Introduction

Antimicrobial resistance (AMR) presents a significant global health threat, particularly pronounced among low-middle-income countries (LMICS) and migrant populations, as highlighted by multiple studies led predominantly by researchers from high-income countries [1,2,3,4,5,6]. Despite Antimicrobial stewardship programs (ASPs) being pivotal in the WHO's Global Action Plan on AMR, their application in refugee, migrant, or displaced communities remains relatively underexplored [7]. The intersection of migration and public health calls for an examination of AMR along migratory routes. Understanding the motivations driving migration is vital for assessing the health impacts, including the various determinants potentially contributing to AMR before, during, and after migration. Hence, the relationship between AMR and migration, encompassing forcibly displaced persons, appears complex. Factors related to countries of origin, transit, or destination must be considered. The AMR risk in migrant communities may vary due to factors such as limited healthcare access or antibiotics in certain regions. Additionally, migrants face even bigger barriers to healthcare along the migratory journey, such as the presence of fragmented public health infrastructure and infection control policies, which further contributes to the AMR risk. Moreover, the escalating burden of AMR is particularly concerning in conflict-affected countries where effective AMR policies may lack consistent implementation [8]. Most available data on AMR and human mobility pertain to a distinct group: international travellers. This could be attributed to the dominance of data published by researchers from high-income countries and clinicians in travel clinics, who are particularly invested in this area. Furthermore, gathering data in a mobile population poses inherent challenges, further complicating such assessments. As a matter of fact, in a recent modelling study, the net migration rate (meaning the annual difference in number of immigrants and emigrants), has been shown positively associated with AMR at a global level [9]. Migration is a multifaceted phenomenon that reflects geopolitical and environmental factors. The present global climate crisis will significantly impact health due to the upheaval of social and economic systems. Shortages of land, shelter, food, and water will worsen poverty, ultimately leading to widespread migration and conflict, with profound implications for public health [10]. Additionally, migratory routes are constantly evolving, and with the establishment of new pathways, potential new challenges emerge. These developments may give rise to unforeseen outbreaks, whether zoonotic or non-zoonotic, stemming from geopolitical or climate-related factors.

Data on Migration to Europe

Europe total population includes almost 87 million international migrants, of whom 44 million born in Europe but living elsewhere in the region and the remaining born outside Europe, according to the 2022 IOM World Migration Report [11]. Of those born outside Europe, nearly 23 million were born in Asia, 11 million in Africa and around 5 million in Latin America and the Caribbean [11]. Thanks to more updated data from European Union (EU) countries, we know that in 2023, 273,640 arrivals at the south-eastern borders of the European Union were registered, the highest number since the 2015 refugee crisis [12]. Over the last five years, the top ten nationalities of people arriving at the south-eastern borders of the EU included five from the Eastern Mediterranean WHO Region (EMR), four from the Africa WHO Region (AFR), and one from the Southeast Asia WHO Region (SEAR) [12]. These nationalities belong to seven low-middle-income countries (LMICs) and three low-income countries (LIC) as per the World Bank classification [13]. From Eastern Europe, the Russian Federation, Ukraine, Poland, and Romania have the largest migrant populations within the region. With almost 11 million citizens living abroad in 2020, Russia had the highest migrant population in Europe [11]. Moreover, the number of refugees fleeing from Ukraine to Europe has increased since the start of the Ukraine-Russian war in 2022. As per the latest figures released by UNHCR on 28th December 2023, the number of refugees has reached nearly six million [14]. According to demographic data, since the year 2000, the gap between the percentage of male and female migration has slowly increased, with males accounting for 52% and females for 48 in 2020 [11]. Around 78% of migrants were of working age (15 to 64 years old). In the past few years, the number of young migrants (under 19 years old) has decreased, while the percentage of older international migrants (over 64 years old) has remained stable [11]. In recent years, certain migration routes have become well-established [15]. By analysing these routes with the countries of origin of the migrants, it is possible to identify the transit regions where migrants often settle temporarily, i.e. for months or years, before completing their journey to Europe, either voluntarily or forced, as a result of realities on the ground. In each migration route, there is a country that acts as a bottleneck where large migrant communities temporarily settle or are forced into detention or refugee camps. Notably, the most important are Turkey, Libya, Tunisia and Morocco [15].

Methods

In this paper, we use the United Nations Department of Economic and Social Affairs (UNDESA) definition of world regions in order to provide a European perspective [16]. We used definition of migrant, asylum seeker, refugee and internally displaced persons according to International Organization for Migration (IOM) glossary on migration [17]. This narrative review was produced identifying the research question, search methods for defining relevant studies, study selection, summarising data, and reporting the results (Table available as Supplementary material 1). The main research aim was to summarise current evidence on antimicrobial resistance in migratory paths, refugees, asylum seekers and forcibly displaced people. A search was run On January 1st 2024 on PubMed using the terms (((“Antimicrobial resistance”) OR (“AMR”) OR (“Multi-drug resistant”)) AND ((“Refugees”) OR (“Migrants”) OR (“Asylum seekers”) OR (“Forcibly displaced people”))), resulting in 51 articles. Results were limited to the time frame December 2018 – December 2023. Studies were filtered for original articles, systematic review, review, case reports and case series. Articles in languages other than English were excluded. Articles were screened according to the eligibility criteria and revised independently by A.C. and G.S. References of included original studies were also screened and selected independently. We reviewed the summary of all articles searched, and ultimately used data from 85 full articles to compile this narrative review.

For the section “AMR in countries of origin”, data were mainly extracted from the most updated figures on the AMR of Global Antimicrobial Resistance and Use Surveillance System (GLASS) project [18]. Figures were selected to describe the epidemiology of the top 25 countries of origin of migrants who arrived in Europe from 2019 to 2023 [19]. For countries not enrolled in GLASS a search was run On January 1st 2024 on PubMed using the terms (((“Antimicrobial resistance”) OR (“AMR”) OR (“Multi-drug resistant”)) AND (“country name”).

Articles were grouped in three sections according to the migration phases: i) AMR in countries of origin, ii) AMR in transit camp and iii) AMR in countries of arrival.

Both available data on AMR in a particular setting and its determinants were presented for each section. Considering the relevance of the current situation, a focus on AMR in conflicts was presented as a separate topic.

AMR in Countries of Origin

As outlined in the introduction, the top 25 countries of origin of migrants who arrived in Europe from 2019 to 2023 [19] include mostly LICs and LMICs (see Table 1). Social and economic factors, such as poor hygiene, limited healthcare access, and unregulated antibiotic use, facilitate AMR spread in developing countries [20]. Additionally, conflicts and insecurity, which are common reasons for migration, are also recognised as determinants of AMR [21].

Table 1 Resistance and frequency of Bacteriologically Confirmed Infections (BCI) per 100.000 tested patients in the top 25 countries of origin of migrants according to GLASS AMR data 2020 (GLASS—Country, Territory or Area AMR dashboard)
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Determinants of AMR in Countries of Origin

Antimicrobial overuse is common in human and animal health in LIC and LMIC [22]. Unregulated drug prescription is one of the main drivers. In developing countries, self-medication accounts for 63.4 to 78% of antibiotic dispensing in pooled prevalence from recent systematic reviews and meta-analyses [23, 24]. Asian countries, particularly Bangladesh, have the largest proportion of self-medication antibiotic dispensing and of non-licensed antibiotic dispensing points [25]. The main dispensing points are pharmacies, family and friends, old prescriptions and leftover antibiotics [24]. Qualitative findings suggested that self-medication is considered to be less time-consuming, cheaper, and more convenient than accessing treatment through healthcare facilities from the patients’ viewpoint [23, 25]. Strong customer demand, lack of training, economic motivation, and weak legal regulation are frequently reported as dispensing drivers among sellers [26,27,28,29]. In LMIC, more than 50% of patients attending primary care facilities receive antibiotic prescriptions in adult and paediatric settings [30, 31]. Prescription appropriateness is seldom assessed. In a three LMIC study, 76.5% of paediatric consultations resulting in antibiotic prescriptions were determined not to require antibiotics [30]. Upper respiratory and gastroenteric syndromes, even if more likely viral self-limiting conditions, led prescribers to recommend antibiotic treatment [30, 32, 33]. In this context, the lack of diagnostic tools reduces the possibility of targeted management of such conditions. Prescribers are often healthcare professionals who lack sufficient training [34], official guidelines are often lacking and it leaves space for the influence of pharmaceutical companies [35]. The lack of regulations favours counterfeit medication use. The most common quality issue encountered is the defect in the content of active pharmaceutical ingredients [36]. This means that the medicine is not as effective in treating bacterial infections and may also lead to the development of resistant variants among microorganisms due to low concentrations of active ingredients. Poor hygiene and sanitation are well-known risk factors for spreading infectious diseases. Terrific urbanisation in LIC and LMIC over the last few decades has resulted in unsafe settlements, resulting in unsatisfactory access to clean water and waste disposal [37, 38]. Unhealthy living conditions are tightly linked to increased antibiotic use due to higher incidence of respiratory and gastrointestinal infections, as well as increased transmission of AMR [39, 40]. Antibiotic use in animal agriculture is another critical factor. Antimicrobial resistance in animal farms of LMIC is increasing, with over 50% of antimicrobials showing resistance for different pathogens [41] and the local population may be exposed through direct exposure to animals, animal products and animal waste[42].

Data on AMR in Countries of Origin

Measuring the burden of AMR in the countries of origin of migrants, often LMICs, can be challenging due to the limited data availability and consistency. Since 2015, the WHO has set up the Global Antimicrobial Resistance and Use Surveillance System (GLASS) project, which collects AMR data on high-priority pathogens [18]. Table 1 shows the AMR data available for the top 25 countries of origin of migrants who arrived in Europe from 2019 to 2023, including E. coli, K. pneumoniae and S. aureus. Table S2 complete the overview of other high-priority pathogens' AMR data: Acinetobacter spp, S. pneumoniae and Salmonella spp (see Supplementary material 2) [43]. Fourteen out of the 17 African countries and 7 out of 8 Asian countries included in the top 25 list are enrolled in the GLASS AMR surveillance system. Even if enrolled, 5 out of 14 African countries did not send data to GLASS (Table 1). Those estimates, even if they represent the first interesting insight into AMR data for most of those countries, are affected by a substantial amount of selection bias. For example, data often originate from few facilities in the country and the percentages shown are often calculated against very small denominators [43]. The figures which describe E. coli and K. pneumoniae resistance to 3rd generation cephalosporins (3GC) are quite impressive, ranging from 30 to 90% in E. coli and from 63.7 to 96.1% in K. pneumoniae (blood isolates, Table 1). Carbapenem resistance in K. pneumoniae (range 0–67%, blood isolates) presents a challenge for treatment management and patient outcomes. Figures about the relevance of methicillin resistance among S. aureus are very limited. The few data on Acinetobacter spp. show a rate of carbapenem resistance ranging from 30.8 to 85%.

Among the top 25 countries of origin of migrants, Guinea, Senegal, Eritrea and Turkey are not enrolled in GLASS-AMR surveillance.

A search strategy focused on these countries did not identify any systematic analyses of the national burden of AMR in humans.

However, two multicentre studies conducted in Turkey on healthcare–associate and lower respiratory tract infections showed a high rate of extended-spectrum beta-lactamase (ESBL)-producing K. pneumoniae and E. coli (> 50%), of carbapenem-resistant A. baumanni (> 90%) and > 30% of methicillin-resistant S. aureus (MRSA) among the bacterial isolates [44, 45].

AMR in Conflicts

Several conflicts in recent years have caused migrants to flee to Europe from their countries of origin. Various reports have highlighted the risk of transmission of resistant bacteria in these contexts. Since February 2022, one million people have fled Ukraine due to the Russian invasion [46]. In 2022, the Center for Public Health of Ukraine (UPHC) conducted a point prevalence survey in three public health hospitals in three different regions of Ukraine dealing with hospital-acquired infections (HAI) and antimicrobial resistance. Among HAI detected, 60% were due to carbapenem-resistant organisms [47]. Moreover, the discovery of six extensively drug-resistant bacteria in a soldier who received surgical care in two Ukrainian hospitals highlights the alarming situation in the country [48]. Other examples of multidrug resistant organisms (MDRO) spreading during conflicts are provided by findings from Middle East countries. A retrospective analysis of microbiological data from soft skin tissues and bones collected between 2016 and 2019 from civilians wounded in Middle East conflicts was conducted. It showed a high proportion of MDRO, particularly Enterobacteriaceae (44.6%), MRSA (44.6%) and P. aeruginosa (7.6%). In Gaza, antimicrobial resistance among bacterial isolates increased by 300% from injured patients after the Great March of Return demonstrations, compared with non-injured patients [49]. Several factors contribute to AMR in conflict-affected areas. These factors include damage to water and sanitation infrastructure, reduced laboratories’ capacity to test germs susceptibility, enhanced use of antibiotics, suboptimal infection prevention control (IPC) and environmental pollution from infrastructure destruction [50]. Additionally, conflicts cause a high incidence of traumatic injuries that require surgery to be performed in informal facilities that lack the usual IPC measures [50]. Recently, it has been suggested that contamination of the environment with heavy metals could contribute to the emergence of new mechanisms of resistance [51].

AMR in Transit Centres

Many people who migrate often find themselves living for years in transit centres, refugee camps, or detention facilities at some point during their journey. The living conditions of these settlements can contribute to the spread of antimicrobial resistance (AMR) among migrants.

Determinants of AMR in Transit Centres

Refugee camps and other types of transit centres often pose similar issues to migrants, such as overcrowding, inadequate access to clean water and sanitation, insufficient healthcare access, and gender-based violence [52]. These issues become even more severe in detention centres where no external support from NGOs or UN organisations is available. Limited access to healthcare and essential medications may lead refugees to resort to self-medicating with non-prescribed antibiotics [53, 54], resulting in possible antimicrobial resistance. In Uganda, a cross-sectional study documented inappropriate antibiotic-prescribing practices in a refugee setting. The practices included the excessive use of antibiotics (prescribed in 23% of consultations) and a failure by healthcare workers to prescribe in line with the national treatment guidelines (in 47% of cases) [55].

Data of AMR During Migration

No systematic collection of data on AMR in refugee camps is available.

Table 2 summarises published papers dealing with AMR in refugee camps in the last 5 years. Although these are merely observational data, the risk factors associated with antimicrobial resistance in the refugee settlement are an important indicator of a potentially significant burden of AMR in this area. This burden is likely to be underestimated at present.

Table 2 Papers on AMR in refugee camps published in the last 5 years
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AMR at Arrival

In 2023, there were 273,640 arrivals recorded at the south-eastern borders of the European Union, marking the highest figure since the refugee crisis of 2015 [10]. The top countries of arrival are shown in Fig. 1.

Fig. 1
figure 1

Top countries of arrival and number of arrivals in 2019–2023 (source IOM). Spain: 183.014, Italy: 352.024, Malta: 7.239, Cyprus: 47.027, Greece: 144.944, Bulgaria 49.225

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Determinant of AMR at Arrival

Similarly to other settings during the migratory pathway, overcrowding, inadequate access to clean water and sanitation, insufficient healthcare access, and gender-based violence is common for migrants and asylum seekers upon arrival [56]. Often, these populations refrain from disclosing their presence in countries where migration is illegal, thereby restricting access to screening and healthcare. Specifically, the fear of deportation from the country, or the deliberate direct goals of policies designed with the goal of deterring migrants from staying within host countries, is a primary factor limiting the opportunity for screening upon arrival [57]. One important determinant in this population in initial reception centres is a very high rate of inappropriate antibiotic prescriptions (up to 75%), mirroring what is seen in the community setting, or in countries of origin and during transit [58]. Similar data come from migrant communities in host countries even months after arrival, highlighting misperceptions about antibiotic use in the migrant community [59]. Interestingly, a French study analysing a mixed migratory population, besides confirming similar data to what is known in the literature for what pertains to carriage of different MDROs, found out that older age, originating from eastern Europe or northern Africa, direct flight and shorter delay from arrival to sampling were significantly associated with ESBL-producing Enterobacteriaceae (ESBL-PE) carriage [60]. A different very interesting study focusing on refugee minors found mainly ESBL E. coli and K. pneumoniae; some of the isolates had > 90% similarity suggesting clusters and recent transmissions, possibly after arrival in France [61].

Data on AMR at Arrival

Limited data exists regarding the prevalence of AMR upon arrival, as national institutions typically do not conduct routine screenings in the majority of countries at points of entry, except for tuberculosis, chronic viral infections, parasitic infections or, in limited cases, for research purposes. National institutions from bordering countries may have developed specific guidance on the topic, whose implementation is underway. Moreover, available studies do not routinely present data in a way in which data “at arrival” and “after arrival” can be easily recognized. Overall, published data on this matter are scarce, resulting in few studies being able to collect data within this population.

In particular, in a recent Danish study, high rates of parasitic infections or colonization were found, while low estimates were retrieved for ESBL and carbapenem-resistant Enterobacteriaceae (CRE) (about 1%) and a slightly higher rate of MRSA colonization (6.7%) [62]. Similar data have been described for what pertains CRE in a similar population of asylum seekers at arrival in Germany [63], while ESBL was present (19%) with some degree of variation between persons arriving from Eritrea/Somalia, Afghanistan/Pakistan/Iraq or Syria. Therefore, in absence of other risk factors, being a newly arrived asylum seeker from a region with increased faecal ESBL-PE colonisation prevalence is not a clear indicator for CRE colonisation and thus not a reason for routine pre-emptive isolation upon hospital admission, an evaluation that should be conducted with a comprehensive assessment of health status. Generally speaking, this highlights surveillance gaps that should be addressed in the future. Data from Italian studies retrieved a large number of unusual gram-negative bacteria species isolated upon arrival [64, 65].

Carriage, Infections and Onward Transmission Risk

Although there has been significant attention on AMR stemming from migrant resettlement, evidence suggests that their role in AMR dissemination is minimal. The prevalence of AMR seems to be similar between short-term international travellers and migrants seeking resettlement, with possibly higher rates observed in the former group. Interventions to reduce AMR among long-term migrant populations are vital but must avoid worsening their existing stigmatization [66]. As a matter of fact, with some limits in the interpretation of findings [67], a systematic review and meta-analysis on AMR among migrants and refugees in Europe found a high prevalence of AMR carriage or infection (25.4% across all migrants), especially among asylum seekers and refugees in high-migrant community settings like transit centres or camps [68]. However, these estimates varied significantly among different populations and bacteria. Importantly, the data suggest that antibiotic-resistant organisms are mainly acquired during or after migration, with no evidence of transmission to surrounding populations. This underscores the role of migration and conditions in high-migrant settings in AMR acquisition among these groups. On the other hand, a Swiss metanalysis identified slightly different figures for refugees presenting at hospital acute care, with high ESBL (9%) and MRSA (21%) carriage reported, and low CRE (0%) [69]; similar data were found in a Finnish study, with higher figures for ESBL (32%) [70]. These data highlight the need for better surveillance and knowledge gaps. Moreover, with the limit of potential selection bias due to the nature of the population under analysis, another study identified being a refugee at higher risk of also being colonised by MDR microorganisms [71]. Rates of colonisation were higher for ESBL E. coli (23.8 vs 4.9%), Klebsiella pneumoniae (4.2 vs 0.8%). Additional co-resistance for FQ was common for both the surveyed microorganisms (26.6 vs. 6.9% and 4.2 vs. 1.9%, respectively). CRE were uncommon in this study population, differently from what was registered for S. aureus (5.6% vs 1.2%). Similar data were found in a very different setting (Turkey) on a community sample. However, data regarding MDRO resulted similar, showing a greater proportion of refugees (6.7%) carrying MRSA compared to the local community (3.2%). On the other hand, the ESBL-positivity rate was 17.9% in Syrian refugees and 14.3% in the local community. VRE and CRE resulted low with no difference between populations [72]. However, another study from the Netherlands demonstrated that carriage rate of MDRO in asylum seekers remains high even after prolonged stay [2]. A recent study conducted in Denmark, which examined data from urinary cultures focusing on bacteriuria or active urinary tract infections (UTIs), revealed a notable finding: it showed that the prevalence of antibiotic resistance in E. coli isolates was considerably higher among migrants, including both refugees and family-reunited individuals, compared to non-migrant patients. Furthermore, the study found that these differences couldn't be accounted for by other comorbidities or income status per se [4]. In addition to urinary cultures, blood samples were examined by another research group in Denmark. Among 4,703 cases of bloodstream infections, family-reunified migrants and refugees exhibited increased likelihoods of E. coli compared to non-migrants (odds ratio [OR] 1.89, 95% confidence interval [CI]: 1.46–2.44 and OR 1.55, 95% CI: 1.25–1.92, respectively), along with decreased odds of S. pneumoniae. These differences in pathogen distribution were primarily observed in community-acquired bloodstream infections. Refugees also demonstrated elevated odds of Escherichia coli resistance to piperacillin-tazobactam, ciprofloxacin, and gentamicin compared to non-migrants. Moreover, family-reunified migrants exhibited increased odds of E. coli and other Enterobacteriaceae resistant to ciprofloxacin [73]. Similar data were confirmed in another Danish study with mixed infections, in particular in female migrants [3].

Microbiological Perspective

Unravelling the microbiological intricacies of AMR in migratory contexts, we examine the spread of resistant strains and their implications for global health, and the different lineages that may spread. Evolutionary aspects, microbiome changes, co-resistance and plasmid dissemination should be considered in this perspective [74]. Interestingly, victims of conflicts may present very specific mechanisms of resistance that recent microbiological studies have mapped. In particular, mechanisms of resistance through genome sequencing for A. baumannii were identified, showing patterns in the AmpC, OXA, GyrA (S83L) and ParC (S80L) for different antibiotic classes [75]. Further data from the WHONET in war-wounded people identified a very high proportion of resistant Enterobacteriaceae and S. aureus, in particular from the Iraqi conflict [76]. Heavy metal toxicity in armed conflict may have played a role in exacerbating this high AMR emergence through peculiar mechanisms, as already outlined in the above-dedicated paragraph [51]. Wrapped up, although suffering probably from selection bias, these factors highlight the role of conflicts and war determinants in the microbiological spread of MDR. This is confirmed in different German studies analysing data from war victims of the Ukrainian conflict, showing an even higher rate of resistance, still with a low rate of MRSA. Since the spread of carbapenem-resistant genes, in particular, NDM-1 or OXA that resulted among the main gene signatures poses a great risk to further dissemination, appropriate IPC measures should be put in place for these patients [77,78,79]. For this same class of carbapenemase, a very recent study from Lebanon performed in-depth characterization and investigated genetic relatedness of emerging blaNDM-5-harbouring E. coli ST617 isolated from vulnerable hospitalized Lebanese individuals, Syrian refugees escaping war, livestock and the environment of the refugee camps, typifying strains that remain sporadic in the Mediterranean region up to date [80]. On top of this, various S. aureus genome signatures, different from the locally distributed typing, was found among refugees, possibly showing a different origin of the strains, but no common transmission pathway in Germany [71]. Opposite to this data, a previous German study, with the exception of ESBL, does not highlight a particularly higher prevalence of carriage compared to some European countries that are also highly endemic for these MDR microorganisms [63]. More generally speaking, the most common underlying mechanisms of resistance for ESBL seems to pertain to CTX-M or related gene signatures [1], and for MRSA mainly mec cassettes types IVa and V [81] with high similarity from what is observed in endemic European countries. Further studies analysing the microbiome and the resistome of migrants and asylum seekers found that the fecal microbiota of refugees is substantially different from that of resident Germans. Three categories of resistance profiles were found: (1) antibiotic resistance genes (ARGs) independent of geographic origin of individuals comprising BIL/LAT/CMA, ErmB, and mefE; (2) vanB with a high prevalence in Germany; and (3) ARGs showing substantially increased prevalences in refugees comprising CTX-M group 1, SHV, vanC1, OXA-1, and QnrB. The majority of refugees carried five or more ARGs (higher than German controls), although the observed ARGs occurred independent of signatures of potential pathogens [82]. These data are interesting in the perspective of potential re-organization of local microbiome populations and spread of ARGs.

Conclusions

AMR and migration are two of the most significant global health challenges of our time. In this review, we have emphasized that they also constitute a binomial that deserves particular attention.

Targeted interventions at each stage of migration are urgently needed to limit the spread of the AMR pandemic, particularly among this vulnerable population.

Thanks to the GLASS AMR initiative, in the last few years a more detailed understanding of the impact of AMR in LMIC is available, but more comprehensive and representative data are needed.

Transit camps are likely to be breeding grounds for AMR due to the presence of most of the key determinants of AMR. Unfortunately, the data on the AMR burden in such contexts is still lacking. Furthermore, the first health assessment and screening policies in arrival countries do not include AMR carriage assessment and rarely migration is considered as a risk factor for MDR pathogen carriage. However, the few available data are sufficient to advocate for better access to care and management of antibiotic prescriptions in both the countries of departure and along the migration path. To complicate things further, in recent years, a growing body of literature has reported that armed conflicts act as a magnifier of AMR spreading.

It is time for European countries to use the AMR prevention and control competencies acquired in the last decade to support LMIC in the fight against antimicrobial resistance and to improve migrant health.