) for 2018–2022 to guide multisectoral efforts. This study aimed to evaluate the implementation of Jordan's AMR NAP, identify progress and challenges across its five strategic objectives, and suggest actionable recommendations for strengthening future AMR responses. Methods The Jordan Center for Disease Control (Jordan CDC) conducted a comprehensive 'end-term evaluation' for the NAP 2018–2022. Data were collected from approximately seventy national stakeholders through a national workshop and follow-up electronic communications. The evaluation tool included sector-specific and multisectoral indicators aligned with the NAP's five objectives. Descriptive statistical analysis was performed using SPSS to determine implementation rates across human, animal, and environmental health sectors, applying the One Health approach. Results The evaluation revealed uneven implementation across NAP objectives, with notable achievements in the rational use of antimicrobials (69%) completion, mainly in the human health sector. Infection prevention and control (IPC) efforts reached (63%), while surveillance-related activities achieved (56%). Awareness-related activities reported limited progress (47%), and no activities were implemented under the research and innovation objective. Multisectoral collaboration was limited, particularly in the animal and environmental sectors. Significant barriers included the absence of a unified communication strategy, lack of dedicated funding, insufficient investment in human resources and laboratories, and disruptions caused by the Coronavirus Disease 2019 (COVID-19) pandemic. Conclusions Despite progress in different areas, the overall implementation revealed significant challenges, particularly in research, multisectoral collaboration, and One Health integration. Future action should prioritize a unified national AMR policy framework for strategic planning, emphasizing resource distribution, active participation of all relevant sectors, and systematic monitoring and evaluation to inform policymaking. Strengthening coordination between human, animal, and environmental sectors is essential to achieving a robust, One Health-aligned AMR response in Jordan.

Antimicrobial resistance (AMR) is a global health risk that compromises the efficacy of antibiotics and other antimicrobial medicines vital to human and animal well-being. Containment of AMR requires robust multisectoral collaboration (MSC). We determined the extent to which MSC in strengthening AMR interventions in Uganda occurs. We conducted a cross-sectional study among AMR stakeholders in Uganda during November 2024–February 2025. We purposively selected adults aged ≥ 18 years. Data were collected using tools adapted from the WHO’s Tripartite AMR Country Self-Assessment Survey (TrACSS, 2023) and the EPICAP One Health surveillance evaluation tool (2022), tailored to capture Uganda-specific multisectoral collaboration for AMR. Data on sociodemographic factors and MSC for AMR were collected. Multisectoral collaboration was categorized as either non-existent, existent, or established. A total of 166 participants were included, with 49% being aged 31–40 years and most holding at least a master’s degree (53%). Multisectoral collaboration for AMR was reported to be established by 33% of participants and was observed to exist among 55% of the stakeholders. Multisectoral collaboration for AMR was partially established, with less than half of participants reporting shared leadership (73/166, 44%) and most indicating representation of relevant sectors (132/166, 80%) and inclusion of relevant disciplines (121/166, 73%). While a majority noted the existence of a national strategic plan (141/166, 85%) and that MSC contributes to stakeholder awareness (128/166, 77%), intersectoral coordination, preparedness, and resource availability were limited, with structured coordination reported by 52/166 (31%), dedicated budgets by 12/166 (7%), and assigned human resources by 6/166 (4%). Collaboration modalities were mostly defined and present but only partially operational (103/166, 62%), and supporting documentation was partial (87/166, 52%), with MSC often defined but not fully aligned with stakeholder expectations (77/166, 46%). Multisectoral collaboration for AMR in Uganda is partially established, with sector representation and strategic planning. However, there is limited shared leadership, coordination, and resource allocation. Strengthening intersectoral coordination, ensuring dedicated resources, and aligning collaboration with stakeholder expectations could enhance the effectiveness of AMR governance.

Antimicrobials play a vital role in treating infectious diseases in humans, animals, and plants, thereby supporting health, food safety, and food security. However, inappropriate use and overuse of antimicrobials across sectors contribute to the development and spread of antimicrobial resistance (AMR), particularly antibiotic resistance, which poses a growing threat to global public health. Resistant microorganisms can be transmitted between humans, animals, plants, food, and the environment, with significant implications for both human and animal health, food production, biodiversity, and economic stability. AMR causes around 35,000 deaths annually in the EU/EEA and significantly increases healthcare costs and productivity loss. While the EU promotes a One Health approach through the 2017 Action Plan and the 2023 Council Recommendation, surveillance remains largely sector-specific and fragmented. Strengthening integrated, cross-sectoral AMR surveillance holds significant potential. It enables timely evidence-based interventions that reflect the full scope of AMR's impact across human, animal, plant, and environmental health, thus effectively contributing to sustainable health and well-being. This workshop will explore the opportunities and challenges of developing integrated AMR surveillance across EU/EEA member countries. Based on a recent EU-commissioned feasibility study, it aims to support the countries in designing effective One Health surveillance systems for AMR and AMC by outlining key components, identifying barriers and enablers, and proposing practical solutions across sectors.Objectives1. Describe the key characteristics and objectives of an integrated AMR surveillance system; 2. Present core components for designing and implementing effective integrated surveillance systems for AMR and AMC at national level; 3. Explore barriers and enablers for cross-sectoral surveillance across human, animal, plant, food, wastewater, and environmental sectors; 4. Based on concrete examples, examine potential synergies and trade-offs in implementing integrated systems at national and EU levels; 5. Discuss and propose practical solutions to overcome challenges for implementing integrated One Health surveillance systems.Key messages• Supports EU/EEA countries in building integrated AMR/AMC surveillance to enable timely, One Health-informed interventions across human, animal, plant, and environmental sectors.• Advances cross-sector collaboration by identifying key components and solutions for sustainable, evidence-based AMR surveillance, improving public health and food system resilience.Speakers/PanellistsIvo ClaassenEuropean Medicines Agency, Amsterdam, NetherlandsMarie-Cécile PloyUniversité de Limoges et CHU de Limoges, Limoges, FranceAnn-Sofie HintzmannDanish Veterinary and Food Administration, Glostrup, DenmarkGunilla EklundEuropean Comission, Brussels, Belgium

The English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) antimicrobial resistance (AMR) chapter reports on bacterial, viral, and fungal AMR trends between 2017 and 2021 in England. A 10.8% increase in patient episodes of bacteraemia or fungaemia was observed, and the estimated burden of resistance decreased by 4.2%. Individuals with an antimicrobial-resistant strain (resistant to ≥1 key AMR burden-defined antibiotics) had a higher crude case fatality rate (18.1%) compared to those with a susceptible strain (16.3%). The effect of deprivation on carbapenemase-producing organisms (CPO) incidence, and the impact of the AMR burden across ethnic groups, have been described for the first time. Understanding the impact of ethnicity, deprivation, regional divergence, and potential confounders remains a crucial avenue of enquiry to target appropriate AMR interventions. These findings were presented at the ESPAUR Report webinar on 23 November 2022.