The Environmental Objective of the PNCAR 2022–2025: From Origins to Future Perspectives

Introduction

Addressing antimicrobial resistance (AMR) requires a One Health, multidisciplinary approach, originally developed in Europe through systems for risk monitoring and mitigation in both the human and animal sectors (European Commission, 2011). Over time, this framework has progressively expanded to encompass the environmental dimension of AMR (European Commission, 2017; WHO, 2021; European Commission, 2023), which is now formally integrated into Italy’s National Action Plan on Antimicrobial Resistance 2022–2025 (Piano Nazionale di Contrasto all’Antibiotico-Resistenza 2022–2025, PNCAR).

The environment is a key component of the AMR ecosystem, acting both as an interface between the human and animal sectors and as a natural reservoir of antimicrobial-resistant bacteria (ARB) and antimicrobial resistance genes (ARGs). Furthermore, in the presence of co-selective factors such as antibiotic residues, heavy metals and microplastics, aquatic and terrestrial environments may facilitate AMR persistence and evolution (Sassi, 2025). However, the role of the environment in the transmission of ARB and ARGs to humans remains poorly understood, with limited and often inconclusive epidemiological evidence. Moreover, studies on environmental AMR are mostly fragmented, based on heterogeneous methodologies and difficult to compare, thereby hindering a comprehensive assessment of the phenomenon (Miltgen et al., 2026).

Regulatory planning requires short-, medium- and long-term objectives that are technically feasible, financially sustainable and linked to possible mitigation measures. The aim of this communication is to describe how Italian sub-national authorities, namely the Regions and Autonomous Provinces, addressed the implementation of the environmental dimension of the Italian National Action Plan (NAP) on AMR.


The strategy to implement the environmental dimension of the PNCAR 2022–2025

The Italian PNCAR 2022–2025 addresses AMR through a holistic approach that includes the environmental dimension. However, given the resource limitations associated with the implementation of all actions envisaged under the current NAP, sub-national authorities had to focus on a limited number of priority objectives. In 2025, twenty strategic objectives were identified and formally endorsed in State–Regions Agreement No. 52/CSR of 17 April 2025.

Among the twenty strategic objectives, one specifically addressed the environmental dimension and aimed at making AMR surveillance in urban wastewater operational at sub-national level, based on harmonised methods defined by regional representatives and experts coordinated by the Italian National Institute of Health (Istituto Superiore di Sanità). The formal designation of the local bodies responsible for sample collection, laboratory testing and data collection, analysis and dissemination was a key element of the agreement.

This approach to the environmental dimension reflects the pragmatic choices made by regulators, recognising that environmental AMR surveillance is still at an early stage of methodological and operational development, with several issues still to be clarified before full-scale environmental AMR surveillance can be implemented (Hart et al., 2023). The aim of sub-national authorities was therefore to establish a structured surveillance system built on dedicated expertise and a national laboratory network operating in a coordinated manner, applying harmonised methodologies and centralised data collection and analysis. This aim is fully in line with WHO (WHO, 2021) and European Commission (European Commission, 2023) recommendations.


Wastewater AMR Surveillance as an Operational Tool

The environmental strategic objective selected by local regulators addressed the second objective of the environmental chapter of the Italian PNCAR 2022–2025 — specifically actions 2.2 and 2.3 — aimed at integrating the logistics for monitoring antibiotics, ARB and ARGs with those of the ongoing SARS-CoV-2 wastewater surveillance system.

To this end, the following operational objectives were set:

  • to set up the legal framework at regional or Autonomous Province level to support the implementation of a wastewater-based surveillance (WBS) system for public health purposes;
  • to identify a national laboratory network;
  • to nominate the focal points of the network;
  • to strengthen technical, microbiological, molecular and analytical expertise on AMR surveillance in untreated urban wastewater;
  • to identify the network of wastewater treatment plants to enrol in surveillance activities;
  • to set up logistics for sample collection and delivery to laboratories;
  • to develop a centralised system for the collection, management and analysis of WBS data.

The operational objectives were designed to ensure interoperability with other national and European surveillance systems and programmes. Specifically, the reactivation of the Italian Wastewater Surveillance Network (SARI), which had been scheduled for discontinuation at the end of the COVID-19 emergency, also strengthens pandemic and epidemic preparedness for respiratory pathogens. Overall, the operational objectives contribute to the implementation of Article 17 of Directive (EU) 2024/3019 on urban wastewater treatment, which requires Member States to set up a WBS system for AMR and other viral or emerging pathogens of public health concern.

In particular, the environmental scientific objective of the PNCAR 2022–2025 focused on the study of urban wastewater collected at the inlet of wastewater treatment plants. These samples are informative for assessing AMR within the community and investigating the role of treatment plants as potential AMR hotspots. For this purpose, wastewater samples are analysed for a panel of clinically relevant resistant bacteria affecting humans, including ESBL-producing Escherichia coli, carbapenem-resistant Escherichia coli, vancomycin-resistant Enterococcus faecium and Enterococcus faecalis, together with major associated resistance genes (blaCTX-M, blaKPC, vanA, qnrS, intI1).

These activities will be carried out across the network of wastewater treatment plants distributed throughout Italy for at least two years, using harmonised methodologies approved by the Italian Ministry of Health (Ministero della Salute, 2026).

Data from WBS will be compared for consistency with data from the national human AMR surveillance system (AR-ISS), in order to establish local and national baseline values and identify geographical and temporal trends, if any. Selected bacterial isolates collected from the regions may be further analysed at the genomic level.


Future Perspectives

As such, WBS is a useful tool to assess AMR dynamics at population level and to provide evidence to evaluate the effectiveness of mitigation measures, as well as to plan new risk-reduction interventions.

In view of the upcoming implementation of Article 17 of Directive (EU) 2024/3019, several initiatives have been launched at EU level to study AMR in wastewater, such as the EU-WISH research consortium (https://www.eu-wish.eu/) and activities developed within the framework of the EU-JAMRAI2 Joint Action (https://eu-jamrai.eu/). In this context, harmonisation of methodologies, analytical panels, sampling frequencies and criteria for the selection of wastewater treatment plants are an essential starting point (Hock et al., 2026). Such harmonisation is necessary to generate comparable data across Europe, as has been done for human and animal AMR surveillance in the EU. Both process and outcome indicators need to be defined in order to evaluate the public health utility of these surveillance systems (European Commission, 2025).

WBS is currently the most advanced and internationally implemented AMR surveillance system within the environmental dimension. It primarily generates knowledge on AMR dynamics in the population upstream of the sewage system, with epidemiological and public health significance that is sufficiently well understood. Yet it must be noted that AMR WBS is only one element for studying environmental AMR. Other environmental compartments, including areas downstream of wastewater treatment plants, surface waters, marine environments, soil and air, remain largely unexplored. The broader study of environmental AMR encompasses complex issues, including the role of environmental concentrations of antibiotics and their metabolites, the impact of wastewater and sewage sludge in agriculture, the horizontal transfer of ARGs and the development of new treatment technologies (Larsson and Flach, 2022). Nevertheless, within the framework of the Italian AMR NAP, it remains important to adhere to the “information for action” principle recommended by the ECDC (ECDC, 2025) for WBS. According to this principle, surveillance activities should have a direct utility for public health and AMR mitigation and should support subsequent risk mitigation measures. Furthermore, a clear understanding is required of the significance and limitations of the different environmental surveillance approaches that may be implemented (Hujbers et al., 2019; Larsson et al., 2023; Hart et al., 2023), together with careful consideration of their technical and operational feasibility, as recommended by WHO (WHO, 2024). National and sub-national environmental regulators need to define the scope and prioritise objectives of surveillance systems (Hart et al., 2023).

For example, within the next PNCAR it may be worthwhile extending monitoring activities to wastewater treatment plant effluents in order to assess treatment performance, thereby enabling the identification and ranking of facilities contributing most significantly to the environmental release of AMR. Such information may support assessments of human and animal exposure risk and guide future interventions aimed at improving treatment systems (Hock et al., 2026). Targeted monitoring of specific AMR hotspots, particularly hospital wastewater discharges, may help evaluate the effectiveness of treatment technologies. Both examples, however, present operational challenges that should not be underestimated. Experience gained during the implementation of the PNCAR 2022–2025 has highlighted the importance of focusing available resources on a limited number of priority objectives selected according to feasibility and potential public health impact. To this end, it is essential to prioritise AMR mitigation measures by assessing the relative importance of the main routes of human exposure, including person-to-person transmission, food, animals and the environmental route.

Indeed, recent evidence supports the need for risk prioritisation. In a recent study, Miltgen et al., (2025) describe two distinct AMR transmission scenarios for low-income and high-income countries. In the latter, characterised by effective management of urban and industrial wastewater, including pharmaceutical manufacturing effluents, high standards of hygiene and advanced livestock production systems, the environmental contribution to human transmission of ESBL-producing Escherichia coli appears limited. Consistent with these findings, Mughini-Gras et al., (2019) estimated the environmental contribution to ESBL-/pAMPC-producing E. coli transmission to humans to be approximately 3%, compared with 8% attributable to companion animals, 19% to food and 68% to person-to-person transmission.

In conclusion, extending AMR monitoring activities to the broader environment represents an important scientific opportunity. However, translating the resulting knowledge into effective public health interventions remains challenging. Yet, as surveillance consists of the continuous monitoring of a risk in order to inform mitigation interventions, local regulators need to optimise resources. It therefore appears useful to identify activities that directly contribute to improving public health, are technically and operationally feasible and sustainable, and can be incorporated into local surveillance systems as they are or with limited adaptation. Activities addressing research questions should be managed and supported by appropriate boards and budgets. WBS clearly belongs to the former category, whereas, given the current state of knowledge and the organisation of the Italian National Health Service, broader studies, including surveys and monitoring of environmental AMR, should be classified as a research endeavour.

Initiatives launched so far in selected Italian settings represent an important opportunity, as they can provide organisational and operational models to support the implementation and consolidation of environmental AMR surveillance activities, while also promoting greater harmonisation at national level. At the same time, a limited number of priority cross-cutting research areas should be identified and developed through the involvement of institutions with established scientific expertise under central coordination. This would help maximise existing capacities, avoid duplication, and ensure both the robustness and practical relevance of results.


References

  1. European Centre for Diseases Prevention and Control (ECDC), 2025. ECDC framework to guide the integration of wastewater-based surveillance at the EU/EEA level

  2. European Commission, 2011. Communication from the Commission to the European Parliament and the Council: Action plan against the rising threats from Antimicrobial Resistance. COM 748 final, Brussels, 15.11.2011

  3. European Commission, 2017. A European One Health Action Plan against Antimicrobial Resistance

  4. European Commission, 2023. Council Recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach (2023/C 220/01)

  5. European Commission: European Health and Digital Executive Agency, Tetra Tech International Development and Intellera Consulting, 2025.  Study on the design of a monitoring framework of the EU One Health Action Plans against AMR and Council Recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach – Final report, Publications Office of the European Union, 2025

  6. Hart A., Warren J., Wilkinson H., Schmidt W., 2023. Environmental surveillance of antimicrobial resistance (AMR), perspectives from a national environmental regulator in 2023. Euro Surveill. 2023;28(11):pii=2200367. https://doi.org/10.2807/1560-7917.ES.2023.28.11.2200367

  7. Hock L., Luiken R., Valério E., Vargha M., Vierheilig J., Börjesson S., Pitkänen T., Schmitt H., 2026. Integrating AMR surveillance into wastewater monitoring systems in 2025: a position on the implementation of Article 17 of the Urban Wastewater Treatment Directive (UWWTD). Euro Surveill, Jan 22; 31(3):2500289. doi: 10.2807/1560-7917.ES.2026.31.3.2500289

  8. Hujbers P.M.C., Flach C-F., Larsson D.G.J., 2019. A conceptual framework for the environmental surveilance of antibiotics and antibiotic resistance. Environment International 130, 104880

  9. Larsson D.G.J., Flach C-F., 2022. Antibiotic resistance in the environment. Nature Reviews Microbiology, 20, 257-269

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  12. Ministero della Salute, 2026

  13. Mughini-Gras L., Dorado-Garcia A., van Duijkeren E., van den Bunt G., 2019. Attributable sources of community-acquired carriage of Escherichia coli containing β-lactam antibiotic resistance genes: a population-based modelling study. Lancet Planet Health, 3: 357–69

  14. Sassi A., Basher N.S., Kirat A., Meradji S., Ibrahim N.A., Idres T., Touati A., 2025. The role of the environment (water, air, soil) in the emergence and dissemination of antimicrobial resistance: a One Health perspective. Antibiotics, 14,764

  15. World Health Organization (WHO), 2021. WHO integrated global surveillance on ESBL-producing E. coli using a “One health” approach: Implementation and opportunities

  16. World Health Organization (WHO), 2024.Wastewater and environmental surveillance for one or more pathogens: Guidance on prioritization, implementation and integration.


Fabrizio Agnoletti
Istituto Zooprofilattico Sperimentale delle Venezie, Dipartimento di patologia animale e sanità pubblica, sede in Friuli Venezia Giulia

Elena Mazzolini
Regione Friuli Venezia Giulia, Direzione centrale salute, politiche sociali e disabilità, Servizio Prevenzione, Sicurezza Alimentare e Sanità Pubblica Veterinaria

Francesca Cito
Istituto Zooprofilattico Sperimentale dell'Abruzzo e del Molise "G.Caporale", Centro di referenza nazionale per l'epidemiologia veterinaria, la programmazione, l'informazione e l'analisi del rischio (COVEPI)

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