Table 1.

Frame to approach the AMR problem according to stakeholders’ groups with common objectives. Gaps and challenges.

Level	Stakeholders	Objectives	Required Information	Scope	Information Source	Gaps and Challenges
Patient-centered (addressing clinical demands)	Patients (and their families), doctors, clinical microbiologists, prescribers, and drug dispensers (pharmacists), and infection control practitioners.	Improving patient treatment. Design and implement standard treatment guidelines and essential drug lists. Expected burden of disease (BoD) at any geo-administrative level (individual setting).	Fine-scale information of individual risks for infection, colonization, and/or expected treatment outcome. Fine-scale information at setting level (identification of risks areas).	OUSs 1 Composite indexes (DRI, microbiome indexes) AMU	Real-time collection of local and stratified patient and AMC/AMU data. Lateral Public Health [208]	Develop criteria to define HAIs cases, still based on 48–72 h admission time [195,196]. Microbiome precision medicine [161,194]. Develop composite indexes [171,175]. Combine AMR and AMC/AMU trends in categorized patient populations [122,130,131,132,209,210]. Understand microbial transmission (plasmid, clones, and microbial consortiums). Plasmid surveillance: criteria, tools, and databases [156,160,211,212]. Evaluate the impact of the indoor microbiome on the health and safety of patients [164]. Implement AMU interventions based on behavioral models [13,213].
Population-centered (addressing policy demands)	Health managers, infection control practitioners, public health experts, and health insurance companies. Politicians, policymakers, economists, and economic growth sectors.	To estimate the impact of AMR at national, regional, or international levels (trends and benchmarking). Identifying the leading causes for AMR emergence and spread. Quantifying AMC (pharmaco-epidemiology, sales).	Information aligned with validity, reliability, and comparability data from local, regional AMR surveillance networks.	Surveillance. OUS (list of priority pathogens). AMC (sales). Composite indexes.	Real-time collection of local and stratified patient data linked to local, regional, and/or national databases. Active population-based surveillance at local and regional levels	Identify population-level factors/groups linked to the emergence of AMR Granularity of the information to extrapolate estimates. Harmonize units of analysis and indicators (with appropriate corrector indexes. See Section 3 (data quality and comparability issues). Omic tools and infrastructures (capacity building, harmonized and standardized tools) [149,161]. Put AMR in the context of other Public Health threats (syndemics). Real-time surveillance only available in a few countries [121]. Community level surveillance adapted to healthcare loops (hospital wastewater, and insurance health networks,) [138,198,214].
		To design guidelines and policies. To monitor the effect of interventions.	Information aligned with validity, reliability and comparability data from regional AMR surveillance networks.	Aligned with National Antibiotic Plans (NAPs).	Active OneHealth sector-based surveillance aligned with NAPs	Harmonize NAPs according to local data and governance [181].
		Estimating the cost–benefit impact on public health, environment, and economy (BoD, biodiversity).	Return estimation ISOR. Social impact.	Public Health economics.	Public Health and Social data repositories.	Integrate the human, animal, and environmental policy outcomes with the economy markers.
		Efficient awareness tools and campaigns between stakeholders and lay public to inform alerts or interventions (control, drug policies,…).	Awareness through feedback influencing consumers, policies, and investment.	Awareness Tailored according to social and cultural norms.	Consumers-public polls and enquiries. Data from patient’s associations (ITUs).	Develop efficient communication tools and channels (intra and inter-sectorial) [203]. Assure updating of messages [203]. Revise prescription models.
		Revise market and marketing practices (pharma and food industry).	Evolution of sales and prescriptions. Control good practices.	Market and marketing.	National Health and Consumer services.	Strengthening governance, management, innovation, and financing [181].
Pathogen-centered (addressing infection-control demands) 2	Scientists and researchers, pharmaceutical industry, funding bodies, and global health donors.	Identification of transmission routes and microorganisms. Identify diagnostic biomarkers. Identification of reservoirs of MDR bacteria, plasmids, and hotspots for horizontal gene tranfer Identify PD parameters as minimal selective concentrations. Identify PD parameters as ecotoxicological concentrations.	Scientific publications, grey literature, workshop reports, international dossiers, white papers, and society reports.		Strains of microbial species (bacteria, fungi) of biomedical relevance from catalogued repositories and type strain collections.	Determine ethe effects of AMU (antibiotics and non-antibiotic antimicrobials) on dysbiosis patterns [164,215]. Understand microbial transmission (plasmid, clones, and microbial consortiums) Understand transmission pathways. (e.g., effects of particulate matters in the bacterial and fungal transmission, particularly in water–soil edges [216]. Plasmid surveillance: criteria, tools and databases [156,160,211,212]. Involve engineers in Public Health policies and guidelines. Environmental impact of sanitation measures [38]. Effects of interkingdom microbial interactions in the dynamics of MDR bacteria and ARGs [150]. Actions targeting the reduction of pharmaceuticals in the environment including the design, synthesis, and production of pharmaceuticals [38]. Determine the concentration of selective antibiotics for AMR in local environments [205,217,218]. Determine the impact of drugs in the environment to regulate microbial residue limits (MRLs) [218] 3.

¹ The number of Operational Units of Surveillance (OUSs) tested greatly varies for different units of analysis. Although routine clinical laboratories measure all pathogens against a battery of antibiotics in order to guide therapy of individual patients, most surveillance studies are based on the collection of these data. ² The increasing annual global growth of the pharma sector, prescriptions, and sales of pharmaceuticals at a rate greater than the increase of the population and with up to more than 50% of people in Western countries taking pharmaceuticals prescribed from more than one specialist, will force us to revise pharma workflow [38] as the effects of novel AMU/AMC patterns. ³ For most licensed medicines (+88%), data on environmental toxicity is not available [38].