Policy paper

Tackling antimicrobial resistance 2019 to 2024: addendum to the UK's 5-year national action plan

Published 16 May 2022

This was published under the 2019 to 2022 Johnson Conservative government

Tackling antimicrobial resistance 2019 to 2024: commitment change process

This addendum sets out changes to the commitments in Tackling antimicrobial resistance 2019 to 2024: the UK’s 5-year national action plan. The national action plan is in its third year of delivery and these changes were required to make the commitments:

• more specific, measurable, achievable, realistic and time-bound (SMART)
• reflect lessons learned from the coronavirus (COVID-19) pandemic
• reflect progress that has already been made against ambitions to reduce antibiotic prescribing in food-producing animals
• work towards new sector targets

The Department of Health and Social Care (DHSC) worked with other government departments and agencies, as well as the devolved governments in Scotland, Wales and Northern Ireland to consider, review and update the commitments published in the national action plan. Changes to the human health commitments were approved by a sub-group of the expert committee for Antimicrobial Prescribing, Resistance and Healthcare Associated Infections (APRHAI). Animal, plant, and environment commitments were reviewed, and changes approved, by the Cross-Defra Steering Group. The changed commitments maintain the overall ambition of the UK antimicrobial resistance (AMR) programme and will support progress towards the UK’s vision to contain and control AMR by 2040.

Changes to the commitments were approved by the Secretary of State for Health and Social Care and the Secretary of State for Environment, Food and Rural Affairs in March 2022.

Delivery of the UK’s 5-year national action plan

In January 2019, the UK government published its vision for AMR to be contained and controlled by 2040. The vision recognises that a global problem as significant and complex as AMR requires a long-term course of action that progressively strengthens our understanding of AMR and what works to contain and control it.

In support of the vision, the government also committed to develop a series of 5-year national action plans that will each prioritise actions and direct resources based on the latest information about what the biggest risks are, and which interventions are most effective in addressing them. The government’s current 5-year national action plan in support of the 20-year vision was also published in January 2019 and will run until 2024.

The current national action plan focuses on 3 key ways of tackling AMR:

• reducing the need for, and unintentional exposure to, antimicrobials
• optimising the use of antimicrobials
• investing in innovation, supply and access

The plan also sets out 4 measures of success to ensure progress towards our 20-year vision. These include, among others, targets to:

• halve healthcare associated Gram-negative bloodstream infections (GNBSIs)^{[footnote 1]}
• reduce the number of specific drug-resistant infections in people by 10% by 2025
• reduce UK antimicrobial use in humans by 15% by 2024
• reduce UK antibiotic use in food-producing animals by 25% between 2016 and 2020 and define new objectives by 2021 for 2025
• be able to report on the percentage of prescriptions supported by a diagnostic test or decision support tool by 2024

Summary of changes

In total 93 commitments have been reworded, 17 new commitments have been added, and 8 commitments have been removed. As well as reflecting lessons learned during the COVID-19 pandemic, the proposed changes:

• improve the surveillance of AMR and antimicrobial use
• improve the availability of data to better understand the prevalence of antimicrobial resistance across human-health and animals, and linking of this data to enable analysis of AMR and our approach to managing infection through dashboards and research
• reflect priorities identified by the UK AMR Research Programme to explore and evaluate antimicrobial use, prescribing, new therapeutics, diagnostics, stewardship and resistance across both human health and animals
• reflect the particular role the UK is playing internationally in non-traditional and informal political groupings including supporting the UK Special Envoy on AMR and taking a lead role in AMR interest groups
• introduce 4 new commitments to reduce urinary tract infections (UTIs), in support of the national action plan ambition to halve healthcare associated Gram-negative bloodstream infections (GNBSIs) by 2024. These commitments reflect the fact that UTIs are a common pathway to GNBSI, and that successful management of UTIs requires a coordinated focus on prevention, diagnostics and treatment, underpinned by clear evidence and data

Detail of the changes to the commitments can be found below, according to chapters in the UK AMR national action plan.

1. Existing efforts

1.1 At a global level

To strengthen global collaboration, the UK will:

Commitment published in 2019	Revised commitment
Help ensure that AMR remains a global priority by continuing to lead international policy dialogue at the highest political levels through the G7, G20 and other international and regional fora, and as a major supporter of the UN and wider multilateral system.	Help ensure that AMR remains a global priority by continuing to lead international policy dialogues and negotiate commitments at the highest political levels, including through the G7, G20 and other international and regional and bilateral fora, and as a major supporter of the UN and wider multilateral system.
Urge sustained, joined-up international action to address AMR including holding the Tripartite Plus (WHO, the FAO OIE and UN Environment (UNEP)) and the wider UN family to account for their individual and collective efforts to address it, and by increasing links to the delivery of the sustainable development goals.	Urge sustained, joined-up international action to address AMR including holding the Tripartite Plus (World Health Organization (WHO), the Food and Agriculture Organisation (FAO), World Organisation for Animal Health (OIE) and UN Environment (UNEP)) and the wider UN family to account for their individual and collective efforts to address it, and by increasing links to the delivery of the sustainable development goals and the mainstreaming of action on AMR into country-level UN Sustainable Development Cooperation Frameworks.
Back the development of internationally agreed solutions to promote robust stewardship and access plans for new and existing antimicrobials and to protect antimicrobials as global public goods.	Support the development of, and seek to mainstream, internationally agreed solutions to promote robust stewardship and access plans for new and existing antimicrobials and to protect antimicrobials as global public goods.
New commitment	Engage internationally to mainstream AMR within current global agendas, including pandemic preparedness, ‘building back better’ post-COVID-19, climate change and food security and resiliency through COP26 and the UN Food System Summit.
New commitment	Support the UK Special Envoy on AMR to represent the UK overseas and advocate for an ambitious and aligned work programme to address AMR domestically, including through her role on the UN Global Leaders Group on AMR.
New commitment	Help drive political coordination through chairing, co-chairing or investing time in AMR interest groups including the ministerial ‘Alliance of Champions’ (with Sweden), the Permanent Representative-level ‘Group of Friends’ at the UN in New York, the Global Health Security Agenda (GHSA) action package on AMR and the informal health attaches network in Geneva.
New commitment	Following EU exit, accept a formal invitation to join the Transatlantic Taskforce on AMR (TATFAR) and provide UK expertise, leadership and commitment to deliver on a shared workplan with the other members (USA, Canada, Norway and the European Union). Commitment now complete.
New commitment	Support the introduction of an AMR lens on investments made by the CDC Group. Advocate for a similar adoption by the World Bank Group, International Monetary Fund and other multilateral and bilateral lending and development finance facilities. Explore the use of an AMR lens on relevant UK Aid projects and implement (and encourage other official development assistance (ODA) donors to do likewise) if viable.

To support countries to prevent, diagnose and treat infection, the UK will:

Commitment published in 2019	Revised commitment
Use UK Aid to support countries’ efforts, promoting prevention by continuing to fund delivery of vaccinations through international initiatives such as Gavi, the vaccine alliance.	Commitment merged into: continue to support global initiatives, including Gavi and the Global Vaccine Action Plan, to expand access to and distribution of vaccines against priority pathogens and increase immunisation coverage in humans and animals, especially in low- and middle-income countries (LMICs).
Invest in effective regulatory and delivery systems for human and animal health, the food chain, in AMR surveillance, and in linked work on nutrition and water, sanitation and hygiene (WASH) in LMICs – all of which help to prevent resistant infections spreading.	Commitment merged into: Through UK Aid, invest in effective regulatory and delivery systems for human and animal health, disease surveillance, the food chain, nutrition, and water, sanitation and hygiene (WASH) in LMICs, all of which help to prevent infections spreading (and helps stem the development of AMR).
Promote equitable access to quality antimicrobials and responsible use through system strengthening approaches in LMICs and our support to the Global Fund and other initiatives that provide diagnosis and treatment, as well as prevention, for the diseases of poverty, including drug-resistant tuberculosis (TB) to help meet the first, globally agreed AMR target: to successfully treat 1.5 million people with the disease worldwide between 2018 and 2022.	Commitment merged into: Through UK Aid, help reduce the global burden of drug-resistant infections, in line with agreed global targets on key diseases of poverty, including TB. In addition, help meet the first, globally agreed AMR target (to successfully treat 1.5 million people with the disease worldwide between 2018 and 2022), through support to the Global Fund and other initiatives that provide access to preventative, diagnostic and treatment services.
New commitment	Through UK Aid, invest in effective regulatory and delivery systems for human and animal health, disease surveillance, the food chain, nutrition, and water, sanitation and hygiene (WASH) in LMICs, all of which help to prevent infections spreading (and helps stem the development of AMR).

To support research and innovation, working with the research community and the private sector the UK will:

Commitment published in 2019	Revised commitment
Use our funding for research and innovation to include support for research groups, including public-private partnerships, to promote the development of new, priority vaccines, therapeutics and diagnostics, including for diseases of poverty such as TB and spanning both human and animal health. It will also encompass investment in applied health research and behavioural science to help us understand which approaches to tackling AMR work, where and when.	Fund existing and emerging product development partnerships (PDPs) and other global R&D initiatives and international research collaborations that support applied health research and behavioural science to help us understand which approaches to tackling AMR work, where and when.
Work with the private sector to build on our support for research innovation and the development of affordable tools to tackle AMR across the whole One Health agenda, to improve approaches to antimicrobial development, marketing and environmental risk management as well as promoting better corporate social responsibility where investors and consumers can bring their own influence to bear.	Continue to influence global research strategies on AMR-related topics by representing the UK on regional and global mechanisms such as Joint Programming Initiative on Antimicrobial Resistance (JPIAMR), the Global Strategic Alliances for the Coordination of Research on the Major Infectious Diseases of Animals and Zoonoses (STAR-IDAZ) and the Global AMR R&D Hub, ensuring the alignment of UK-funded research with that of other research funders, emphasising the need for research to be useful for frontline teams nationally and overseas (with a particular emphasis on LMICs). This includes identifying and supporting neglected or underfunded areas of AMR research, through, for example, the £50 million Global AMR Innovation Fund (GAMRIF).

2. Reducing need for and unintentional exposure to antimicrobials

2.1 Lower burden of human infection

To strengthen the prevention and control of priority infections, the UK will:

Commitment published in 2019	Revised commitment
Add carbapenem (CP) resistant Gram-negative infections to the list of notifiable diseases in existing laboratory reporting systems (commitment now complete)	Develop a 4-nations approach to monitoring and understanding of the impact of COVID-19 and remobilisation on carbapenemase-producing enterobacterales (CPE) surveillance data.
Continue work to halve healthcare associated Gram-negative BSIs, adopting a systematic approach to preventing infections and delivering a 25% reduction by 2021 to 2022 with the full 50% by 2023 to 2024.	Continue to support improvement and surveillance programmes to reduce the risk of transmission of resistance by adopting a systematic approach to preventing infections.
Work through UK Aid to help reduce the global burden of drug-resistant infections, in line with agreed global targets on key diseases, including TB.	Through UK Aid, help reduce the global burden of drug-resistant infections, in line with agreed global targets on key diseases of poverty, including TB. In addition, help meet the first, globally agreed AMR target (to successfully treat 1.5 million people with the disease worldwide between 2018 and 2022), through support to the Global Fund and other initiatives that provide access to preventative, diagnostic and treatment services.
New commitment	Enhance the prevention of UTIs, the early, accurate diagnosis of UTIs and the treatment of suspected and confirmed UTIs, including the prescribing and use of antibiotics and therapeutics in older people, both in their own homes and in care homes, by developing mechanisms to support implementation or adoption and spread of optimal practice and potentially beneficial interventions.

To improve the professional capacity and capability for infection prevention and control (IPC), the UK will:

Commitment published in 2019	Revised commitment
Ensure board-level leadership with a combined IPC and antimicrobial stewardship role for all regulated health and social care providers. The four countries will decide how best to achieve this within their own frameworks, but all will ensure a local accountable role that enables regular self-assessment, training and data-driven review.	Commitment retained.
Assess current and future workforce needs for strong IPC and antimicrobial stewardship across health and care settings; and develop future workforce targets based on the results of this assessment.	Commitment retained.
Facilitate and support an open and learning culture within healthcare settings on AMR by supporting the dissemination and implementation of learning strategies that are most likely to bring about behavioural change.	Commitment retained.
Establish the IPC and care standards developed in Scotland (and already adopted in Wales) as the national standards in England, to be measured annually by the regulators.	Commitment retained.
Commission a review of the optimal facilities and infrastructure required to reduce transmission and enhance IPC in hospitals and community care settings.	Commitment retained.
New commitment	With Health Education England (HEE), develop new and promote existing educational materials and resources for prevention and management of UTI for the primary and social care sectors.

To promote better IPC practices among the public, the UK will:

Commitment published in 2019	Revised commitment
Develop more targeted interventions to improve behaviour around hand hygiene	Complete: this commitment has been delivered.
Work with educators and local authorities to ensure that all school leavers understand how to wash hands, prevent infections and use antimicrobials appropriately, and that those messages are shared in all communities.	Work with educators and local authorities to provide tools and resources to all school leavers to support their understanding of how to prevent infections, including hand hygiene, and use antimicrobials appropriately and that those messages are shared in all communities.
Survey public attitudes to and awareness of AMR and self-reported behaviours through new technologies, including social media; and use these to assess the impact of national public health campaigns and local awareness-raising activities.	Commitment retained.
New commitment	With the UK Health Security Agency (UKHSA), develop a programme for enhancing patient and public awareness of a) how to support people to better self-manage their risk of developing a UTI, b) how people, or those who care for them, can identify when they may be at risk of developing a UTI and how they can help to prevent it, and c) how and when to seek help.

To turn research into practice for effective IPC, the UK will:

Commitment published in 2019	Revised commitment
Support research to better understand the routes and burden of transmission of drug resistant infections and potential interventions to inform control measures and behaviour change initiatives	Commitment been divided into: 1. Support research to understand the relative importance and contributions of different routes of transmission of drug resistant infections. 2. Research potential interventions for control measures and behaviour change initiatives (including their economic impacts) and test impact, acceptability and feasibility within real world settings. Understand what behaviour changes related to COVID-19 have been helpful and what have been harmful.
Strengthen research commissioning to ensure interventions are piloted and evaluated to help translate evidence-based research into practice more quickly.	Ensure interventions are piloted and evaluated to help translation of evidence-based research into practice more quickly (and optimise the use of national and Local Improvement Networks and Patient Safety Collaboratives to drive improvements). This should include social science research and implementation research to enable effective evaluation of impact.
Assess the average time taken for national guidelines to go from publication to implementation; and develop a plan using national and local improvement networks and the NHS PSC to drive improvements.	Commitment removed, as NHS trusts are not required to implement guidelines, so it is not practical to assess.
Include AMR as a priority area in the contracts and licenses NHS England has with Academic Health Science Networks (AHSNs) as they are renewed over the five years of this plan.	The AMR programme to work with the National NHS England and Improvement (NHSEI) AHSN team and the AHSNs to seek to identify and take forward opportunities to make AMR a priority area
New commitment	Conduct research on barriers and enablers to embedding fundamental IPC principles within healthcare practice.
New commitment	Conduct research on the potential impact of non-pharmaceutical methods (interventions and behaviours) to prevent common syndromes of infection, including hydration, increased mobility, hygiene practices.
New commitment	Work with DHSC, UKHSA and with research bodies to develop commitment to research in key elements of UTI prevention, diagnosis and treatment where further evidence is needed, including: any association between hydration and the prevalence and outcome of urinary tract or blood stream infections, antibiotic prophylaxis, the use of ibuprofen, and the potential role of UTI vaccines and barriers to roll-out.

2.2. Greater global access to clean water and sanitation

To support greater access to clean water and sanitation, the UK will:

Commitment published in 2019	Revised commitment
Integrate consideration of AMR thinking into the UK’s case for investing in WASH programmes in low- and middle-income countries.	Commitment merged into: Through UK Aid, invest in effective regulatory and delivery systems for human and animal health, disease surveillance, the food chain, nutrition, and water, sanitation and hygiene (WASH) in low- and middle-income countries LMICs, all of which help to prevent infections spreading (and helps stem the development of AMR).
Support world class science to improve understanding of how to change behaviours for improved hygiene.	Support research to understand how to change behaviours for improved hygiene. Identifying which health behaviours resulting from COVID-19 have had positive benefits and understanding how these can sustainably be implemented into practice.
Promote research in countries affected by contaminated drinking water to identify its role in the global spread of AMR.	Commitment retained.

2.3 Lower burden of animal infection

To promote animal husbandry that prevents endemic diseases, the UK will:

Commitment published in 2019	Revised commitment
Develop plans with the veterinary profession and livestock industry to improve animal health and address endemic disease issues through disease control schemes, veterinary advice and health planning, and tools for promoting knowledge transfer (such as guidance, training and communication).	Implement plans with the veterinary profession and livestock industry to improve animal health and address endemic disease issues through disease control schemes, veterinary advice and tools for promoting knowledge transfer (such as guidance, training and communication).
Work with the veterinary profession to encourage best practices for infection control in companion animals (pets) and horses and address infection risks specific to companion animals.	Work collaboratively across UK government administrations, the veterinary profession and professional bodies to encourage best practices for infection control and address infection risks in companion animals (pets) and horses.
Evaluate the impact of changes in animal husbandry practices and antibiotic use on farm economics and use the findings to promote best practice.	Commission research to evaluate the impact of changes in animal husbandry practices and antibiotic use on farm economics and use the findings to promote best practice.
Encourage regular monitored animal health planning as a key strategy for infection prevention and control in farmed animal enterprises. Review the effectiveness of animal health planning interventions to learn and disseminate best practice at regional and national level	Incentivise regular monitored animal health and welfare reviews as a key strategy for infection prevention and control in farmed animal enterprises. Monitor the effectiveness of animal health and welfare interventions to learn and disseminate best practice at regional and national level.

2.4 Minimise spread of AMR through the environment

To better understand how AMR spreads within and between animals, humans and the environment, and how to control it, the UK will:

Commitment published in 2019	Revised commitment
Identify and address evidence and knowledge gaps on transmission pathways of AMR between animals and the environment within a systems approach.	Commitment retained.
Improve our understanding of available disease data by working with the industry and the veterinary profession. Consider how to expand this and share at farm, regional, national and species level. Use in tandem with the development of a new Livestock Information Service to develop more targeted interventions to improve animal health and reduce antibiotic use	Work with industry and the veterinary profession to improve our understanding of available disease data. Consider how to expand this and share at farm, regional and species level as well as nationally. Use in tandem each country’s multispecies databases to improve disease surveillance and reduce antibiotics use.
Explore options to map awareness-raising activities and support collaboration, including running collaborative campaigns to promote good animal health and measure change over time.	Commitment retained.

To deepen understanding about AMR in the environment, the UK will:

Commitment published in 2019	Revised commitment
Support research to reduce evidence gaps and improve understanding of the hazards and risks from AMR in the environment.	Commitment retained.
Explore the establishment of a river catchment based research programme with clear standards for sample collection, analysis and review, with the aim of delivering AMR monitoring data that can be used to evaluate existing management interventions and inform any new policy initiatives.	Commitment retained.
Increase public awareness of the hazard and risk of AMR in the environment.	Gather evidence to understand the possible risks and hazards that AMR in the environment may pose to the public; and develop and appraise policy options guided by this knowledge to increase public awareness if necessary.

To minimise antimicrobial contamination, the UK will:

Commitment published in 2019	Revised commitment
Look to maintain in domestic legislation, the standards set by the Environmental Quality Standards Directive as amended by the Priority Substances Directive for harmful substances in the aquatic environment which might otherwise contribute to the spread of AMR; and to amend our lists of priority substances and contaminants of emerging concern (including antimicrobials) and their corresponding standards in future to take account of technical and scientific developments.	To mitigate the spread of AMR in the environment, look to maintain legislation to control the release of harmful substances in the aquatic environment which might otherwise contribute to its spread; and to amend our lists of priority substances and contaminants of emerging concern (including antimicrobials) and their corresponding standards in future to take account of technical and scientific developments.
Work with other countries to ensure responsible antimicrobial procurement from manufacturers with transparent world class environmental stewardship in their supply chains.	Advocate for internationally recognised antimicrobial manufacturing environmental discharge limits to be introduced by other countries via regulation and/or responsible procurement practices, and in bilateral and multilateral drug procurement mechanisms such as the Global Fund, UNICEF, Gavi and so on.
Collaborate with industry to promote the development of a global environmental stewardship certification system that can distinguish responsible manufacturers of antimicrobials.	Collaborate with industry, multilateral organisations, academia and other countries to develop internationally recognised environmental stewardship standards and a certification system for the responsible manufacture of antimicrobials for both human and veterinary use that minimises the discharge of active pharmaceutical ingredient into the environment.
Continue to support the AMR Benchmark to 2020 to stimulate improved accountability.	Continue to support the AMR Benchmark to stimulate improved accountability and positive competition in industry.
New commitment	Scope then implement the most effective mechanisms to privilege the use of antimicrobials for human and veterinary medicine that have been produced according to the highest environmental standards (and can demonstrate compliance with new discharge limits), through medicines regulation, procurement processes and other relevant levers.

2.5 Better food safety

To strengthen the evidence base for AMR and food safety, the UK will:

Commitment published in 2019	Revised commitment
Support a collective surveillance effort for the food chain by working with industry and exploring data-sharing options and the wider use of new technologies and approaches such as genomics.	Support a collective surveillance effort for the food chain by working with other government departments and agencies and industry to explore data-sharing options and the wider use of new technologies and approaches such as genomics.
Explore research collaborations and partnership working to improve the scientific evidence base, including contributing to the Codex AMR taskforce.	Commission food safety research including exploration of collaborations and partnerships to improve the scientific evidence base.
Do a third intestinal infectious disease (IID) study to gather population-based data on the gut resistome.	Commitment retained.

To promote good practice across the food chain, the UK will:

Commitment published in 2019	Revised commitment
Assess and track the perceptions and understanding of food handlers and consumers about AMR bacteria in food and what can be done to protect people through food hygiene at home.	Continue to promote good hygiene practices by food handlers and consumers in the home to reduce the risk of bacteria in food, thereby reducing the risk of exposure to AMR bacteria.
Advocate for all relevant stakeholders to adopt the new code of practice for food chain actors, once developed by the Codex Alimentarius Commission.	Contribute to the Codex AMR taskforce and advocate for all relevant stakeholders to adopt the new code of practice for food chain actors once developed by the Codex Alimentarius Commission.

3. Optimising use of antimicrobials

3.1 Optimal use of antimicrobials in humans

To strengthen stewardship programmes, the UK will:

Commitment published in 2019	Revised commitment
Develop a patient-level prescribing and resistance data source (including health and infection outcome and impact data) with timely access at point of care to support clinical decision making along with access to National Institute for Health and Care Excellence (NICE) guidance.	Commitment retained.
Enhance the role of pharmacists in primary care to review the dose and duration of antimicrobial prescriptions (especially long-term or repeat ones) and work with prescribers to review those that are inappropriate through evidence-based, system-wide interventions.	Commitment retained in England, Wales and Northern Ireland. Revised commitment in Scotland: Support and promote a multi-professional approach to stewardship of antimicrobials across all care settings.
Raise public awareness to encourage self-care and reduce expectations of antibiotics.	Commitment retained.
New commitment.	Research impact of COVID-19 on antimicrobial usage, prescribing, stewardship and resistance. Review messaging on antimicrobial stewardship in order to highlight best practice.
New commitment	Explore extent of ‘just in case’ prescribing in primary care of antimicrobials and the underlying causes. Test and implement interventions to mitigate ‘just in case’ prescribing.

To improve data management, the UK will:

Commitment published in 2019	Revised commitment
Require all infection consultations to record an appropriate diagnostic code, and be subject to audit.	Commitment divided into 2. In England, Wales and Northern Ireland: Work with expert clinical groups to develop standardised diagnosis codes for infection and require all healthcare professional consultations for suspected infection to have an appropriate diagnosis code recorded in the electronic health record and be subject to audit. Work with systems and national partners to embed evidence-based clinical decision support tools, informed by clinical prediction rules (for example FeverPAIN) or diagnostic tests where appropriate, into the clinician workflow for suspected infection, and record use of these tools and associated data in the electronic health record, for continuity of care and audit purposes In Scotland: NHS Scotland will consider working with expert clinical groups to develop standardised diagnosis codes for infection and require all healthcare professional consultations for suspected infection to have an appropriate diagnosis code recorded in the electronic health record and be subject to audit. NHS Scotland will consider working with systems and national partners to embed evidence-based clinical decision support tools, informed by clinical prediction rules (for example FeverPAIN) or diagnostic tests where appropriate, into the clinician workflow for suspected infection, and record use of these tools and associated data in the electronic health record, for continuity of care and audit purposes.
Ensure that all NHS hospitals have electronic prescribing systems within the electronic health record by 2025, and that these systems support and drive good antimicrobial stewardship by coding, auditing and providing feedback for surveillance.	As electronic prescribing systems within the electronic health record are implemented, ensure that these systems support and drive good antimicrobial stewardship by influencing the development and implementation of the systems so that they support AMR surveillance by way of coding, auditing and providing feedback.
Use electronic prescribing data to give healthcare providers feedback on guidance compliance and prescribing rates.	Commitment retained.
Use sentinel general practice surveillance linked to hospital data to monitor the impact of fewer prescriptions for antimicrobials.	England, Wales and Northern Ireland: use sentinel general practice surveillance linked to hospital data to monitor the impact of delayed prescribing and fewer prescriptions for antimicrobials. Scotland: use sentinel general practice surveillance and hospital data to monitor the impact of fewer prescriptions for antimicrobials and the impact of COVID-19 pandemic and remobilisation.
Increase training to ensure death certification correctly records AMR.	Work with the relevant professional bodies to seek to enhance training in death certification so that it records AMR where this can be identified as a cause of death’.
New commitment	Develop standardised diagnostic test codes and, as they become available, advise all healthcare professional consultations for suspected infection, where a diagnostic test is indicated and used, to record an appropriate diagnostic test code in the electronic health record (in addition to the diagnosis code) for audit.

To promote evidence-based guidance and interventions, the UK will:

Commitment published in 2019	Revised commitment
Support multidisciplinary research to identify which AMR interventions work to reduce antimicrobial use at different levels and in different contexts	Build the evidence base for which antimicrobial stewardship interventions work to optimise antimicrobial including understanding of different contexts and populations (for example, gender, ethnicity, socioeconomic status).
Test and implement national and local behaviour change interventions to nudge improved antibiotic prescribing and consumption using behavioural science	Test and implement national and local behaviour change interventions, to reduce inappropriate antimicrobial prescribing and consumption, using behavioural science.
Work with global partners to commission and implement evidence-based guidance (including health technology assessments) to optimise infection management for all common infections and syndromes.	Work with global partners to develop evidence for and evaluate guideline-based antibiotic management of common infections and syndromes.
New commitment	Research methods for improving and supporting clinical confidence in diagnostic testing.
New commitment	Derive, validate and test implementation of clinical prediction rules to reduce diagnostic uncertainty and identify: patients with self-limiting infections who are unlikely to benefit from antibiotics, and patients at risk of infections resistant to first-line treatments who are likely to benefit from broad-spectrum antibiotics.
New commitment	Commission randomised controlled trials to compare length or duration of antibiotic courses and examine impact on clinical outcomes and carriage of resistant microorganisms. Use to identify the characteristics of patients who may benefit from longer courses of antibiotics.

3.2 Optimal use of antimicrobials in animals and agriculture

To strengthen stewardship for responsible use, the UK will:

Commitment published in 2019	Revised commitment
Work with industry to develop appropriate training, guidance and other communications for antimicrobial users and prescribers to encourage the uptake of recommended practices and evaluate their impact.	Work collaboratively across, for example, UK government administrations, the veterinary profession and agriculture industry to develop appropriate training, guidance and other communications for those who are (or influence or are training to be) antimicrobial users and prescribers to encourage the uptake of recommended practices, and evaluate their impact
Explore, in collaboration with industry, options to develop rapid and reliable diagnostic tools to inform veterinarians’ prescribing decisions; and promote the uptake of these tools.	Commitment retained.
New commitment	Explore research into antifungal use in crops and its impact on antifungal resistance.

To improve data and control, the UK will:

Commitment published in 2019	Revised commitment
Improve the data available on levels of antimicrobials used in main livestock sectors and work with industry to review, refine and implement sector-specific targets.	Improve the accuracy, availability and coverage across the UK of antibiotic use data in the main livestock sectors. This will include working collaboratively across UK government administrations, the veterinary profession and agriculture industry to implement sector targets by the end of 2024.
Explore and work with existing systems that are monitoring the use of antibiotics and AMR in companion animals and horses to refine our understanding of the situation in these sectors; and report on collective use of antibiotics in household companion animals.	Work with systems that are monitoring the use of antibiotics and AMR in companion animals and horses to refine our understanding of the situation in these sectors. Work collaboratively across UK government administrations, the veterinary profession and professional bodies to improve the accuracy, availability and coverage of antibiotic use data in companion animals and horses.
Aligning with EU legislation, we will implement the provisions of the new EU Veterinary Medicines legislation on the use of antibiotics, subject to the official public consultation process and through collaboration with stakeholders to agree how it can be applied in practice	Implement similar provisions on the use of antibiotics as those in the EU regulations on veterinary medicines and medicated feed in the revised Veterinary Medicines Regulations 2013 as they have an effect in Great Britain, subject to the official public consultation process and through collaboration with stakeholders to agree how it can be applied in practice.
Work with global partners to build regulatory capacity in LMICs’ animal health sectors (by supporting control options for manufacturing, authorising, distributing, marketing, inspecting and surveying use of veterinary medicines).	Commitment retained.

3.3 Stronger laboratory capacity and surveillance of AMR in humans

To harmonise data collection and use, the UK will:

Commitment published in 2019	Revised commitment
Implement universal data coding (using SnoMed) and interoperability of data systems across health and social care.	Identify the appropriate code sets within universal data coding (using SnoMed) to support the interoperability of data systems across health and social care in relation to AMR.
Further develop standard, evidence-based laboratory testing practice and reporting guidelines, mandating their use where appropriate.	Commitment divided into 2: 1. All clinical diagnostic laboratories should be ISO15189:2012 accredited. 2. All diagnostic laboratories should follow SMIs for routine diagnostic work.
Work with global partners to promote the establishment of a One Health reference centre collaborative to better harmonise data on common or emerging threats.	Work with global partners, including the Tripartite Plus, to promote, strengthen and integrate AMR and antimicrobial usage surveillance on common or emerging threats through a One Health approach, including through the establishment of an AMR One Health UK Reference Centre, to better harmonise and integrate data on common or emerging threats across human, animal, food, and environment sectors internationally.

To enhance existing data and guidelines, the UK will:

Commitment published in 2019	Revised commitment
Promote adherence to existing guidelines through accrediting and professional bodies, and commissioning processes, within a strengthened regulatory framework.	Commitment divided into 2: 1. Work with relevant professional and accreditation bodies and regulators to promote adherence to existing evidence-based guidelines for antimicrobial stewardship and identify opportunities for these to be refined and strengthened to further reduce AMR, together with identifying where further research or guidelines are required. 2. Influence the development of commissioning processes and commissioning requirements so that good clinical practices for reducing AMR are reflected and incentivised in their content.
Maximise use of existing datasets to understand resistance hotspots by developing new surveillance methods and infrastructure to detect the emerging drug resistance	Commitment maintained
Use patient e-records and data links to optimise surveillance of community and healthcare-associated infections (including surgical site infection).	Support the availability and access of linked data to enable analysis of AMR and infection management patterns across pathways, across multiple organisations and at different organisational levels via research and dashboards including: the use of patient e-records and data links to optimise surveillance of community and healthcare associated infections, and the use of sentinel general practice surveillance, linked to hospital data, to monitor the impact of fewer prescriptions for antimicrobials.
Develop a single UK portal as a source of data and information on AMR.	Commitment retained.

3.4 Stronger laboratory capacity and surveillance of AMR in animals

To strengthen laboratory capacity and surveillance of AMR in animals, the UK will:

Commitment published in 2019	Revised commitment
Explore how to coordinate and integrate surveillance schemes to provide a more complete picture of antibiotic resistance, use and residues that can facilitate analysis of trends over time and across animal sectors.	Commitment divided into 2: 1. Work with relevant professional and accreditation bodies and regulators to promote adherence to existing evidence-based guidelines for antimicrobial stewardship and identify opportunities for these to be refined and strengthened to further reduce AMR, together with identifying where further research or guidelines are required. 2. Influence the development of commissioning processes and commissioning requirements so that good clinical practices for reducing AMR are reflected and incentivised in their content.
Work with the private sector, industry and academia to develop ways to share data to enhance the sensitivity of our surveillance systems for antibiotic resistance and use.	Commitment retained.
Explore options for including new monitoring tools, such as whole genome sequencing and other molecular-based methods, to improve and add value to our surveillance data.	Determine how to use new monitoring tools, such as whole genome sequencing and other molecular-based methods, to improve and add value to our surveillance data.
Explore ways of using UK surveillance data to better understand AMR transmission pathways between animals, environment and humans.	Commitment retained.
Work with global partners to promote the establishment of surveillance systems overseas, and establish an international AMR One Health UK reference centre to work within an international collaborative to better harmonise and integrate data on common or emerging threats across human, animal, food and environment sectors.	Commitment merged into: Work with global partners, including the Tripartite Plus, to promote, strengthen and integrate AMR and antimicrobial usage surveillance on common or emerging threats through a One Health approach, including through the establishment of an AMR One Health UK Reference Centre, to better harmonise and integrate data on common or emerging threats across human, animal, food, and environment sectors internationally.
Further develop harmonised One Health AMR surveillance including laboratory methodologies and reporting approaches.	Commitment removed for England, Wales and Northern Ireland but incorporated as a deliverable to: Develop a plan to coordinate and integrate surveillance schemes, and harmonise laboratory methodologies and reporting approaches, to provide a more complete picture of antibiotic resistance and use across animal sectors and human health. This will facilitate analysis of AMR transmission pathways and trends over time. Explore the potential for expanding this to antibiotic residues. Commitment retained for Scotland.

4. Investing in innovation, supply and access to tackle AMR

4.1 Sustainable investment in basic research

To provide strategic leadership in AMR research, the UK will:

Commitment published in 2019	Revised commitment
Support coordinated AMR related research on priority areas, including TB.	Support coordinated AMR-related research on priority areas including pathogens on the WHO priority pathogen list as well as TB.
Continue to influence global research strategies on AMR-related topics through JPIAMR and the Global AMR R&D Hub, ensuring the alignment of UK-funded research, and emphasising the need for research to be useful for front-line teams.	Continue to influence global research strategies on AMR-related topics by representing the UK on regional and global mechanisms such as JPIAMR, STAR-IDAZ and the Global AMR R&D Hub, ensuring the alignment of UK-funded research with that of other research funders, whilst also identifying and filling gaps and neglected or underfunded research areas, including the £50 million Global AMR Innovation Fund (GAMRIF), emphasising the need for research to be useful for frontline teams nationally and overseas (with a particular emphasis on low- and middle-income countries).
Keep supporting successful product development partnerships; and evaluate the effectiveness of current investments to inform future investment decisions.	Commitment removed as activity incorporated into existing funding commitments.

To strengthen our insight and capacity for doing high-quality research, the UK will:

Commitment published in 2019	Revised commitment
Continue to develop the scientific capacity needed to support and deliver ongoing high-quality research in infectious disease, prevention and microbiology-related disciplines.	Continue to develop the scientific capacity, by enabling context-specific training opportunities, needed to support and deliver ongoing high-quality research in infectious disease, prevention, social and behaviour sciences and microbiology related disciplines.

4.2 Development of new therapeutics

To support the development of new therapeutics, the UK will:

Commitment published in 2019	Revised commitment
Work with international partners to agree a coordinated global system for incentivising new therapeutics.	Work with international partners through bilateral and multilateral fora to advocate for use of existing medicines and a coordinated global system for incentivising innovation for new therapeutics, leveraging learning from the NICE and NHSEI Reimbursement Project and ensuring that stewardship and access provisions are embedded in any new initiatives.
Establish collaboratives that link UK researchers and industry to make best use of data, information and skills.	Establish collaboratives and support existing public-private partnerships, that link UK researchers and industry, addressing the gap in skills and capabilities for developing new therapeutics.
Support successful and emerging PDPs for priority therapeutics.	Support successful and emerging PDPs and other global R&D initiatives and international collaborations that fund early-stage and/or clinical development of novel and priority anti-infective therapeutics and the expanded use of existing medicines for humans and alternatives to antibiotics for animals, with a particular focus delivering products into use that meet the needs of low- and middle-income countries.
Invest in research in academia and businesses, including SMEs, through UKRI and other funding agencies.	Invest in research in academia and businesses, including small and medium enterprises (SMEs), to advance the development of new therapeutics for humans and animals down the commercial pipeline, through UK Research and Innovation (UKRI) and other funding agencies.
Continue to support the AMR Benchmark to stimulate improved accountability and positive competition in industry.	Commitment retained.
New commitment.	Explore alternative interventions and therapies such as bacteriophages, monoclonal antibodies, virulence factor modulating products and bacterial biofilm inhibiting or resistance materials and modulators or components of host innate immunity.

4.3 Wider access to therapeutics for those who need them

To support global initiatives increasing access and stewardship, the UK will:

Commitment published in 2019	Revised commitment
Include access provisions in the design of market incentives and relevant AMR specific capacity building projects	Commitment merged into: Work with international partners through bilateral and multilateral fora to advocate for use of existing medicines and a coordinated global system for incentivising innovation for new therapeutics, leveraging learning from the NICE and NHSEI Reimbursement Project and ensuring that stewardship and access provisions are embedded in any new initiatives.
Support global health initiatives to accelerate access to new health technologies, especially in LMICs.	Continue to support global initiatives, including Gavi and the Global Vaccine Action Plan, to expand access to and distribution of vaccines against priority pathogens and increase immunisation coverage in humans and animals, especially in LMICs.
Work with international organisations to develop a global approach to supply and access for new and existing essential antimicrobials, advocating the development of global supply chain mapping.	Work with international organisations and industry to develop a global approach to improve antimicrobial drug and product supply-chain security, with a focus on antibiotic therapeutics, advocating the development of global supply-chain mapping as a first step.
Will work with WHO, GARDP and other partners to determine economic models of optimal pricing for generic antibiotics.	Commitment merged into: Support global health initiatives to accelerate and maintain access to antimicrobial health technologies (especially in low and lower middle-income countries), building greater supply chain resilience and supporting modes of administration appropriate to the setting including through working with WHO, Global Antibiotic Research and Development Partnership (GARDP) and other partners to determine optimal pricing, reimbursement and/or procurement models for existing and new antibiotics.
Develop and test new models for national purchasing arrangements that de-link the price paid for antimicrobials from the volumes sold, using a NICE led healthcare technology assessment to support robust stewardship	Commitment retained.

To strengthen national procurement and supply, the UK will:

Commitment published in 2019	Revised commitment
Assess whether our antimicrobial procurement and supply mechanisms provide the best balance between ongoing supply and financial cost to the NHS.	Commitment retained.

4.4 Development of, and access to, diagnostics

To incentivise R&D for new diagnostics, the UK will:

Commitment published in 2019	Revised commitment
Address R&D gaps, including in the identification of biomarkers	Building on learnings from the COVID-19 pandemic and the rapid roll-out of centralised and de-centralised diagnostics, identify and address R&D gaps for AMR diagnostics (including evaluation of impact) across humans and animals, including the identification of biomarkers and sample collection for validation, to reduce antibiotic-prescribing by ensuring that the right antibiotic is prescribed at the right time. Research should consider the uptake and use of diagnostics and behavioural aspects of use alongside R&D.
Work with international partners to develop global plans for incentivising new diagnostics and for stimulating the behaviour change needed to realise the benefits for human and animal patients.	Work with international partners to develop global plans for incentivising the development and uptake of new diagnostics and for stimulating the behaviour change needed to realise the benefits for humans and animals.
Support the establishment of the Accelerated Access Collaborative and Pathway and ensure antimicrobials and diagnostics can be supported by its work.	Work with the Accelerated Access Collaborative and Pathway to support development and adoption of AMR-related diagnostics and support development of antimicrobials in line with DHSC and NHSEI antimicrobial-related priorities.
Work with NHS partners and industry to tackle the barriers to new innovations being adopted in the NHS, building on the Life Sciences Industrial Strategy and the response to the Accelerated Access Review	Commitment retained.
Prepare a 2 to 5-year urgent diagnostics priority list and use target product profiles to push research and development.	Commitment retained.
Introduce incentives to develop and evaluate rapid diagnostics.	Commitment retained.
Support existing and emerging PDPs for new diagnostics, including through the Foundation for Innovative New Diagnostics (FIND).	Fund existing and emerging PDPs and other global R&D initiatives and international research collaborations that support the development of diagnostic technologies or solutions for use in human and veterinary medicine, with a particular focus on the needs of LMICs.

To support rapid uptake of diagnostics, the UK will:

Commitment published in 2019	Revised commitment
Make antimicrobials and diagnostics a priority area for the Accelerated Access Pathway.	Commitment merged into: Work with the Accelerated Access Collaborative and Pathway to support development and adoption of AMR-related diagnostics and support development of antimicrobials in line with DHSC and NHSEI antimicrobial-related priorities.
Use modelling and test-pilot data to develop alternative funding models for faster diagnostics that support targeted treatment. This includes commissioning work to develop a method for assessing the value of new technologies that considers not only cost effectiveness but the value proposition at a system level	Commitment retained.
Maximise use of NICE guidance, including the Medical Technology Innovation briefs, to assess new diagnostic tests and offer prescribers advice on their use.	Commitment retained.
Streamline the regulation process to help get new diagnostics through as quickly as possible, including developing evidence-based guidance for using tests.	Commitment retained.

4.5 Development of, and access to, vaccines

To stimulate broader access to vaccines for humans and animals, the UK will:

Commitment published in 2019	Revised commitment
Continue to support global initiatives, including Gavi and the Global Vaccine Action Plan, to expand access to vaccines and increase immunisation coverage, especially in LMICs.	Continue to support global initiatives, including Gavi and the Global Vaccine Action Plan, to expand access to and distribution of vaccines against priority pathogens and increase immunisation coverage in humans and animals, especially in LMICs.
Support the animal medicines industry in their initiative to improve image and uptake of vaccines through proactive campaigns and encourage private investment in vaccine development	Commitment retained.

To stimulate more R&D into vaccines and alternatives, the UK will:

Commitment published in 2019	Revised commitment
Evaluate existing R&D capacity for developing, improving, adapting vaccines or other alternatives to antibiotics for humans.	Evaluate existing R&D capacity (including those available through COVID-19) and explore options for developing, improving, adapting vaccines or other tools that prevent infections (and the need for antibiotics) in humans and animals.
Support existing and emerging PDPs for human and animal vaccines, including for meningitis and diarrhoeal diseases.	Fund existing and emerging PDPs and other global R&D initiatives and international research collaborations including Coalition for Epidemic Preparedness Innovations (CEPI) that support the development of new vaccines technologies against priority pathogens for human and animal use to reduce infection and the need for antibiotics, with a particular focus on the needs of LMICs.
Use UK Aid to promote the global use of accelerated access approaches to vaccines for priority pathogens in humans and animals.	Commitment merged into: Continue to support global initiatives, including Gavi and the Global Vaccine Action Plan, to expand access to and distribution of vaccines against priority pathogens and increase immunisation coverage in humans and animals, especially in LMICs.
Work with the pharmaceutical industry, the OIE and veterinary profession to identify market gaps and options for new product development in animal sectors.	Consult with stakeholders, including the pharmaceutical industry, the OIE and veterinary profession, to identify market gaps and understand options for new product development in animal health sectors, in order to support reduction in antimicrobial use. Disseminate findings to relevant bodies to encourage product development to fill critical gaps identified.
Explore options to set up a coordinated research programme to develop novel and improved vaccines, strategies and diagnostics for livestock, fish, companion animals and horses, based on identified market gaps.	Set up a coordinated research programme to develop novel and improved veterinary vaccines, strategies and diagnostics by engaging with science funders to shape the scope of relevant research calls, identifying opportunities to coordinate and co-fund research, and by engaging with established research networks and initiatives.

4.6 Better quality assurance of AMR health products

To improve quality assurance of AMR health products, the UK will:

Commitment published in 2019	Revised commitment
Commission research into the extent of on-line purchasing and of illegal sales of antimicrobial agents in the UK.	Commission research into the extent of on-line purchasing, ‘under the counter sales’ and other illegal sales of antimicrobial agents in the UK, including in light of COVID-19 and the increase in telemedicine.
Use our regulators (MHRA and VMD) close working relationships with major websites to tackle the illegal sales of human and veterinary antimicrobials online	Reduce illegal sales of human and veterinary antimicrobials through our regulators’ (Medicines and Healthcare products Regulatory Agency (MHRA) and Veterinary Medicines Directorate (VMD)) close working relationships with major online marketing platforms, by collaborating to identify and remove products from sale. Improve intelligence on illegal sales and use of antimicrobials and strengthen enforcement in this area.
Explore options for including veterinary medicines in the EU’s Falsified Medicines Directive.	Commitment removed following EU exit.
Continue to support international monitoring of therapeutic quality through the Global Surveillance and Monitoring System and, with partners, advocate for animal medicines to be included.	Continue to support international monitoring of therapeutic quality through the Global Surveillance and Monitoring System and, with partners, advocate for animal medicines to be included through raising awareness of the issue of substandard and falsified veterinary antimicrobials.
Work with global industry to promote ways of formulating and packaging products that reduce the risk of falsification	Work with global industry and representative bodies to raise awareness of the issue of counterfeit antimicrobials, and support companies taking actions to prevent this.

Glossary of terms

Acquired immune deficiency syndrome (AIDS): the name used to describe a number of potentially life-threatening infections and illnesses that happen when your immune system has been severely damaged by the HIV virus.

Agriculture: the cultivation of land and breeding of animals and plants to provide food, fibre, medicinal plants and other products.

Antimicrobial: a drug that selectively destroys or inhibits the growth of microorganisms. Sometimes referred to as an ‘antimicrobial agent’. Examples include antibiotics (also known as antibacterials) antivirals and antifungal agents. In this document, antimicrobials includes anti-infectives where that would be relevant in the context of the text.

Antibiotic resistant bacteria: bacteria with the ability to resist the effects of an antibiotic to which they were once sensitive.

Antibiotic resistant genes: occurs due to changes, or mutations, in the DNA of the bacteria, or the acquisition of antibiotic resistance genes from other bacterial species through horizontal gene transfer.

Anti-infective: is a general term used to describe any medicine that can inhibit the spread of an infectious organism; in this document, it includes cleaning products such as antibacterial sprays.

Animals: unless specified otherwise, the term animal is used in this publication to refer to food-producing animals and aquaculture as well as companion animals and horses.

Antimicrobial resistance (AMR): occurs when the microorganisms that cause disease (including bacteria, viruses, fungi and parasites) cease to be affected by the drugs we use to kill them and treat the disease.

Antimicrobial stewardship (AMS): a key component of a multifaceted approach to improve the safety and quality of patient care whilst preventing the emergence of AMR. Good antimicrobial stewardship involves selecting an appropriate drug and optimising its dose and duration to cure an infection while minimising toxicity and conditions for selection of resistant microbes. Good AMS includes a review of the continuing need for antibiotics following clinical diagnosis and documented actions to stop, continue or change antimicrobial treatment.

Autologous vaccines: a therapeutic agent produced by isolating cells from an individual and processing these cells into a vaccine formulation for treatment of that individual.

Bacteriophage: a group of viruses that infect specific bacteria, usually causing their disintegration or dissolution.

Bacteraemia: the presence of bacteria in the bloodstream.

Broad-spectrum antibiotics: these are drugs effective against a wide range of bacteria. For example, meropenem is a broad-spectrum antibacterial. Their use needs to be limited to resistant infections because they tend to increase the risk of resistance in other bacteria.

Carbapenems: broad-spectrum antibiotics, often used as the last line of treatment for hard to treat human infections caused by Gram-negative bacteria.

Carbapenemese producing Gram-negative organisms: a group of bacteria that is resistant to carbapenems class of antibiotics.

Cephalosporins: a class of beta-lactam antibiotic exhibiting broad-spectrum activity to bacteria.

Third-generation cephalosporins: cephalosporins with activity against a wide range of Gram-positive and Gram-negative bacteria.

Commensal: living on or within another organism and deriving benefit without harming or benefiting the host individual.

Commissioning for Quality and Innovation (CQUIN): an NHS initiative intended to deliver clinical quality improvements and drive transformational change in the acute sector or hospitals. Achieving improvement against a defined set of criteria enables an NHS trust to qualify for a payment.

Critically important antimicrobials (CIAs): antibiotics identified by the World Health Organization as critically important for human health and their use needs to be restricted, especially in the veterinary sector. In the UK, we use the European Medical Agency definition of the CIAs. There are 3 classes of highest priority CIAs to which the animal industry applies restrictions.

Disease burden: includes the number of infections in the population and includes economic costs like treatment costs and the cost to health in terms of mortality and morbidity.

Escherichia coli (E. coli): a type of bacteria common in human and animal intestines, and forms part of the normal gut flora (the bacteria that exist in the bowel).

Extended-spectrum beta-lactamase (ESBL): enzymes that can be synthesised and expressed by bacteria, resulting in resistance to many penicillin and cephalosporin antibiotics and often to other types of antibiotic. In humans, the most frequently identified bacteria that produce ESBLs are Escherichia coli (E. coli) and Klebsiella species. The ESBLs that E. coli most often produce are called CTX-M enzymes. E. coli with ESBLs may cause urinary tract infections (UTIs) that can sometimes progress to more serious infections like blood poisoning.

Falsified medications: medications that deliberately or fraudulently misrepresent their identity, composition or source and are likely to be ineffective.

G7: the Group of Seven (G7) is a group consisting of Canada, France Germany, Italy, Japan the United Kingdom, and the USA. These countries, with the seven largest advanced economies in the world, represent more than 62% of the global net wealth.

G20: the Group of Twenty (G20) is an international forum for the governments and central bank governors from Argentina, Australia, Brazil, Canada, China, the European Union, France, Germany, India, Indonesia, Italy, Japan, Mexico, Russia, Saud Arabia, South Africa, South Korea, Turkey, the United Kingdom and the USA. Founded in 1999, the G20 aims to discuss policy pertaining to the promotion of international financial stability.

Gram-negative bacteria: those bacteria that do not retain crystal violet dye in the Gram-staining procedure. They can cause many types of infection and include E. coli and Pseudomonas aeruginosa.

Gram-positive bacteria: those bacteria that are stained dark blue or violet in the Gram-staining procedure. They include Staphylococcus aureus and Clostridium difficile.

Healthcare associated infections: infections associated with the provision of healthcare in hospital or community settings.

Healthcare associated Gram-negative blood stream infection: a laboratory-confirmed positive blood culture for a Gram-negative pathogen in patients who had received healthcare in either the community or hospital in the previous 28 days.

Hepatitis C: a virus that can infect the liver.

Human immunodeficiency virus (HIV): a virus that damages the cells in your immune system and weakens your ability to fight everyday infections and disease.

Inappropriate prescribing: for the purpose of delivering the ambition of halving inappropriate prescribing in the UK, inappropriate prescribing is defined as:

• prescribing an antibiotic for a patient in the absence of (documented) evidence of bacterial infection
• prescribing a critical broad-spectrum antibiotic (piperacillin-tazobactam or carbapenems in secondary care; co-amoxiclav, cephalosporins and quinolones in primary care) to patients in the absence of a (documented) rationale
• continuing an antibiotic prescription beyond the course length recommended in local or national guidelines, in the absence of a (documented) rationale

Intestinal infectious diseases: viral, bacterial or parasitic infections that cause gastroenteritis, an inflammation of the gastrointestinal tract involving both the stomach and the small intestine.

Klebsiella spp: Gram-negative bacteria that can cause infections including bloodstream infections; wound or surgical site infections; and meningitis.

Low- and middle-income countries (LMICs): as included in the OECD Development Assistance Committee (DAC list) – a list of all countries and territories eligible to receive official development assistance (ODA). These consist of all LMICs based on gross national income (GNI) per capita as published by the World Bank, except for G8 members, EU members, and countries with a firm date for entry into the EU. The list also includes all the Least Developed Countries (LDCs) as defined by the United Nations.

Malaria: a life-threatening disease caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes.

Macrolides: a class of antibiotic effective in the treatment of a range of infections, including respiratory, skin, soft tissue and sexually-transmitted infections. Erythromycin, azithromycin and clarithromycin are examples of macrolide antibiotics.

Meticillin-resistant Staphylococcus aureus: a strain of Staphylococcus aureus that is resistant to beta lactam antibiotics which include penicillins (for example, methicillin and oxacillin) and almost all cephalosporin antibiotics.

Microbiome: the microbiome comprises all the genetic material within a microbiota (the entire collection of microorganisms in a specific niche, such as the human gut).

Milligram per kilogram of use in animals: a measure of the use of antibiotics in animals. For example, a 50mg/kg figure for food producing animals would mean that on average, and over the course of a year, 50mg of antibiotic active ingredient was used for every kg of bodyweight at time of treatment.

Multi-drug resistant: resistant to multiple classes of antimicrobial.

Sensitivity breakpoints: a concentration (mg/L) of an antibiotic which defines susceptibility of bacteria is to the antibiotic. If the Minimum Inhibitory Concentration (MIC) is less than or equal to the susceptibility breakpoint, the bacteria is susceptible to the antibiotic. If the MIC is greater than this value the bacteria is considered intermediate or resistant to the antibiotic.

SNOMed CT: a structured clinical vocabulary for use in an electronic health record.

Infectious disease surveillance: the systematic collection of data from the population at risk, the identification of infections using consistent definitions, the analysis of these data and the dissemination of the results to those who collected the data, those responsible for care of the patients and those responsible for prevention and control measures.

‘One Health’ approach: collaborative multi-disciplinary work at local, national, and global levels to attain optimal health for people, animals and the environment.

Pathogen: an infectious agent (bug or germ), a microorganism such as a virus, bacterium, or fungus that causes disease in its host.

Patient Safety Collaborative: a safety initiative in the NHS supporting and encouraging a culture of safety, continuous learning and improvement, across the health and care system. It is a joint initiative, funded and nationally coordinated by NHSEI, with the 15 regional PSCs organised and delivered locally by Academic Health Science Networks (AHSNs).

Piperacillin-Tazobactam: a drug combination that has activity against many Gram-positive and Gram-negative bacteria including Pseudomonas aeruiginosa. Piperacillin is a synthetic penicillin; tazobactam enhances the effectiveness of piperacillin.

Population Correction Unit: a theoretical unit of measurement developed by the European Medicines Agency (EMA) in 2009. It takes account of a country’s animal population over a year, along with the estimated weight of each particular species at the time of treatment with antibiotics.

Prevalence: a snapshot at a point in time of the total number of cases of interest, like cases of healthcare-associated infection, in a given population.

Primary care: services provided by GP practices, dental practices, community pharmacies and high street optometrists.

Quality premium: an NHS scheme intended to reward clinical commissioning groups (CCGs) for improvements in the quality of the services that they commission and for associated improvements in health outcomes and reducing inequalities.

Quinolones: a family of antibiotics, including broad-spectrum agents like ciprofloxacin.

Responsible prescribing: the use of antimicrobials in the optimal way, for the right pathogen, at the right dose, for the right duration, for the treatment or prevention of infectious disease.

Resistome: the antibiotic resistome is the collection of all the antibiotic resistance genes, including those usually associated with pathogenic bacteria isolated in the clinic, non-pathogenic antibiotic producing bacteria and all other resistance genes.

Secondary care: covers acute healthcare, either elective care (planned specialist medical care or surgery, usually following referral) or emergency care.

Sepsis: a serious a complication of infection leading to potentially life-threatening organ dysfunction.

Staphyloccocus aureus: Staphyloccocus aureus (S.aureus) is a Gram-positive bacterium which is not always pathogenic (and can commonly be found existing as a commensal) but is a common cause of infection and bacteraemia. Meticillin-resistant Staphylococcus aureus (MRSA) is the antibiotic-resistant strain of S. aureus.

Substandard medications: medications produced by legitimate companies, but are damaged or degraded through poor manufacturing, storage or distribution.

Susceptibility testing: testing to detect possible drug resistance in common pathogens and to assure susceptibility to drugs of choice for treatment of infections.

Sustainable development goals (also known as the global goals): a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity. The 17 goals build on the successes of the Millennium Development Goals while including new areas such as climate change, economic inequality, innovation, sustainable consumption, peace and justice, among other priorities.

Therapeutics: the branch of medicine concerned with the treatment of disease. In this context specifically, the treatments against microbial infection.

1. It was agreed by the UK AMR national action plan delivery board that this target may need to be reviewed. DHSC has commissioned the University of Strathclyde to undertake work to model clinical pathways to GNBSI and the impact of various interventions, in order to inform recommendations on if the target should be adjusted and, if so, what a more appropriate target may be. ↩