Global Antibiotic Resistance: review of WHO surveillance report, 2025

Disclaimer: This post is for academic purposes only. Please read the original document if you intend to use them for clinical purposes.

This document summarizes the findings of the World Health Organization (WHO) Global Antimicrobial Resistance and Use Surveillance System (GLASS) report for 2025, which presents the most comprehensive analysis of antimicrobial resistance (AMR) to date. The report is based on over 23 million bacteriologically confirmed infections from 104 countries and territories, covering over 70% of the world’s population. The findings are concerning: resistance to essential, life-saving antibiotics is critically high, rising, and unevenly distributed, disproportionately affecting low- and middle-income countries (LMICs) and those with fragile health systems. This creates a syndemic where AMR interacts with and exacerbates existing health system weaknesses.

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1. Context:

AMR is recognized as one of the top ten global health threats, undermining modern medicine by rendering common infections untreatable and routine medical procedures unsafe. Bacterial AMR was linked to approximately 1.14 million deaths in 2021, with the highest mortality rates in low-resource settings. To address this crisis, WHO established the GLASS in 2015 to standardize data collection and generate evidence to guide national and global strategies.

Global commitments have been reinforced through the 2024 United Nations General Assembly Political Declaration on AMR, which set targets for 2030, including:

• Reducing deaths associated with bacterial AMR by at least 10%.
• Ensuring at least 70% of human antibiotic use is from the WHO AWaRe “Access” group.
• Achieving the capability in at least 80% of countries to test all bacterial and fungal GLASS pathogens for resistance.
• Ensuring all countries report high-quality surveillance data to GLASS.

2. Progress and Gaps:

2.1 Participation:

Country participation in GLASS has grown steadily, reflecting an increased global commitment to AMR surveillance.

• Participation: By the end of 2024, 130 countries, territories, and areas were enrolled in GLASS. For 2023, 104 countries submitted AMR data, a more than 300% increase from the 25 countries that reported in 2016.
• Regional Participation (2023): Participation was highest in the South-East Asia (90.9%) and Eastern Mediterranean (76.2%) regions. It remains lowest in the Region of the Americas (20.0%) and the Western Pacific Region (37.0%).
• Surveillance Coverage: Between 2016 and 2023, the number of infections with antimicrobial susceptibility test (AST) results reported per million population rose globally.
  • Urinary Tract Infections: 26.0% median annual increase.
  • Bloodstream Infections: 20.0% median annual increase.
  • Gastrointestinal Infections: 11.4% median annual increase.
  • Urogenital Gonorrhoea: No meaningful change, with coverage remaining critically low.

2.2 Persistent Gaps:

Despite progress, significant weaknesses in national surveillance systems persist, challenging the quality and comparability of global data.

• System Infrastructure: Only 46.2% (48 of 104) of reporting countries had fully implemented all five WHO-recommended core components of a national surveillance system in 2023, including a national reference laboratory and quality assurance programs.
• Data Completeness: The overall global score for national data completeness was only 53.8%. While demographic data (age and sex) were largely complete, critical information on the origin of infection (community vs. hospital) and the total number of patients sampled was frequently missing, limiting the ability to stratify resistance patterns and assess sampling bias.
• Geographical Gaps: Large parts of sub-Saharan Africa, Central Asia, and Latin America still report limited or no data to GLASS, indicating persistent inequity in access to diagnostics and surveillance infrastructure.

3. Global Landscape of AMR:

3.1 High and Uneven Distribution:

In 2023, approximately one in six laboratory-confirmed bacterial infections worldwide were caused by drug-resistant bacteria. The burden varies significantly by infection type and region.

Resistance was most common in urinary tract infections (approx. 1 in 3) and bloodstream infections (1 in 6).

3.2 Key Pathogen-Drug Resistance Levels:

The report details widespread resistance to essential first-choice, second-choice, and last-resort antibiotics.

• Gram-Negative Pathogens: Resistance to 3rd-generation Cephalosporins (a “Watch” antibiotic) in bloodstream infections was critically high for E. coli at 44.8% and K. pneumoniae at 55.2%. In the African Region, this figure exceeded 70% for both pathogens.
• Carbapenem Resistance: Resistance to carbapenems (essential “Watch” antibiotics) was 54.3% in Acinetobacter spp. bloodstream infections globally. In the South-East Asia Region, carbapenem resistance in K. pneumoniae bloodstream infections reached 41.2%.
• MRSA: Methicillin-resistant S. aureus (MRSA) remains a global problem, with a resistance level of 27.1% in bloodstream infections. The Eastern Mediterranean Region reported the highest level at 50.3%.
• Fluoroquinolone Resistance: Resistance to fluoroquinolones was widespread. In Shigella spp. gastrointestinal infections, global resistance was 29.7%, reaching 75.5% in South-East Asia. In N. gonorrhoeae, fluoroquinolone resistance was almost universal at 75.0% globally.

4. Alarming Trends:

Analysis of trends (2018-2023) reveals that the threat from key pathogens is increasing. AMR has increased in 40% of the 16 priority pathogen–antibiotic combinations monitored globally, limiting empirical treatment choices and forcing a shift towards last-resort intravenous treatments.

Notably, methicillin resistance in S. aureus showed a decreasing trend in the European, South-East Asia, and Western Pacific regions, but no significant global trend was observed.

5. AMR as a Syndemic:

The report establishes a clear link between AMR, health system capacity, and socioeconomic status, identifying AMR as part of a syndemic that disproportionately harms vulnerable populations.

• Inverse Correlation with Surveillance: Countries with low surveillance coverage report higher levels of AMR . This may reflect both genuinely higher resistance and a data bias from sampling severe cases in tertiary hospitals.
• Inverse Correlation with Health System Strength: A strong inverse correlation exists between a country’s UHC service coverage index and its median percentage of AMR in bloodstream infections. Countries with lower income classifications and weaker health systems consistently report higher resistance levels.
• Drivers of Resistance: Disproportionate reliance on broad-spectrum “Watch” group antibiotics is a major driver. In 2022, “Watch” antibiotics accounted for 45.3% of global use, far exceeding recommended levels and falling short of the 2030 target of keeping “Access” group antibiotic use at 70% or more.

6. AMR Patterns:

6.1 Bloodstream Infections(BSI):

• Epidemiology: These are among the most severe infections. E. coli was the most frequently reported cause globally (44.9%), followed by S. aureus (21.9%) and K. pneumoniae (21.1%).
• Resistance Highlights:
  • SDG Indicators: Global resistance of E. coli to 3rd-generation Cephalosporins was 44.8%, and methicillin resistance in S. aureus was 27.1%.
  • Acinetobacter spp.: High resistance to Carbapenems (54.3% to Imipenem) and Aminoglycosides (44.6% to Gentamicin).
  • K. pneumoniae: Extremely high resistance to 3rd-generation Cephalosporins (60.4% to Ceftriaxone) and rising resistance to Carbapenems (15.1% to Meropenem).

6.2 Gastrointestinal (GI) Infections:

• Epidemiology: Salmonella spp. was reported 5.1 times more frequently than Shigella spp. globally.
• Resistance Highlights:
  • Shigella spp.: High global resistance to Fluoroquinolones (29.7% to Ciprofloxacin), 3rd-generation Cephalosporins (27.8% to Ceftriaxone), and Azithromycin (25.6%). Resistance to Ciprofloxacin reached 75.5% in South-East Asia.
  • Salmonella spp.: While still largely susceptible to 3rd-generation Cephalosporins, resistance to Fluoroquinolones is a concern, reaching 18.0% globally for Ciprofloxacin in bloodstream infections and 16.3% in gastrointestinal infections.

6.3 Urinary Tract Infections (UTI):

• Epidemiology: These are among the most common bacterial infections. E. coli was reported 5.9 times more frequently than K. pneumoniae.
• Resistance Highlights:
  • Resistance to commonly used antibiotics like 3rd-generation Cephalosporins, Fluoroquinolones, and Co-trimoxazole was typically higher than 30% globally for both E. coli and K. pneumoniae.
  • The South-East Asia Region reported the highest resistance levels, with resistance to Imipenem (a carbapenem) reaching 16.3% in E. coli and 31.1% in K. pneumoniae.

6.4 Uro-genital Gonorrhoeal Infections:

• Epidemiology: N. gonorrhoeae remains a major public health challenge, with high transmission rates and frequent asymptomatic carriage.
• Resistance Highlights:
  • Resistance to Ciprofloxacin was nearly universal at 75.0% globally, rendering it unsuitable for empirical treatment.
  • Resistance to Azithromycin was 12.6% globally.
  • While resistance to Ceftriaxone—the last effective empirical treatment—remained low globally at 0.3%, its emergence, particularly in the Eastern Mediterranean Region (2.5%), threatens future treatment efficacy.

7. Corroboration:

A systematic review of literature published between 2019 and 2024 was conducted to complement the GLASS data.

• Geographical Coverage: The review provided data for 14 additional countries for bloodstream infections, 9 for gastrointestinal, and 33 for urinary tract infections not covered by GLASS in 2023. However, the data was heavily concentrated in a few countries and biased towards tertiary care facilities (80% of bloodstream infection articles).
• Findings: The review broadly corroborated the high resistance patterns observed in GLASS data. In many cases, resistance estimates from the literature were even higher than those from GLASS, likely reflecting the overrepresentation of severe, drug-resistant cases in tertiary hospitals. For example, MRSA in bloodstream infections was 47.1% in the review versus 27.1% in GLASS.

8. Priorities:

The report outlines five key priorities for a robust global response to AMR:

1. Strengthen National Surveillance: Countries must overcome barriers to data collection, improve the coverage and representativeness of their national AMR surveillance systems, and ensure timely data sharing with GLASS by 2030.
2. Implement Integrated, Context-Specific Interventions: Countries should implement comprehensive packages including infection prevention, sanitation, vaccination, and antimicrobial stewardship, tailored to local resistance patterns and health system capacity.
3. Optimize Antibiotic Use and Foster Innovation: Countries should reduce the use of “Watch” antibiotics and increase “Access” antibiotic use to at least 70% by 2030. Investment in R&D for new antibiotics, particularly against carbapenem-resistant pathogens, is an urgent priority.
4. Enhance Surveillance and Laboratory Capacity: Countries must improve their capacity to conduct representative AMR surveillance by strengthening laboratories, investing in quality-assured diagnostics, and developing robust digital information systems.
5. Address AMR Through Health System Strengthening: AMR must be addressed through broader strategies that strengthen health systems, advance Universal Health Coverage (UHC), and expand social protection, with a core focus on equity and access. This requires sustained domestic and global financing.

_{Citation: Development and implementation of national action plans for infection prevention and control: practical guide. Geneva: World Health Organization; 2025. Licence: CC BY-NC-SA 3.0 IGO.}